It is hard to imagine a more uncertain time for the healthcare industry in the United States.
The recession has brought an increase in charity and unreimbursed care as millions of Americans join the ranks of the unemployed and lose their healthcare benefits. Recruiting in the midst of a severe physician shortage is only going to get tougher as more doctors retire and competition intensifies for the too-small candidate pool to replace them.
And, hanging over everything, is healthcare reform. Just about everyone agrees that President Barack Obama will sign some sort of healthcare reform bill this year. Few, however, would venture to guarantee what those reforms will contain beyond an expected expansion of health insurance coverage to some of the 46 million uninsured people in the United States.
So, physicians and other healthcare professionals are looking at a very distinct possibility that they will soon be asked to work harder for more people and probably not make as much money. A little anxiety and outright crankiness is to be expected.
"It's a very trying time for physicians. There are changes going on in the entire context of the healthcare delivery system, and the fact that the economy is down, and so their practices are down," says Jeff Peters, president and CEO of Surgical Directions, LLC, a physician-led consulting firm.
Peters says unhappy physicians should no longer be looked at as disgruntled prima donnas. "That is probably a dying concept. Clearly, the younger physicians are much more balanced and reasonable," he says. "The biggest issue is that they are working too hard. They have too many nights, too many weekends, too much call, and they aren't making enough money. So, there is a general unhappiness with the level of compensation in comparison to the amount of work they are doing."
Being human, Peters says, physicians will take their anger out on whoever is close to them, or whoever is perceived—whether fairly or not—to be the source of their frustration. And in a physician practice, no one is more of a lightening rod for complaints and dissatisfaction—even in the best of times—than the practice administrator.
Give physicians a say
"A lot of the other unhappiness stems from the doctor not making enough money. While the practice manager can't control the market forces, there is a lot they can do to drive the overall processes to help the practice be more successful," he says.
Peters says there are a number of big issues that can sink a physician practice if not correctly navigated. Probably the biggest single mistake a practice can make, Peters says, would be to change the compensation formula without input from the affected physicians. Billing and collections issues are always hazardous. The advent of electronic medical records (EMR)—which has the potential to profoundly reshape healthcare delivery—is another potential iceberg for physician practices. "There are going to be lots of changes associated with EMR, and it never goes perfectly, and they are going to blame the practice administrator," Peters says.
The best way to avoid friction with physicians is to involve them in the important decisions that affect the practice. With compensation, for example, Peters recommends creating a physician-led steering committee. "The administrator should provide the staff and support it and give them data but the ultimate decisions need to be made by the physicians," he says. "You can't just say 'be happy.' You have to create a model that allows them to constructively change how things are. Part of making them happy is to let them be responsible for things that they can control and drive."
In the case of EMR, Peters says it's imperative that operating processes are not changed before the EMR goes in. "You don't want to have an EMR and broken processes and no way to track what is going on in the practice with those broken processes," he says. "That is a good prescription for disaster."
Simplify as much as possible
Barbara Berry, senior director of planning and marketing at Northern Michigan Regional Hospital (NMRH), in Petoskey, MI, says the 243-bed, regional referral center for 22 counties has developed a management style that builds trust with physicians by clearing the hassles that distract physicians from their healing mission.
"You have to do what you say you're going to do, and you have to get the bureaucratic drag away from the physician. A practice manager or hospital administrator who can help dissolve and compress that decision-making cycle has the ability to win over physicians. Keep the noise away from them. They are here to practice medicine and take care of patients. Really, just make their life as simple as possible," says Berry.
Most recently, Berry and Peters helped nine NMRH-affiliated cardiologists change a practice business model that had been failing for two years. "A number of physicians had left the practice. They weren't able to recruit. Because the hospital depended on that practice as their largest service line, the market share was dropping," Peters says. "What the organization was able to do was acquire the practice, employ the physicians, and put in a new model for physician leadership, not just for the practice, but for the cardiology service line. And if you talked to each of the cardiologists, it has totally changed their lives."
Berry says the physicians' decision to change the business model was not pushed on them by hospital administrators, but was gently supported as the physicians realized their existing business model wasn't working. "It took 18 months, to where they had reached a point in their practice where they were pretty frustrated with their own inability to have a succession plan and then recruit," she says. "Knowing they were really the highest contributor to our revenue, it became an organizational strategic initiative to assist them."
Peters says the cardiologists went into the affiliation with NHRH assuming they would be hired into an employment model. "What was ultimately decided was we would create a cardiac institute where they would be a group but they would also have a role in co-managing the cardiovascular service line," he says. "They have really stepped up to the plate. The practice is doing better. They've made changes in how they cover their patients, how they interact with primary care physicians and with staff. There is a totally positive revamping."
The success, Berry says, came in part because the physicians and the hospital administrators were able to address key concerns around clinical technology and information sharing, and physician leadership. "Those are two areas that healthcare has danced around. This was explicit," Berry says. "This was a group of physicians that not only recognized they had some culture and leadership issues within the group and the service line, but they also agreed they needed some assistance with it. We hired outside consultants to help evaluate the past culture and identify dynamics of a future culture. And I have to applaud the physicians and the staff; they addressed those issues head on and they have made huge cultural changes."
Under the new affiliation, Berry says, the physicians are able to spend more time concentrating on healthcare, attending conferences, and reading, and are more open to interaction with colleagues and hospital administrators. "They really began to see the folks were there to assist and not to dictate. We have created a model that we originally didn't know would exist. We've all learned from it," Berry says.
Enjoy shared success
Berry says they've also gotten compliments from referring physicians. "They talk about the ease of access, the ease of patient information, the collegiality, the respect," she says. "The other piece is that we now have a hospitalist program that is working arm in arm with these cardiologists, whereas before there were episodes where they were adversarial."
Peters says he hopes he can help NMRH expand the model to other key service lines, like surgery, a driver for 65% of all hospitals' bottom lines. "There is always tension between the surgeons and the hospitals and there are complaints that the OR is mismanaged," Peters says. "That same leadership model works well in the OR. Where you put anesthesiologists and surgeons in charge of it by establishing a surgical services executive committee and let them co-manage the ER with a nursing director. You typically get improved surgeon satisfaction, a growth in volume, and improvement in OR profitability."
What should remain constant in any leadership model is giving the physicians as much support as possible to create an effective working environment. "What you do is try to put them in a position of leadership and then give them the tools so they can be successful," Peters says. "It's not treating them like children but treating them as adults and making them responsible but giving them the support they need to do what needs to be done."