A comparison of quality and utilization problems in large and small group practices

Physicians practicing in large, multispecialty medical groups share an organizational culture that differs from that of physicians in small or independent practices. Since 1980, there has been a sharp increase in the size of multispecialty group practice organizations, in part because of increased efficiencies of large group practices. The greater number of physicians and support personnel in a large group practice also requires a relatively more sophisticated management structure. The efficiencies, conveniences, and management structure of a large group practice provide an optimal environment to practice medicine. However, a search of the literature found no data linking a large group practice environment to practice outcomes. The purpose of the study reported in this article was to determine if physicians in large practices have fewer quality and utilization problems than physicians in small or independent practices.     

Compensation for elected hospital medical staff leadership

As physicians' practices become more complex and their practice incomes more difficult to maintain, hospitals concurrently require more physician input into organizational, utilization, and strategic planning matters. Physicians and hospitals across the country are discussing the question of financial compensation to physicians for the time they spend performing these hospital administrative tasks. It is already common practice for hospitals to pay a salary for medical direction of hospital departments such as intensive care units or pulmonary laboratories. The question has become whether this practice should be extended to elected medical staff leadership.     

Twenty steps to survive managed care.

The health care industry is in the midst of discounted, price-driven, managed care. Many older physicians, not wanting to practice in this environment, are opting for early retirement. Others sell their clinical practices to management companies or hospitals to avoid the economic reality of day-to-day financial management. Most of these private practices are losing money every year. However, there still are a large number of physicians who have not sold their practice. As capitation continues to grow, these physicians will experience severe cash flow problems unless their financial plight is addressed rapidly. If it is not, the resultant cash flow problems will cause accounts payable to grow. Twenty steps are outlined that a physician or group should take right away to maintain a healthy cash flow. These include: Instituting a nurse triage system, setting up an after-hours clinic, getting the co-pay at the time of service, implementing a patient satisfaction questionnaire, monitoring the capitation reports, and checking capitation lists.     

Resolving conflicts: principles and practice

Physicians and other medical professionals undergo extensive professional training for the privilege of obtaining their professional licenses. For most physicians, clinical training is conducted in extremely competitive circumstances. Many physicians endorse competition as an appropriate method for producing greater individual and collective competence within the profession. Competition, however, is a very limited way to resolve conflicts. And, in the current environment of greater resource restrictions and reform, the competitive model, at best, seems short-sighted. Many of the current relationships involving physicians and others are transitional, involving various partners in numerous practice and professional relationships. For example, medical practices are merging; hospitals are engaging physicians in numerous business structures, even employment. However, longer term relationships are enhanced by mutual respect and collaboration, rather than chronic competition to "win" one's rights over another. Thus, the need among physicians to enhance their conflict resolution skills is expanded in today's environment.     

Administrative fellowships in emergency medicine

Physicians today need to be effective managers, as well as clinicians. In previous years, physicians gained managerial experience either through on-the-job training, degree programs, or continuing medical education courses. The specialty of emergency medicine began its first administrative fellowship in 1990 in California. Currently, three administrative fellowships exist nationally in emergency medicine. This article will describe the purpose of the fellowships and their curricula. Each fellowship has a different emphasis, with the goal to educate physicians who are interested in developing administrative skills to manage emergency departments or management groups or accept roles in hospital leadership. The existence of these fellowships will ideally influence the establishment of administrative fellowships in other specialties.     

Attracting qualified physicians to underserved areas. Part 1: Why has the U.S. experienced such difficulty?

With health networks searching for additional market share and with a projected 30.2 million to be enrolled in Medicaid HMOs by 2000, more health executives will be weighing various strategies of how to attract qualified physicians to practice in poor inner-city and rural areas. Most frequently cited as solutions are: supplying more physicians, encouraging more medical school graduates to pursue primary care residencies, and modifying the number of international medical graduates entering U.S. residency programs. Part 1 of this article reviews the efficacy of these approaches, while the second part, which will appear in the January/February 1999 issue, explores a more pragmatic option: to simply improve the working conditions and just pay substantially more to physicians who practice in "less desirable" locations.     

The Piñata syndrome

The Pi?ata Syndrome is manifested by physician lounge grumbling and griping; sniping at medical and administrative leadership; resistance to examining best practices; refusal to hold colleagues responsible for their behavior, and general melancholy. This disease is characterized by grousing physicians who do not enjoy the practice of medicine and if self treated will leave medicine. It is accompanied by patients who receive inappropriate care and caring. The treatment, which can result in an excellent prognosis, is self-administered and must be vigorously pursued to avoid chronic Pi?ata Syndrome, a professional death.     

Get real: what will draw physicians to the Web?

What are physicians waiting for? What will it take to stimulate widespread adoption of Internet medical systems? How can health care leaders and physicians help the technology innovators and the executives of technology firms understand the components necessary to assure physician acceptance and utilization of new tools? (1) Don't underestimate the personal nature of a physician's practice. It really isn't a "business." (2) Most physicians are not Luddites; they are just extremely pragmatic and practical. (3) For the majority of physicians to adopt a new technology in their private office practice, it must address three major issues: money, hassle, and patient care. There are many obstacles to adopting the new technologies that are the result of physician training and expectations and the current models of payment and revenue generation. Some technological innovations are presented to physicians without sufficient respect for their knowledge of how medical practices really work. The benefits promised often don't match with the needs structure of the physicians. As a consequence, the cycle of diffusion of these new systems is extended and delayed.     

Medical practices: hot properties of the '90s

The buying and selling of medical practices is big business around the country. Fueled by fears of where health reform is headed, frustrated by reduced reimbursements and mountainous paperwork, physicians are bailing out of solo practices, and small group practices are approaching large groups looking for safety in numbers. The large groups are aligning themselves with hospitals, and hospitals are luring large groups by offering to build them clinics. Clearly, this is a trend that will be heightened by anticipated structural reform of the health care system, but it is not without its dangers for all those who participate in the process.     

The evolving role of the medical director.

A medical group, be it under one roof, as a single or multispecialty group, or in separate offices, as an independent practice association, develops with the size and make-up of its patient base. In this article we document the growth of selective contracting by third-party payers with medical groups in California and discuss the implications of these trends on the structure and management of medical practices. Specifically, we focus on the emerging role of the medical director.     

The evolving role of the primary care physician

In today's climate of health care reform, the title of this article might more appropriately be "Is the Role of the Primary Care Physician Evolving or Going the Way of the Dinosaur?" According to Koop, primary care is in trouble. Whereas only 29 percent of U.S. physicians are primary care physicians, in Great Britain, 72 percent of physicians are primary care physicians and in Europe and Canada the average is 50 percent. Many U.S. primary care physicians are in the later stages of their careers and nearing retirement age. Unless the supply increases, this number will dwindle further. However, in 1992, only 14 percent of U.S. medical school graduates were headed for primary care careers. Even if the supply of primary care graduates were increased to 50 percent of the graduating medical school class, it would be well into the next century before the ratio of primary care physicians to specialists would be equal. Primary care is at a critical juncture and the next few years will decide the fate of the primary care physician. Given the state of primary care today, I believe that a fundamental look at the assumptions regarding the role of primary care physicians is in order. The current health reform movement has placed a major responsibility on primary care to solve many of the problems in health care delivery today, such as cost, utilization, and prevention. Many health care organizations are planning strategies involving primary care providers, and physician executives can play a key role in these decisions.     

Attracting qualified physicians to underserved areas. Part 2. Pay physicians more to practice in underserved areas.

With health networks searching for additional market share and with a projected 30.2 million to be enrolled in Medicaid HMOs by 2000, more health executives will be weighing various strategies of how to attract qualified physicians to practice in poor inner-city and rural areas. Most frequently cited as solutions are supplying more physicians, encouraging more medical school graduates to pursue primary care residencies, and modifying the number of international medical graduates entering U.S. residency programs. Part I of this article, which appeared in the November/December issue of The Physician Executive, reviewed the efficacy of these approaches. The second part explores a more pragmatic option: to simply improve the working conditions and pay substantially more to physicians who practice in "less desirable" locations. Although this idea is consistent with economic principles, drawbacks must be considered, such as: (1) the American taxpayers' reluctance to finance a more costly health care delivery system for the poor; (2) the inherent conceptual difficulties of a capitated Medicaid HMO serving as the linchpin for organizing, financing, and delivering care for the underserved; and, (3) many providers being expected to react in a fairly litigious manner to such an approach.     

The medical director as educator: an interview with Elizabeth M. Gallup, MD, JD, MBA. Interview by Richard L. Reece

Richard L. Reece, MD, interviewed Elizabeth M. Gallup, MD, JD, MBA, on July 9, 1999, to talk about the evolving role of the physician executive. Dr. Gallup discusses how medical directors have evolved from a purely clinical role to participating in the business side of medicine as well. The traditional medical director, a Dr. No who denies treatment and watches clinical performance, is now becoming an educator helping physicians to manage their behavior and change their practices based on comparative data. Her book, How Physicians Can Avoid Surrender and Lead Change: Gaining Real Influence in Your Own Health Care Organization Before It's Too Late, (American College of Physician Executives, 1996) promotes acting together as a group if physicians want to stay independent and not become employed. Independent physicians can form IPAs and act together as a group, avoiding some antitrust laws. Unless physicians get together and act as a group, she says, they are doomed to further and further erosion of their economic interests as well as their clinical autonomy.     

Physician leadership. Learning to be a leader

As the business role of health care delivery expands and complex reform is imposed, physicians must assume leadership roles and imprint medical expertise on business dynamics. Before the end of this century, health care and its delivery will likely become unrecognizable to those who ended their practices only a decade ago. Traditional management will wither away to be replaced by self-managed, self-trained, and self-motivated workers, no longer employed in jobs but working through processes, projects, and assignments in integrative health care delivery systems. Becoming a leader is an active and arduous process that can no longer be approached haphazardly. To be effective, the physician must plot a course with clear and calculated intent and effort, which requires acquiring organizational tools and administrative skills to innovatively alter medical care for the good of all.     

Physician profiling: trends and implications

Every professional is subject to profiling, and most are profiled more rigorously, more thoroughly, and more dispassionately than are physicians. Profiling occurs when society has the technologies and the economic incentives to perform profiling. In the first of this two-part article, we will consider trends in profiling all professionals and those in profiling physicians. We conclude in the second part of the article with a discussion of the specific methodologies and vendors used in profiling the practice habits of physicians.     

Getting a firm grip on the realities for physician executives

Today, physician executives can be found in every health care setting-group practices, hospitals and academic medical centers, insurance companies, drug companies, airlines, the government, and more. But before physicians land these positions, they must negotiate the often difficult passage from clinician to manager to executive to business-minded leader. To manage this transition successfully, physicians must be aware of and understand some basic realities of management positions. The nature of these realities and how physicians interested in management can deal with them are the subject of this article.     

The impact of health care reform on group practice

Just two years ago, it would have been very difficult to imagine that reform of the health care system would today be a national domestic priority and that Congress would be considering one of the most significant and far-reaching pieces of legislation in the past 50 years. The issue is still in doubt, but it seems clear that, in this session of Congress or the next, legislation of far-reaching consequences will likely be passed. In fact, change on a widespread scale has already begun. During 1993, every state legislature except those of Nevada and Wyoming considered measures that would alter the way medical care is financed and delivered. Of the states that acted, both last year and in recent legislative sessions, eight have passed laws with the ultimate objective of ensuring access to medical care for all citizens. Government, at both the state and federal level, is clearly taking on the health care issue. The impact of reform on physicians, and thus on group practices, will be substantial. This article outlines the current course of health care reform and addresses its specific implications for the management of group practices.     

The challenge for women physician executives

After half a century of constituting 5 percent of the physician population, women will soon make up more than one-third of U.S. physicians. Women now practice in virtually every specialty. This enormous change has created both opportunities and tensions. Within the broader context of the changing role of women in U.S. society, women physicians are exploring new career paths--paths that are both similar to and different from those of their male colleagues. A future challenge for women physicians will be achieving significant representation in the medical management ranks.     

Why an MBA?

As physicians move into medical management, leaving clinical practice behind to play a major role in managing physician performance and clinical processes, they are having to deal in the business world. Physician executives are donning the pinstripe suit instead of the white coat, and adding a business acumen to their clinical skills. Many have opted to pursue executive MBA programs to learn the business competencies they need to manage health care organizations. This article summarizes the educational opportunities available in executive MBA programs and discusses the value of business training for aspiring physician executives.     

Improving performance in a contracted physician network

Health care organizations face significant performance challenges. Achieving desired results requires the highest level of partnership with independent physicians. Tufts Health Plan invited medical directors of its affiliated groups to participate in a leadership development process to improve clinical, service, and business performance. The design included performance review, gap analysis, priority setting, improvement work plans, and defining the optimum practice culture. Medical directors practiced core leadership capabilities, including building a shared context, getting physician buy-in, and managing outliers. The peer learning environment has been sustained in redesigned medical directors' meetings. There has been significant performance improvement in several practices and enhanced relations between the health plan and medical directors.