KEY SKILLS FOR PHYSICIAN MANAGERS – Class 6

Most important skill for physician executives:

Communication skills

A consistent theme of what qualities make a good hire for an HMO medical director is that communication is the most important along with interpersonal skills, clinical credibility, ego strength, concern about quality, motivation, data orientation, and leadership qualities, along with organizational/systemic variables. Medical directors have enormous influence on medical cost and quality.

From Medical Director’s Perspective:

The customer is both the providers and the HMO members and part of the job of the medical director usually is to satisfy both

Managed care is basically an approach that superimposes organizational structure, control, measurement and accountability upon the health care system to effect a balance in the utilization of health care resources, cost containment, and quality enhancement. It does so by employing three strategies: (1) the alteration of financial incentives for providers, (2) the introduction of management control, and (3) the use of information systems to facilitate operational decisions. To accomplish those strategies, the HMO medical director is expected to understand health care and to have a management orientation in a managed care system.

Why Working with physicians who do not know how to practice quality effective medicine is a big challenge for medical directors:

These physicians may tend to tie cutting down of services with cutting down on quality when actually quality is, according to many medical directors, receiving appropriate services in a timely manner. For example, some physicians might order a MRI for a headache because they are worried about lawsuits when a MRI may not be appropriate.

A clear philosophy of managed care for a medical director might be: a belief that health care can be delivered and practiced in a different way – one that is more cost effective; a way that is equitable and acceptable to patients; a way that retains the quality of the present health care system without its excesses and extravagances.

It is a belief that most physicians want to do the right thing for their patients and for society; a belief that physicians can change their style and practice patterns if shown other effective ways to do it; a belief that physicians will change if given credible information on which to base decisions.

The philosophy incorporates an understanding of the role and limitations of the managed care organization as it attempts to organize, staff, and control delivery systems. That results in a belief in the job of the medical manager as a change agent, a coach to the profession and a leader ready to confront the hard issues.”

The key competencies and skills for physician managers include: Clinical Credibility, Communication Skills, Leadership Skills, Team Building, Negotiation and Conflict Resolution and Quality Management.

Based on the results of a study described in David J. Ottensmeyer’s article, “Lessons Learned Hiring HMO Medical Directors”, it was found that the typical combination of skills and personality characteristics for a HMO medical director are:

  • Communication and interpersonal skills, clinical credibility, ego strength, concern about quality, motivation, data orientation, and leadership qualities along with organizational/systemic variables were rated the most important skills and personality qualities for a prospective hire of a medical director.
  • Licensed physicians with more than five (5) years of clinical practice, sound clinical skills and good reputations should be sought to fill HMO medical director positions.
  • They need not be in a primary medical specialty, have a degree in management, maintain hospital privileges or plan to keep up a private practice.
  • bullet They need data skills as well as people skills and should have demonstrated ability to control utilization and influence providers.
  • bullet Communication skills are the utmost importance. To be a team player and be willing to confront.

An unusual place to look for the physician executive position it seems would be the local newspaper. However, the Chicago Tribune, advertised in its Sunday Business section for jobs in September, 1996 for a Blue Cross Blue Shield Medical Director. This ad stated the following:

“Medical Director, Administrative Services & PPO

We are seeking an outstanding Physician who will oversee provider relations, identify enhancements for utilization review and case management, set management goals, and modify existing policies/procedures to align them with PPO objectives. In addition, you will support subscriber Services/ Claims Adjudication as well as assist t eh fraud/abuse section of internal audit. The board certified Physician we select will be a graduate of an AMA-accredited medical school who is eligible for or has a non-restrictive license to practice medicine in Illinois. Requirements include demonstrated clinical experience; familiarity with the claims adjudication process; background in developing, implementing and managing fraud/ abuse program activities; and strong interpersonal skills. We offer a highly competitive salary and comprehensive benefits. Forward resume with salary history to Blue Cross Blue Shield of Illinois.”

A big challenge for medical directors of HMO’s is to make decisions that allow for “win-win” situations. This means to please providers and address member needs and to answer both sides is difficult. The customer is both the providers and the HMO members and part of the job of the medical director usually is to satisfy both.

A common joke going around the managed care industry past several years: where medical director of a HMO passes on and is at the gates of heaven and St. Peter looks at his chart and says ok you can enter but you can only stay for three days

According to David Nash’s book, physician executives must forge a partnership between managers, clinicians, and patients in order to arrive at reasonable compromises – those that promise optimal use of our limited resources and enhanced quality of patient care.

Working with physicians who do not know how to practice quality effective medicine is also a big challenge. These physicians may tend to tie cutting down of services with cutting down on quality when actually quality is, according to many medical directors, receiving appropriate services in a timely manner. For example, some physicians might order a MRI for a headache because they are worried about lawsuits when a MRI may not be appropriate. It has been said that you will always see bad outcome, even before managed care, and it is very important for physicians to have good rapport with their patients and that is the best way to prevent lawsuits.

Consider the effect of physician executives doing both medical management and remaining practicing clinicians.  That is, whether by gaining credibility as managers, physician executives ultimately lose the credibility as physicians.  According to the article by Timothy J. Hoff, “The Paradox of Legitimacy: Physician Executives and the Practice of Medicine,“ Health Care Management Review (September 22, 1999), there is a proliferation of medical management degree programs nationally, new forms of training such as through the American College of Physician Executives (ACPE) with over 12,000 physician executives as members, and increased numbers of physicians pursuing M.B.A. degrees.

According to Hoff’s article, A national mail survey with three mailings to 598 physician executives belonging to the managed care section of the ACPE were selected.  This resulted in about a 50% usable response rate. This study showed that slightly less than one in four physician executives surveyed had some kind of graduate management degree  (such as M.B.A., M.P.H., M.S.).  Almost two-thirds of respondents had either a graduate management degree or extensive non-degree management training through courses and workshops.  The findings from this study support the legitimization of medical management as a unique occupational group in medicine.  However, by gaining credibility as managers, physician executives may jeopardize their credibility as physicians.

According to the article by Harry Neuwirth, M.D., “Moving Into Management,” Healthcare Executive (May/ June, 1999), With the transition to managerial work, physicians need to learn a more tolerant attitude toward risk and failure.  Many physician have difficulty with business risks which are inherently different from medical risks.

The author of this article, Neuwirth, is medical director for clinical integration and vice chief of staff at Marin General Hospital in Greenbrae, California.  He feels he has assumed dual roles of practicing physician and healthcare system manager at the small suburban hospital he works at.

Many of the Physician Executive skills used by Medical Directors of HMOs are translatable skills for physicians running a medical group practice

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