“Alignment” is a neutral sounding word that represents a very large problem in medical management.
Forbes magazine, reflecting on the conflict between physicians and “management-led organizations” writes “A major reason for the tension is a lack of alignment between physicians and their organization’s vision and goals.”
A recent report by Bain and Company highlights this lack of alignment. The reports documents a number of the trends that we have explored in this blog including “the accelerated loss of autonomy over clinical decision making… increasing use of standardized clinical protocols and electronic medical records, more objective metrics for measuring clinical performance,” and “payment models that put providers at risk for outcomes.”
These trends can be summarized by saying that while physicians will be held responsible for outcomes, they will no longer have the means to make the decisions that lead to those outcomes. Is this the conflict of vision and goals between the physicians and management that Forbes is concerned about?
The Bain report, in an attempt to quantify physician satisfaction, developed a net promoter score which measures whether a physician would recommend their organization to someone else. According to Bain “physicians working in management-led systems of care are significantly less likely than those in physician-led organizations to recommend their organization to others.” And consistent with these findings “When management-led organizations take the time to engage physicians effectively, their Net Promoter Score rises dramatically….”
Clearly unengaged physicians are unhappy, but is there a way of discussing engagement in which it is measured by more than the subjective scale of the physician? Can we work toward a physical engagement that can be measured by real outcomes?
Engagement like alignment is a hard word to define and one wonders about the sincerity of all this engagement. Bain measures the effect the engagement has on physicians, but not the effect the engagement has on medical outcomes which would also be an important measure of whether engagement is working for the system.
In their systematic review of literature on physician hospital integration Trybou et al write “Physician–hospital integration is clearly more than just strengthening the economic ties between both. Instead, from a policy perspective, added value is realized by increasing the underlying day-to-day cooperation in order to improve efficient care delivery and to improve the quality of the delivered care.”
The Bain report is in part an analysis of medicine aimed at the medtec and pharma industries. Integration is not only important to improving patient outcomes, but also for knowing who to sell your product to. According to the report, two-thirds of surgeons report being “pressured to go along with their hospital’s purchasing guidelines.” And two-thirds of physicians say that formularies limit their decision making. The study also reports that sales reps are becoming less important as a source of information for doctors. From the perspective of the patient it is hard to see that as bad news but it does complicate the question of integration in so far as it is both a medical and business decision. This should also be seen as a cautionary tale in which, from the doctor’s perspective, integration, alignment and engagement are distinct from cooptation.
According to a study by Sowers et al that evaluates Physician- Hospital Alignment models, “The goal and outcome of alignment should be clinical integration, defined by the physicians’ and hospital’s ability to share the same mission, vision, and strategies to improve organizational performance. The strategy to achieve this goal will depend on organizational culture readiness, trust, the catalyst for change, and leadership alignment within the physician practice and hospital.”
Traditionally two models have been used to create physician–management alignment: Non economic integration and economic integration. Economic integration obviously uses financial means to unite the physicians and management. It is the non-economic which is both more complicated and more powerful. As Sowers et al write “The noneconomic integration is the foundation for true clinical integration and often the most challenging component in achieving alignment. Shared planning, decision-making, and development of improvement strategies that drive organizational performance will allow for physicians and hospitals to operate more effectively in a complex and ever-changing payer environment.”
Doctors Council takes this idea very seriously. In our last round of negotiations in New York and Chicago our major demand was non-economic integration. In a future blog we will explore our White Paper and final contract language that we believe puts Doctors Council members in the forefront of both engagement and alignment.
For as written in Forbes, “health care organizations need to redouble their efforts to involve physicians in key decisions from the very start of the process. No longer can administrators rely on support for decisions in which the physicians had no real input…. implementing it will take significant commitment…. There must be meaningful action and follow-through…. Fixing these areas of friction can increase cooperation, and that can improve care quality, lower costs and eliminate significant wasted effort.”
And this can lead to a win-win-win for patients, health systems and doctors.
Sowers et al concluded “The measure of success in building physician-hospital alignment is measured in improvements in care for the patient, reduced cost of care delivery, and improved relations between physicians and hospital leadership.”