Is leadership born or made?

Is leadership born or made? By profiling three colleagues who made the transition from clinician to top-flight executive in a health care organization, the author provides case studies from which to discuss leadership issues. An evolutionary pattern has developed with respect to physicians changing careers: The first model was the medical director, followed by the vice president for medical affairs, and finally the move to managing the health care system, group practice, or managed care organization. Are physician executives fundamentally different from clinicians in terms of leadership characteristics? What are the essential qualities needed to lead health care organizations? These questions are explored in-depth.     

A behavioral profile of physician executives

In late 1993, ACPE and Tyler & Company, a national health care executive and physician search firm based in Atlanta, Ga., jointly conducted a survey of physician executives to determine their most likely behavioral patterns. It is the first of a two-part survey that, when complete, will create a multifaceted profile of the "ideal" physician executive as seen through physician executives' eyes and through the eyes of hospital management. Questionnaires based on the DiSC method of behavioral analysis were mailed to 750 randomly selected members of ACPE. More than 170 responses were received. The survey results showed that the majority of physician executives have strong communications skills, are people-oriented, and are strong leaders. The majority of respondents are self-motivated and industrious and are driven by accomplishments. The second part of the survey, which will be conducted later this year, will poll hospital CEOs and boards of directors about their preferences for behavioral patterns in their executives. Comparisons and consistencies will be analyzed between the two surveys to develop a comprehensive profile of the "ideal" physician executive, and the results will be reported in Physician Executive.     

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."     

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.     

Leading beyond the bottom line, Part 4. The questions it has raised

The Leading Beyond the Bottom Line article series has received an overwhelming response from ACPE members, mostly in enthusiastic support of this new leadership concept. Some of the important questions raised by members are presented with answers from the authors. This article also explores the moral challenge of leadership and why health care is more than a business. In recent years, there's been confusion about the role of the health care enterprise, its leadership and its management. We have lost our way about the "moral" thing, the "right" thing, because we have no philosophy to guide us. To manage or lead in this "business" of health care, a philosophy is required that recognizes the multiple elements to which the leader has responsibility and obligations: the customers, community, employees, and, certainly, the financial assets.     

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.     

Lonely at the top and loving it: physicians as CEOs

As little as five years ago, most hospital board members scoffed at the idea of hiring physicians as chief executive officers or chief operating officers. Physicians, they maintained, belonged at the bedside, not in the board room. For the most part, physicians didn't take issue with this thinking. Profit and loss statements, strategic planning, and other CEO duties were alien. Besides, being a "suit" was unconscionable, a total fall from the true grace of medicine: patient care. Dramatic changes in health care have wrought dramatic changes in the mindsets of both board members and physicians. Today, both sides have developed a new perspective on physicians in top hospital administrative positions. In this article, the author reports on the experiences of physician executives who have made the trip to the top.     

The compensation of physician executives.

In January of this year, the American Academy of Medical Directors and the Physician Executive Management Center mailed a survey questionnaire to the approximately 2,300 members of the Academy of record at that time. More than 1,000 responses were returned. The purpose of the survey was to begin to collect data and establish a reliable baseline of compensation information for the physician executive profession. Subsequent annual surveys will allow the two organizations to track the course of the profession, insofar as this can be done on the basis of compensation. In this article, we provide a summary of some of the findings of the survey as they relate to physician executives in a variety of nongovernment health care settings. Except for the summary of overall data, the report is limited to the responses of physicians who indicated full-time involvement (75 percent or more) in management. Later this year, the complete findings of the survey will be published in a monograph that will be available from the Academy and Center.     

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.     

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.     

Poll finds that physicians long for political action

The latest ACPE survey explores physician executive participation in politics, and the need for doctors to make an impact on health care policy.     

The Informatics Institute: why do we need it?

Why should physician executives care about medical informatics? For that matter, what is medical informatics anyway? Broadly defined, medical informatics is the study of the collection, storage, retrieval, and analysis of data and information in health care to support clinical and administrative decision making. Informatics is important because, in the past 10 years, powerful computer, software, and information technologies have been developed to enable health care organizations to automate some of the work of decision making, for improved quality of care and cost control, and for successful managed care contracting. This new emphasis on informatics in health care was the impetus for the founding by ACPE earlier this year of The Informatics Institute, which will be involved in educational and research activities in the growing area of medical informatics. In this new column in Physician Executive, Dr. Marshall Ruffin, President and CEO of the Institute, will discuss the role of medical informatics in health care delivery and financing and its relation to physician executives.     

Physician resiliency?

The profound changes in the health care industry have led to the anger, frustration, and unhappiness that physicians are feeling. It is important to examine physicians' responses to the threats to their professional autonomy, image, lifestyles, and relationships with their patients. The "learned helplessness" behavior exhibited by physicians is astounding, considering the education, status, and reputation of physicians as healers for those in need. This article explores the concept of resiliency among physicians and describes why physicians as a group may be less resilient than other individuals. In fact, the structure and training of the medical profession stacks the deck against those who want to change or to be resilient in the face of the changing environment.     

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 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.     

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.     

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 should managed care physicians be paid?

When paying a physician for medical or surgical services, most patients expect the traditional bill or charge for that encounter or visit. While most people also pay health insurance premiums, few patients expect to prepay for their health care. But that is the foundation of most managed health care systems-prepaid medicine. PPOs, IPAs, and HMOs are typically health care providers linked together to provide services to a set population for a specific prepaid fee or "capitation" payment. Other providers contract with these managed care insurers to receive a predetermined and often "discounted" professional fee for services. These managed care organizations have already gone through a number of stages in determining how physicians are to be compensated for their services, and further changes loom on the horizon.     

The five stages of managed care. Strategies for physicians in health care's market revolution

What are the five stages of managed care? From "Can't Spell HMO" to Managed Cooperation, each stage has predictable market events and strategic responses. At every stage, a new set of relationships evolves among the major players, including physicians and hospitals, HMOs and insurers, and employers and government. At each higher level of managed care penetration, the players restructure their relationships as they seek to control their market and their destiny.     

Managed care information needs: a summary perspective

The key to survival in managed care is management of financial risk. You need to know what is in your contract and what you are obligated to do for which population during which period. Information systems can be an enormous help in managing managed care contracts and the financial risks they entail, but poorly selected and configured information systems will do little good for the organization that licenses them. The most important activity of a physician executive who is moving his or her organization into managed care contracting is to lead the process to define the functional requirements for information the organization will need to manage managed care contracts successfully.