The paradox of legitimacy: physician executives and the practice of medicine

This study looks at the legitimation of medical management and its effect on the likelihood of physician executives practicing medicine. The findings of a national survey show that several individual-level characteristics associated with legitimation such as working in senior management positions and for-profit organizations lower the probability that a physician executive will also be an active clinician. In addition, physician executives possessing graduate management degrees are more likely not to practice medicine than individuals without a degree. These results suggest that the specialty of medical management should pay greater attention to its unique qualities as it legitimizes if it is to be of long-term value to health care organizations and rank-and-file physicians.     

Exploring dual commitment among physician executives in managed care

The growth of a medical management specialty is a significant event associated with managed care. Physician executives are lauded for their potential in bridging the clinical and managerial realms. They also serve as a countervailing force to help the medical profession and patients maintain a strong voice in healthcare decision making at the strategic level. However, little is known about their work loyalties. These attitudes are important to explore because they speak to whose interests physician executives consider and represent in their everyday management roles. If physician executives are to maximize their effectiveness in the healthcare workplace, both physicians and organizations must view them as credible sources of authority. This study examines organizational and professional commitment among a national sample of physician executives employed in managed care settings. Data used for the analysis come from a national survey conducted through the American College of Physician Executives in 1996. The findings support the notion that physician executives can and do express simultaneous loyalty to organizational and professional interests. This dual commitment is related to other work attitudes that contribute to success in the management role. In addition, it appears that situational factors increase the chances for dual commitment. These factors derive from a favorable work environment that includes both organizational and professional socialization in the management role. The results of the study are useful in specifying the training and socialization needs of physicians who wish to do management work. They also provide a rationale for collaboration between healthcare organizations and rank-and-file physicians aimed at cultivating physician executives who are credible leaders within the healthcare system.     

The leadership and executive potential of physicians in an era of managed care systems

The emergence of managed care signals a need for an expanded role for physicians. Physician executives, trained in management, have the potential to become champions of clinical integrity, negotiators with patient agent organizations, public interpreters of hospital performance data, consultants to the profession, and designers of health care systems. Nonclinically trained administrators have been slow to recognize the unique skills and perspective that physicians bring to the managerial suite. The clash of professional and managerial cultures has often been perceived as precluding a strong working alliance between physician and nonphysician executives. As hospital margins are threatened, decision protocols must not be designed to incorporate teams of leaders who are able to overcome the managerial/clinical divide. The management of this interface will demand the attention of both administration and boards and may require the establishment of new structures in health care organizations.     

The potholed path to becoming a physician executive

This article discusses evolving career pathways for physician executives--pathways that take physicians out of primarily patient care roles and into management activities. The discussion is textured with "how-to" advice for readers who may have aspirations of becoming physician managers and executives. The advice stems from my own experiences in the pharmaceutical industry and other healthcare sectors. Specific topics addressed include: attending business school, gaining management experience, working in large corporations, dealing with job loss, acquiring both hard and soft skills, cultivating mentors, and developing leadership competencies. Physician executives must demonstrate strong leadership abilities and learn how to tactfully confront difficult people and problems.     

Physician executives in managed care: characteristics and job involvement across two career stages.

This paper examines characteristics, job involvement, and career stage differences among 294 physician executives working in managed care settings. The following research questions guide the study: What types of physicians are currently in managerial roles in these settings? What role (if any) does medical career stage play in physician executives' professional and job-related attitudes? What factors are related to physician executives' involvement in their management roles? Several observations are made from the findings. First, contemporary physician executives see management as an exciting alternative career that involves multiple work loyalties, weaker beliefs in traditional professional values, and the sacrifice of significant amounts of clinical for management work. Second, these trends are more pronounced for physician executives at earlier points in their medical careers, although their work loyalties to profession and employing organization are weaker than older physician executives' loyalties. Younger individuals' involvement in management work, more than older individuals' involvement, appears to depend upon the surrounding work climate within the organization. Finally, the amount of time spent by physician executives as clinicians is inversely related to how psychologically attached they are to management, regardless of career stage.     

What are we without risk? The physician organization at a crossroads

The managed care market in Chicago is experiencing rapid change. As health maintenance organization (HMO) enrollment flattens or even declines, and capitation becomes less sustainable for many, physician organizations are reevaluating their continued participation in risk-based contracts and are struggling to define their future roles. Physician organizations are looking for new ways to provide value to their physician members. Physician hospital organizations (PHOs) in particular are reassessing how the organization can continue to serve the interests of both the physicians and their hospital partners. To better understand the concerns of physician organizations, The Lowell Group surveyed Chicago area provider executives on their top issues. Three major concerns emerged: (1) protecting the financial health of the organization; (2) predicting the future of the managed care industry; and (3) evolving the physician organization to meet changing market conditions. Ultimately, physician organizations must make business decisions that support their true goals-serving patients and purchasers of care, physician members, and the organization's owners.     

Sustaining the edge: factors influencing strategy selection in academic health centers

Competition within the acute care sector as well as increased penetration by managed care organizations has influenced the structure and role of academic health centers during the past decade. The market factors confronting academic health centers are not dissimilar from conditions that confront other organizations competing in mature industries characterized by declining profitability and intense rivalry for market share. When confronted with intense competition or adverse external events, organizations in other industries have responded to potential threats by forming alliances, developing joint ventures, or merging with another firm to maintain their competitive advantage. Although mergers and acquisitions dominated the strategic landscape in the healthcare industry during the past decade, recent evidence suggests that other types of strategic ventures may offer similar economic and contracting benefits to member organizations. Academic health centers have traditionally been involved in network relationships with multiple partners via their shared technology, collaborative research, and joint educational endeavors. These quasi-organizational relationships appear to have provided a framework for strategic decisions and allowed executives of academic health centers to select strategies that were competitive yet closely aligned with their organizational mission. The analysis of factors that influenced strategy selection by executives of academic health centers suggests a deliberate and methodical approach to achieving market share objectives, expanding managed care contracts, and developing physician networks.     

Managing outcomes: the perspective of the players

Outcomes management is most deeply rooted in clinical issues that interrelate concerns about quality with cost effectiveness of care. This is ground-breaking activity from many perspectives. Researchers must work more closely with clinicians and decision makers than ever before. Hospital executives must contend with many new external data demands and determine how to operationalize outcomes management programs within their institutions. There are new roles for clinician executives who act as change agents within health care organizations, while data on outcomes of care can lead to increased bargaining power among purchasers of services. In this article we discuss the major implications this new focus on managing outcomes is having on researchers, hospital executives, clinicians, and the purchasers of health care services.     

Defining Competencies and Performance Indicators for Physicians in Medical Management

The recent and profound changes in the American health care delivery system have created a need for physicians who are trained and willing to assume a high level of responsibility for managing evolving health care organizations. Yet most physicians receive no formal training in medical administration and management because changes in medical school and residency education have lagged behind changes in clinical practice and reimbursement. To avoid haphazard approaches and unnecessary duplication of resources, it is important for physicians involved in managerial medicine to collectively identify competencies in this area needed in the marketplace. The American College of Preventive Medicine (ACPM), with funding from the Health Resources and Services Administration (HRSA), undertook an effort to identify competencies essential for physicians who will fill leadership roles in medical management. Like ACPM’s earlier effort to develop core competencies in preventive medicine, this project drew upon the theoretical model of competency-based education. This article describes the strategy we followed in reaching consensus among a diverse group of physician executives and preventive medicine residency program directors, and includes the list of medical management competencies and performance indicators developed. Recurrent issues that can sidetrack competency development projects are also presented as well as suggestions for overcoming them. The competencies can serve as a framework for expanding current core preventive medicine training in management and administration and for developing new training programs to equip physicians with the special expertise they will need to provide management leadership within the changing landscape of health care delivery.     

Professional commitment among US physician executives in managed care

This paper examines professional commitment among physician executives working in managed care settings in the United States. The rise of an 'administrative elite' in medicine is central to the notion that physicians preserve their professional dominance despite changes in their prestige, work and employment status. Implicit in the notion of Freidson's restructuring perspective, physician executives presumably remain dedicated to professional interests in their management roles. The findings of a national survey support this assumption. Physician executives maintain meaningful, stable levels of professional commitment over time in management and the organization. This commitment is positively related to work-related characteristics involving favorable perceptions of the management job and physical and mental 'connection' to the practice of medicine. Belief in one's ability to successfully deliver appropriate clinical care, however, moderates the positive association between involvement in the management job and professional commitment. The findings provide a rationale for the maintenance of professional loyalty among physicians in management rooted in the work-related perceptions and activities of the individual physician executive.     

Managed care plans and the organizational arrangements with group practices

This article addresses the variety of structural and legal arrangements between group practices and health plans. The continuum of relationships will be discussed, including long-term arrangements whereby in exchange for long-term commitments to provide physician capacity, providers are given a capital contribution from managed care plans; management services organizations whereby managed care plans create management companies that provide turnkey management services in exchange for capital, with a commitment by the group practices to provide physician services to the health plan over a long period of time; mixed equity relationships where physicians and managed care plans jointly own the group practice, which group practice also has an ownership interest in the managed care plan itself; and acquisition of the group practice by the managed care plan. Each of these structures will be described, along with the legal issues that may be considered in any of these relationships.     

Managing managed care. The task calls for an integrated management team

Healthcare providers must learn the art of "managing care," a concept integral to but broader than managed care. Managing care has four dimensions: recruiting skilled operations managers; developing systems, procedures, practices, and protocols that meet the demands of capitation and risk management; fully integrating physician leaders; and preserving society's resources by providing care on the wellness, rather than the sickness, model. Managing managed care, which is now usually the task of a single executive, will tomorrow require a team comprising these four roles: The CEO articulates the system's vision, helps develop its strategic plan, and leads the effort to educate all its associates and employees about managed care. The operations leader (which may in fact be a group of operations executives) redesigns the systems organizations, redeploys its managers, and dismantles its obsolete methods. The physician leader (which may also be a group, rather than an individual) helps retool the system's practices and protocols in a way that enables it to deliver the highest quality of care at the lowest possible cost. The managed care executive acts as the broker between the system and insurance firms. In larger systems, this executive designs long-term partnerships between the system and insurers.     

Is a management degree worth the investment for physicians? A survey of members of the American College of Physician Executives

In a survey of 568 physician members of the American College of Physician Executives (ACPE), most of whom had advanced management degrees (MBA, MMM, MPH), approximately 90% of respondents reported that their investment in the education was "worth it." The return on investment was independent of the quality of the academic institution, although primary care physicians stood to gain more relative to specialists. Salary comparisons showed that female physicians had approximately 20% lower incomes than male physicians, confirming the presence of a "glass ceiling" for female physician executives as seen in other medical specialties. These findings have implications for early and mid-career physicians and physician recruiters.     

A profile and educational framework for physician managers in a teaching hospital.

The role of the physician executive is explored in this article using a case study approach to outline administrative performance. Based on a survey of clinician executives at University Hospital in London, Ontario, a profile of background characteristics, activities and responsibilities, and reports on physician attitudes on the merit of administrative training, qualities that make good physician leaders, ethics in health care, and the nature of physician participation in management is presented. Recommendations from this research for developing an administrative training program designed for clinician executives in a teaching hospital follow.     

The effect of managed care on hospital marketing orientation

Marketing is a central activity of modern organizations. To survive and succeed, organizations must know their markets, attract sufficient resources, convert these resources into appropriate services, and communicate them to various consuming publics. In the hospital industry, a marketing orientation is currently recognized as a necessary management function in a highly competitive and resource-constrained environment. Further, the literature supports a marketing orientation as superior to other orientation types, namely production, product and sales. In this article, the results of the first national cross-sectional study of the marketing orientation of U.S. hospitals in a managed care environment are reported. Several key lessons for hospital executives have emerged. First, to varying degrees, U.S. hospitals have adopted a marketing orientation. Second, hospitals that are larger, or that have developed strong affiliations with other providers that involve some level of financial interdependence, have the greatest marketing orientation. Third, as managed care organizations have increased their presence in a state, hospitals have become less marketing oriented. Finally, contrary to prior findings, for-profit institutions are not intrinsically more marketing oriented than their not-for-profit counterparts. This finding is surprising because of the traditional role of marketing in non-health for-profit enterprises and management's greater emphasis on profitability. An area of concern for hospital executives arises from the finding that as managed care pressure increases, hospital marketing orientation decreases. Although a marketing orientation is posited to lead to greater customer satisfaction and improved business results, a managed care environment seems to force hospitals to focus more on cost control than on customer satisfaction. Hospital executives are cautioned that cost-cutting, the primary focus in intense managed care environments, may lead to short-term gains by capturing managed care business, but may not be sufficient for long-term success and survival. Understanding consumer needs and perceptions, and using appropriate marketing strategies to ensure greater customer satisfaction and repeat business, will be among the key tasks for hospital executives in the future.     

Building relationships with physicians. Internal marketing efforts help strengthen organizational bonds at a rural health care clinic

Physician turnover is costly for health care organizations, especially for rural organizations. One approach management can take to reduce turnover is to promote physician loyalty by treating them as an important customer segment. The authors develop an information--oriented framework for generating physician loyalty and illustrate how this framework has helped to eliminate physician turnover at a rural health care clinic. Rural health care organizations must develop a more internal marketing orientation in their approach to establishing strong relationship bonds with physicians.     

Managing Change in the Context of Health Reform: Lessons from Alberta

A qualitative field study of health system reform in Alberta was undertaken to identify, describe, compare and contrast the processes of change management adopted and implemented as a result of legislated health policy shift. Chairs and chief executives of the new regional health authorities and provincial leaders managing the change processes within Alberta's hearth care system were interviewed. Components of change strategies important to the structure, process and impact of the health policy shift to a regionalized system of care were identified and analyzed. Stakeholders involved in managing change inside Alberta's health care system were able to consistently identify a range of issues important to beginning and sustaining health policy shift. These issues and insights did not come from the literature, but rather from experience. To test and share this experience further, it will be important to study more consciously the management of change in relation to expected outcomes. With so many natural experiments altering health care systems across Canada and beyond, a window of opportunity exists for researching both the quality and quantity of such change, comparing and sharing findings over time and, eventually, linking process to outcome.     

Managing diversity: a senior management perspective

Diversity and managing diverse workgroups have become strategic imperatives for many organizations. Corporations are developing programs and opportunities to increase the participation of their employees, especially those who have not been previously included in the mainstream of their organizations. Many health care institutions are also focusing on diversity management. This study was designed to examine the manner in which diversity management is perceived and implemented by hospital executives. To determine the perception of executives, a 16-item questionnaire was developed and distributed to hospital executives. The data showed that executives in urban teaching hospitals considered their workforce diverse, and many of these organizations had implemented diversity management programs in their facilities. Surprisingly, this study found that although most executives (68 percent) agreed they had a diverse workforce, less than one-third (30 percent) of these executives had specifically developed diversity management programs in their hospitals.     

The impact of corporate memory loss: What happens when a senior executive leaves?

PURPOSE: The author is a nursing management practitioner, whose purpose in writing this paper is twofold: to examine the impact of corporate memory loss on a health care institution, caused by increasing retirement rates of senior executives; and to use this research as an opportunity for action learning where both the author and the institution can benefit from the learning outcomes. DESIGN/METHODOLOGY/APPROACH: Using qualitative research methods based on ethnographic interviewing techniques and grounded theory, the author interviews 12 senior executives from four diverse health care facilities. The purpose is to determine the point at which corporate memory loss, in the form of tacit knowledge in the heads of departing executives, becomes a problem for the institution. FINDINGS: The research determined that the requisite managerial competencies normally assumed for senior management positions are insufficient to minimize the negative impacts of corporate memory loss caused by departing senior executives. Effective knowledge management and knowledge transfer within the organization are fundamental for ongoing organizational effectiveness. RESEARCH LIMITATIONS/IMPLICATIONS: The research is limited to 12 senior executives. The grounded theory nature of the research provides a framework for more research in other institutions to test and further explore some of the findings. PRACTICAL IMPLICATIONS: One of the most significant threats facing the majority of health care organizations related to the aging workforce is the greater number of staff who are retiring from all levels within the organization. The development of techniques to reducing the impact of corporate memory loss on the culture of an organization will increase its effectiveness, help build continuity, and provide a more secure footing for the workforce of the future. ORIGINALITY/VALUE: The exit of knowledge workers is causing a major problem for Canada's health care organizations. This study throws more light on to this problem from the point of view of senior executives who have been specifically impacted by the problem of corporate memory loss.     

Texas hospital chief executive officers evaluate content areas in health administration education

Health care executives are confronted by a working environment that is increasingly difficult to manage. Skyrocketing health care costs, with shrinking reimbursement, threaten the existence of hospitals. A successful hospital chief executive officer (CEO) is one who can effectively manage his/her hospital in spite of industry challenges and problems. Graduate programs in health services administration must be designed to meet the needs of future health care executives. Many times, educators are criticized for not addressing "real world" issues within the curricular structure. The present study was conducted to gather information from executives who are the experts on what to expect in the health care industry regarding the appropriateness of curricular topics. Results indicate that practicing CEOs believe those curricular areas which focus on financial planning, budgeting, medical-legal issues, and strategic planning are more important than those that deal with international health care, epidemiology, or research methods. The information gathered in this study may be useful as a guide for educators, to evaluate and revise existing graduate programs in health care administration. Data presented here may also be used to assist in long-range planning for new health administration programs.