“Physician Alignment” Payments Won’t Fix Broken Healthcare Delivery Systems. Considering a New Path Forward.

A colleague at a hospital-based health system recently told me about “physician alignment” initiatives his employer was introducing. These included “co-management” deals (where doctors get per-patient incentives for on-time discharges, and high quality scores) and new salary models that adjusted based on various metrics. At the same time, he noted, his hospital was laying off clerks, leaving him spending hours on clerical tasks and on the phone with insurance company pre-authorization folks. Alignment, he noted, would have been much easier to achieve if there was honest discussion about what was needed and how hospital and doctor could get there, together.

From my perch, straddling two worlds as both a physician and health care administrator, it seems to me that (sometimes ham-handed) “physician alignment initiatives” are a troubling example of what’s wrong with many administrator/physician relationships today. I’ve observed that many systems often talk about “alignment” and then interact with physicians as though they are coin-operated: health systems shoving money across the barrelhead in an attempt to grab the attention of a bunch of often demotivated, tired and uninspired doctors.

I have some sympathy for my administrative colleagues: At meetings I’ve spoken to non-physician administrators who tell me that “alignment” is their biggest problem. They can’t accomplish their corporate goals without physicians, who seem unwilling to get with the program. In very broad strokes: they don’t show up, they don’t participate and they never seem to hold themselves accountable for even routine performance metrics.

My doctor colleagues, in contrast, argue that the real barriers to “alignment” are administrators who run health systems that are strikingly nonfunctional (judged by standards typical of any modern large business): wait times are long, access is inadequate, staffing is not sufficient, the electronic record is primitive, costs are out of control, and the like. Administrators aren’t providing good places to deliver and receive care, which ultimately is what they are there to do… To many doctors, administrators obsequiously seek physician input in the name of “engagement”– and then promptly ignore it.

If we want to improve the system of care delivery, I’d offer that we need fewer cash incentive payments and more honest dialog about shared goals and strategies.   Doctors, I believe, are passionate about delivering great care and they need work environments that enable this. They are generally willing to participate in the hard work of systems optimization so long as their contribution isn’t token “stakeholder buy-in” and that health systems move quickly to implement change.

Physicians and health administrators might consider a compact, which spells out their respective responsibilities for improving the system of care. I’m considering one for our own organization: here is my short list for what might be on it.

Physician expectations of health system leadership:

  1. Healthsystems will minimize, to the greatest extent possible, nuisance work assigned to the doctor that generates no value.
  2. Healthsystems will build sufficient capacitance into the system of care that the physician (usually the most expensive link in the chain) becomes the bottleneck in the workflow. A lack of low-cost resources should not slow patient care.
  3. Healthsystems will provide robust technology, that actually works, preferably developed and maintained by clinicians.
  4. Healthsystems will rapidly solicit, and quickly respond to clinician input. They will be nimble enough to fix local nuisances immediately, without needing committee or executive approval.
  5. Healthsystems will not make big decisions without meaningful representation from physicians. Token doctor representation, or representation from a CMO with no formal authority doesn’t count.
  6. Healthsystems will stop treating physicians as means to an end, and will look to them as sources for effective solutions to health delivery problems.

In exchange, health systems should expect a few things from doctors:

  1. Doctors will stop accepting token payments for achieving quality benchmarks, and will consider meeting quality and performance standards as inherent to the profession. Receiving tips for practicing medicine properly is beneath us.
  2. Physicians will approach new system initiatives with a spirit of inquisitiveness, enthusiasm and sense of purpose. The system of care delivery will never improve unless doctors are willing to work hard, troubleshoot and sometimes fail at system improvement initiatives.
  3. Doctors will agree make the needed investments in the long-term success of the system, even in lieu of short-term income opportunities.
  4. Physicians will treat administrators as valued colleagues and peers. An honest collaboration between doctor and non-doctor leaders is critical.

There are many more items that could be added to these lists, and I’m sure that the lists will differ depending on local circumstances and personalities (I’m eager to hear more suggestions in the comments below).

In the end, I’d offer that effective doctor/ administrator relationships will distinguish successful health systems going forward. Systems that progress with a shared sense of purpose and true collaboration will thrive, while those that offer “physician alignment” payments in lieu of real partnership will fail. “Alignment payments”, to my mind, are a symptom of a far more serious organizational problem.


Photo: US Army. Flikr, Creative Commons 

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