“I hope you have good disability insurance my friend,” although I did not know it at the time, these were the words in 1998 that began my coaching career.
As the founding partner of a busy multi-office multi-surgeon practice, I was running all the time. Running to see the next patient in the office, or one of the three hospitals emergency rooms I covered. Running to deal with the next employee dilemma, equipment malfunction, patient complaint and the many business decisions and family obligations. No matter how early I set my alarm to awaken in the morning, I was always behind.
The practice of oral and maxillofacial surgery was less hectic when I first started practicing in 1980. However, once managed care became the pervasive delivery model for healthcare in the 1990s, everything dramatically changed. I treated more patients, spent less time with each patient, worked longer hours, and added more staff to deal with the administrative complexities of reimbursement.
From How Many to How Well
In 2005 a decision made by the Centers for Medicare and Medicaid Services (CMS), the U.S. government program that pays the provider, again changed everything.1 No longer would a physician’s income be determined by how many patients a physician could treat in the least amount of time. CMS decided quality of care along with efficiency is what would matter most. Essentially, CMS shifted the medical payment system from one based on the volume of services provided, to a system based on the “quality and efficiency of care,” or value-based purchasing (VBP). Patients’ opinions of their doctors now mattered. Patient safety mattered. Quality of care and outcomes mattered. As a result, collaboration between providers and other healthcare stakeholders mattered and mindsets had to change. Coaching provides a vehicle to help facilitate these changes.
There are four business imperatives supporting the foundation of the VBP system: patient medical outcome success, clinical quality, patient safety and system efficiency.
1. Patient Medical Outcome Success
Physician knowledge of the patient and patient trust of the physician strongly correlates with patient adherence to the physician’s recommended treatment. In practical terms, the physician who treats the patient as a “whole” person yields a strong bond that translates into the patient being up to three times more likely to likely follow the physician’s advice.2 Thus, the better the patient adherence, the more successful are the patient medical outcomes.
Beginning in 2013, about 70% of incentive payments driven by the VBP model are determined by clinical processes of care, or “hard data,” because it is quantifiable. The remaining 30% are based on patient experiences, otherwise known as, “soft data,” because it is based on your patients’ subjective opinions. This patient’s opinion poll measures the communication abilities of your physicians and nurses, as well as overall responsiveness of the hospital staff.3
2. System efficiency and Clinical Quality
Collaboration between providers and healthcare stakeholders (hospitals, insurance companies, pharmacy companies, etc.) is critical for success.
Rather than pay hospitals, physicians and pharmaceutical companies for their individual treatments, CMS instead pays for the bundle of services encompassing the entire episode of a patient’s care to all the involved stakeholders. Collectively, these stakeholders then decide how to best successfully and efficiently provide the services and allocate the payments among themselves. All participants must share data and coordinate cost-effective care in order for all to succeed. Working effectively in teams is important. Once the data is shared and analyzed, best practices can be determined allowing for the improvement of Clinical Quality based on evidence-based medicine.4
3. Patient safety
From 1999 to 2008 there has been a greater than eight-fold increase in the healthcare costs to treat preventable medical injuries and deaths from $2 billion to $17 billion dollars.5,6 The Joint Commission of Accreditation of Healthcare Organizations attributes team communication failures to be the 60% of sentinel events and the primary cause of errors leading to patient’s death.7 Healthcare reform has transferred the high costs of medical errors from society directly to physicians and medical institutions.
The Role of Coaching
The Broken Covenant in US Healthcare
A covenant can be generally defined as an agreement that yields a relationship of commitment between two parties. In healthcare, the covenant was historically between physicians and society: by sacrificing their 20’s (in some cases, a good portion of their 30’s) and dedicating themselves to become proficient in the healing arts, physicians would be granted by society a better than average living, an independent career and a place of respect in their communities. In the 90s with the shift to a managed care delivery system, physicians remained committed to sacrificing many hours to learn their trade, while salaries are now capped and their independence is curtailed. Now with healthcare reform physicians must make the transformation from independent autonomous providers with many solutions to collaborative partners willing to accept standardizations in healthcare.8
Coaching for physicians can drive improvements in business relationships (e.g. with patients and healthcare team co-workers), communication skills, interpersonal skills, and work performance. With coaching, physicians can shift from survival and fear-based mindsets to ones of self-awareness. The coaching process facilitates physicians’ self-awareness as they recreate meaning in their lives and careers that have been redefined by governmental interventions. They attain the emotional intelligence to reexamine and refocus on why they chose a career in healthcare: to connect with and help people. Moreover coaching will improve physicians’ communication skill sets resulting in stronger relationships with their patients and coworkers, thereby enabling physicians to experience an improvement in career satisfaction.8
Other valuable benefits of stronger physician relationships with patients and coworkers have been well documented (see Table 1.)9,10 the benefits for patients include an improvement in satisfaction with their physicians, better adherence to physicians’ medical and therapeutic recommendations and an increase in medical outcome success. The positive outcomes for society are a decrease in preventable medical injuries and deaths with a reduction in healthcare costs. Society also gains due to improved overall productivity from a decrease in lost workdays from illness. For physicians, the improved communication skills result in a decrease in medical liability exposure and improved career satisfaction.
Coaching Can Mitigate Physician Medical Liability Risk
Perhaps the best area to illustrate the importance of the physician-provider relationship is in medical liability claims. Here, the physician’s communication skills are paramount to whether or not he or she will be sued. In a study of malpractice settlements, awards and costs, 75-85 % were attributed to only 2–8 % of the internists, surgeons and obstetricians.11Why are a small minority of practitioners receiving such a large majority of malpractice suits? Numerous studies demonstrate that a physician’s lack of communication skills, not involving a patient in his or her healthcare decisions and lack of interpersonal care of the patient are all characteristics of the physicians who repeatedly suffer multiple claims.12-14 The less satisfied the patient is with the physician’s interpersonal care, the more likely the patient is to initiate a suit. Beckman et al., in a review of plaintiff’s depositions, showed that 71 % of malpractice claims were due to a break down in patient-physician communication.15 Physicians who communicate and have an effective rapport with their patients are less likely to be involved in a malpractice suit. Similarly, trust is another patient determinant in the whether or not they will initiate a malpractice suit.
Conclusion
My 27 years of practicing medicine coupled with my “second career” as an executive business coach provides me with the unique opportunity to form a partnership with physicians who are participating in the transformation of greater than 16% of the US economy. I find physicians are not only eager to jump off the treadmill and stop running to reconnect with why they originally chose the healing arts as a career, but also to apply the business coaching principles that positively impact their businesses, career satisfaction and their patients’ health. The business coaching of physicians is growing in acceptance as evidenced not only by my partnering with larger and larger groups, such as state medical societies, but also the addition of emotional intelligence to the medical school curriculum. So, watch out and hold on, because the growth in the business coaching of physicians is about to become exponential!
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References
1. Roadmap for Implementing Value Driven Healthcare in the Traditional Medicare Fee-for Service Program, Centers for Medicare and Medicaid Services, US Dept. of Health and Human Services, April 2010
2. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213-220.
3. Medicare Program: Hospital Inpatient Value-Based Purchasing Program, Centers for Medicare and Medicaid Services, US Dept. of Health and Human Services, Jan 2011
4. Cassatly M, Stakeholder Partners: The New Landscape in U.S. Healthcare, Journal of Medical Practice Management, Vol 26:4, 199-202, Jan/Feb 2011
5.Institute of Medicine, To Err is Human: Building a Safer Health System, 1999
6. Shreve J, Van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E, Economic
Measurement of Medical Errors, Society of Actuaries, Milliman, June 2010
7. Medical Teamwork and Patient Safety, AHRQ Publication No. 05-0053
8. Cassatly M, Coaching the Patient-Physician Relationship: A Successful Approach to
Lower Healthcare Costs with Improved Medical Outcomes, J Med Prac Manage, Vol 25:4, 229-234, Jan/Feb 2010
9. Cassatly M, Bergquist W, The Broken Covenant in US Healthcare, J Med Prac Manage, Vol 27:3, 136-139, Nov/Dec 2011
10. Cassatly M, Mitsch D, The Successful Application of Business Coaching to
Decrease Preventable Medical Errors, J Med Prac Manage, Vol 27:2, 107-109, Sept/Oct 2011
11. Sloan F, Mergenhagen EM, Burfield WB, Bovbjerg RR, Hassan M. Medical malpractice experience of physicians: predictable or haphazard? JAMA. 1989;262:3291-3297
12. Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that Prompted Families to File Medical Malpractice Claims Following Perinatal Injuries. JAMA. 1992;267(10):1359-1363.
13. Hickson GB, Clayton EW, Entman SS, Miller CS, Whetten-Goldstein K, Sloan FA. Obstetricians’ Prior Malpractice Experience and Patients’ Satisfaction wit Care. JAMA. 1994;272(20):1583-1587.
14. Levinson W, Roter, Mullooly JP, Dull VT, Frankel RM. Physician-Patient Communication: The Relationship with Malpractice Claims Among Primary Care Physicians and Surgeons. JAMA. 1997;277(7):553-559.
15. Beckman HB, Markakis KM, Suchman AL, Frankel RM. The Doctor-Patient Relationship and Malpractice: Lessons from Plaintiff Depositions. Arch Intern Med. 1994;154(12):1365-1370.