How practicing physicians are adjusting to managed care

Managed care is here to stay. In fact, for the foreseeable future, health care will become increasingly more managed each year. The purpose of this article is to help physician leaders and executives understand how clinicians are reacting and adjusting to managed care. Those of us who are doing primarily management activities have our own set of problems and adjustments. Sometimes we can be insensitive to the problems that physicians who are primarily treating patients can have as a result of managed care. Health care executives who are managing physicians or attempting to influence their behavior must attempt to understand clinicians' feelings, reactions, and coping mechanisms.     

The physician's alternative career transition model: a stepwise approach

The recent intense focus on marketplace reform has stimulated a reassessment of career planning options for some physicians. These socioeconomic changes have created unique opportunities beyond the traditional arenas of clinical practice and medical management for physicians to leverage their medical degrees and experiences in the business world. This paper presents three case reports of physician executives who have successfully pursued medically related business career options, each following different motivations at various stages of their medical careers. It then discusses the Physicians' Alternative Career Transition (PACT) model developed by the authors to assist other physicians who are considering making transitions into business-related careers. The PACT model is based on four critical steps for practicing physicians to make these transitions successfully: an internal self-evaluation process, an external environmental evaluation process, seeking the best "career match," and securing the career match.     

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.     

The Zen of physician initiatives

Many physicians today feel ravaged by the brutal speed with which change has been occurring. They see the beliefs and practices of a lifetime being abandoned and replaced by the flavor of the month, management du jour. But if you are willing and able to take the brave step of approaching your physicians without an agenda, meeting with them to listen to their concerns, and can also avoid hanging a lightning-rod label on every bright new idea that comes out of the sessions, you'll be on the way to effective new management. This new style is a "Zen" approach (but don't give it that label) that lets real collaboration come into the place that is supposed to be all about healing--the health care organization. From "never call it anything" to "stay with them until they get it," ideas on how to be a Zen manager are presented, with the ultimate goal of truly partnering with physicians and infusing them with a desire to move beyond the frustration and disenchantment they are feeling.     

The new health care civilization: integration of physician land and manageria

Changes occurring in health care demand that physicians expand their professional knowledge and skills beyond the medical and behavioral sciences. Subjects absent from traditional medical education curricula, such as the economics and politics of health care, practice management, and leadership of professional organizations, will become important competencies, particularly for physicians who serve in management roles. Because physicians occupy a central role in planning and allocating medical care services and other health care resources, they must be better prepared to work with other health care professionals to create a new civilization, even if this means leaving the cloistered domain of "physician land" to serve as interface professionals between the delivery of medical services and the management of health care. Our research findings and conclusions strongly suggest that economic, management, and leadership competencies need to be incorporated into the professional development of physicians, especially in postgraduate and continuing education curricula.     

The emerging role of the physician in administration

Physicians often find it difficult to determine the type of training needed to prepare themselves for administrative roles in health services organizations. Without extensive knowledge about organizations and how they function and how administrators contribute to organizational performance, physicians tend to view management roles as either overwhelmingly complex, or, conversely, simply a matter of using good judgment. In an attempt to help clarify this issue, we have outlined six management problems that an entry-level physician executive should be able to deal with successfully without asking for help. If physicians find that they are unable to deal with these issues, they should seek additional training before considering a management role.     

The angry physician--Part 2. Managing yourself while managing others

One of the most difficult aspects of physician leadership is addressing angry colleagues. The first article in this series called attention to the problems that come with the Type A coping styles of many physicians and outlined strategies for managing oneself. Part 2 provides specific strategies that can be helpful in managing others' anger-generating behaviors and anger reactions. There are eight practical communication guidelines recommended by experts in the field for managing anger in others. They include: Strike while the "iron is warm." Match, then lead. Stay in your own zone. De-escalate the other's angry reactions. Do something different. Be assertive, not aggressive. Use effective negotiation tactics. Operationalize the problem.     

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.     

Physician leadership. How do physician executives view themselves?

Most physician executives today have acquired substantial management training and experience, and many have worked with and relied on the expertise of mentors for their career guidance and development. Physician executives are actually becoming executives who happen to be physicians. They view themselves first as leaders, then as physicians, and finally as managers. That is a remarkable transformation in perception. To chronicle this process, Witt/Kieffer, Ford, Hadelman & Lloyd conducted a national survey this spring among senior physician executives in both payer and provider organizations. The data provide a "snapshot" of their role, and may also suggest some future scenarios for the industry. The primary reasons for choosing to pursue a management role noted by most participants include a desire to be part of the health care solution and an interest in management and leadership challenges.     

Leadership is the key to chief medical officer success

Senior physician executives were surveyed in 1998/99 to ascertain that they see as their greatest value to their organizations. They believe that their most significant contribution is their accumulated knowledge and experience--both in medicine and management. This medical management perspective is considered the key advantage of serving on the senior management team and helping to shape the organization's decisions and direction. Additionally, they rated their relationships with physicians as a critical aspect of their position. They were also asked what activities they most enjoyed. The number one response was working with the physicians on the medical staff and in the community. This includes the day-to-day involvement as a leader, as a mentor and educator, and overall as a liasion to the organization's practitioners. The activities that they found most rewarding were also those they perceived to be of greatest value. If these physicians are correct about what is valued in their organizations, they are the right people in the right jobs--and they enjoy what they do.     

The physician executive in a changing world.

Physicians are losing their historic franchise as sole and primary providers of medical care. In addition to eroding moral and scientific authority, physicians are also losing income and status. It is no wonder that physicians are retrenching--confused and angry about the increasing marginalization of their profession and about society's changing expectations. Physicians are caught in a transition zone between the world that was and the one that will soon be. This is destabilizing and causes great anxiety. Rather than being buffeted by changing social and cultural definitions of health care, physicians must become proactively involved in the future of their profession. Physicians can only do this by offering a better mental model of health, medicine, and the community. This cannot be a defensive retreat from engagement. Rather, it must be an imaginative vision, vigorously set forth--a vision that will enlist the support of all constituencies involved in the effort to improve the health and well-being of all members of our society. The physician executive needs to work with physicians to orchestrate this effort to create a new vision of health in the 21st century.     

Changing work environments: Innovative coping responses to occupational stress

To what degree do individuals adapt their work environments in response to occupational stress? The research reported below addresses this question through a qualitative questionnaire survey that assesses the extent to which innovation is used as a stress coping strategy amongst health care professionals (community and hospital nurses, administration workers and paramedics; N = 333). Overall, 32% of these workers reported a coping response subsequently coded as innovative, and significant between-occupational group differences in the frequency of usage were found. Overwork, procedural difficulties and dealing with others were the stressors eliciting the greatest number of innovative coping responses. The study indicated that such responses were perceived as an effective and important way of dealing with occupational stress. It is concluded that stress management programmes that encourage individuals to change workplace factors through innovation, would be a worthwhile addition to interventions that emphasize individual adaptation to stressful work environments.     

How the psychosocial work environment of motor vehicle mechanics may influence coping with musculoskeletal symptoms

A number of studies have shown that musculoskeletal symptoms are related to the physical and psychosocial work environments. Workers with musculoskeletal symptoms are often advised to cope by such measures as changing working technique, using lifting equipment and discussing health and environmental problems with supervisors and colleagues. Intervention studies at the individual level, however, have shown that such advice has limited effects in reducing the prevalence of musculoskeletal symptoms. The hypothesis for this study was that negative social and organizational factors may prevent workers from implementing such coping strategies. All 103 motor vehicle mechanics surveyed in 12 different garages responded to a questionnaire on coping with musculoskeletal symptoms and the psychosocial work environment. Positive and significant relationships were shown between how mechanics coped with their musculoskeletal symptoms and such psychosocial factors as work demands, social support, control, manager's involvement in health and safety work, and whether the garages had regular meetings between management and workers. Achieving positive results from preventive work through back schools and other ergonomic interventions seems to require that an organization with positive attitudes towards health and safety work be created before such interventions are implemented.     

Physician executives: managers first, clinicians second

The literature is replete, many would say depressingly so, with accounts of the changes that are rocking the health care delivery system. The demands on the system's leadership increases with every change. And the future holds even more changes, with a level of uncertainty that will makes today's demands seem childplay. Physicians, especially physician executives, will surely be key factors in helping the system maintain its fundamental charge of high-quality patient care provided at reasonable cost, but what exactly is expected of them? One point is clear: While their clinical backgrounds will continue to arm them well for reaching the executive suites of health care organizations, physicians who hope to fully succeed in management will have to acquire and master a widening range of management skills. An indication of just how demanding the health care management job will be is provided in this report, based on interviews with physician executives and the people who seek and sell their services.     

Is there a physician union in your future?

Physician unions are in the news. Patient management and patient care decisions are increasingly being taken out of the hands of physicians and put into the hands of "The Suits." To take their case for a return to physician-driven patient care to the people, some physicians are joining unions. Some are even collectively bargaining for salary and other issues that are historically more closely associated with unions. The simple fact is that physician unions exist and the number of physicians joining them is expected to increase. What are the pros and cons of unionization? What motivates physicians to join unions, and what potential negative and positive factors are associated with physician unionization? This article reviews the pros and cons and the issues related to physician unions, for physicians attempting to answer the question, "Is there a union in my future?"     

Are your economic incentives self-defeating?

In a prior column (Long, H., "Group Practices May Ignore Economic Realities: Commingling of Rents and Returns," Physician Executive 14(5):33-35, Sept.-Oct. 1988), the author discussed the tendency of many group practices to ignore ordinary business economics. The examples discussed in that column was the inappropriate commingling of rents and returns from the various factors of production in medical practice. A frequent result of this is physicians who also have ownership interests and/or managerial responsibilities having an inflated perception of their worth as physicians because they are undercompensated for their ownership/management roles. In this column, the author addresses the inadvertent structuring of physician remuneration via income distribution or externally negotiated formulas that reward individual behavior that actually threatens the economic viability of the group.     

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.     

Medical staff handling of concerns with physicians' performance

Medical staff organizations and their leaders are frequently confronted with concerns about physician knowledge, performance, or behavior. Dealing with these concerns is a serious and time-consuming task. Poorly handled issues may result in serious legal consequences. In highly structured organizations, authority for responsibilities, income, and employment rests with individuals who must manage these problems, but medical staff structures do not always lend themselves to dealing with these issues. Introduction of quality improvement processes into medicine has been received as a panacea for physician problems. Certainly the majority of physicians understand quality improvement and work toward common goals to improve patient care. Unfortunately, a small minority remain problem physicians. Steps that can be taken to deal with problem physicians, particularly for issues of quality management, are described in this article.     

The new breed

Structural changes within the health system--particularly in the organization and financing of services--have made new and different opportunities available to physicians interested in management. What types of physicians are currently going into management? How do they compare to others who have been in management for a longer period of time and to the "traditional" portrait of the physician executive? The author profiles the emerging, contemporary physician executive and explores the implications for the viability of the field of medical management as a whole.     

Physician opportunities in management: signs and portents

There are many trends today that spell great opportunity for physicians who seek to shift their careers into management. Some of those trends are outlined here, with commentary on each opportunity presented. Like much in life, most opportunities contain uncertainties and unanticipated consequences. Thus, no opportunity comes without some possible negative side effects and blind alleys for the unaware. Some of these pitfalls are also presented, along with some suggested strategies for physicians who seek major roles in the management of the health enterprises of the future.