Medical Management and Executive Leadership


In 1983 I became medical director of a staff model health maintenance organization in Lexington, KY. I practiced half-time in the clinic, while spending the other half-time re-organizing the health care system and hiring/replacing personnel. The HMO had been founded as a non-profit for poorer residents of the area.

One of my first challenges was to encourage staff that their key concern had to be the patients. Many of the employees were more interested in their own concerns. In other words, they were not customer focused. They had come to see our patients as a problem (non-adherent, poor health habits, less important than their own priorities), not their service client. Over the first year we changed that by instituting intensive training programs, customer satisfaction surveys, and performance evaluations. Employees who couldn’t make the switch were asked to leave. 50 of the 55 of them did.

Also we had to train the physicians to understand the concept of comprehensive, coordinated, integrated care. This was not just our primary care physicians who worked in the clinic, but also our specialists to whom we referred patients. We needed to train the specialists that we weren’t just referral sources; we were partners in the health care of our patients. We wanted to maximize convenience and quality care for patients, which often meant providing service to patients at one visit in the location they knew – the primary care clinics. And we wanted all non-emergency decisions to be made in partnership between the primary care physicians and the specialists.

Changing physician practice patterns is not easy. It takes daily review of practice habits by questioning medical leadership. It needs to be done collaboratively, and at the same time with a firm managerial hand. It requires training physicians to think differently from the way they are trained in residency. It requires a bit of humility on the part of physicians – they need to understand that they can continue to learn new competencies while they are practicing; they need to rely on their colleagues who may have complementary skills; and they need to broaden their creativity skills.

At the same time we needed to provide the physicians and staff with a feeling of personal control. While we implemented strong and strict performance standards for patient satisfaction (and quality control), we also provided the physician staff with greater control over their workday patterns – providing schedule flexibility and teamwork models to increase workflow efficiency.

All of this is in saying that the November 2 Atlantic Monthly article, “The Quiet Health Care Revolution” was a pleasure to read. Finally there are some places getting it right.

The danger is, of course, that once the larger insurer, Wellpoint, gets its hands on it it might be corporatized without the ability for continuing intrapreneurship. I say this with some experience. For several years in the late 1980s and 90s I was medical director at Aetna, where I also headed a strategic investment unit. We looked at acquiring certain companies that might have let us do this same kind of work but without the medical ownership. My supervisor at the time was a wise man who had been with Aetna for a long time. He nixed more than one potential acquisition of an innovative and creative company of entrepreneurs because of his fear that “Aetna will destroy this” by requiring bureaucratic policies to be implemented that would stifle competitiveness and innovation in efficiency and effectiveness of care.

Alan Hoops is a smart fellow. I hope he’ll be able to avoid too much corporatization of CareMore, and will recognize that the essence of improvement in the health care system requires strong and close physician management and creativity.

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