Common denominators of success

There is no mystery to the success stories described in this column. In addition to a lot of hard work, a few basic principles have been applied to widely differing scenarios. These common denominators provide the philosophies and dynamics that can lead to your breakthroughs in quality health care delivery: (1) Trust--among the physicians and then between them and management and the board of directors; (2) positive physician culture and attitudes; (3) effective physician leadership; (4) patient care focus; (5) strong team orientation; and (6) true accountability by all stakeholders. Your job is to help your physicians feel they are major stakeholders in your health care delivery system and be their voice in clinical and financial decision-making at the highest level.     

Can you take your soul to work?

David White in The Heart Aroused: Poetry and the Preservation of Soul in Corporate America explores ways for professionals to take their souls to work, instead of checking them at the door. "We simply spend too much time and have too much psychic and emotional energy invested in the workplace for us to declare it a spiritual desert bereft of life-giving water." Several ideas are presented to help physician executives preserve their souls in an increasingly corporatized U.S. health care system: (1) Figure out what you are meant to do as your life's calling; (2) know what you think and want; (3) share some of what you think at work, while being careful to not lose your job unless you choose to; (4) be a trustworthy listener and find one; (5) get yourself outside; (6) pay attention to your physical space; and (7) develop some new hobbies or refresh old ones. "One of the disciplines of building a rich soul life seems to be the simple act, on a daily basis, of remembering what is most important to us."     

The coming alliance revolution in health care

Like it or not, the health care profession is being "shifted" into a revolutionary new world. The question is not will it change but rather how will it change? Who will determine its fate? What form will these changes take? What are the best alternatives for physicians, institutions, health care workers, insurers, employers, and, most importantly, patients? Some of the changes will come from government mandate, others from market forces. To understand what the future might bring, we should look at both the driving forces behind the changes and how other industries have responded to similar forces. An important consideration for health care professionals will be how, if at all, the concepts of collaboration and cooperation that are inherent in networking and alliances will guide their planning.     

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.     

An approach to the impaired physician

The 1988 California Administrative Code requiring all acute care medical staffs to provide assistance to impaired physicians has not resulted in an increase in the annual census in the Medical Board of California Diversion Program. In part, this lack of an increase is due to the failure of some hospitals to form physician aid committees and to the poor functioning of such committees in other hospitals. The common reasons for these deficiencies are that the medical staff leadership does not think there are any impaired physicians on staff and that they don't know what the committee would do if it were formed. This attitude demonstrates a lack of appreciation for the prevalence of impaired physicians and the tremendous amount of work required (establishing policies and procedures) to identify and help them. This article discusses the prevalence of the impaired physician, the types of impaired physicians, a "cookbook" approach to managing these physicians, and the success of intervention.     

Managing diversity in the workplace

Recognizing and dealing with cultural diversity has become a critical issue in health care because of the growing numbers of women, minorities and foreign-born physicians and patients. To avoid a culture clash, physician executives have become more aware of the differences and are working to find ways to help the staff interact more effectively with each other and with patients.     

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.     

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.     

A new industrial order for physicians: a talk with Jeff C. Goldsmith, PhD. Interview by Richard L. Reece

Richard L. Reece, MD, interviewed Jeff C. Goldsmith, PhD, President of Health Futures, Inc. on October 12, 1999 to discuss how the Internet will affect health care delivery in the millennium. One of the most profound changes that he sees is how the relationship between physicians and patients will be altered. Empowered consumers are where the real revolution is happening--a trend sometimes overlooked by physicians. Goldsmith says, "The key thing physicians have missed is that the patient is in charge of the process.... The Internet has enabled patients to aggregate their collective experience across disease entities." But there is too much information. "It is almost universally acknowledged by patients and physicians that there is a terrible quality problem. Getting from information to knowledge is a huge commercial opportunity for somebody." He doesn't think that people have put enough emphasis on the collective learning part of this new technology.     

Health care futures, Part 1. The emergence of the new health care consumer. Panel discussion

In Part 1 of this second annual panel discussion, six experts examine the new health care consumer. The whole concept of the patient as consumer still makes people uneasy when it's applied to health care. Whether you prefer consumer, customer, purchaser, end-user, ultimate buyer, or beneficiary, one thing's for sure: Many of us are as different from the bygone patient as an HMO is from the general practitioner who made house calls. One of the reasons for many Americans' new interest, knowledge, attitudes, and expectations about health and health care is the Internet, the second topic in this discussion. In Part 2, physician executives from the three leading physician practice management companies (PPMCs) join Jeff Goldsmith, Barbara LeTourneau, and Uwe Reinhardt for a spirited exchange about this burgeoning new industry in the American health care sector. They will tackle questions such as: Are PPMCs delivering what they promise? What will separate successful PPMCs from the rest? Can PPMCs meet Wall Street's earnings expectations and also help physicians deliver better care? When PPMCs win, who loses? And, what roles will physician executives play in PPMCs?     

From managing access to managing care: the impact of primary care on health care delivery organizations.

Professional "revenge of the nerds" is currently taking place, as managed care evolves generalist physicians into new professional prominence. Primary care physicians are finding themselves at the center of health care market reform as health plans, insurers, and other financing organizations turn to them as the key to cost control. In short supply, they are prospering financially from the demand. As the source of patients, they are gaining in prestige from specialists and hospitals who once demeaned them. But these newfound roles are only the initial steps in the transformation of the primary care practitioner. The change that the generalists are experiencing is essentially managing access to care, not truly managing care itself. There are large and crucial differences between managing access to care and actually managing care. These differences are, in many ways, a higher calling for primary care practitioners as they refocus attention on patient outcomes, which will in itself result in a lower resource utilization above and beyond the crude controlling of access. What those differences are, what new roles they require, and what impact they will have on organizations that either house or contract with primary care physicians will be the focus of this article.     

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.     

Physician anger, Part 2. More on the dance of anger.

This article is a follow-up to an interview with Charles Dwyer, PhD, which appeared in the 1999 March/April issue of The Physician Executive. He described how physician executives can change the perceptions of today's beleaguered physicians and help them cope with change. We then asked him for some hands-on strategies to deal with physician anger, fear, and resentment. After much contemplation on providing a list of "fixes" that will restore each of us to a state of greater satisfaction, Dr. Dwyer concludes that there are no generalizable solutions because there are too many variables that come into play in each organization, individual, or group. Attending to the self can provide both individual rescue from these turbulent times and the best hope for changes in the system from which patients and health care providers can benefit. If physicians are to regain their power and maintain, or even improve, their quality of life, clearly changes are called for. And these are changes that require persistent effort and uncomfortable adjustments.     

The importance of data warehouses for physician executives

Soon, most physicians will begin to learn about data warehouses and clinical and financial data about their patients stored in them. What is a data warehouse? Why are we seeing their emergence in health care only now? How does a hospital, or group practice, or health plan acquire or create a data warehouse? Who should be responsible for it, and what sort of training is needed by those in charge of using it for the edification of the sponsoring organization? I'll try to answer these questions in this article.     

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.     

Hold or fold?

This article examines some of the problems of the health care organizations we serve and that support us. While external problems can besiege an organization, the fundamental building block for success is to develop physician buy-in and a well-functioning team. The author describes how his IPA failed because the physicians in his organization didn't bond sufficiently, and for a sustained period, to carry out business operations. What are the warning signals that might help you decide whether to stay or move on? An IPA must have: (1) A clearly articulated vision of what success will look like, one that is accepted by its members; (2) effective leadership; (3) clear evidence of adaptability and flexibility; (4) financial stability; and (5) good data available to physicians. There can be other evidence of trouble you need to watch for. In some areas, hospitals and health plans are hostile to physician initiatives. Don't rely on politically motivated decisions--they are too easily changed. If you plan to be a leader for your physician organization, focus on creating or revising the internal architecture of the group.     

Health care trends, Part 2. The new health care team. Panel discussion

In Part 2 of this third annual panel discussion, six experts talk about the growing diversity of health care providers and what it means for consumers and physicians. Americans are getting their wellness and health care services from a wider variety of non-physician practitioners than ever before. The number of allied health and alternative providers with direct patient access is likely to continue growing. This trend is being driven by consumer demand, by the lobbying efforts of non-physician providers, and by federal, state, and private payers who see the potential for reduced health care spending, greater consumer satisfaction, and better outcomes. In practice, this means physicians and non-physician providers, some of whom may not be sanctioned by the medical establishment, are obligated to collaborate as a team. Members of this new provider team will have to communicate effectively (with each other, with consumers, and with payers) and make evidence-based clinical decisions. Physicians may have to share decision-making with other members of this new health care team.     

Primary care: the driver in health care reform

The changes occurring in the health care industry have resulted in a cost-quality competition that has not been present in the past. Because of this competition, managed care is a growing way of financing and providing health care to the people of the United States. Managed care depends heavily on competent primary care physicians. Because primary care physicians are in short supply, the status and financial rewards of primary care practice are increasing. The primary care physician will be the dominant force in medical practice in the immediate future. He or she is capable in a managed setting of resolving the perceived problems of the health care industry in responding to the drivers of health care reform. Costs are reduced while quality is maintained. Access to health care is improved, and fragmentation of health care is significantly lessened.     

The quality debate: Consumer Bill of Rights

Inherent in any discussion on quality for a delivered service is understanding what outcomes you want to achieve and assuring that your consumer agrees. The Presidential Commission's Consumer Bill of Rights supports this principle. Its' goals include: strengthening consumer confidence by providing them with a system responsive to their needs and with a credible mechanism to address their concerns; reaffirming the importance of a strong relationship between patients and their health care providers; and, reaffirming the role consumers play in safeguarding their own health. Striking the balance between cost and quality requires all the stakeholders of the health care system to focus on the true issues that impact quality: outcomes, accountability, and consumer satisfaction, however defined.     

Provider satisfaction: an analysis based on expectation

Provider organizations will need to be in closer touch with their medical staffs in order to successfully anticipate and react to the many changes that lie ahead in the financing and delivery of health care services. This will mean understanding both physicians feelings and expectations. If you were asked today how satisfied your physicians are with your HMO, what would be your reply? How would you know? This staff-model HMO conducted a formal survey of its physicians to determine their expectations of the organization and their level of satisfaction with their work and environment. Such a tool is recommended for others interested in maintaining good relations with their physicians.