Playing Well With Others – Building Strong Relationships in an Evolving Environment


By Cindy Sanders

In theory, hospital adminis­trators, physicians and nurses are all on the same team with the same ultimate goal — delivering the highest quality of patient care possible. In practice, those relationships are easily strained as fiscal realities, misaligned objectives and strong person­alities are factored into the equation.

Like most personal relationships, alliances built on mutual trust and respect are much stronger than those where involved parties operate from a base of suspicion and angry recrimi­nation. Communication … or lack thereof … generally sets the tone for the type of relationship between providers and adminis­trators whether that be to work in concert as partners or to set up adversarial camps engaged in barely concealed turf wars.

Quite simply, hospitals need doctors to carry out the core mission. Furthermore, the administration must recognize the vital role physician referral plays in keeping the doors open and the bottom line healthy. Certainly, physicians need hospitals, as well. However, in large markets where there are multiple acute care facilities and ambulatory surgery center options, the balance of power tips in the general direction of the physician.

However, in the uncertain climate leading up to the passage of healthcare reform legislation and now in nervous anticipation of how enactment will ultimately play out, many hospitals find themselves in the catbird seat. Pearson Talbert, chief development officer for Aegis Health Group, noted at the recent Healthcare Financial Management Association southeastern regional meeting, a consultant asked a room full of adminis­trators how many were seeing more physicians than ever before asking to be hired by the hospital. “Everybody in the room raised their hand,” said Talbert. “It’s a function of healthcare reform.”

Aegis has been in business for 20 years helping hospitals nationwide form lasting relation­ships with area employers. More recently, the company has translated that knowledge into helping hospitals build stronger relationships with area physicians. Talbert noted building bigger, better facilities won’t really change the payer mix. To broaden the market base, hospital CEOs must reach out to the community to ensure employers are aware of the full range of services the hospital provides and to extend that same courtesy to referring physicians.
When it comes to physician alignment, Talbert said, “At the end of the day it’s all about education.” It’s a mistake, he noted, to presume all physicians know each other, are familiar with the latest procedures being done by a particular specialist or even the range of service options at a hospital.

When it comes to referral patterns, there are three types of physicians, Talbert continued, — those who are fiercely loyal; those who are disloyal, and those in the middle … the “splitters.” Talbert said that while the fiercely loyal shouldn’t be taken for granted, it should be a matter of simply maintaining the goodwill that already exists. For those who are disloyal, it’s imperative to find out why to see if the issues could be resolved. The splitters, which tend to be the largest group, represent the biggest opportunity to improve relation­ships and pick up referrals.

Talbert said most physicians have four basic desires when it comes to their vocation:
· They want to have more time with patients and family.
· They want to make a reasonable living.
· They want to feel secure that their patients will be well cared for when referred to a hospital or specialist.
· They want to be heard …to ahave a voice.

With a decreasing supply of physicians and increasing demand, Talbert said the hospital that meets these needs is in the best position to add skilled physicians to the ‘fiercely loyal’ category. Getting to that point, however, requires a commitment at the highest level.

“It starts with an effective communications strategy, and the CEO needs to lead it, but there also needs to be a team of dedicated liaisons that interface with those physicians in the community,” said Talbert. He added the liaison team’s respon­sibilities include educating community physicians, ferreting out problems and responding to them, allaying concerns and listening to ideas.

With upwards of 80 percent of hospital admissions coming from patients geographically located within a few miles of the hospital or the referring physician, Talbert said educational activities should really begin in the facility’s own backyard. For hospitals interested in tapping into suburban or rural markets, that might mean extending their current reach. “It behooves the hospital to have a presence in the community,” Talbert continued, “whether it be a standalone facility (such as a clinic) or through a group of physicians aligned with the hospital.”

Just as it’s important to establish strong community ties, Joe Miller, senior vice president for the Society of Hospital Medicine, said it’s equally important to look at what is happening inside the walls of the hospital.

“What healthcare reform does is perhaps accelerate or propel a lot of the changes that have been happening over the last 10 to 15 years,” he said. Over the past decade, Miller continued, there has been an increasing emphasis on transparency, accountability and quality. “And that’s going to cause the physicians and hospitals to figure out how to work in a collaborative way.”

Certainly one accelerant of the push for collaborative partner­ships is the new healthcare reform legislation’s sanctioning of Accountable Care Organiza­tions (ACOs). Both Talbert and Miller cited the new delivery/reimbursement model as having the potential to really change hospital-physician relationships.

The Robert Wood Johnson Foundation defines ACOs as follows: “A local entity and related providers — including at least primary care physicians, specialists and hospitals — that can be held accountable for the cost and quality of care delivered to a defined population.”

In a recent speech, Martin Hickey, MD, president and CEO of Alegent Health Clinic in Nebraska, noted, “Reform’s holy grail is based on bending the cost curve while improving the quality and outcomes.” Although there have been previous attempts to control costs, he said, the ACO model is different in that it looks to simultaneously reform clinical delivery and reimbursement.

Beginning in 2012, groups of qualifying providers could form voluntary ACOs. Any savings achieved for the Medicare program would then be shared with the providers, assuming the ACO meets all quality targets. “That’s going to cause the physicians and hospitals to figure out how to work in a collaborative way,” said Miller. “The executive team of the hospital needs to begin to understand their dependence on physicians to achieve results.”

For hospitalists, Miller continued, this federal push toward measuring quality parameters and outcomes is simply a reaffirmation of the founding strictures of this rapidly growing specialty. Miller said more hospital executives are beginning to look at their hospitalists, emergency department physicians and critical care doctors as the “home team” to address and implement quality initiatives.

“The challenge here is that if hospitalists are going to be successful, they need to look at their own skills. They need to develop leadership skills and understand how to be change agents,” Miller continued.

While it’s always easier to talk about change than to actually implement it, sometimes small gestures speak volumes. Miller said Carolina-based Novant Health is an example of an institution that has underscored the importance of collabo­ration by simply including “our physician partners” as part of the “we” in their vision statement.

Although the devil is in the details when it comes to how the Patient Protection and Affordable Care Act of 2010 will ultimately impact physician-hospital relations, both Miller and Talbert think the potential exists to create a collaborative, integrated team that could ultimately result in a win/win/win for hospitals, physicians and patients. 

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