The Case for Physician Leadership
Much of my writing has assumed that getting practicing physicians involved in the leadership of hospitals and healthcare organizations is essential, but I recognize that I have not always made the rationale explicit. Fortunately, the work has been done for me by Michael Porter and Thomas H. Lee.i
Porter and Lee point out that the system is trying to change from one based on volume to one based on value, but they also point out that reform efforts have been hobbled by lack of clarity about the goal, or even pursuing the wrong goal.
“Narrow goals such as improving access to care, containing costs, and boosting profits have been a distraction. Access to poor care is not the objective, nor is reducing cost at the expense of quality. Increasing profits is today misaligned with the interests of patients, because profits depend upon increasing the volume of services, not delivering good results.
In health care, the overarching goal for providers, as well as for every other stakeholder, must be improving value for patients, where value is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes. Improving value requires improving either improving one or more outcomes without raising costs or lowering costs without compromising outcomes, or both. Failure to improve value means, well, failure.”
The authors lay out a six-step roadmap for change, with the first being to organize “integrated practice units,” and the second to measure outcomes and costs for every patient. Both of these steps are critically dependent upon physician leadership. The integrated practice unit is an expanded concept of what we called “Tumor Board” in the old days. The example they use is Virginia Mason Medical Center’s approach to the problem of low back pain. They were inspired to focus on this area, because employers were having high expenses and employees were missing many days of work. The group organized a care process that featured “one-stop” access, with rapid triage of those with more serious causes of low back pain such as tumor and infection, followed by protocol-driven assessment and treatment. Initial evaluation is conducted by a physical therapist, although a physiatry- trained physician is also onsite and sees many of the patients on the first visit as well. Although the authors extol the practical and “business” success of the program, they gloss over the fact that Virginia Mason lost a lot of money in the early years of the program, which they freely publicized at the time. Changes in payment mechanisms, though, are now making the program pay for itself.
These programs, though, would not work if they were not led by physicians with expert knowledge of the clinical syndromes involved. If the goal is simply to reduce costs, an employer perspective, then the surest way to do that is to avoid MRI and surgery. On the other hand, not all low back pain is benign, and those patients would be hurt. The fee-for- service driven hospital or physician, though, might design the program to increase volume, so a strategy that used MRI for triage might be developed. Virginia Mason was trying to improve outcomes and save money, and thus developed a program based upon clinical realities. They had the vision to make the investment and the change “ahead of the curve.”
Can this example be replicated elsewhere and in other areas? Said another way, can we identify critical elements that must be in place for such efforts to succeed?
Virginia Mason has had doctors, the outpatient clinic, and the hospital under one organizational umbrella from its founding almost 100 years ago.ii To many, this organizational structure is a key to its ability to create an integrated practice unit, but we clearly are not going to wait another 100 years for the rest of the county to develop similar “integrated” cultures. In today’s fractured culture of doctors, hospitals, payers, and insurance companies pursuing their interests separately, what is to be done?
When I interviewed the founders of my multispecialty group practice, I asked them why they had been willing to go against the tide and do this. After all, they all knew that Alton Ochsner had received thirty silver dimes from the local medical society when he organized the Clinic that bears his name. Since making the sort of change advocated by Porter and Lee is going to cost money upfront, one of the stakeholders is going to have to take the financial gamble and lead the process and make the investment “because it is the right thing to do,” not because there is a predictable return on investment. Whether that stakeholder is the doctors, the hospital, or the health plan probably depends upon very local factors.
Unfortunately, in many, perhaps most, markets, no stakeholder will take the lead until forced to do so, and by then, the divisions among the various groups will be so deep and bitter, it will take a lot of time and trauma to make necessary changes. While physicians usually lack adequate financial capital, they are usually the only ones with the intellectual capital and the emotional commitment to patient care necessary to lead these changes, because it is “the right thing to do.” Are you up to the task? What skill sets will you need? I hope the articles posted on this website will help you answer those questions, or at least lead you to do more research, because if we as practicing physicians do not lead, we won’t like the results of changes produced by others who are more than willing to do so.
i Porter ME and Lee TH. The Strategy That Will Fix Health Care. Harvard Business Review, October 2013, reprint
R131OB, located at hbr.org.
ii https://www.virginiamason.org/AboutVirginiaMason, Accessed 14 May 2014.
14 May 2014
Doctors and hospitals operate with different cultures and unexamined assumptions may cause conflict.
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Paradoxes for Physician Leadership
I started this website to share some notions about physician leadership. I have also reviewed many other people’s ideas about these subjects, some of which I have shared in other articles. What strikes me about much of the “literature” on physician leadership, though, is how they fail to grapple with the inherent paradoxes of the role of physician leader. Here are some that I think matter, with some links to other articles on this site, which develop the ideas in more detail.