Physician leadership in a clinically integrated environment

The velocity of change sweeping through healthcare is restructuring care delivery and reordering traditional provider relationships. As hospitals and physician groups move toward tighter integration, effective physician leadership becomes essential for success.

Without physician commitment and the leadership needed to achieve it, clinician buy-in can be problematic and cooperation may be undermined. At the same time, the mechanisms required to operate effectively in an integrated environment are jeopardized.

By creating appropriate expectations and incentives and by empowering physicians to lead, hospitals and other provider organizations can create a powerful, flexible and sustainable framework for integrated care. In addition, establishing effective information systems that can help leaders translate data into actionable information is equally important for success.

Establishing trust, setting expectations  
A first step in developing the mindset necessary to support clinical integration is for both hospitals and physicians to set aside — to the greatest extent possible — the mutual distrust and enmity that has frequently dominated their relations. In today's emerging healthcare paradigm, hospitals and physicians must work together to an unprecedented extent. It is therefore critical that both sides abandon counterproductive, outdated and self-defeating attitudes and assumptions.

Regardless of whether a hospital is acquiring a practice or aligning with an independent physician organization, it is important to establish clear expectations regarding physician accountability. Performance assessment is an integral part of the emerging value-based care model. As such, it should be made clear to physicians at the outset that their clinical activities, outcomes and ultimately, clinical costs, will be measured and compared to national benchmarks, as well as to peers both inside and outside the organization.

This kind of scrutiny may be uncomfortable for many physicians. But continual measurement is critical for establishing a high-performance organization. Regularly assessing both individual and overall team performance allows for systematic improvement and also provides the data required to populate a growing number of reimbursement schemes.

By explaining how and why clinical teams will be assessed, organizations establish clear expectations and minimize the likelihood that physicians will view such oversight as punitive or intrusive. Those not comfortable working in such an environment may wish to pursue other opportunities.

New compensation models  
Just as physician behavior must evolve to meet new roles and expectations, so too must compensation schemes be modified to reflect today's realities. Payment based strictly on a physician's productivity and relative value units — a staple in the fee-for-service universe — is no longer appropriate in a clinically integrated organization.

Instead, incentives should be created that reward not only quality but also collaboration, efficiency, use of ancillary personnel and patient empowerment. In addition, physicians may also be incentivized to reduce clinical spend as reimbursements move toward case-rated bundled payments and ultimately, population-based budgets. The shift toward incentivized reimbursement underscores the importance of clinical and financial data collection and analysis.

A robust electronic infrastructure that can enable data collection and sharing across the enterprise is therefore critical to effective clinical integration. EMRs, practice management systems and billing platforms can all play a role in providing the information needed to coordinate, measure and reimburse for care in the integrated environment.

Evidence-based care is likewise a key foundation for successful clinical integration. By developing order sets and other point-of-care tools that can convey best practices, organizations will reduce clinical variance and help ensure the most effective outcomes.  

An understanding and appreciation of the power of information is mandatory for effective leadership in today's environment. Being comfortable with quantification and empirical evidence enables critical decisions based on a range of inputs, and allows the physician leader to tackle the many challenges that integration inevitably will bring.  

Fostering a culture of excellence
Achieving healthcare's triple aim — improving the individual experience of care, improving the health of populations and reducing per-capita healthcare costs — requires a commitment to teamwork and a culture of performance excellence. In addition to aligning expectations and incentives, harnessing technology and embracing evidence-based care, organizations should develop leaders who can champion new models of care and instill unity of purpose among clinicians.

Admittedly, this can be challenging, given that physician training has traditionally been focused almost exclusively on clinical issues. Given this background, physicians typically default to "command and control" leadership, which essentially means giving orders. This top-down approach undermines clinical unity and inhibits creativity and initiative among clinical team members.      

A more effective style of leadership is to serve as a facilitator by encouraging communication between team members. This will instill a sense of pride and purpose among all clinical team members and will allow each member to maximize his or her contribution to the overall effort.

An effective leader should also consistently work to unite physicians behind the organization’s collective goals. A key ingredient in creating unity is to avoid complaints and negativity. It is far too easy in the current environment to focus on perceived inequities, shortcomings or systemic deficiencies. This kind of thinking, however, can poison collaboration between the hospital and physician group.  

Sharing the clinical burden
As clinical integration becomes more far-reaching, hospitals and physician groups should identify those procedures that can be performed most cost-effectively in the outpatient setting. By transitioning clinical services to the outpatient environment, costs are reduced and efficiency is enhanced. This process should ultimately lead to a redefinition of the hospital's role as an entity for handling only the most acute cases.  

Beyond the clinical process itself, another area where mutual assistance and collaboration is important is discharge planning. Ensuring that physicians and hospitals work closely to develop an effective post-discharge plan helps improve outcomes and reduce costly readmissions.

One issue that will become increasingly important as 2015 progresses is medical coding. The much-delayed transition to the ICD-10 code set is now scheduled for Oct. 1, 2015. Because ICD-10 has far more codes than its ICD-9 predecessor, and because greater documentation detail is required to code effectively in ICD-10, hospitals should work closely with physicians to improve clinical documentation skills ahead of the deadline.

A new world  
Successful clinical integration depends on the establishment of appropriate physician expectations and incentives, the implementation of key infrastructure and tools, and the ongoing development of — and support for — physician leadership. By embracing change, organizations will gain a competitive advantage that will position them well to meet the emerging requirements of healthcare's shifting paradigm.

Jerry Floro, MD, is an interventional cardiologist and president of Pioneer Medical Group, a Cerritos, Calif.-based multi-specialty group of more than 50 physicians in the highly competitive Southern California managed care market. The practice serves approximately 40,000 covered lives with nine HMO commercial and senior contracts and is responsible for about 220,000 patient encounters annually at eight facilities in Southern California.

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