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.     

Re-forming the traditional organization medical staff

The traditional, two-bylaws-model organized medical staff was created in another age (1919) to serve a simple health care system, controlled by physicians, in which the only players were patients, doctors, nurses, and small hospitals. This medical staff model does not meet the needs of the U.S. health care system of the 1990s. The purpose of this article is to provide the physician executive with a resource to use when he or she is called on to help determine what, if any, changes are needed in his or her organization to make the role of physician leaders more effective. Finding the right answer to this question is part of discovering ways to reduce health care costs without reducing the funds available to pay for direct delivery of health care services. Maintaining traditional, bureaucratic, legalistic organized medical staff activities is a very expensive game that we can no longer afford to play.     

The physician exodus from hospitals

Physicians are spending increasingly less of their work week in the hospital. This is true of surgeons because they are performing more ambulatory surgery, often off the hospital premises, and for primary care physicians because they are delegating hospital care of their patients to others. What are the effects of this physician exodus on hospitals, patients, physicians, and medical education? Some of these consequences are explored, from disruptions in the continuity of care, to increase in practice productivity, to preparing undergraduates for the realities of medical practice.     

Compensation for chiefs of staff: a '90s phenomenon

As part of its annual survey of physician executive compensation levels, the Physician Executive Management Center, a Tampa, Fla.-based physician executive search firm, sought information on compensation of medical staff leaders. In this report, the Center's findings are summarized. Forty percent of the responding hospitals compensate these leaders in cash, with an additional 34 percent providing noncash benefits. Three-quarters of the hospitals thus indicate recognition that some kind of compensation for voluntary medical staff leaders is warranted.     

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 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.     

The physicians practice profile: a piece of the quality puzzle

In responding to a New York State law and regulations that essentially mandated high quality and required hospitals to implement a system of physician practice profiles, Genesee Memorial Hospital involved the medical staff at all stages and made heavy use of computers for the ultimate system. The result is a profile system with the backing of physicians and with easy access to maximum amounts of information. Still, the author asserts, such profiles are at best an imperfect response to issues of quality.     

Physician executive contracts: negotiating the future

Once viewed as a matter of standard protocol, physician executive contracts have become as complex as the health care industry itself. Historically, hospital administration and physicians negotiated a few key points, then sent the ideas to an attorney for insertion of standard legalize and boilerplate. Today, physician executive contracts are an important part of the changes in health care. They not only cover traditional hospital and physician relations, but increasingly apply to new types of relations (such as employment) between hospitals and physicians, physicians and physicians, and health plans and physicians. In this article, we will explore both the "content" and the "context" of physician executive contracts. Content will deal with the specific provisions typically included in contracts. Context will address issues associated with preparing for and negotiating a contract.     

Physician executives: where they are and what they do

As hospital operations become increasingly complex, so does the institution's management and organizational structure. Physician executives with titles of medical director, vice president for medical affairs, medical administrator, chief of staff, medical staff president, etc., are playing more important roles than ever before. This article will briefly review some recent literature describing physician executive profiles. The results from a survey of ten university teaching hospitals are also presented as supplementary information regarding current staffing models. Finally, several physician executive staffing-related issues will be discussed in light of the literature and the survey results.     

Certain physician recruitment and retention activities found to be suspect

A new "Fraud Alert" from the Office of Inspector General of the Department of Health and Human Services will cause hospitals to be especially circumspect in their dealings with actual and potential members of the medical staff. The authors analyze the alert and its potential impact on hospitals and physicians.     

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.     

Graduate medical education funding crisis

Medicare, the major funding source for graduate medical education, is under intense scrutiny. Some think that Medicare should not continue to overtly pay to train graduate physicians, while others believe continued direct funding is an important social obligation. Recent policy discussions could dramatically transform the way graduate physician training is funded and teaching hospitals are paid. This is an important debate because of the strong influence Medicare has in determining the willingness of other payers to contribute to graduate medical education. Funding reductions are already threatening the viability of the U.S. teaching hospital system.     

In pursuit of physician/organization linkage

A friend of mine once said that medical staff/administrative relationships are the Bermuda Triangle of health care management. The Bermuda Triangle, as I recall it, is an area of the Atlantic Ocean into which ships and planes disappear without a trace, for no apparent reason. Sometimes, especially late at night on reruns of "Twilight Zone," these planes reappear years later, crew intact and youthful. Sometimes, salt and sharks get the ships, planes, and voyagers. In a like manner, problems in medical staff/administrative relations draw consultants into a vortex. Sometimes, the consultants and their reports float to the surface a long afterward. Sometimes, they are digested by the organization and become a part of its mythology. Sometimes, they vanish forever. This is the story of three consultations. All were intended to make recommendations concerning the structural relationship of management to the physicians and their groups in our HMO: How to link the physician organization to the corporate structure. Like any narrative, this story is constructed to provide a context for reflection and is not intended to question the value of the contribution of specific individuals or companies.     

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.     

Making a match: inexperienced physician executives and the job market

Hospitals and other health care organizations are adding physician executives at such a rate that demand is outstripping supply-there are more opportunities for seasoned physician executives than there are physicians with track records as medical managers. It is possible that hiring management will have to consider the employment of a physician who wants to be in management but has no track record as a physician executive. In some cases, it may even be preferable to employ a neophyte physician executive, especially when the physician is a respected clinician already on the organization's medical staff. In selecting such a physician, however, an evaluation must be made of the probability that the physician will be successful in the new role. The author points to 10 criteria that the hiring organization should observe in hiring inexperienced managers.     

Hospital and medical staff strategic planning: developing an integrated approach

The physician as the principal customer of the hospital is a relatively new concept, indicative of the shift to a more complete market orientation in strategic planning. Although medical staff and medical community dynamics receive increasing attention in strategic planning, much more sophistication is now needed to involve physicians constructively in strategic planning for the hospital and medical staff. While full consonance of physician and hospital plans may be achievable only in a completely integrated delivery system, there is considerable room for improvement in current organizational models.     

Developing loyal physicians: a five-point plan

Now, more than ever, health care centers are forced to compete for physicians. There could be no greater argument in favor of establishing the position of Vice President for Medical Services. A physician executive is infinitely more qualified and better prepared to understand the probable reaction of different types of physicians when "loyalty" to the organization is the central issue. The Vice President for Medical Services seems best positioned to remind the Chief Executive Officer and the Board to keep sight of the legal, and moral, duty to "exercise reasonable care in the selection of a medical staff and in granting specialized privileges," including selecting practitioners who are "worthy in character and matters of professional ethics."     

Models for medical practice integration

Decreased physician income, increased administrative burdens, and interference with the compassionate delivery of high-quality medical care are threatening the independent practice of medicine in solo and small group practices. Many established physicians, and the hospitals with which they relate, are searching for organizational models that, by integrating some or all aspects of their practices, will preserve incomes and reduce regulatory and administrative burdens. This article will describe several "practice integration models," pointing out advantages and disadvantages to physicians in established practices. (Many of the same arguments could be made for physicians new to practice, with different emphasis). The continuum of integration models is shown in figure 1, page 19. The group practice without walls and its two submodels, the independent group practice without walls (IGWW) and the affiliated medical practice corporation (AMPC) are more recent and more effective models and will be covered in depth in the article.     

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.     

Legal issues in accepting capitation

The effort to reduce the cost of medical, hospital, and ancillary services increasingly focuses on shifting the financial risk for the cost of these services to those who provide them. Shifting arrangements include capitation for physicians classified as "primary care" physicians; capitation arrangements that include primary and specialty services; risk shifting to medical groups, IPAs, and other physician organizations; as well as the packaging of physician and hospital services on a "full risk," "per case," or other basis. Accepting financial risk for the cost of medical and other health care services, as well as the responsibility for managing the provision of services, may very well be the only remaining opportunity for providers to maximize reimbursement and maintain administrative and clinical self-direction. However, physicians must work with managed care organizations (MCOs) through negotiation of contracts and throughout the relationship to make sure: Unnecessary financial and legal risks to the MCO and physicians are eliminated. Risks that cannot be eliminated are apportioned between the MCO and physicians. All risks are managed in a coordinated fashion between the MCO and physicians.