On the road to alignment: Are we getting there?

11 metrics for measuring physician alignment

Both in the physician and hospital management communities there is a growing tendency to describe the state of physician-hospital alignment in sunny terms. The continuing trend of physicians seeking employment with hospitals is often cited in support of an improved alignment climate. Missing from the picture so far is evidence to support this theory, and the reality may be quite different from the upbeat chatter.

A common perception is that the challenge of achieving alignment between hospitals and physicians is more of an issue when physicians are not employed directly by the hospital. Hospital managers often express the view that alignment challenges are more pronounced with outsourced groups than with their employed physicians even while little objective evidence is forthcoming to support this view. Indeed, the drive to achieve better alignment is frequently cited by hospital management as a key reason to employ their own physicians. This is a line of reasoning put forward to justify the substantial investments that have already been made to acquiring physician practices. One might reasonably view this argument as a convenient way to justify prior hiring decisions that have yet to demonstrate a return on the investment, at least from an alignment perspective. Perhaps in the absence of evidence of financial or even clinical benefit to physician employment, hospitals intent on hiring more physicians may have little else to go on to make their case.

Hospitals' drive toward alignment also has the effect of lending weight to decisions related to subsidization of physician compensation. Clearly the upward march of direct funding from hospitals to subsidize physician compensation continues in full stride. In hospital medicine, for example, subsidy payments to hospitalists are now well over half of their total compensation, according to the Society of Hospital Medicine. The drive to achieve better alignment with speed and alacrity leads many hospitals to conclude that they have to subsidize heavily to get it. This "pay for alignment" option may have the advantage of expedience, but it is an option for which hospitals pay dearly.
The trend toward hospital employment has been underway for more than five years, plenty of time for some evidence to emerge showing improved alignment from this trend. One might reasonably expect that hospitals with a multi-year history of a growing workforce of employed physicians would exhibit more alignment characteristics than hospitals with largely outsourced physicians. Yet published metrics supporting the comparative advantages of physician employment — clinically or financially — do not appear to be available, if they exist at all.

A systems approach toward alignment
Not long after a hospital acquires a practice group, the temptation to proclaim "Mission Accomplished" and usher in the new era of alignment can be all but irresistible. It is as if the alignment challenges are resolved once the signature at the bottom of the paycheck is that of the hospital CEO rather than the practice group owners. Well-intended anecdotes of improved relations between the physicians and the hospital management team soon begin to circulate at board meetings and committees. Proactive initiatives to manage and measure the impact of the newly aligned physician-hospital relationship, however, are set aside "for the time being."

It is important to keep in mind that from the hospital's viewpoint, alignment discussions with physician practices are viewed in a multilateral context. The hospital's goal is to align all of the practice groups, not only with the facility but also with each other. The hospital stands to benefit greatly when it choreographs the alignment among the physician groups in a manner that is equitable, constructive and in concert with the overall financial, operational and clinical goals of the facility. All this requires a substantial commitment from physician and hospital leadership in the form of an articulated, realistic and executable game plan, but the effort is worthwhile; absent such a commitment, the alignment objectives that all the stakeholders share are not likely to be fully realized.

Managers that raise expectations among the physician workforce about improved alignment and don't deliver run the risk of inviting skepticism that will eventually take its toll on morale, in effect undermining the very goals that better alignment seeks to achieve. It also fosters the perception among physicians that when management talks alignment it is really just "happy-talk." The more cynical physicians will come to view alignment as a code word for control. Physicians don't want just to hear that the hospital is on the alignment track, they want to see the evidence.

Moving toward evidence-based alignment
What would a suite of metrics look like that, taken together, serve as a reasonable proxy for the measurement of an improving or deteriorating alignment scenario? Following is a representative sample, by no means complete, of metrics that when viewed collectively, and in accordance with other data, might serve to remove some of the subjectivity and emotion from these discussions and maintain the focus on the facts.

  • Physician turnover and retention rates, transparently defined, with reason codes to categorize terminations
  • Physician satisfaction and engagement scores, evidenced by annual surveys
  • Patient satisfaction with their physicians
  • Physician work hours and self-reported levels of job stress
  • Physician representation among hospital leadership positions, and identifiable opportunities for upward mobility
  • Physician representation, participation and influence on key hospital committees
  • Joint Management-physician participation in community organizations and events related to the hospital
  • Cross-functional management participation at physician policy committee meetings
  • Management participation in physician hiring decisions and hiring criteria
  • Regular attendance at  Joint Operating Committee meetings between management and physicians with each practice group at the hospital
  • Management and physicians making calls together on community-based practices and healthcare organizations

 

Identifying specific goals for each of these metrics as they pertain to improving alignment-organized and prioritized by physicians and managers together in accordance with the needs of the individual facility should create a picture of what effective alignment would look like. At that point, it should be possible to perform a gap analysis to measure differences between the current state of each metric and the agreed-upon goal. The hospital's board of directors could create a pool of incentive monies for physicians and management alike tied specifically to a basket of metrics that indicates improvement or deterioration in alignment.

Over time, one would expect to observe a cumulative impact of improved alignment at facilities that have developed a well-defined initiative with true accountability to show progress. Such an initiative should prove valuable regardless of what physician employment model is currently in use, but it should also serve to create a meaningful basis for comparison between insourced and outsourced physicians. Some healthcare systems have already begun to take steps along these lines, and hopefully their results will be made available to generate more public discourse. Eventually the positive impact should spill over and yield measureable improvements in many key clinical performance and quality metrics as a result of a more engaged medical staff and enlightened hospital culture.

Just as we chart the growing influence of evidence-based medicine, we should be able to develop "evidence-based alignment" guidelines to develop a series of metrics such as the list above that fairly reflects the state of alignment that exists between the physician workforce and hospital management. The hospital management team as well as financial investors might legitimately consider alignment metrics as core measures of the financial health of a hospital; consequently they may wish to consider alignment metrics as a measure of ROI. As with any goal worth managing, alignment can and should be measured.

Success in the new environment of value-based care will require that demonstrated improvements in alignment between hospitals and physicians is a high priority for all the stakeholders. This will take action planning, executive commitment and openness to cultural transformation at a deep level throughout the facility. Traveling the road toward better alignment is too important a goal to be tackled with earnest talk and good intentions.

Todd Kislak is a healthcare consultant. He has spent more than 20 years as a healthcare executive, most recently as vice president at IPC The Hospitalist Company. He holds an MBA from Harvard Business School. He can be reached at tkislak@gmail.com.

 

 

 

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