Getting administrators to listen to my suggestions about practice growth

There are numerous administrative duties that physicians encounter daily in order to deliver efficient, effective and equitable care to patients.  Many of these frustrations have been well publicized, if not effectively addressed, such as time spent documenting in electric health records, obtaining prior authorizations and performance measures reporting. How health care administrators decide to make investments into an existing practice (or initiating a new service), whether it is space, new equipment, or additional personnel, isn’t typically highlighted as a burden. Yet, physicians who are interested in growing their clinical practice or starting a new program can become frustrated if they do not understand the rationale for how these decisions get made. The combination of administrative burden and the perceived lack of support can contribute to physician dissatisfaction.

This article is meant to assist physicians become more knowledgeable, and hopefully successful, in partnering with administrators to help advance clinical service opportunities. Although one may be skeptical, administrators are not indiscriminately opposed to committing resources to a physician’s program development ideas, especially since they too want the organization to be successful. However, they need to understand more than just the story someone tells them when a request is made to commit limited financial resources since the total amount asked from all departments of an organization is several times more than what is available to invest. Understanding this is the first step in creating a concise, impactful proposal.

Why might there be disagreements between administrators and physicians in growth strategies?

Eric J. Keller and colleagues, writing in PLoS ONE, highlight some of the different perspectives physicians and administrators bring to their professional responsibilities. Some physicians perceive that only specialties that make money for the institution are prioritized while others view administrators through an “us versus them” lens instead of trying to build mutually respective relationships that include understanding concerns and issues from both parties. The authors also highlight how administrators and physicians approach problem solving and the time horizon used to make decisions.  Physicians make clinical decisions in a time-sensitive, high-acuity environment and decide on a best course of action, whereas administrators typically look at the welfare of the organization over a long period of time and typically examine multiple options to advance the organization’s goals. So how can these different viewpoints be reconciled so that an enterprising idea can be put into practice?

Recommendations for physicians when asking administrators for more resources

Ask how your organization makes decisions regarding new financial investments. Many organizations have a very defined budgeting process, so asking a practice manager, your chief financial officer, and even your president or CEO, can ensure you don’t waste time talking to the wrong individuals, especially if you are part of a large organization. Typically, the larger dollar amount of the request, the more administrative committees the proposal must be vetted through.  There also may be a preferred format that administrators like so they are viewing competing proposals in a similar way. Adjusting your proposal to this format will minimize missing key information that administrators need in analyzing it.

Think about the proposal from a holistic viewpoint that includes information about finances. Although proposals need realistic financial assumptions, it is not true that all surgical/procedural ones are automatically a higher priority than medical ones because reimbursement might be higher for the former than the latter. Perhaps hiring a case manager for a chronic disease program might not lead to greater reimbursement, but it might prevent readmissions to the hospital that cause the hospital to lose money, contribute to worse quality scores and pose equity concerns for disadvantaged populations.  Therefore, using a balanced scorecard approach that analyzes not only finances but also examines the proposal from a human resources, quality and patient experience perspective can help administrators support the proposal despite it not having a significant return on investment. In other words, proposals may have a strong value proposition despite it not having the largest financial return.

However, every proposal should calculate a return on investment (ROI). This involves identifying all costs (labor, facilities, supplies, etc.) to get the total cost of the investment and estimating the gain from investment, or the reimbursement. The formula would then be calculated as follows:  ROI= Gain from investment-Cost of investment/ Cost of the investment expressed as a percentage. Some organizations use what is called the internal rate of return and have a “hurdle rate,” meaning the lowest expected percentage return the proposal should have in order to be approved. Again, depending on how organizations analyze investment proposals, the value of a proposal might be clearly beneficial despite its low conventional ROI.

Who can be your administrative partner when developing the proposal? It is not necessary for a physician to be expected to calculate a proposal’s ROI but understanding it can help clinicians engage in a productive dialogue with administrative partners who can calculate it. For example, can alternative workflows, certain equipment that has favorable pricing, etc., be used to lower the cost and make the ROI more favorable. Partnering in this fashion can help physicians and administrators create a proposal that leverages both parties’ expertise while building a mutually respectful relationship. These collaborations that are meant to solve an existing problem or grow a program are energizing for both physicians and administrators.

Ask to present, or be present, when decisions are being made. Just having physicians show up and being engaged in these types of decisions demonstrate a commitment that most administrators respect and appreciate. Although showing up doesn’t necessarily guarantee a proposal’s acceptance, I can tell you from personal experience that administrators will want to work with him/her in the future on other opportunities. Additionally, transparent meetings where physicians can both observe and participate in these decisions can help break down silos and contribute to better partnerships that lead to operational and clinical excellence. Additionally, I have witnessed physicians see their colleagues present other proposals in these meetings whereby they understand their colleagues need is more pressing and offer to resubmit their proposal the following year. This further contributes to goodwill and the desire for administrators to see physicians be successful.

Joseph M. Geskey is the Vice President of Medical Affairs at OhioHealth Doctors Hospital in Columbus, OH. He is currently working on a book about the healthcare experiences of patients with limited health literacy and challenging social determinants of health in the digital and technological era medicine is embracing.