Managing the medical-industrial complex

Leadership and Advanced Degrees: Evaluating the Association Between Dual Degrees and Leadership Roles in Academic Plastic Surgery

BACKGROUND

There are increasingly prevalent formal educational programs for physicians who seek to be better trained to advance their fields. Although higher education and advanced degrees are not necessarily linked to leadership, we hypothesize that leaders in plastic surgery commonly have dual degrees. We sought to evaluate the prevalence of and association between additional advanced degrees in academic plastic surgery and plastic surgery leadership.

METHODS

Plastic surgery faculty from 96 academic training programs and all executive committee and board of directors' members from national, regional, and local plastic surgery societies were evaluated. Surgeons' institutional online profile pages, personal web pages, societal websites, and LinkedIn profiles were all evaluated for current/past leadership roles, as well as for advanced degree. Odds ratios (ORs) were used to determine if the presence of extra degrees increased their likelihood of leadership roles.

RESULTS

A total of 1036 plastic surgeons were evaluated. Sixteen percent of academic faculty have a dual degree. Furthermore, 25.5% of plastic surgeons holding formal academic leadership roles have a dual degree (OR, 2.15; P = 0.043), as do 34.4% of those serving on the executive committee or board of directors in national plastic surgery societies (OR, 2.23; P = 0.026) and 29.2% of those serving in local/regional societal leadership roles (OR, 1.96; P = 0.043). Among all dual degrees, Masters in Business Administration has the highest association with leadership roles (OR, 3.45; P = 0.002).

CONCLUSIONS

Academic plastic surgeons with dual degrees are approximately twice as likely to hold a formal academic or societal leadership role. Additional studies are needed to determine if causative relationships exist.

Medical student healthcare consulting groups: A novel way to train the next generation of physician-executives

Meeting the challenges of the evolving healthcare environment requires leadership of physicians well-trained in clinical medicine and healthcare management. However, many physicians lack training in business and leadership. While some residency programs have management tracks, training at the medical school level is currently lacking. We developed the Hopkins Health Management Advisory Group, an extracurricular program at Johns Hopkins University School of Medicine that exposes medical students to healthcare management and fosters development of leadership skills. Teams of students work directly with health system executives on 3-6 month-long projects using management consulting principles to address problems spanning health system domains, including strategy, operations, and quality improvement. Since the program's inception, 23 students have completed seven projects, with 13 additional students currently working on three more projects. Sponsors leading six out of seven completed projects have implemented recommendations. Qualitative survey respondents have found the program beneficial, with students frequently describing how the program has helped to develop professional skills and foster knowledge about healthcare management. These early assessments show positive impact for both students and the institution, and suggest that such programs can train students in management early and concurrently in their medication education by immersing them in team-based health system projects.

Patient-level information and costing systems (PLICSs): a mixed-methods study of current practice and future potential for the NHS health economy

Background

Traditionally, the cost object in health care has been either a service line (e.g. orthopaedics) or a clinical intervention (e.g. hip replacement). In the mid-2000s, the Department of Health recommended that in the future the patient should be the cost object, to enable a better analysis of cost drivers in health care, resulting in patient-level information and costing systems (PLICSs). Monitor (the economic regulator for health care) proposes that PLICS data will now form the basis for mandatory prices for health-care services across all care settings.

Objective

Our main aim was to investigate the use of PLICSs.

Methods

We surveyed all English foundation trusts and NHS trusts, and undertook four case studies of foundation trusts. Three trusts were generalist and one was specialist. We also surveyed commissioning support units to explore the potential for PLICSs in commissioning.

Findings

The most significant use of PLICSs was cost improvement within the trusts. There was only modest utilisation of PLICSs to allocate resources across services and settings. We found that trusts had separate reporting systems for costs and clinical outcomes, engendering little use for PLICSs to link cost with quality. Although there was significant potential for PLICSs in commissioning, 74% of survey respondents at trusts considered their PLICS data to be commercially sensitive and only 5% shared the data with commissioners. The use of PLICSs in community services was, generally, embryonic because of the absence of units of health care for which payment can be made, service definitions and robust data collection systems. The lack of PLICS data for community services, allied with the commercial sensitivity issue, resulted in little PLICS presence in collaborative cross-organisational initiatives, whether between trusts or across acute and community services. PLICS data relate to activities along the patient pathway. Such costs make sense to clinicians. We found that PLICSs had created greater clinical engagement in resource management despite the fact that the trust finance function had actively communicated PLICSs as a new costing tool and often required its use in, for example, business cases for clinical investment. Operational financial management at the trusts was undertaken through service line reporting (SLR) and traditional directorate budgets. PLICSs were considered more of a strategic tool.

Conclusions

Both PLICSs and SLR identify and interrogate service line profitability. Although trusts currently cross-subsidise to support loss-making areas under the tariff, they are actively considering disinvesting in unprofitable service lines. Financial pressure within the NHS, along with its current competitive, business-oriented ethos, induces trusts to act in their own interests rather than those of the whole health economy. However, many policy commentators suggest that care integration is needed to improve patient care and reduce costs. Although the Health and Social Care Act 2012 (Great Britain.Health and Social Care Act 2012. London: The Stationery Office; 2012) requires both competition and the collaboration needed to achieve care integration, the two are not always compatible. We conclude that competitive forces are dominant in driving the current uses of PLICSs. Future research should interrogate the use of PLICSs inNew Care Models – Vanguard Sites(NHS England.New Care Models – Vanguard Sites. NHS England; 2015) and initiatives to deliver the ‘Five Year Forward View’ (Monitor and NHS England.Reforming the Payment System for NHS Services: Supporting the Five Year Forward View. London: Monitor; 2015).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Dentists' leadership-related perceptions, values, experiences and behavior: results of a national survey

BACKGROUND

The authors developed a survey and administered it to members of the American Dental Association (ADA) to elicit their views on leadership in dentistry, as well as to explore their leadership-related values and evaluation of their effectiveness as leaders, their experiences with leadership-related activities and perceptions of barriers to being a leader. The authors also examined how male and female dentists differed in their leadership-related responses.

METHODS

The authors collected survey data from 593 ADA members (mean age, 51 years; standard deviation, 10.75 years). Seventy-seven percent of respondents were male and 85 percent were European American.

RESULTS

The most frequently reported aspects of leadership were leadership in one's own practice (31 percent), in the profession (26 percent), in the community (14 percent) and in dental organizations (9 percent). The most valued aspects of leadership were being a good leader in one's own practice (mean rating = 4.64 on a five-point scale, with 5 = very important) and having patients perceive them as leaders (mean rating = 4.38). The most frequent past leadership experiences were related to leadership in dental organizations (47 percent), and the most frequent current activities were related to leadership activities in the community (40 percent). Time constraints (46 percent) and family obligations (20 percent) were the biggest barriers to taking on more of a leadership role. According to the survey results, female respondents valued the importance of leadership more highly than did male respondents.

CONCLUSIONS

The results of this survey show that dentists perceive professional leadership as closely related to leadership in their own dental practices and value this type of leadership most highly. However, about 40 percent of respondents reported that they engaged in current leadership activities in their communities, and 32 percent reported doing so in professional organizations. Practical Implications. ADA members who responded to this survey focused primarily on leadership in their own clinical practices. However, substantial numbers of dentists valued leadership activities in their communities and on a state and national level.

Training the next generation of physician-executives: an innovative residency pathway in management and leadership

The rapidly changing field of medicine demands that future physician-leaders excel not only in clinical medicine but also in the management of complex health care enterprises. However, many physicians have become leaders "by accident," and the active cultivation of future leaders is required. Addressing this need will require multiple approaches, targeting trainees at various stages of their careers, such as degree-granting programs, residency and fellowship training, and career and leadership development programs. Here, the authors describe a first-of-its-kind graduate medical education pathway at Duke Medicine, the Management and Leadership Pathway for Residents (MLPR). This program was developed for residents with both a medical degree and management training. Created in 2009, with its first cohort enrolled in the summer of 2010, the MLPR is intended to help catalyze the emergence of a new generation of physician-leaders. The program will provide physicians-in-training with rigorous clinical exposure along with mentorship and rotational opportunities in management to accelerate the development of critical leadership and management skills in all facets of medicine, including care delivery, research, and education. To achieve this, the MLPR includes 15 to 18 months of project-based rotations under the guidance of senior leaders in many disciplines including finance, patient safety, health system operations, strategy, and others. Developing both clinical and management skill sets during graduate medical education holds the promise of engaging future leaders of health care at an early career stage, keeping more MD-MBA graduates within health care, and creating a bench of talented future physician-executives.

Management education during radiology residency: development of an educational practice

The practice of radiology has dramatically increased in complexity, largely due to three broad influences. These include the proliferation of imaging technologies, the economic pressures to limit healthcare costs, and the increasingly intrusive role of third parties (whether payors, regulators, or government) in everyday healthcare transactions. Practicing radiologists have been adapting to these technologic and socioeconomic changes and will continue to do so by managing the quality and scope of their professional services, the workflow of radiology operations, and the economic viability of their practices. It is likely that radiology practices would benefit from the presence of one or more radiologists with managerial training and skills. In this article, it is proposed that management education for radiologists may actually be initiated during residency; the value and the experiences with such an educational practice are described.

Creating a satisfying practice setting for physicians. The experience of a hospital-based group practice

Medical groups are challenged to develop a satisfying context for physicians to deliver patient care. This article reports on the efforts of the Lovelace Medical Center and the Lovelace Clinic, P.C. (professional corporation), in Albuquerque, New Mexico, to create a distinctive environment for its medical staff members. A job-design model is examined wherein core job characteristics and physician growth-need strength influence critical psychological states and satisfaction. The results of this longitudinal study suggest that from the perspective of primary care physicians, the practice setting at Lovelace has improved markedly between 1984 and 1990. In addition, fewer changes were observed for specialists, ostensibly due to extremely favorable perceptions of the practice setting at Lovelace during this time period. The implications of these results point primarily to the value of consciously designing and periodically monitoring the practice environment within medical groups.

The business education of Canadian plastic surgeons

Business and economic aspects of a medical practice are rapidly becoming more complex. Physicians are at a crossroads in the manner by which medical and surgical care will be delivered in Canada, at the very base of which are the business aspects and management of health care. The purpose of this research study was to determine the business acumen of plastic surgeons in active practice. The resource base was Canadian plastic surgeons who are members of the Canadian Society of Plastic Surgeons. The intent of the questionnaire research study was to evaluate whether these surgeons perceive this area as necessary and whether they feel adequately prepared to manage this aspect of their practice. The findings of the research indicate that the plastic surgeons surveyed did perceive a need for business acumen in the practice of medicine. The majority felt they were not prepared adequately to deal with the business side of operating a medical practice and perceived a need for basic knowledge in the area of business. The implications of this research are that medical education has ignored this important aspect of preparing a physician to practise medicine in the present economic environment. Educational materials to structure and systematically disseminate business resource information need to be developed so that this group would be able to deal adequately with business-related problems when faced with them in medical practice. Due to the specialty-specific nature of the business needs, this education should likely occur during residency or fellowship training.

Residency education in administrative psychiatry : a national survey

In 1989, the authors surveyed all general psychiatry residency programs to assess the availability, extent, and emphasis of administrative teaching currently being offered during residency training. With a return rate of 74.5%, the results reveal that 69.5% of the respondents presently include administrative training within their curricula and 56% offer didactic teaching about administrative issues. These results are compared with a similar survey performed 10 years previously in which 85% of the respondents reported offering some administrative training but only 39% offered didactic instruction in this area. An analysis of these data and a review of proposed curricula for training in administration are provided.

Corporatization of medicine: the use of medical management information systems to increase the clinical productivity of physicians

Large corporate health care firms are seeking to reorganize the production of health services under growing cost-containment pressures from government and business payors. Medical management information systems (MMIS) applications are producing an increasing number of financially motivated utilization management interventions designed to constrain wide variations in the practice of medicine. In this article we examine how innovations in MMIS will be used to monitor practitioners' clinical decisions in order to improve the productivity of physicians and other health care personnel. As MMIS technology shifts power from previously autonomous physicians to corporate health care managers, the medical profession is likely to be subjected to far more administrative and bureaucratic controls than conceivable even a few years ago.

The design and implementation of a management information system for Australian public hospitals

Existing management information systems (MIS) in hospitals are often inadequate. This has occurred because of a variety of antecedents, including past funding mechanisms, organisational structure and the accepted role of management. A variety of new pressures, including demands for increased accountability, greater resource control and changing relationships between physicians and hospitals are demanding improved MIS to enable the hospital to manage. This paper explores these influences on past and future hospital MIS. It describes the design of a MIS that enables patient care to be costed in clinically meaningful ways. Patient costs may be aggregated to cost specific diagnoses and procedures, Diagnosis Related Groups (DRG), a clinician's case load, a clinical unit or a division. The information can be used for clinical budgeting, flexible budgeting, utilisation review and quality assurance.

Corporately managed health care and the new role of physicians

The roles described are not all-inclusive, since a small proportion of physicians, as in times past, will continue to pursue diverse careers outside of an tangential to health care. Neither are the roles mutually exclusive, as physician-managers are also organizational employees, as independently contracting professionals may also be partly fee for service, as physician entrepreneurs may be fee for service practitioners or contracting professionals, and so forth. The point is, that as the delivery of health care becomes a more complex and formalized process, and as large organizations delivering and insuring health care become more predominant, the various roles of physicians are becoming more distinctly obvious. What are the implications of this trend toward greater internal segmentation of the medical profession? At this juncture, they are not entirely clear. It could mean that some groups of physicians will achieve higher status and more rewards than other groups, which might result in greater conflicts within the medical profession. Undoubtedly, the emergence of corporately managed health care and the development of new (and possibly divergent) roles for physicians confronts the medical profession and its members with the gnawing questions of who they really are and what do they really want to be? Ultimately, the greatest challenge may be in finding a common set of commitments and values which transcend our many different roles, and which provide physicians with a clear and continuing sense of ourselves as medical professionals.

Escaping from the dual organization: physician self-governance

This article discusses a way of coping, in a time of limited resources, with the dual organization problem in hospitals. First, the historical roots of the dual organization problem are analysed. It is ascertained that the power structure within the hospital crucially depends on the socioeconomic circumstances and the state of medical knowledge. Since the health care systems of most industrialized countries are in transition from a stage of rapid expansion into a stage of consolidation, new problems arise which cannot be adequately handled within the context of the dual organization structure. The crux of the dual organization problem lies in the separation of the related responsibilities for resource allocation and patient care. Most proposals to solve this problem try to develop models of shared authority, which may be elegant in theory but often raise tremendous problems when implemented in practice. A straightforward solution would be the reunion of both responsibilities under one head, the physician-executive. It is argued that in a situation of limited funds for medical care, patients, physicians as well as administrators will be best off when physicians become primarily responsible for the resource allocation within the hospital. Some empirical evidence for this supposition is discussed. Finally, attention is paid to the prerequisites for, and implementation of, physician self-governance.