How to Become a Physician Executive: From Fellowship to Leadership

Graduating fellows in gastroenterology and other medical specialties are entering clinical practice in the midst of major health care delivery transformations. Partially as a result of recent Federal legislation such as the Medicare Access and CHIP Reauthorization Act of 2015, traditional fee-for-service reimbursement is evolving into “Alternative Payment Models.”¹ These reimbursement models attempt to tie payment to health “value” defined as meaningful improvements in health (for both patients and populations of patients) and cost reduction. Many Alternative Payment Models favor health care delivery by health systems with large provider networks and coordination across multiple specialties and sites of care. These changes often disadvantage smaller gastroenterology practices that have thrived in the traditional fee-for-service system.^2,3 Large, single specialty and multispecialty groups have become midsize employers with >$100 million in annual revenues and hundreds of employees. Practices of this size need physician leaders with sound business backgrounds who understand the need to demonstrate clinical quality,⁴ can use real-time data captured from modern electronic health records,⁵ will identify and implement cultural and infrastructure changes that enhance health value, and are able to lead colleagues through the complexities of current multispecialty practice. In this article, we discuss some critical learnings that you, as an early career gastroenterologist, can acquire so that you will be prepared to become a physician leader.

At least 3 specific actions that can help in your preparation to become a successful physician executive: (1) find a mentor who understands business and operational aspects of health care systems, (2) learn specific knowledge about “revenue cycle management” (RCM), value enhancement, “big data,” cybersecurity, and other learnings discussed herein, and (3) gain experiential knowledge by participating in key committees and activities within your center’s health care administration structure. The sections that follow provide an outline and structure for fellows to successfully pursue each of these actions.

Finding a Mentor

Gastroenterologists interested in executive leadership often struggle to find a mentor who is a successful physician executive and who has the time and ability to help you understand your own leadership skills, who can define specific knowledge needed, and who actively participates in health system administration. Often these physicians have a defined leadership role within the division, department, professional faculty plan, or hospital (and may not be a gastroenterologist).

Once you find such a mentor, they must commit to meeting with you on a regular basis to discuss the challenges of ongoing projects as well as your progress and professional growth. Physician executives often have formal MBA training, but all such leaders will have secured significant administrative experience and can help you to learn the language of management that can be applied both within and outside of health care administration settings. As you develop your skillsets and become increasingly adept at identifying opportunities to improve efficiency in quality or cost of care within your organization, you will learn how your mentor has led strategic changes within the organization. One of the greatest difficulties executives encounter as they promote cultural change is that colleagues come from disparate departments and divisions, have various professional backgrounds, and face differing cultures and challenges, yet all must accept the need to change engrained behaviors. Understanding how different types of providers learn and accept structural change, become increasingly accountable for health care decisions, and how their personal actions impact system finances is a critical learning that you need for successful professional development. Having a mentor with past experiences in changing the culture of your institution can be enormously beneficial to your own growth. These experiences will make a lasting impact and help you to seek out projects and committees focused on making anticipatory rather than reactive changes.

Your mentor should help you learn team-based management perhaps following the outline illustrated in Figure 1. A training plan that includes appropriate mentorship and some formal coursework should focus on relevant core competencies (Figure 1). The following sections discuss some of the core competencies needed to become a successful physician executive.

Figure 1.

A structured learning plan to become a successful physician executive. Compatible formal mentorship should oversee an individual learning plan, and the characteristics of an ideal business mentor are defined. The learning plan should be composed of didactic teaching and experiential learning. The focus of mentorship and individual efforts should be proficiency in the outlined core competencies. GI, gastrointestinal.

Revenue Cycle Management

RCM encompasses the entire financial lifecycle related to revenue and expenses directly related to patient care, from the moment an account is created (during initial referral) until final reimbursement is paid. Understanding RCM enables an executive to define each step in the care and financial process and will enable leaders to reduce waste while enhancing value both for the patient and health system. Focusing on RCM will allow leaders to teach colleagues how their individual actions enhance or reduce value (and margin) within a division, department, hospital, and health system. RCM education also ties internal finances to regional, state, and national health economics.

Fundamental to understanding RCM is learning basic coding classifications for claims:

• International Statistical Classification of Diseases and Related Health Problems, a billing and coding system that standardizes thousands of medical diagnoses;

• Current Procedural Terminology system, a structure that defines codes for professional medical services;

• Diagnosis-related groups, which bundles medical inpatient services; and

• Ambulatory Payment Classifications for outpatient services.

Patient claims usually include professional fees for services provided by licensed providers (physician, nurse practitioners, physician assistants, and others) and technical fees generated by the facility at which service is located (inpatient services, hospital outpatient department, ambulatory surgical or endoscopy centers, and others).

As you review “fee schedules,” the lists of payments for specific services (such as the Medicare Physician Fee Schedule),⁶ you will notice that the unit of reimbursement for each service is defined as a resource-based relative value unit (RVU). The history of RVU development and ongoing negotiated changes is beyond the scope of this article, but makes for fascinating reading. Suffice it to know here that each Current Procedural Terminology code has a defined value that is relative to other codes based on the intensity of work involved, the risk, geographic location, and other factors. These roll up into a single value for each code. Although Medicare defines these values, virtually all commercial payers use the RVU methodology.

Reimbursement does not equal collections, however. You will need to learn the differences between charges and collections, the internal billing cycle (from date of service to bill submission), the definition of accounts receivable (money billed but not yet paid), and how each payer handles bill adjudication and code modification. Understanding these details are what distinguishes effective physician leaders and will help you to identify successes and areas of concern in your practice.

Electronic Health Records

As electronic health records have become commonplace in clinical practice, certain tools that integrate coding, billing, reimbursement, and clinical information have become essential for executives to make better decisions about practice management. You should be aware of the limitations of electronic health records (they are only as good as the information that is put in). Current electronic systems have facilitated population health monitoring, and the identification of health inequities, care gaps, and resource efficiencies. Emerging systems will enhance virtual health, remote monitoring, and patient reminders. In the last few years, interconnectivity among hospital systems has advanced rapidly, allowing swift retrieval of patient information. Physician leaders are essential to optimize clinical workflow within the electronic health record and also to identify standard templates, order sets, red flag alerts, and other efficiencies. Electronic health records that are not optimized are a major contributor to physician burnout and frustration.

Physician executives must continually monitor federal regulations and financial initiatives related to health information technology. They must also assess the sustainability of your electronic health record system and identify new implementations, especially regarding how individual information technology systems will connect through enterprise data warehouses and national patient registries.

Data Security

With the development of larger electronic health systems, data security has emerged as the number one threat from both internal and external miscreants. Data security is tied directly to privacy, so the audit, compliance, and privacy departments of health systems are critical groups that ensure that physician and administrative leaders do not end up in jail or owing substantial fines. The consequences of ignorance or carelessness are enormous, because federal, state, and health system scrutiny are ever present. Physician leaders must have a firm grounding in audit, compliance, privacy, and cybersecurity issues.

Formal risk analysis (internal or outsourced) is a process that can help to mitigate potential disasters and ensure that the practice has appropriate, proactive monitoring systems, enterprise risk management and threat response. The senior author (JA) sits on the Board of Directors (and the Audit and Compliance Committee) of a large health system in the Twin Cities of Minnesota, and this system has spent >20 months enhancing cyber security combined with electronic and physical risk mitigation just for the 2018 Super Bowl, as an example. Much of this preparation involved cybersecurity and privacy issues. Understanding risk analysis, and being able to converse with external experts who will help your practice is an essential component of leadership and will help you to understand your practice’s compliance with the administrative, physical, and technical safeguards required by multiple regional, state, and federal regulatory agencies, especially as codified within the Health Information Portability and Accountability Act.⁷

Quality Metrics

Quality metrics are used to describe clinical or operational performance as well as health outcomes.⁴ These metrics can now be generated in real time using electronic health record systems,⁵ and enable executives to make timely, data-driven decisions that can be tied to achievable, measurable milestones. They also help executives to measure and communicate strategic successes and failures to colleagues, payers, and regulators. Working with your mentor to identify the key performance metrics that translate to meaningful clinical outcomes and RCM for your practice is important to learn how to identify leading signals that help in making informed business decisions.

Operations: Implementation, Analysis, and Measurement

Managing operations begins with the measurement of mission critical processes. Unlike clinical quality metrics, operations depend on process measurement and maximization. These efforts help leaders to understand patient flows, provider workflows, and the linked revenue stream. Applying variations of value stream mapping will aid in identifying bottlenecks and sources of inefficiency within the practice. Several analytical techniques are helpful (eg, https://healthit.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools).

A variety of other techniques must be learned to effectively focus a management team’s energy and attention. Understanding Lean, Six Sigma, Gaant charting, process flow mapping, fishbone analysis, and other fundamental management tools should be part of your planned education. Once you are able to describe an entire health care process and model the inputs and expected outputs associated with each step in the process, use methods such as the 4-step Deming cycle (Plan–Do–Study–Act)⁸ to improve efficiency and reduce errors in care and in the revenue cycle.

Focused business school coursework on operations management can teach these techniques in a case-based manner, providing the context needed to practice and assimilate knowledge. Alternatively, the Institute for Healthcare Improvement (available: http://www.ihi.org) offers online courses on quality improvement methods through their Open School program that are often accessible through a subscription service. If the group practice setting already incorporates Six Sigma or other lean methods in addressing health care delivery, obtain Six Sigma training through a variety of short courses online or in person.

Payer Negotiation

Although Medicare reimbursement is reassessed nationally on an annual basis, this is not the case for commercial payers that together comprise more than one-half of the revenue of a practice or health system. The recent consolidation of national commercial payers has lessened the ability of most practices and many health systems to negotiate directly on quality, timeliness, access, and other issues important to providers and payers. Depending on the regional market and the breadth of a health systems provider network, commercial payers managing price-sensitive markets will focus most on overall price of services and provider’s ability to demonstrate geographic coverage. Cost-effectiveness analysis and life table methods⁹ may help you to assess the financial value of services within your practice so you can be ready to respond to payer inquiries about your services. With recent mergers among payers, frontline clinical providers (primary care and urgent care centers, for example) suggest that national payers are beginning to focus on “channel management” (managing how patients are referred through the health care system), a trend that will intensify and place specialty practices at risk for loss of market share if they are high-cost providers. Negotiating power, even of large practices, is lessening in the face of payer consolidation.

Regulations, Law, and Governance

State and federal regulations govern the practice of medicine as well as the organization and governance of practice groups. These regulations provide the language and rulebook used in leadership meetings throughout the practice. These regulations are derived from a number of organizations including the Centers for Medicare and Medicaid Services (ie, Conditions of Participation), the Joint Commission, state medical boards, and commercial payers, as well as institutional policies covering hospitals and ambulatory centers. All of these regulations (as well as some not mentioned) are relevant to a physician leader specialty practice and health system. Working with your mentor to identify the most pertinent regulations with which to become familiar, augmented by some formal coursework in business law or health care regulation, is mandatory.

Human Resources

Effective leaders must be able to communicate effectively with colleagues from various professional backgrounds and experiences and motivate colleagues to work toward common goals. These skills are especially important within a complex, multispecialty practice representing a number of different specialties and a variety of care facilities.¹⁰ Understanding how to work with nursing and administrative leaders (and sometimes union leaders) to achieve common patient-centered goals is critical for executives in most large multispecialty practices. These competencies are useful to help you develop idea champions who can promote shared goals across a health system. Physician leaders understand that the field of human resources has a rich scientific basis, is fraught with state and federal regulations, and must include human and humane relations that promote joy in professional and staff workdays.

Marketing and Branding

Effective marketing is closely related to an organization’s strategic vision. Effective marketing and branding should a promote system’s thinking within an organization while demonstrating quality, coordination, and patient-centered care externally. Components of marketing include paper and electronic communications, social media, advertising, and other media venues that brand practices with positive health outcomes. The marketing budget should include sufficient resources to actually achieve an organizational vision. Investing time to learn about previous successful and unsuccessful marketing campaigns (and the associated marketing plans) are worthwhile.

Strategy and Change Management

Large single-specialty or multispecialty groups have a theoretical advantage over large health systems to streamline patient experiences and clinical service lines because of their more narrow focus.¹⁰ At some point, however, the size and depth of these organizations can lead to delivery inefficiencies that rival those of a large, integrated health system. Leaders must understand and overcome organizational inertia, a rigid organizational structure, and the common lack of buy-in by frontline providers about the need for change. Leading cultural change successfully requires a deep knowledge about the infrastructure and cultures within a practice that usually comes only after attending multiple committee meetings, repeated analysis of financial spreadsheets, and understanding the specific factors that influence strategic change.¹¹

Conclusion

With the growth of large, multispecialty practices and the emphasis on health value, trainees and early career physicians have ample opportunities to become successful physician executives. Successful physician executives are not simply business executives—they are physicians at their core and are grounded in their desire and clinical training as physicians to improve the health of their patients. Patients come first. But, much like aspiring academic laboratory investigators and health care policymakers, successful physician executives seek to enact these meaningful improvements in health on a broader, actionable systems-based level. We outlined a roadmap that combines the needed background skills with experiential knowledge derived from a compatible mentor who can guide you through hands-on experience. We are currently entering an invigorating time in medicine that emphasizes value of care that we provide, and it is this upcoming generation of physician leaders who will define that value for the future of our field.