Why We Still Struggle with Physician Alignment

Posted by: Larry Sobal on Thursday, March 16, 2017
Why We Still Struggle with Physician Alignment

 

The idea of aligning physicians with hospitals and health systems has been actively pursued since the 1990s. Today, economic changes, new payment models, and the demands of various federal health policies all suggest the need for greater alignment between hospitals and physicians for both to be successful. If you talk to hospital/health system leaders, they will often say it remains one of their top priorities—and challenges. If you talk to physicians, they will often point to the reasons why alignment isn’t happening.

It’s possible that the elusiveness of physician alignment comes from vagueness of the concept. Like much of health care terminology these days, such as “Value” and “Clinical Integration,” the definition of physician alignment is muddy and open for personal interpretation. It is almost certainly seen differently by physicians and hospital leaders. 

Dictionary.com defines alignment as “a state of agreement or cooperation among persons, groups, nations, etc., with a common cause or viewpoint.” However, my experience as a facilitator of the many forms of alignment vehicles ranging from co-management agreements and professional services agreements to physician employment contracts, is that hospital-physician alignment is much deeper and more complex than the standard definition.

With the diversity of viewpoints, there continues to be tremendous effort, and angst, associated with achieving alignment. Today's health care climate is tumultuous, and unfortunately, the large degree of change and uncertainty can create increased potential for tension between hospitals and physicians, rather than bringing them closer together.

On one hand, unprecedented levels of consolidations, mergers and acquisitions, as well as the numbers of physicians who are now employed by hospitals and health systems creates (in theory) far greater opportunities for alignment. Alternatively, voluminous regulations, changing types of reimbursement, increasing operating costs and decreasing profit margins have caused both hospitals and physicians to struggle to find common ground in what some people describe as a profits vs. patients conflict.

Alignment is about shared vision and trust, not dollars.

 

It shouldn’t really surprise anyone. The traditional role of the physician as controller of the delivery of health care services has been increasingly superseded by an expanding array of corporations, integrated delivery networks and large medical groups, which often place physicians in corporate-style structures that are far different than the traditional, single specialty medical practice.

In addition to feeling loss of control over delivery of their services, physicians may be subject to pressures from leadership to make the physicians more direct participants in overall corporate economic strategies. Hospitals recognize that they cannot be successful in a volume-to-value transition without high levels of physician alignment and engagement, while physicians view these pressures as unreasonable affronts to their traditional autonomy. 

Furthermore, the role of the hospital as the center of the health care delivery system is changing. While inpatient activity still gets much attention, health care is now much more of an ambulatory industry where patient care is mostly handled outside the walls of the hospital, sometimes in nontraditional settings or ways.  Hospital leaders who maintain a myopic view and fail to see this broader picture will continue to struggle with physicians who are no longer as hospital centric as they were in the past.

So as health care delivery and financing shifts from a volume-based to a value-based business model, hospital and physician mutual success will be achieved through working together to achieve the best possible quality, outcomes and access for the lowest possible cost across the continuum of patient care services and sites.  

Based on the alignment successes and failures I’ve seen, here are a few pieces of advice:

  • Stop seeing alignment as a “hospital” initiative. Almost all alignment activities today involve hospitals proposing employment, gainsharing or other hospital-based alignment vehicles to attract physician engagement. Far too many health care CEOs have learned that these arrangements don’t guarantee the physician’s willingness to align with the organization’s goals.  It may be wiser to let the physicians take the lead in outlining what would best achieve alignment and work hard to understand their definition and expectations that come with it.
  • There is too much emphasis on financial incentives as the panacea for misalignment. Alignment is about shared vision and trust, not dollars. Complicated metrics and compensation incentives are short-lived as satisfiers, and have rarely been the reason both parties feel they have achieved better and sustainable alignment with each other.
  • Pay careful attention to the leadership and governance structures that you put in place. Too often there ends up being a competing set of silo’d organizational and leadership structures that are not well integrated across individual physician practices, hospitals, service lines and medical groups.
  • Rethink the processes used to involve physicians. I hear physicians express feeling patronized by being asked to give their blessing on a decision rather than provide input. Or worse, the physicians aren’t involved in key decisions at all.
  • Autonomous strategic plans, where multiple components of the same entity create their own independent strategies and tactics without a conscious connectivity and interdependency, can breed inconsistency, confusion and internal competition.
  • Finally, with whatever method you choose to create greater alignment, make sure you are placing as much, if not more, time on the crucial conversations to articulate, listen to, and craft mutual expectations. Too often, most of the energy goes into creating a legal arrangement, which then fails from lack of a formal or implied compact.

Improved alignment between hospitals and physicians will be essential to changing the way care is delivered, enhancing patient and physician satisfaction and improving each element of the value equation: quality, outcomes, cost and access. But as Einstein once said, insanity is doing the same thing over and over again and expecting different results. If it’s alignment with physicians you are after, you may need to take a different approach.

 

Illustration: Lee Sauer


 

Larry SobalLarry Sobal is Executive Vice President and a Senior Consultant at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and health insurance. Larry consults, writes and presents on topics relevant to transforming physician practices and health systems. His weekly blog post comes out on Thursdays and can be accessed at www.medaxiom.com.

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Comments

Steve, thank you for your comment. Indeed, we are in an era where uncertainty abounds. What's interesting is that I rarely hear a physician or physician group talk about needing "better alignment" with the hospital. And yet, the ability for hospitals and physicians to work together will become more and more important as the industry evolves.
Posted by: Larry Sobal on March 21, 2017 @10:30:22 am

Bravo!! so well said especially when we look and how healthcare is evolving I have told many colleagues, todays healthcare is a living thing changing and evolving almost daily, you have nailed the Sacred Cow!
Posted by: steve delach on March 19, 2017 @2:47:06 pm

Fred, thank you for your comments. I fully agree with your added insights. A transformational CV Service Line is responsible for the population of CV patients across the full continuum of care, including primary care and post acute - the hospital is but one aspect on that continuum. Furthermore, as health systems create large multispecialty medical groups, these often first focus on finding homogeneity among the many physicians and subspecialties, sometimes to the detriment of the unique aspects of each practice to have connectivity to its patients.
Posted by: Larry Sobal on March 16, 2017 @11:21:44 am

Larry, a very thoughtful analysis of the challenges with regard to physician integration. I would add a couple of other observations. First, health systems often insist on full control of the service line as the hospitals on the inpatient facilities. As outpatient services become continually more important a true sharing of control is equally important. Second, healthcare is still about the individual and personal relationship between the patient and the doctor. The larger the organization grows the more difficult it can be to maintain this personal relationship. It is not impossible to maintain this individual relationship in a large organization but it can be much harder to maintain
Posted by: fred Simmons on March 16, 2017 @10:20:57 am

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