Physician anger: leggo dem managed care blues--leadership beyond the era of managed cost.

While managed care has caused great disruption, it has also provided physician executives with a natural leadership raison d'être. Managed care, with all its pros and cons, is largely a response to certain unrelenting trends. The core functions of leaders comprise the stewardship of organizations and colleagues in response to these trends. Four trends are explored: (1) The demise of open-ended funding of American health care; (2) continued competition for health care resources; (3) thriving pluralism; and (4) patients continually adjusting to assure themselves of appropriate health care access, quality, and service. In the 21st century, the industry will need a new brand of leader, one capable of balancing the needs of the professionals with the business and accountability requirements of a permanently competitive and resource-constrained service industry. The keys to successful leadership in the future include: (1) Clear service differentiation and a compelling vision to match it; (2) recruiting and retaining top clinical talent, including the required return to physician self-direction and governance; (3) successful partnerships with others outside your organization; and (4) a steady focus on performance in all its dimensions.     

Physician executive leadership. Leading the way

Today's health care leaders are faced with tremendous pressures for change from diverse, powerful sources including payers, regulators, legislators, patients, and competitors. The leadership approaches of the past, designed to get things back under control, no longer work. In our turbulent times, leadership demands the creation of flexible, adaptive organizations with conscious, capable, and committed people who feel ownership and responsibility for their entire group. Critical components of this new leadership approach include: (1) Energizing the organization; (2) sharing responsibility for outcomes; and (3) resolving conflicts without command and control tactics.     

Bouncing back

If you have taken a career sidetrack, realize that you are still marketable. You have skills, traits, and knowledge that are transferable to many new opportunities. Fortunately, many leaders today in health care and executive search are familiar with your plight, given that they all have their own version of initiatives that did not fly. They will not judge you unfairly because they understand all too well the complex pressures of today's health care environment, filled with risk, cost constraints, and unrealistic profit targets. If you're bouncing back from an unfortunate career move, these steps may keep you focused on your search for new opportunities: (1) recognize that you are not alone, (2) realize that the entity failed, not you, (3) discuss the former position in a positive light, (4) don't give in to cynicism or self-pity, (5) don't let it happen to you again, and (6) play an active role in structuring your next position.     

Health care applications of complexity science. Life at the edge of chaos

The authors explore complexity science, a relatively new field of inquiry, which holds for both clinicians and health care leaders the real possibility of stimulating fresh insights and approaches to health and medical care-both its provision and its organization. Two case studies are presented to illustrate how complexity theory can provide health care leaders with a new perspective on how to address the myriad challenges they confront daily: (1) a patient with dissociative identity disorder; and (2) a physician task group charged to advise on hospital medical staff reorganization and governance. These case studies help clinicians and leaders of health care organizations understand how complexity: (1) may be relevant, even helpful, as they consider difficult challenges in both patient and organizational management; and (2) might emerge as a synthesizing force as they face the extraordinarily complicated task of jointly creating integrated health care systems. A resource section is provided for those who may wish to further pursue the topic.     

Overworked? Lighten your load

Physician executives are suffering from creeping task migration--putting in too many hours for few appreciable results. Controlling this increasing workload has become one of the most important issues in health care, brought on by too few people trying to do too much. The only way to lessen the workload is to take charge, analyze, and act. Bosses won't care about the details. Several suggestions are presented to help physician executives downsize their workload while not reducing their output: (1) Compare your priorities with your boss's; (2) lighten up on the perfectionism; (3) change expectations; (4) look for "orphans" to cut--those projects that nobody is invested in; (5) don't target symbolic events; and (6) use logic to drive change. If you spend the next few months getting rid of the ineffective, inefficient, and redundant, you'll be ahead of the game. This is an ongoing task, and much easier done every three or four months than once a year.     

Development of a local Physician Executive Leadership Program

Dramatic changes are occurring at a rapid pace throughout the United States in virtually all aspects of health care delivery. Physicians, hospitals, consumer groups, and others are thus facing new and greater uncertainties and are forced to adapt to a continually shifting environment. Fundamental change of this magnitude has and will continue to result in the formation of new alliances and organizations within which physicians and others will be forced to function. To participate effectively in these processes of change and to maintain influence within these new organizations, physicians will need leadership and management skills. To address the challenges facing current physician leaders and the need to develop more effective leaders, Sharp HealthCare developed its Physician Executive Leadership Program. This article describes the program and summarizes some of the lessons learned regarding the training of physician executives and leaders in today's changing health care environment.     

Value-based health care. Part I: Physicians reestablishing clinical autonomy

Clinical decision-making was once the sole purview of physicians, but no longer. Medical judgment has been usurped by third parties in the name of cost control. To reestablish this rightful authority, physicians must organize to assume the financial risks for their patients' health, using objective, clinical information to deliver superior quality outcomes. To successfully manage their patients' clinical and financial risks, physicians need to: (1) establish a structure independent of the hospital medical staff for outpatient contracting; (2) secure a capital partner that supports their independent, clinical decision-making; and (3) be leaders in acquiring and effectively using clinical information that accurately risk-adjusts and integrates both inpatient and outpatient data for all episodes of care. Physicians who acquire these skills will secure premium contracts from purchasers who are demanding value-based health care delivery.     

Thriving in change

The turbulent state of health care and the rapid changes that show no sign of abating point to many career-related challenges for physician executives. How can you predict the impact of these changes on your career? What measures can be taken to prevent any negative impact of change? And how can you prevail when dealt a negative blow like job loss? The signs that foreshadow the unraveling of a physician executive's career are described. The warning signs are: Not keeping up with change, losing your influence; getting negative feedback; turning your "concerns" into complaints; the economy working against you; and being blindsided because we think leaders operate logically. Being proactive puts more control in your hands and leaves less to chance. You can prevent being blindsided if you: develop your people skills; get comfortable and involved with e-business; stay abreast of health care trends; pick up the pace; and develop "You, Inc." There is a final component to prevailing over adverse circumstances--find your work-related passion and apply it to your career.     

Constitutional rights versus malpractice insurance settlements

The increasing costs and complexity of malpractice litigation have created an statutory right that allows malpractice insurance companies to settle malpractice claims regardless of the desires of the defendant physician. In the past, the consequences of settling a malpractice claim out of court were not as important as they are today. The Health Care Quality Improvement Act of 1986 mandates that any settlement in behalf of a physician be documented in the National Practitioner Data Bank (NPDB), which must be consulted every time the physician is credentialed. This NPDB requirement denies due process to health care providers and thus becomes a violation of the federal and many state constitutions. Physician executives and medical leaders must bring these issues to the table and negotiate solutions before damage to practicing physicians and the U.S. health care delivery system caused by this legal paradox become too severe.     

Physician leadership. The time is now

During the past 30 years, third party payers have imposed virtually every imaginable form of external cost controls on the traditional health care system. All have failed. And now those paying the bills--the large-scale health care purchasers--have finally seized control. They are fomenting fundamental structural change in the health care system. In order to continue doing business with these purchasers, health care providers are finding that they must form alliances to present a comprehensive "package" of health services for the constituents of these purchasers. In short, they must form integrated delivery systems. Current developments have created a unique opportunity for physician leaders to take a commanding role in shaping the emerging American health care system.     

Cost-effectiveness and coverage policy.

Cost-effectiveness analyses have become a pervasive element of health care. But they have not had a major impact on medical coverage policy. The challenge of implementing cost-effectiveness as a medical coverage criterion is related to the following issues: (1) Contract language does not include cost-effectiveness as a coverage criterion; (2) cost-effectiveness analyses often take the societal, population-based perspective, while health care is delivered on an individual basis; (3) there is no standard methodology for cost-effective analysis; (4) there is no explicit cut-off between cost-effective and cost-ineffective; and (5) cost-effectiveness analyses are not time sensitive.     

Culture in chaos: the need for leadership and followership in medicine.

The health care industry is changing at a dizzying pace and most of its players are struggling to maintain some form of the status quo. But resisting change will not prove fruitful--ultimately, it will rob physician executives of the opportunity to be architects in designing a new, more efficient health care system and their role in it. Because health care is a complex adaptive system (CAS)--change occurs rapidly and events are unpredictable--the old command and control style of leadership and a linear way of interpreting events is too rigid and, therefore, an ineffective model for guiding change. Complexity science offers insights about leading for change. In CASs, changes emerge in response to environmental demands for adaptability. Since the nature of these demands is unpredictable, the role of leadership is to manage the relationships and context out of which these changes emerge. A leadership style is called for that leads to purpose, makes positive changes by influencing context and relationships, and takes followers to a better place.     

A new perspective on quality

The U.S. health care sector consumes nearly 13 percent of our nation's gross national product, $800 billion annually. Our nation allocates the highest amount per capita to health care in the world. Yet many measures of health care outcomes from these expenditures are inferior to other developed nations. The American health care system costs too much, excludes too many, fails too often, contains much excessive and inappropriate care, and knows too little about the effectiveness of the things it does. The purpose of this article is to discuss current payers' perspectives on the potential for quality improvement in the U.S. health care system.     

The levers of influence

Physicians often determine the demand for health care services, as well as control the clinical processes aimed at improving health outcomes at the individual and population level. Given their important role in enhancing health status and improving the health care delivery system, it is critical that physician executives master the tools necessary to positively influence physician behavior. But changing behavior is far more complex than "doing it or not doing it." The Nike slogan "just do it" is motivating, but over-simplified. The roots of human change include: consciousness-raising, emotional arousal, commitment, helping relationships, self-reevaluation, reward, and environmental control. A model to effectively influence behavior is presented and includes setting clear expectations, measuring and monitoring performance, providing feedback, and rewarding and recognizing improvement. If all else fails, try discipline. This five-step approach is based on the science of human behavior and working with physicians in diverse settings, ranging from academic medical centers to small practices.     

The health care system has an eating disorder

The health care system crisis has been proclaimed and analyzed so much by economists, policy analysts, politicians, business executives, and journalists that the key statistics and phrases are becoming as familiar as the lyrics of a popular song-14 percent of the GNP goes to health care, 37 million Americans lack health insurance, too many specialists and not enough primary care physicians, etc. What I have not found is a comprehensive assessment of how the health care system got so sick. The different social science specialists focus on their respective symptoms or organs, but do not propose therapies to treat the entire organism. Ilya Prigogine's Theory of Dissipative Structures (now old hat since he won the Nobel Prize in 1977) demonstrated that self-organizing systems, be they health care systems or individual patients, respond in similar ways to the demands of illness and growth. Therefore, a clinical correlation for the health care system may have more than poetic appeal. I would like to offer the following clinical analogy for what ails our health care system.     

Elements and strategies of an effective provider integration strategy

Regardless of the outcome of the debate in our nation's capitol, a health care revolution is sweeping the nation. In fact, if the debate lasts much longer, policy makers will be playing catch-up and responding to policies already in place in the trenches. Everywhere we turn as health care leaders, there is evidence of major change on the horizon. Reimbursement methodologies are undergoing radical alteration, traditionally stable institutions are being challenged, new organizational models are evolving, the types and roles of providers best suited to provide care are being questioned, and consumer expectations are being heightened. One of the basic strategies that is receiving attention throughout the country as a response to all this change relates to the development of integrated delivery organizations (IDO), integrated delivery systems (IDS), or integrated delivery networks (lDN). This article discusses these emerging systems in terms of health care reform, describes the rationale for their creation, and provides some strategies for their successful development.     

The hidden competitive weapon supporting innovation in health care

It is trite to say health care is experiencing an era of unprecedented change. However, with the preoccupation with reimbursement and economic reform, it is easy to focus on this single dimension and lose sight of the pervasiveness of the need for continuous change throughout the entire health care organization. Health care organizations that will emerge as leaders within the industry will have incorporated not only radical changes to deal with new patterns of reimbursement, but also simultaneous changes in core medical services--changes that not only incorporate new technology, but also push down costs. They will also have to cope with radical changes in information and quality systems. Physical facilities will look less like citadels, and new flexible architectures will emerge. Coping with transportation logistics and remote site service provision will be part of the new industry. Patients will become full partners in ?health,? requiring very different approaches to patient education and involvement in prevention, not simply treatment. Indeed, without belaboring the almost endless list, it is impossible to think of a single dimension of health care that will be untouched.     

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.     

Population health--a new discipline

A new discipline--population health--has emerged with the potential to profoundly impact the U.S. health care system. Multiple forces stimulating the new population health concept include: (1) the increasing dominance of managed care and critical scrutiny of its development; (2) the continued refinement of clinical effectiveness and outcomes assessment research; (3) increasing public policy emphasis on cost-effectiveness accountability for health care services; and (4) a new focus on the importance of collaboration between the medicine and public health enterprises in this country. The need for sophisticated analysis of population health determinants has never been greater in history. New programs, like the University of Wisconsin-Madison's interdisciplinary Graduate Program in Population Health, address the need for analysis, dissemination, and application of information about the many factors affecting the health of populations.     

The coming medical apocalypse.

Is there a medical apocalypse in our future? Will it happen soon? No one can say for sure, but five ominous trends suggest that a medical meltdown could occur at any time. These trends are: (1) The practice of providing medical care becoming too complex from both a business and a legal perspective; (2) Less money being spent on medical care without any corresponding reduction in services provided, creating long-term operating deficits; (3) Investor-owned, for-profit corporations changing the focus of medicine by putting shareholder concerns ahead of patient care; (4) Employment-linked health care insurance creating a growing uninsured population, adding extra financial stress to our hospitals; and, (5) Providers losing faith in their future and becoming increasingly demoralized about practicing the healing arts. These dangerous trends are considered, along with some suggestions that physician executives and organizations might take to protect themselves.