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.     

Trends in managed care organizations: implications for the physician executive.

The rapid change in the managed health care industry is placing substantial demands on the managerial and leadership skills of physician executives. These changes are forcing a reevaluation of the fundamental principles of managed care organizations, specifically in terms of patient satisfaction, cost containment, and quality health care. Additionally, the physician executive will be confronted with substantial issues concerning future staffing needs. This article assesses the health care industry's environment to suggest where managed care is going and how physician executives should position themselves to optimize their position in the marketplace.     

Strategic issues requiring public accountability: food for thought

Although the exact outline of U.S. health reform has become fuzzy because of political events, it seems clear that major changes in the manner in which health care is delivered and financed are under way. The initiative for the most part has been assumed by state government and by the health care field itself, as managed care becomes ever more entrenched and the health care system becomes ever more integrated. An expected outcome of these changes will be demands for greater public accountability on the part of health care providers and organizations. In this article, the author discusses some of the issues--professional compensation, documenting community service, ensuring public input into planning efforts, economic credentialing and quality of care, and managing ethics under managed competition--that will have to be addressed at the local level as these shifts take place.     

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.     

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.     

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.     

Leadership clarity and team innovation in health care

The relationships among leadership clarity (i.e., team members' consensual perceptions of clarity of and no conflict over leadership of their teams), team processes, and innovation were examined in health care contexts. The sample comprised 3447 respondents from 98 primary health care teams (PHCTs), 113 community mental health teams (CMHTs), and 72 breast cancer care teams (BCTs). The results revealed that leadership clarity is associated with clear team objectives, high levels of participation, commitment to excellence, and support for innovation. Team processes consistently predicted team innovation across all three samples. Team leadership predicted innovation in the latter two samples, and there was some evidence that team processes partly mediated this relationship. The results imply the need for theory that incorporates clarity and not just style of leadership. For health care teams in particular, and teams in general, the results suggest a need to ensure leadership is clear in teams when innovation is a desirable team performance outcome.     

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.     

Health care economics is changing--the law is sure to follow

Law is intimately related to economics. As the economic relationships in a market change, the legal landscape evolves accordingly. Even if no health care reform is enacted at the federal level, ever-increasing portions of today's managed indemnity sector will convert to plans constraining enrollee choice and seeking to deliver cost-effective care through risk-sharing relationships (both corporate and contractual) with providers. This is inevitable, given employer and federal government pricing demands, and it is changing the face of health care law. If federal reform is enacted and/or the systems adopted in Minnesota, Maryland, Washington, and Florida (to name a few) are replicated elsewhere, the legal concerns of physicians and other providers will shift even more dramatically. In this article, some of the legal fall-out from these economic developments is discussed.     

Management,Competition and Professional Practice: Medicine and the Marketplace

Within the context of the creation of the internal market for health care, the paper examines the role of clinical directors, that is doctors who have retained their professional clinical positions whilst at the same time assumed roles as managers within increasingly well-defined corporate organizations providing health care. This represents considerable change from previous contexts in which doctors could always contract out of difficult managerial decisions. The role of clinical director is examined in terms of its own directorate and its involvement in contracting, co-operation and competition both within its own corporate organization and within the wider market place for health. Key issues are raised for the individuals and organization by these changes, they are discussed in terms of time, succession, managing colleagues, financial and human resources, market behaviour, support and terms of reference. These changes occasion wider discussion in terms of the challenge of coping with future demands for innovation, changes in the distribution of power within an emerging market for health care and the relationship among health care organizations, professionals and lay clients.     

What kind of leaders will be successful?

The U.S. health care system is fundamentally changing. The pace of change is swift but will vary, depending on regional market forces and state legislative mandates. This complex change is leading to rapid market consolidation of providers and insurers into organizations called "integrated health care systems." There is, as yet, no proven role model that will guarantee success. The purpose of this article is two-fold: To help individuals who see an expanding role for themselves in integrated health care management decide if they have what it is going to take to be successful. To identify individual management training needs by use of a self-evaluation tool. Some of the needed skills can be enhanced by education and experience. However, some are personality and style characteristics that may not be changeable.     

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.     

The effects of transformational leadership on followers' perceived work characteristics and psychological well-being: A longitudinal study

Transformational leaders employ a visionary and creative style of leadership that inspires employees to broaden their interest in their work and to be innovative and creative. There is some evidence that transformational leadership style is linked to employee psychological well-being. However, it is not clear whether this is due to (1) a direct relationship between leadership behaviour and affective well-being outcomes, or (2) a relationship between leadership behaviour and well-being that is mediated by followers' perceived work characteristics. (Such characteristics include role clarity, meaningfulness, and opportunities for development.) This study aims to extend previous work by examining the validity of these two mechanisms in a longitudinal questionnaire study. The study was carried out within the elderly care sector in a Danish local governmental department. A theory-driven model of the relationships between leadership, work characteristics, and psychological well-being was tested using Structural Equation Modelling. The results indicated that followers' perceptions of their work characteristics did mediate the relationship between transformational leadership style and psychological well-being. However, there was only limited evidence of the existence of a direct path between leadership behaviour and employee well-being. These findings have implications for design, implementation, and management of efforts to improve employee well-being.     

Health care's power brokers in the 21st Century. Interview by Donna Vavala

Health care has undergone turbulent change in the 20th Century. In addition to dramatic pharmaceutical and technological advances, the entire health care delivery system has been significantly improved. Through all the turmoil, hospitals have been at the center of the health care universe. But, as the 21st Century approaches, that may change, too. What will become of hospitals, which for most of this century have played a commanding role? Will managed care organizations and group practices come out on top? And, once the new power broker takes over, what will be the impact on providers, insurers, and the government, and how will their relationships to each other change? Jeff Goldsmith, PhD, President of Health Futures, Inc., Bannockburn, Ill., and health care futurist, examines tomorrow's health care delivery system and makes some eye-opening predictions.     

Will physicians replace MHAs?: reflections from Australia

Tom Weil, in the preceding article, sees the physician executive playing an increasingly significant role in negotiations between payers and service providers, in offering the public acceptable explanations for the inevitable changes in the provision of care, and in developing more cost-effective methods of delivering high-quality health care at affordable prices. Effective involvement of physician executives will be facilitated by their having received professional training somewhat different from that of the traditional MHA. How do these prognostications relate to the health care scene in Australia? Factors that must be taken into account in considering their applicability to Australia include differences in the structure and management of the Australian health care system, the current state of that system, the background of the leadership that makes the key managerial decisions in the Australian system, and emerging trends within the system.     

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.     

Leading in a chaotic health care environment

How can physician executives be effective leaders during a time of such upheaval in health care? How does anyone lead in a confusing environment where planning seems impossible? Is effective leadership even possible when no one seems to understand what is going on? These important questions are addressed in this article. Health care is a confusing field. But it still needs effective leadership. Even though nobody really knows what is going on, physician leaders can play a beneficial role by encouraging everyone they work with to experiment and innovate with ways to make health care work better for patients. Physician executives can insist on accountability and on implementing what really works in their given context, rather than what the latest theory states should work.     

What skills do physician leaders need now and in the future?

The role of the physician leader is moving beyond traditional medical staff issues. A recent national survey of physician leaders shows a growing need for education on specific technical, leadership, and practical skills. The results reveal the medical leadership skills that physician executives consider important today, and provide a window to the future about the skills that will be important tomorrow. Physicians say they need training now in quality assurance, clinical benchmarking, decision-making, and strategic planning. And when they gaze into the future and see the rapid changes throughout health care, they say they'll need more training in communication, organizational change, effective listening, and systems thinking.     

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.     

Hierarchical linear modeling as an example for measuring change over time in a leadership development evaluation context

One of the difficulties in evaluating leadership development is measuring whether and how people change over the time period of the leadership development initiative. Even when change over time is an inherent part of the design and evaluation of leadership development, events may occur outside of the control of evaluators that limit the effectiveness of adequately and accurately assessing change over time. With data from a leadership development initiative designed to account for change over time, this article suggests hierarchical linear modeling (HLM) as a multilevel methodological technique to assess change over time in a leadership development context. This article will use real change over time data from a leadership development initiative and discuss the logic and rationale of HLM. We use HLM as an example of a multilevel methodological tool to investigate typical change over time questions in leadership development evaluation.