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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 second of a two part blog series, we continue the process of “seeking first to understand” the radically different perspectives physicians and hospital/system leaders bring to integration efforts. This approach creates a starting point for the crucial conversations needed to overcome the apparent chasm between the inhabitants of Mars and Venus, namely physicians and hospital/system leaders.

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

Greeley was asked to help a hospital better optimize its cardiovascular service line. The hospital had joined with the local cardiologists in a service line management contract for more than 10 years. To the hospital it felt more like a win-lose arrangement than win-win because the cardiologists seemed to be acting much more in their own self-interest rather than as true partners with the hospital. Of course the cardiologists saw it quite differently. Greeley’s cardiovascular service line assessment identified that in this setting once again the parties did not agree on what “join” means, even though they had been contractually engaged in service line management for more than a decade. So let’s look at what “join” means from the hospital/system perspective.

Physician-Hospital AlignmentAutonomy: For hospitals and healthcare systems, physician autonomy is a problem to solve. It causes non-value added variation in clinical practice, undermines patient safety, and makes physicians poor team players.

Accountability: Perhaps the greatest dysfunction in the American healthcare system from the perspective of hospital/healthcare system leaders is the self-governing medical staff. Self-governance means the physicians and other practitioners granted privileges are not accountable to management. One hospital CEO from Great Britain, upon learning about America’s self-governed medical staff structure exclaimed, “How can you run a hospital if the physicians aren’t accountable to management?” Solving this problem is a primary goal for hospitals and systems when setting up physician-hospital integration structures such as employment, service line management/co-management or a CIN/ACO.

Compensation & Rewards: Hospitals and systems consistently lose money on their employed physician groups, usually a lot of money and a lot more than they want to. Whether in employment, CIN/ACO or service line arrangements, hospitals and systems want to pay physicians in a way that produces a compelling return on investment (ROI). The cutting edge for integration today involves determining what that ROI is and how to design and renegotiate practitioner compensation models that drive a better ROI.

Performance Expectations: Many hospital/system leaders think, “Now that I employ you, I get to tell you what to do.” Good luck with that one. Just because you sign their paychecks does not mean you get to tell physicians what to do. This produces great frustration for many hospital and system leaders and consternation for their board members. But that doesn’t mean giving up on efforts to establish more clear and enforceable performance expectations.

Roles & Responsibilities: Hospitals and systems need physicians to serve in leadership roles. Today this results in paying physicians to serve in numerous medical director and other leadership positions. The problem is again one of ROI. It’s hard to demonstrate that the sizeable and growing amounts paid to medical directors and other physician leadership roles are meaningfully impacting key hospital and system strategic goals, but they need to.

Personal & Professional Satisfaction: When practitioner satisfaction is low, hospitals and systems experience lower practitioner engagement and higher burnout and turnover rates. These come with costs that make achieving key hospital and system goals difficult. Unfortunately, practitioner satisfaction must compete with other priorities in the eyes of hospital and system leaders, such as financial performance, throughput, and patient satisfaction. Managing these tensions creates challenges for hospital and system leaders.

Physician Engagement:  Lack of physician engagement in hospital/system priorities and activities undermines the ability to achieve important strategic goals. If physicians aren’t engaged, it means hospital/system leaders haven’t successfully identified and communicated “adequate reason” in the eyes of physicians for them to be engaged. This makes the search for “adequate reason” for physicians to choose to be engaged an important management priority.

EMR:  Hospitals and systems have sunk countless resources into their current EMR. Some are in the process of changing out EMR vendors at even greater expense in money and time, all of which crowds out other important priorities. They need physicians to be engaged at every step of the process, from vendor selection to go live. And they need effective physician use of the EMR to optimize the value of their staggering EMR investment, even if it slows physicians down.

Quality & Measurement: The imperatives in healthcare today are to improve quality and reduce costs at a pace and magnitude nobody knows how to achieve. Demonstrating measurable results on both is the currency of success. Hospitals and systems need physicians fully bought into measurement and continuous performance improvement.

Trust: Trust between physicians and hospital/system leaders is always important. In settings of LOW TRUST, everything becomes harder, so rebuilding trust is mission critical. But most leaders don’t know how to do rebuild trust once it’s been broken.

Now that we have the perspectives from Mars and Venus, the process of interplanetary travel can commence. The vehicles for this travel are open communication, effective listening, and the facilitation of crucial conversations. The time to begin is now. The very survival of your hospital and system depend on what happens next.

So there you have it.  The perspective of Venus.  Have you already read the Mars perspective in Part I: When Physicians Join a Hospital/System?

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

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