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Cultural Challenges Integrating Physicians with Hospitals and Systems

More than half of physicians practicing in the United States now identify as “employed”, and the fastest growing groups are those employed by a hospital or system. Most healthcare systems are developing a clinically integrated network (CIN) or accountable care organization (ACO). Service line management and co-management are growing. Bundled payments create new challenges. And paid medical directorships are springing up like weeds. These structures all aim at “integrating” and “aligning” physicians with hospitals and healthcare systems. And most of these structures are under performing, with challenges and conflicts at every turn.

That’s because when it comes to integration, physicians and hospitals/systems seem to come from different planets.

At Greeley we work with physicians, hospitals and systems across the country in all of these structures before, during, and after their development to help make them work for everybody.

In this two part blog series, we “seek first to understand” the radically different perspectives physicians and hospital/system leaders bring to these integration efforts. This approach creates a starting point for the crucial conversations needed to overcome the apparent chasm between Mars and Venus.

Part I: When Physicians Join a Hospital/System
(click here for Part II: When Systems Employ Physicians)

Greeley was asked to help a multihospital system and a large, single specialty group practice they had started employing 5 years earlier to renegotiate the current employment arrangement. Conflicts flared badly when they tried doing this on their own. Once Greeley got involved, we helped everyone recognize that 5 years ago when the group joined the system, they had never agreed on what “join” really meant. To succeed going forward, they had to renegotiate what “join” means, even though they were already “married.” The key issues in this negotiation from the physicians’ perspective were the fPhysician-Hospital Alignmentollowing:

  • Autonomy: For physicians, the loss of autonomy is perhaps the rudest awakening in all the new integration structures, especially employment. Most leave private practice to achieve two goals: make more money than they can in private practice and get away from the administrative hassles of running a practice. They don’t anticipate the degree to which these gains come with a significant loss of autonomy, both over their clinical practice and their day to day work flow and environment. They want the benefits of integration without any loss in autonomy.
  • Accountability: When it comes to the new integration structures, it’s not clear who’s accountable to whom for what. This is especially true when the organized medical staff is supposed to be responsible for overseeing the performance of all practitioners granted privileges. Then who’s responsible for the performance of employed practitioners? What is the authority of a service line medical director compared to a department chair? The response most physicians still have to these and related questions is that they are accountable to themselves and their patients, regardless of what the bylaws or a contract say. That’s a set up for conflict.
  • Compensation & Rewards: Physicians are keenly focused on protecting their current income level. They often don’t “get” the growing role of pay for performance or argue it’s focusing on the wrong metrics. They expect the hospital/system to protect them from MACRA, MIPS and other looming threats to their income. And if they are asked to anything they think is “extra”, from ED call to serving on a committee or in a leadership role, they expect additional compensation.
  • Performance Expectations: Virtually every physician thinks they already are a good doctor. But until recently nobody has defined what “be a good doctor” means. Many of the fights between physicians and hospital/system leaders arise due to failure to adequately define performance expectations for practitioners joining one of the new integration structures.
  • Roles & Responsibilities: Is the job just to see patients, crank RVUs, and go home? When physicians are compensated purely on “eat what you kill”, that’s what they think their role is. Participating in committees and other meetings, cultivating relationships with fellow physicians to garner referrals, and the numerous other responsibilities it takes to make a practice successful tend to fall off their radar screen. This is especially true for Gen X and Gen Y physicians who seek a very different work/home balance than previous generations. Yet you can bet they still want a say over how their practice is run.
  • Personal & Professional Satisfaction: The medical profession is in a crisis over how physicians will find personal and professional satisfaction, how they can rediscover the “joy of medicine.” The more autonomy erodes, the deeper this crisis grows.
  • Physician Engagement:  More and more physicians are just not engaged. They just want to see their patients and go home. Overcoming lack of physician engagement is a major barrier to effective integration.
  • EMR:  For most physicians, the road to happiness begins with, “First, get rid of the EMR..” Then when a hospital or system seeks to impose their preferred EMR on physicians who already have their own EMR, the fights can become very nasty, indeed.
  • Quality & Measurement: Most physicians already believe they give high quality care. Any data that says otherwise means there’s something wrong with the data. So woe to the hospital or system administrator who wants to tie their compensation to dubious quality metrics when physicians don’t trust the data accuracy.
  • Trust: This brings us to the number one, most difficult challenge in integration: LOW TRUST. In most medical communities, physicians do not have high trust in hospital and system leaders. Trying to achieve effective integration in a setting of low trust is a set up for failure.

Now that we have the perspective from the planet Mars, click here for Part II: When Systems Join with Physicians for the perspective from the planet Venus.

Join us for the webinar where we hash it all out: Coming to The Table – Addressing Cultural Challenges of Integration 

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