Ascendancy of primary care will create role intensification for physician executives

The need for physicians in management roles in the health care system has never been greater. And the years ahead will see that need broadened and intensified. To maintain their leadership role in medical affairs in hospitals and other types of health care delivery organizations, physician executives will have to envision provider organizations and systems that have not yet been conceived, let alone developed and implemented. They have to become totally open-minded and futuristic in their thinking. And they will have to help other physicians accommodate this new way of thinking if the medical profession is to continue in a leading role in health care matters. Although numerous factors will have to be anticipated and analyzed by these new physician leaders, the ascendancy of primary care in a managed health care world long dominated by the technical and technological superiority of hospital care will present a particular challenge to the physician executive.     

Can doctors and administrators work together?

The working relationship between physicians and health care organizations has dramatically changed since the introduction of competitive factors. Fifer suggests that future doctors may have as many as five or six economic relationships with their associated health care system, in contrast to the singular role as admitting physician of the past. The physician will continue to admit patients, but may also belong to an HMO or some other joint venture (freestanding ambulatory care center, outpatient laboratory, etc.), be salaried part time for leadership roles, be a leader in some other parallel economic venture, etc. Physicians are already assuming multiple roles as health care providers, private entrepreneurs, and joint venture partners with hospitals. Hospitals and health care systems also continue to change through vertical and horizontal integration. Traditional clinical departments are becoming blended into product line entities, and a sophisticated executive team of market-oriented specialists now augments the traditional administrative leadership. So, from a tradition of predictable roles, relationships, and authority structures, we are now attempting to thrive and prosper with many new partners in an integrated, complex, and conflict-ridden set of interrelationships.     

The implications of practice guidelines for physician medical malpractice liability

Medical practice guidelines are increasingly coming into use, and as more and more physicians are presented with guidelines to follow in the delivery of health care, the question arises of whether these guidelines will become instruments for imposing greater medical malpractice liability on physicians. This column will briefly describe what guidelines are, how they are developed, and how they have been and may be used in litigation against physicians, hospitals, and other health care institutions. As hospitals and managed care organizations continue to implement guidelines, the role these guidelines play in malpractice cases can be expected to increase. It appears, however, that, although guidelines will contribute to the establishment of the standard of care by which a physician's actions will be measured, they are not likely to become the standard that all physician treatment decisions must meet.     

Physician executives straddle the digital divide

e-Health is here to stay and experts predict that the Internet will become the hub of health care. Rapid advancements in biotechnology and medical research, increasingly curious patients who surf the Internet for medical information, and pressures from managed care companies to contain costs and speed treatments are the central components driving e-health. Despite physician reluctance to embrace the e-revolution, many hospitals and medical groups are employing the Internet and information technology to improve their customer interface, as well as to reduce business costs. This article offers seven e-strategies for health care performance improvement: (1) Supply chain management; (2) e-transactions; (3) care management; (4) improving quality; (5) boosting revenues; (6) outsourcing; and (7) provider networks (Intranets). By helping to incorporate these key e-solutions, physician executives can position their organizations for success in the new millennium.     

Is it our turn to be CEO yet?

Physician executives continue to have ambitions for the health care CEO role, despite the difficult economic times. And though few have yet been chosen for the position, the expectation is that this will change markedly in the next five to seven years. Today, physician executives have legitimate, relevant professional experiences that directly qualify them for CEO roles in health initiatives. And no executive is more qualified to deal with medical care management issues than the physician executive. Key elements of preparedness are: Executive thinking, bundling projects, and learning to manage managers. The opportunities will be open to those who are ready to take them on.     

Leadership for the next millennium: the physician executive

We continue to muddle through using tourniquets and bandaids on a health care system that is in dire straits. And the future is even less promising. There will be millions without basic health care, let alone basic health care coverage. Rural and inner-city hospitals will close, with progressive public apathy, as we focus on the marvels of expensive technologies that serve only the few. Costs will continue to rise at double digit rates, and our nation's employers will fall further behind in the global marketplace. Preventive care will be uncommonly provided and only more rarely reimbursed, while a couple more children die of measles in Mississippi. It's not a pretty picture, and it simply doesn't have to come to pass. "What we really need is leadership," the public cries. That leadership can and should come from medicine through physician executives.     

The role of the coordinator of care

Regardless of the specific outcome of the current health reform debate in Washington, it is likely that major changes to the health care system are in the offering. These changes, many of which are already in place or imminent in some locations, will have a major impact on the evolving relationships between physicians and hospitals. Most expect that these changes will accelerate the development of integrated health care delivery systems that will compete in the marketplace for a mixture of public and private health insurance dollars. In this system of "managed competition," health care dollars will flow to those systems that can ensure the best clinical outcomes while using the least economic resources. In this scenario, competing collaborative health networks that can manage the continuum of care will be central to the health care delivery system. The economic and political ties between physicians and hospitals will become more closely linked as government and private payers of health care services foster the development of these integrated, value-based health care delivery systems.     

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.     

When push comes to shove: implementing VBAC practice guidelines

The dramatic increase in U.S. cesarean sections over the past two decades has been significantly driven by repeat C-sections. In response to this trend, clinical guidelines recommending vaginal birth after cesarean-section (VBAC) have been promulgated by national organizations. Adherence to these guidelines would reduce the number of repeat C-sections, lower the overall C-section rate, and improve both the quality and the cost of health care. While these guidelines have received professional endorsement, their implementation has been clouded by issues of patient acceptance and provider payment. To examine implementation of these guidelines by health care organizations, the authors surveyed 156 members of the American College of Physician Executives to determine their policies, practices, and attitudes toward VBAC guidelines. Those surveyed generally were medical directors in HMOs, hospitals, and other practice settings. The findings indicate that the health care organizations represented by these physician executives have not consistently implemented VBAC guideline and that they are reluctant to hold physicians, their patients, or hospitals accountable for the financial, utilization, and quality impact of the elective decision ot to pursue appropriate VBACs. We conclude that, even when widely accepted, clinical practice guidelines may be ineffective in reducing the costs or improving the quality of medical care.     

Clinical reengineering. Integrating medical and operational management

In the continuing push for cost containment in health care, many organizations have turned to cost reduction methods that fundamentally change the way care is delivered. As health care organizations continue to make financially-driven staffing changes that impact patient care, medical leadership must take on greater responsibility for operational management. Physician executives are uniquely qualified to take on leadership roles in work redesign, and must do so to ensure excellent and fiscally-responsible patient care. This article presents a proven methodology for work redesign that helps physician executives apply their clinical skills to operational management in designing new health care delivery models.     

Public hospitals: an assessment and plan for the future.

We are currently living in very difficult times for most health care providers. Even though we have always known it, the fact that resources for health care are limited is now abundantly apparent to consumers, health care providers, fiscal intermediaries, government (local, state, and federal), health care planners, and policy makers. Hospitals, especially, are being severely pressured to reduce resource consumption and costs. Conditions that are difficult for nonpublic hospitals are critical for public hospitals in general and nearly fatal for rural public hospitals. Fortunately, nonpublic hospitals are beginning to realize for the first time that their future depends, to a significant degree, on a strong and financially healthy public hospital system. If the public hospital, the hospital of last resort, closes, medically indigent patients will have to be treated in nonpublic hospitals, with the resultant medical, financial, economic, political, and social consequences. Therefore, the importance of public hospitals has to be even better recognized and appreciated and these institutions actively supported in order for the private and total health care systems to be successful.     

The microprocessor and medicine

Technology continues to accelerate at an amazing pace. Where have we been, where are we going, and what do these technology enhancements mean to the health care industry? We are entering the era of the personal computer becoming the window to the multimedia digital world of cyberspace. Microprocessors will continue to improve from one generation to the next to make cyberspace as realistic as possible-and with their improving capabilities will come myriad applications for health care services, either not cost-effective, or not even contemplated, until now. As a leader of an organization, one who approves substantial budgets for information technology, you must ask yourself what new products and services these startling technological advances will create. How will they change health and medical care?     

Quality management in ambulatory care: the future is now

Ambulatory care has always been a stepchild. Hospitals have been and are the focal point of quality activity. Traditionally driven by Joint Commission decree and more recently inspired by market forces, hospitals find the resources to do quality. It was quality assurance in the '80s. It is quality management in the '90s. Some of this activity has oozed out into ambulatory care, but not much. We in ambulatory care have been too busy producing as many patient visits as possible in an environment of limited resources. All that is now changing. As ambulatory care becomes more and more important in the overall health care delivery scheme, medical quality management in this environment will also take on greater significance. Leading the way will be the electronic medical record.     

An evolving medical leadership position. Tomorrow's Vice President for Medical Affairs

The role of medical leadership in hospitals and health systems is under constant scrutiny and change. The nature of the Vice President for Medical Affairs (VPMA) position and its relationship to leadership in the health care system is explored through a national panel survey conducted recently. The effective VPMA will: be an aggressive manager able to implement change, address strategic planning and quality of care issues; have a high level of integrity; and be a good communicator and problem solver. The results of the research are presented in three sections. The first section describes the background characteristics and compensation of the VPMAs who participated in the survey. The second section focuses on the current role of the VPMA, including duties and responsibilities, job performance barriers and required skills. The final section addresses respondents' perceptions regarding areas for improvement in the role of the VPMA, as well as projections for future changes in this position.     

Formatting and presenting quality data to medical staffs and hospital boards

A host of historical and practical precedents have made hospitals responsible for the quality of care rendered within their facilities. The medical staff and the board of trustees share in this responsibility. Increasing demands for demonstrative evidence of the quality of care in an institution have made the process data-based. There is no substitute for specific data on the performance of both the hospital and its providers in the delivery of care. The trick, however, is in presenting this information to the medical staff and the board in a fashion that will be understandable and that will still maintain confidentiality of provider and patient. The authors offer a presentation system that has met with success in their community hospital.     

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.     

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.     

Credentialing in managed care

Through the use of managed care techniques in recent years, the insurance industry has tried to bring the runaway costs of medical care under control. The result of this control effort is system access limitations, compared to the full choice indemnity plans of the past. This limited system access has now clearly moved HMOs and other managed care organizations into the category of "potentially liable health care entities," based on patient steerage, economic disincentives, and limited choices of the plan's participating providers and facilities. Just as hospitals have had to exercise rigorous care in the credentialing of members of their medical staffs, managed care organizations will have to ensure that the providers they use meet acceptable standards of competence.     

The ascendancy of primary care: permanent or temporary?

The conventional wisdom strongly suggests a health care provider food chain for the future: Primary care physicians (PCPs), principally family practitioners, on the top playing the lead role, distantly followed by specialists, with hospitals and other ancillary services even further down the line. Is this a reasonable expectation? Will PCPs dominate the new systems? Or will they be but one of many equally necessary components of these developing integrated health care delivery organizations? Looking at the various models now developing, it would seem that future integrated delivery systems will utilize both PCPs and specialists, but with strong augmentation from a diverse assortment of other health care professionals, including nonphysician providers, educators, and administrators. To separate the illusion of primary care dominance of the coming health care system from the likely reality, we should first determine what is driving the apparent present demand for primary care physicians. Next, we will examine the possible and probable reactions to that demand from an economic standpoint and from the points of view of both health care professionals and the public. Finally, we must try to picture how health care provider organizations of the future are likely to look and how they will integrate their health care professionals.     

Veteran's health care: time for a change?

The Department of Veterans Affairs' mission is "to care for him who are shall have borne the battle for his widow and orphan." The Veterans Health Administration comprises 172 hospitals that are the hub of the health care delivery system. It is the largest provider of graduate medical education, and one of the major research organizations in the United States. The medical care budget exceeds $17 billion annually. Most of the persons cared for are not legally entitled to this health care based on service connected disability. The utilization of acute care hospital beds appears excessive when compared to that obtainable with managed care for Medicare or commercial insurance beneficiaries--the cost per member per month is three times higher. There may also be exploitation of the Veterans Administration hospitals by university medical schools. The Veterans Health Administration is a very expensive way to deliver care to entitled service connected veterans. Therefore, it is suggested that privatization be considered as an alternative vehicle for delivering health care.