In the group practice setting, I have seen many of my practice manager friends and colleagues retire, change jobs, or—worse yet— be relieved of their management position. What is going on lately?
External pressures from the outside and internal pressures from inside the practice are making for an environment like quicksand for practice managers and owner-physicians. Some of these external pressures are caused by the Centers for Medicare & Medicaid Service (CMS)’s continued reductions, which often influence commercial contracts.
We face great uncertainty with the workings of the Affordable Care Act as it is currently being presented to us. Regulations and threatened penalties from CMS auditors as well as the Health Insurance and Portability and Accountability Act, the Health Information Technology for Economic and Clinical Health Act, the Office of Inspector General, the Employee Retirement Income Security Act, the US Department of Labor, and state and local authorities, are al-ways present and increasing.
Facing the transition to International Classification of Diseases, Tenth Revision, Clinical Modification and fulfilling meaningful use re-quirements for electronic health records are the focus for the near future. High-deductible health plans and a future of bundled
payments to try to bend the untenable growth in the healthcare spending curve also tug on us. If you live in a highly populated area, hospital systems are jockeying for turf and this is affecting the situation, too.
Internally, staff wants to keep up with their existing standard of living with pay raises and health insurance that doesn’t put onerous burdens on their take-home pay. They are insecure with the news of hospital buyouts of physician practices, group closures, outsourced business, and more global problems such as the debt ceiling, which all make reassurances of their job security very important. Spending money to empower staff or boost morale is a difficult sell to practice owners. Replacing staff or combining jobs is on the table. Physicians and staff both feel the pressure of precertifications and other medical insurance policies. The costs of drugs and medical supplies are ever-changing.
At times like these, the shortcomings of both physician owners and practice managers become exposed. There are several choices at this point. A healthy choice is admitting your inadequacies and getting up to speed in areas where knowledge is lacking for either the physician or the manager. If time is short, admitting your need and getting outside help in the area(s) of immediate need would be positive, too. But, unfortunately, what can often happen are unhealthy decisions being made. Either the physician or the manager do not admit their lack of knowledge or understanding and retreat to their corners, and then the problems really begin.
For the manager, modeling leadership is hard when they feel inadequate internally. They continue to try to take care of and please their staff, their physicians, and outside forces, but trying to do that for too long in this state can bring on burnout and cause managers to abruptly leave the job. Sometimes managers escape to another job, hoping it will be different, but it is rarely different. Sometimes managers just keep treading water, hoping things will change, but they don’t and then they are forced out of the job.
How do we stop this vicious cycle? Like growing a plentiful garden, several ingredients are needed to foster a healthy culture so that managers and owner-physicians do not go to their separate corners. There needs to be good seed for the garden to grow.
1. First and foremost, the manager must be good seed—the right person in the right job. Taking enough time for decision-making before hiring is vital for possible long-term employment. Checking the manager’s credentials before he or she is hired is a given, but exploring how the manager’s style of operating will fit into the group’s culture should not be overlooked before a job offer is made. A wrong fit can show up in many ways and cause lots of trouble down the road.
2. Good communication is a vital ingredient between physician and nonphysician leadership. Physicians need to stop and commit enough time to really listen to their managers’ concerns—not a random hallway conversation or a quick meeting while watching the clock.
3. Another ingredient is the need for physicians to respect and appreciate their managers as the assets they are—entrusted with overseeing the practice so it not only remains viable, but that it thrives. A hierarchy in which managers care for the staff and owner-physicians care for the managers is ideal. Instead of allowing more and more to be piled on the managers to their breaking point, the physicians need to take time to see their managers almost like patients and try to keep their expectations in line with a balanced life for the managers. Throwing money or titles at an overworked manager is not the right ingredient, and it won’t pay off in the long run.
4. Another mistake that owner-physicians make is second-guessing a good manager after having outside conversations with other colleagues where apple-to-apple comparisons are just not applicable. Patient demographics can be different, physician competition can be different, managed care penetration can be different, to mention just a few possible variances. In addition, there are the many consultants promising physicians the moon hoping that the physicians will believe the sales pitches and not listen to their own staff who may have concerns. If any of these examples occur, the practice manager is left doing cleanup, explaining actions and trying to get understanding from the physicians on the group’s course. This is wasted time.
Conclusion
As the decades go by and I get ready to retire, I look over the decades and think of examples from around the country on this topic. I am left with a final, unoriginal thought: It would be so much more powerful and productive if physicians and managers really worked together for the common good.