How to change hospital-physician alignment taboo

Depending on who you talk to, hospital-physician alignment is a loaded phrase. The recently established catch phrase is one that hospitals aspire to hold and one that physician skeptics criticize. As private practices across the country continue to struggle, there is increasing pressure to align with hospitals--financially, clinically, and purposefully.

"The way hospitals talk about it often is 'we need to align the physicians,' [as if] 'we're going to do something to them.' In fact, the most successful thing they are doing is 'how do we create alignment with our physicians?' " said Luke C. Peterson, national director of strategy practice for Kurt Salmon in Minneapolis, Minn., a strategic consulting group for hospitals and health systems.

Hospital-physician alignment has gotten a bad rep lately, but it might not necessarily be warranted.

Hospitals view alignment as a huge, onerous investment in money and time, while physicians view it as a way to rob of them of their independence. If conducted properly, though, alignment could translate into better situations for everyone involved: hospitals, physicians, and even patients, Peterson explained.

However, hospitals are far from full alignment, according to a Kurt Salmon executive brief (.pdf). Alignment is defined in three areas of clinical activity, economics, and purpose (that is, a mission), according to the paper.

Financial alignment is more specifically considered hospital-physician integration, notes Peterson. After hospitals and physicians address finances, it oftentimes becomes apparent there are other, sometimes more difficult, issues to deal with.

Clinical alignment, which involves day-to-day activities regarding quality expectations and consolidation in patient diagnosis, treatment, and rehabilitation, is probably the most elusive, according to Peterson. Clinical alignment also has the most impact on the organizations, he said.

In addition, the organizations must address differences in visions. Will they operate with a financial mission? A quality mission? That they must work out.

Alignment and ACOs
Alignment also comes into play as hospitals and physicians (along with providers and insurers) toy with the idea of participating in accountable care organizations (ACO). ACO participation requires coordination and, of course, alignment, particularly between hospitals and physician practices.

However, the largest obstacle to ACO formation is--you guessed it--alignment with physicians, according to a recent study by AMN Healthcare, which pointed to doctors as biggest barrier to ACOs.

Can hospitals and physicians have too much alignment? The too-close-for-comfort relationship raises a few eyebrows about potential financial incentives behind patient care. Some physicians also worry that organizations, once aligned, then have the power to dictate the practice of medicine.

"Physicians are not chess pieces to be set up by hospital administrators. It is also not necessarily the case that the fiduciary duty of a hospital administrator is aligned with the patient responsibility a physician has," said Jesse Cole, MD, past blog contributor to Hospital Impact. "There should be independence and some degree of separation between hospitals and physicians, not less, as so many people championing ACO models insist upon. This is a balance of power which should be encouraged, not destroyed. Physicians must remain patient advocates, not organizational advocates," he said.

Peterson stressed that control isn't too be confused with alignment.

"If it's alignment, it's a two-way alignment. It's not the hospital controlling the physician," said Peterson. "Alignment is fundamentally about a relationship and about a common purpose, a team moving in the same direction. If we all agree on a direction that we want to move in, then that should be better for patients, physicians, and hospitals."

Peterson said ACOs are a team effort that essentially requires alignment at the core.

"The ACO is very dependent upon a single, common team across the continuum," he said.

Strategies for alignment and the woes of physician employment
When it comes to strategies for aligning in clinical activity, finances, and purpose, "No single tool works all the way across the board," said Peterson. Kurt Salmon identifies four areas to be prioritized according to organizations' immediate needs: business services, contracts, structured communication, and employment.

Increasingly, hospitals and health systems are employing physicians. In fact, less than a third of physicians will be in private practice by 2013, according to a report last month by Accenture Health. Employment can be a strong tool for hospitals with legal protections in employment agreements.

However, Peterson warns that employment isn't the end-all, be-all to fix everything. It's an introduction to alignment, he said.

"Professionals have a hard time being told what to do. They want to be part of the solution. If you think employment aligns everybody, and [you] tell everyone what to do, then it's not really alignment; it's control," he said.

Perhaps most important for hospitals to remember is that alignment is an ongoing effort. Like a marriage, as Peterson described it, alignment doesn't end after employment or any other strategy is completed.

"You're never done with alignment. It's like a relationship; the relationship can always get better. Every time there's a change in the market, in the individual or in the outlook, we need to continue to make sure that our alignment is strengthened."

Some of the leading health systems, including Mayo Clinic, Kaiser Permanente, and Geisinger Health System, are proof that aligned, integrated hospital-physician relationships result in the most effective care, according to Peterson.

When truly aligned, "You end up with a single team of advocates of how we can change medicine," he said. The most successful teams are the ones that say, " 'The healthcare system is us. We're the ones that are going to change it together. And operating as a team there's a better ability to changing it than operating at odds.' " - Karen