The physician burnout crisis in the United States is attributable to one key issue, according to William C. Waters, IV, MD, founder of Waters Healthcare Consulting LLC: the devaluation of physicians personally and professionally.
“If the CEO or a highly placed executive in your health system had to do all of their own secretarial work, and everything that they said and did had to be put into a context … and they had to do it all themselves — how would that go over?” Waters asks regarding time spent by providers in EHRs and documentation. “That doesn’t go well with physicians either. … It’s not that they think they’re too good for it. It’s not a good use of their time.”
Time increasingly becomes a critical element in physician behavior. In the days of his father and grandfather, both physicians, their financial stability and work gratification were great, but work-life balance was horrible. “I never saw my father” because of his work schedule, Waters says.
That has drastically changed in today’s healthcare workforce. “Today’s physicians demand time off” that past generations never did,” Waters asserts. This isn’t a failing, by any means — instead, it should shift the focus on how an organization achieves financial stability and levels of gratification among workers without undercutting work-life balance.
This is where clinical integration by way of dyad models of leadership and what Waters calls “synergistic leadership” comes into play so that clinical and administrative sides of a medical practice take on risk and challenges together.
Speaking at MGMA19 |The Financial Conference in March with Ellis “Mac” Knight, MD, MBA, FACP, FACHE, senior vice president and chief medical officer, Coker Group, Waters points to clinical integration as the key — strategic deployment of system resources to achieve an environment in which all clinical and administrative team members unite with the primary focus of providing cost-effective, appropriate, high-quality and available care for patients.
Knight says that improving value in healthcare — quality per unit cost, as he puts it — is “the overarching imperative” in the industry today. For decades, those two tracks have run parallel and rarely worked in tandem to deliver on the value equation, Knight asserts. Yet bringing those two worlds together has cultural and financial benefits beyond improved outcomes for patients.
Financial and human imperatives
Waters notes that financial solvency remains the focus of medical practices. “If you can keep the doors open, you can provide service, but … as it relates to the essence of clinical integration: no margin, no mission, but the margin is not the mission.”
Moreover, just throwing money at operational challenges in the shift to value-based care won’t work, he contends. An erosion of financial margins amid reimbursement changes intensifies pressures on the provider base, which already faces significant pressure.
Citing a Merritt Hawkins survey of 17,236 physicians,1 Waters adds that two-thirds are pessimistic about the future of medicine; almost half (48%) plan to retire soon, seek non-clinical work or cut back on hours; and 49% of physicians do not recommend medicine as a career.
“My dad was a doctor, my granddad was a doctor and I was raised not with being told I was going to be a doctor — I wanted to be a doctor because I saw what it was to be one. But half of [doctors] are telling their offspring, ‘don’t do it.’”
Instead of the two sides operating with shared goals and risk, Waters says clinical integration can share those burdens if a model has two key components:
- Organizational strategy: A mechanism to allow physician integration
- Operational strategy: An operational context which allows/requires physician leadership and team accountability.
This would yield a “synergistic leadership” approach, wherein there exists:
- Commitment to authorize, integrate and hold accountable physician leadership
- A compliant, clear, realistic and financially sustainable plan for physician/clinical integration
- A commitment to being data-driven as a practice achieves organizational reliability and team accountability.
These lead to what he deems “synergistic leadership” — a leadership structure composed of clinical and administrative colleagues such that the effectiveness of the team’s efforts is distinctly greater than the sum of individual efforts.
Mechanisms for integration
While deciding on a model of leadership, it requires a group’s chief executive officer to be present in the change, Waters says — but the true focus should be in pairing the existing physician leadership with the group’s administrative and financial leaders.
Of importance is understanding how financial solvency is achieved in the practice. “We need to figure out the value of palliative care cost avoidance … What about institutional quality measures? … We have to be able to measure these things that we’re making investments that are going to allow us to produce high-quality, low-cost and available care for our patients as a team,” Waters asserts.
A method for establishing a “corridor of profitability,” Waters says, is comparing total revenue per adjusted patient day (TR/APD) versus total expense per adjusted patient day (TE/APD). The separation that occurs is the margin (as seen in Figure 1).
With that financial understanding as the basis, groups and health systems — varying by ownership type and specialty — can begin to explore different forms of clinical integration that make sense for them, including dyad structures, co-management agreements and other similar models.
“There’s certain rules,” Waters says. “You really need a customized approach: what are your goals as you look to lower costs and improve care? In many cases, there’s some overlap.”
Waters says that building this leadership expectation from the physician side often does not need to be specifically compensated because it ultimately boosts a provider’s work gratification. “It’s what they went to medical school for,” Waters says. In many cases, it can be an opportunity to “get out of peoples’ way and let them lead.”
In practice: Orthopedics
In one orthopedic practice Waters worked with, patient volume and satisfaction were stagnant or declining as physicians and operational staff kept to their own areas of focus with their usual vigor. “The overall result in spite of these components wasn’t that great, so there was no growth occurring.”
Waters pushed to develop one-, three- and five-year strategic plans with orthopedists and administrators talking together under a co-management approach.
The financial model needed to be changed: Providers were paid per call at first, but then shifted the per-call pay lower with the addition of quality incentives that would push for better care access and outcomes. The clinical and administrative leaders agreed “to follow the data like crazy,” as Waters puts it, to track functional outcomes, clinical and operational efficiencies and access.
The changes resulted in a comprehensive rebuild of the service line. Costs per patient went down and there was an almost zero infection rate, which significantly reduces the number of follow-up appointments for patients. Functional return of capacity to total joints rose to the 94th percentile in the nation. Those clinical outcomes meant many patients did not need to be seen again for five months, and the days until release for knee replacement went from 5.4 to 1.1.
“That’s where the money is: process improvement,” Waters adds, noting that the co-management structure brought a renewed focus on clinical documentation improvement which contributed to about $1.3 million in net revenue improvement that was also buoyed by case volume increases (see Figure 2).
Healthcare organizations that don’t align vision, goals and operations already between the administrative and clinical sides may have an opportunity to use a synergistic leadership model to begin to embrace the transition away from fee-for-service models, Waters contends.
“We’ve got to be prepared for a value transition,” Waters says. “It’s going to happen with our leadership or we’re going to be led by the nose by others to do it.”
With a leadership model in place, administrators and providers can work together to make contributions that lead to more efficiencies and better care outcomes.
“Don’t be afraid to invest in process improvement. … It is critical to the future,” Waters concludes.
- “Half of U.S. doctors plan to retire, cut-back or seek non-clinical roles.” Merritt Hawkins. Sept. 21, 2016. Available from: bit.ly/2UUqyIj.
What is dyad leadership?
Tim Hewitt, MHA, CMPE, FACHE, and Tammy Tiller-Hewitt, MHA, FACHE, offer these thoughts on dyad leadership:1
Medical group leaders know that it is counterproductive to pay lip service to the claim of being “physician-led/professionally managed.” In too many cases, it is a nebulous ideal that is difficult to define and harder to achieve without the resources, structure and culture to fully engage the medical staff. ... Forming a dyad team management structure — consisting of a clinical member and an administrative member who co-lead or co-manage their area of responsibility — can be a step toward better organizational outcomes.
Denis A. Cortese, MD, and Robert K. Smoldt, MBA, outline five success factors for physician-administrator partnerships:2
- Common core value(s): The old management adage that “what I do is more important than what I say” is very true. It makes little difference what leaders say or write in their medical center communications if they turn around and behave differently.
- Willingness to work together toward a common mission and vision: If the leadership team gets too territorial (e.g., this is my area, keep your nose out), the ideal of leveraging each other’s strengths will be lost.
- Clear and transparent communication with each other and the organization: The more time the individuals spend together as a leadership team, the more frequent and open the communication will be. If over time, communication frequency declines, it is probably a sign that the dyad has divided up responsibilities/authorities and is not really working jointly for overall success of the medical center.
- Mutual respect: It is especially important for the physician/administrative leadership to remember that respect must be earned, and a big part of earning respect is to show respect for the views and positions of others. Neither member of the physician/administrative leadership team should assume that her/his view is always the correct one. Each needs to show respect and give thought to the other’s position.
- Complementary competencies: Employing a dyad leadership approach can expand the level of competence in the top leadership. This is precisely why some organizations deliberately look for two individuals who will complement each other — one being strong in an area where the other is weak.
- Hewitt T, Tiller-Hewitt T. “Building effective dyad growth teams.” MGMA Connection. May 2017. Available from: mgma.com/dyad-growth.
- Cortese D, Smoldt R. “5 success factors for physician-administrator partnerships.” MGMA. Available from: mgma.com/dyad-partnerships.