Published in the July 2017 issue of Today’s Hospitalist
IN 2016, a blog posted on the KevinMD site by a guest commentator detailed what the hospitalist-author described as “a dramatic shift of power and clout” from doctors to hospital administrators.
By way of example, he recounted this anecdote: A hospitalist he knew who was practicing in the Midwest was scolded by a 28-year-old MBA, who told the physician which floor he needed to start rounds on. That interaction, according to the blog, convinced the doctor “that the time was right to move on” to another program.
The blog author, Suneel Dhand, MD, currently practices at Boston’s Beth Israel Deaconess Medical Center, but has worked at hospitals up and down the East Coast. While his current group offers strong physician leadership, he says that has been the exception, not the rule, across his practice life.
“We have to decide as a profession whether to continue to go this route or really push back.”
In too many hospitals, he tells Today’s Hospitalist, administration is monopolized by non-clinicians, one of many factors driving what Dr. Dhand calls a “seachange” in the power dynamics of American medicine. Other factors include the ongoing consolidation of hospital systems, with ever-more administrative layers, and the rapidly growing number of employed physicians.
Add in the regulatory requirements of what he admits is necessary health care reform, and Dr. Dhand believes that “we’re at a crucial point in medicine where we’ve come a long way, and not always in a good way. We have to decide as a profession whether to continue to go this route or really push back.”
As he sees it, the needs and natural instincts of clinical and corporate medicine are frequently incompatible. Why? “Health care is very different from every other industry, and many business rules—with their relentless focus on the bottom line— don’t always apply.”
While Dr. Dhand’s assessment may sound bleak, hospitalist groups report a wide range of working relationships with their administrations. Some are indeed hostile standoffs, while many doctors say they’ve forged collaborations. An important point, though, is that successful partnerships are made possible by doctors willing to engage—and administrators willing to learn.
“The good administrators get it,” says David Grace, MD, senior medical officer at Schumacher Clinical Partners, a physician staffing company based in Lafayette, La. “The less effective ones feel the pain of the $100,000 it typically takes to replace a doctor who leaves.”
Signs of trouble
Colleen McCoy, MD, MHA, is currently a hospitalist medical director within UPMC Susquehanna, a health system in north central Pennsylvania. Over the course of her career, Dr. McCoy says she has run up against several short-sighted administrations.
“One typical fallacy of administration is that their management is responsible for the outcomes hospitalists achieve,” she says, “when really, those result from doctors’ creativity and skill.”
And administrators can be so wedded to the allure of new business—think orthopedists and interventional cardiologists—that they don’t appreciate the savings hospitalists deliver through better length of stay, higher case mix index, and improved quality and throughput. “When your sole focus is on how to generate new income,” she says, “hospitalists are always perceived as a financial loss.”
“It’s really been a lot of PR, with me explaining, ‘This is who we are and what we’re about.’ “
As a consultant called in to fix failing hospitalist programs, Martin Buser, MPH, founding partner of Hospitalist Management Resources LLC, says he runs into that bias a lot. He also meets administrators who think they can ride roughshod over their medical staff. The anecdote about the 28-year-old MBA, says Mr. Buser, is a classic example.
“That’s an administrator who doesn’t know how to use—or respect the use of—channels,” he says. “The appropriate response for a hospitalist in that situation is, ‘Why don’t you bring that up at your next meeting with our medical director, and I’ll let him or her know you mentioned it.’ ”
Invariably, Mr. Buser adds, one of his company’s first moves with a new client is to set up formal monthly meetings between administration and hospitalist leadership, if that infrastructure doesn’t already exist.
But “administrators’ behavior really sets the culture, and they need to own it,” he points out. “Do they view hospitalists as true partners, or as another labor line item?” The most destructive mindset he runs into is “administrators who treat physicians as some sort of uninformed labor force they can take advantage of.”
Searching for common ground
Schumacher’s Dr. Grace notes that while most physicians retain autonomy over individual patient care, “what’s been lost is decision-making power over how the hospital or practice is run.” The need to mitigate that loss is real, he adds, given how many studies link perceived lack of autonomy to runaway burnout.
That said, Dr. Grace thinks doctors and administrators can get on the same page. “We have similar goals and can at least start a dialogue,” he says. To jumpstart a conversation, hospitalists need to identify administrators’ true agenda, then meet frequently with them to discuss it.
“Do they really want you to start on 6 West?” he asks. “Or is their real agenda improving throughput, and they just think that starting there would do that?”
Effective hospitalists, Dr. Grace adds, “need to be experts in the hospitalization process, beyond the medical care of the individual patient in front of us.” Bringing that expertise in hospital processes to administrators “can go a long way to having our opinion listened to and often agreed with.”
“But administrators are less willing to listen to the non-clinical opinions of physicians, simply because they’re physicians,” he says. “You can’t expect people to see you as an expert in operations solely because you have the title of doctor. The onus is on us to demonstrate our value.”
So how do you prove value to administrators turning a deaf ear? When he and his company are called in, Mr. Buser says he often asks the hospital CEO: What hospital metrics is your bonus pegged to? “We know that if the hospitalists work on those, they at least have the CEO’s attention.”
“If we want to retain our ability to make decisions independently, we need to demonstrate the value our individual expertise can add.”
In Boone, N.C., Lisa Kaufmann, MD, medical director for the hospitalist program for the Appalachian Regional Healthcare System, has taken that approach. Dr. Kaufmann’s system includes an 80-bed community hospital and a critical access hospital.
“Administrators are accountable for metrics like a balanced budget,” Dr. Kaufmann points out. “I look for a place where we can meet.” When her hospital was hit with readmission penalties, for instance, she and her group worked with case management to implement post-discharge phone calls. She and her colleagues also approached outpatient practices to open up more follow-up appointments.
When the hospital suffered some cases of C. diff, she first talked to her system’s infection control, then the hospital joined a state consortium that’s establishing best practices for C. diff prevention. She’s now working with maintenance to better sterilize rooms.
“When we show the complex things that go into a health outcome,” Dr. Kaufmann says, “we show administrators that we’re not interchangeable. If we want to retain our ability to make decisions independently, we need to demonstrate the value our individual expertise can add.”
At the same time, Dr. Kaufmann points out that breakthroughs with her administration came as the hospital was trying to develop a sustainable hospitalist program.
“The hospital having some struggles made everybody more willing to say, ‘The status quo is off the table,’ ” she says. One breakthrough was when hospital executives gave the hospitalist director protected administrative time.
Another was when executives—who she characterizes as “amazingly supportive”—recognized the relationship between out-of-control hospitalist census and rising length of stay. “They agreed to staff up during a flu epidemic and to cover the winter surge in patients every year,” Dr. Kaufmann recalls. “Those are an acknowledgement that our capacity to get work done is important.”
In Lansing, Mich., Carol Nwelue, MD, medical director of the hospitalist service for Sparrow Health System, says that forging a better working relationship with administrators came about through better communication. When she became interim medical director in September 2015, the program had gone through four directors in as many years and had lost almost one-third of its doctors.
“The administration’s attitude was, ‘We pay your salaries, so you have to do what we say,’ ” Dr. Nwelue recalls. Physicians weren’t paid for working extra shifts, and administrators had no plan to staff all the new services they were insisting the hospitalists should provide.
What turned that around, says Dr. Nwelue, was having the vice presidents of her medical group set up a weekly meeting with her to help bring her along, a young leader with no management experience. She quickly realized the meetings were as much of an education for them as for her.
“Within a month, I learned they really didn’t understand what we did,” says Dr. Nwelue. “They also didn’t understand that the hospitalists were upset or why.”
She brought in survey data from the Society of Hospital Medicine on median compensation and productivity—and turnover rates—and got the hospitalists’ contracts changed. She pushed back on hospitalists becoming universal admitters and hammered out agreements with the cardiology and neurology departments to determine which service would admit which patients.
She charted out how many FTEs the group would need to cover new services, and she presented PowerPoints on the projects each hospitalist was working on.
“That was a game-changer,” she says. “That was when we began to gain recognition for how our clinical work fits into their business model.”
A new tone
Part of improving the working relationship, Dr. Nwelue points out, was changing the tone. “Previous directors may have been less diplomatic,” she says. “The message was there, but not in the context that administration could appreciate. It’s really been a lot of PR, with me explaining, ‘This is who we are and what we’re about.’ ”
Further, any strategic makeover has to go both ways, Dr. Nwelue notes. “I take things back to the group and tell the doctors, ‘Administrators are not terrible people. They are learning about who we are and what we do, and it is in their best interests for us to succeed. Let’s talk about what that looks like.’ ”
And sometimes, hospitalists have to take matters into their own hands to break through. When David Yu, MD, MBA, as medical director of the adult inpatient medical service for the Presbyterian Medical Group in Albuquerque, first began working there, hospital administration was at least forward-thinking enough to sign off on a comprehensive Lean Six Sigma program.
But when he started his first geographic unit— which has since been adopted hospital-wide, with the hospitalists lowering the hospital’s average length of stay by almost a full day—he launched the project without formal approval.
“I did it without their official permission,” Dr. Yu explains. “The project would have been stalled going through all the different financial and administrative approval processes.” The fact that the pilot project ended up being “hugely successful” made future efforts much easier. “But if it didn’t succeed, I would probably have been fired.”
Leadership and consolidation
Schumacher’s Dr. Grace points out that groups now are much more savvy when it comes to demonstrating value.
Doctors may at least have the data-gathering resources they need to spell that value out on a spreadsheet, he says. But that’s one big reason why hospital medicine continues to see so much consolidation, with more and more hospitals turning to national staffing companies like his own.
“Smaller groups often lack the resources to invest as heavily in IT to understand what they’re doing well and where opportunities exist,” Dr. Grace says.
But consolidation—including larger academic centers and hospital systems taking over smaller hospitals throughout a state or region—can also affect physician autonomy. That’s particularly true when large networks don’t help tailor local practice solutions and instead take a very “prescriptive” approach, says Pennsylvania’s Dr. McCoy.
“They determine how you will round, what time multidisciplinary rounds will take place, how many patients you’ll see, and whether or not you’ll work with an advanced practice provider,” she notes. Local hospitals and physicians suffer when all “solutions are top down. It’s the local doctors who understand the roadblocks and nuances and who know where the difficult solutions come from.”
And consolidated networks can dilute local leadership. “Local leadership goes from a medical director to a site leader” with less protected administrative time, she points out. “That site leader talks to a regional director,” who may not have the on-the-ground knowledge necessary to set effective policies or engineer solutions.
But Dr. McCoy also notes one positive consequence of far-flung hospital networks and practice management programs: Many of those administrators up the chain of command tend to be physicians. For Beth Israel Deaconess’ Dr. Dhand, who’s so concerned about doctors’ loss of practice control, physician leadership—throughout hospital and health care administration, not just heading up hospitalist programs—is the only viable solution.
“The best way to change physician ‘behavior’ is to have it come from the right source,” Dr. Dhand notes. That source, he believes, needs to be another clinician, who “should ideally still have a hand in clinical medicine, whether it’s one day a month or some time shadowing. It’s really important that the people enforcing rules for front-line workers walk in those workers’ shoes.”
Mr. Buser points out that in a growing number of hospitals, “the majority of new CMOs are being appointed through the ranks of their hospitalist group.”
But advancing beyond CMO in hospital administration can be a real challenge. While physicians want to work with other physicians, Dr. McCoy says, administrators value the experience of other administrators, and not necessarily doctors.
“Administrators aren’t going to share their world with a doctor who, in their mind, hasn’t earned it,” she says. “People who have been full-time administrators find it enormously insulting that they’d need to be replaced by a physician executive who hasn’t put in 20 years in the lower ranks of an organization.”
A “golden age” of hospital medicine?
Far from being pessimistic, Dr. Yu feels hospital medicine is on the verge of its “golden age of process.” Having practiced in New Mexico, where two out of every five residents are on Medicaid (which is capitated) and only 25% of patients have commercial insurance, “we’ve had to be very innovative and way ahead of the curve,” he says. “We’ve had to focus on being a cost center, not a revenue center, and that involves process. That makes the way we practice in New Mexico everyone’s future.”
Most hospital administrators, he explains, have succeeded with the revenue model, handling high-margin producers such as cardiologists and orthopedists. But as reimbursements get squeezed and the fee-for-service model fades in the MACRA/MIPS era, “the first thing many administrators will do is knee-jerk cost-cutting. They’ll cut hospitalist groups to save money.”
That, he adds, is precisely what hospitals shouldn’t do. Hospitalists are the sole group of doctors who can help hospitals transition from a revenue center to a cost center.
“A lot of wrong decisions will be made, and we’ll need administrators to think according to a new paradigm,” says Dr. Yu. “But eventually they’ll come up with the right solution, which is to invest in hospitalists and in process to survive under the new economic model. There is no other option.”
And the 28-year-old business types who want to tell physicians how to practice? “I don’t think they’re long for a career in this business,” says consultant Mr. Buser. “You can’t have that attitude as an administrator and survive. You may have some short-term successes, but in the long term, the doctors will get you. It’s just a question of time.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
• “Data-mining is critical,” says David Yu, MD, MBA, the medical director of the adult inpatient medical service for the Presbyterian Medical Group in Albuquerque. That can be a problem when hospitals collect much more data on revenue than on costs, which are the data hospitalists need to make their case for value. “Some reports you have to beg for,” he says. “Others, you have to collect yourself.”
• Hospitalist leadership needs a structured, formal communication channel with administration, with monthly meetings. “We tell hospitalists: You want to be there, and you want to brag,” says hospital medicine consultant, Martin Buser. “You want to point to the reduction in length of stay you’ve achieved, then spell out what that means to administration.”
• Stop being scared of financials. “I tell every medical director I meet to get an MBA or at least take some financial courses,” says Mr. Buser, who adds that most doctors just “glaze over” when he brings up financial issues. “I don’t know if it’s in their DNA or if they’ve been taught to be afraid of finance, but they don’t need to be. I tell them, ‘The practice of medicine, that’s tough; the financial stuff is a lot easier.’ ”
• Invite administrators to spend time with you doing rounds to give them a better appreciation of your day-to-day activities. “Many of them don’t have the depth of understanding they need to make the policy decisions they’re often making,” says David Grace, MD, senior medical officer at Schumacher Clinical Partners, a national physician staffing company.
• Unless it’s prohibited, Dr. Grace says, hospitalists should attend medical executive committee meetings, even if you don’t have the right to vote. “After you show up, people may start asking your opinion. That goes a long way to having influence, even if you’re technically not an executive member.”
• Populate committees. Even before she became hospitalist director, Carol Nwelue, MD, who’s with Sparrow Hospital in Lansing, Mich., joined close to a dozen hospital committees. “It’s a good way to figure out what’s going on,” Dr. Nwelue says, “and that’s a huge piece for the rest of the group. Instead of complaining, I made it clear that we need to be in the room where decisions are made and speak up for the group.”
• Some administrations can be very forward-thinking. Hospitalist director Lisa Kaufmann, MD, hospitalist medical director for Appalachian Regional Healthcare System in Boone, N.C., points out that her administration brought in Studer Group consultants, a move that changed the entire culture throughout the hospital system, including the culture at the top.
But “it’s very variable whether an institution would do that,” Dr. Kaufmann admits, and “we’re blessed to be in a profession where we can just leave any time we want. If you care about making your workplace better but your hospital does not want hospitalists engaged in fixing problems, you need to quit.”
CHANCES ARE, if you and your colleagues are facing disrespect and a lack of autonomy, you’re also suffering a crisis in hospitalist leadership.
“If you’re a hospitalist medical director and all you’re doing is making a schedule, you’re not doing your job,” says Lisa Kaufmann, MD, the hospitalist director for the Appalachian Regional Healthcare System in Boone, N.C. “It’s your job to identify win/win situations with administrators and build social capital.” Part of the problem with hospitalist leadership, says Dr. Kaufmann, is that most doctors have no formal training in negotiation or cost-benefit analysis.
Another problem: So many hospitalists and hospitalist leaders are young, points out David Yu, MD, MBA, the medical director of the adult inpatient medical service for the Presbyterian Medical Group in Albuquerque. “They’re book smart and experience poor. I’d love to see a survey of the average age of a medical director in hospital medicine vs. a department of surgery.”
According to Dr. Yu, that lack of experience at the top and throughout the group sets up a difficult path for young hospitalists. Many programs do not offer mentors or steer younger doctors toward pertinent committees or important people to know in their hospital. And “a lot of hospitalists are visa candidates,” Dr. Yu points out, “so they’re trying to develop an understanding of American culture, let alone hospital leadership culture and its set of politics.”
That leaves many rank-and-file doctors feeling that “they’re not in control because they don’t invest in the overall system,” Dr. Yu says. “They are disengaged, but complain that they are not being heard when issues affect their daily work.”
The fix, says Dr. Yu, is for doctors to become engaged individually. “It’s the equivalent of people who never vote complaining about the political system.”