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Five steps in phys recruitment 2011
1. OHA Annual Conference 2012
DAVID ANDRICK
DIRECTOR PHYSICIAN ADRIAN R. BYRNE
RECRUITMENT PRESIDENT
LUND-BYRNE ASSOCIATES
2. Every organization requires the right people to make it work. Ensuring
the right-fit with physicians is an essential task of the physician
services department that is best accomplished with a formal “due
diligence” process.
Building an employed physician group practice that meets the needs
of the community while supporting hospital business objectives is
sensitive work.
Some local physicians are feeling the reimbursement and cost pinch
and are intent on hedging their situation.
They will leverage past relationships with the local hospital.
This includes exploring direct employment or some form of joint management arrangement.
3. James Thurber, an American cartoonist and writer best
known for Walter Mitty, wrote:
"Let us not look back in anger or
forward in fear, but around in
awareness."
4. Healthcare delivery models are changing (again)
New players are entering the market to provide
care (Insurers/Pharmacy’s)
New choices exist for physicians and allied
health providers (Walmart, CVS, Corporate
Health)
National Physician contract groups (Team)
Follow the money………………..
5. Independent Physicians look at:
“Obama Care” confusion
Perception v Reality
Belief that things are changing anyway
Independent practice is more complicated
Real erosion of practice revenues
Operating costs continue to increase
Cost of technology (purchase and implementation)
Look for expert help with new reimbursement models
Do not want to be left out of new provider networks
Consumer expectations are changing
6. Hospitals are moving to gain economies of scale:
Increasing M&A activity
Better control of costs and quality
Hospitals need greater control over service area
referrals and.. larger service areas
Hospital performance criteria requires active physician
support and input
Harder to recruit physicians into independent practice
7. A recent Merritt-Hawkins study of Residents
showed:
32% of first-year Residents surveyed in 2011 said they
prefer to be employed by a hospital, up from 22% in
2008.
48 % said that they feel increasingly unprepared to
handle the business side of medicine.
70% of national hospitals and health systems plan to
employ more physicians in the next one to three years.
10. 1. Establish a clear process for decision making
2. Conduct a preliminary due diligence
3. In depth practice and business assessment
4. Preparation of contract and making the offer
5. Acceptance or refusal - next steps
11. Physicians who approach the hospital to be employed
will probably fall into 5 categories
1. Low volume - struggling practices
2. Those not wishing to invest in technology and/or
close to retirement
3. High volume specialties seeing major income
reductions (Cards/Onc/Ortho)
4. Groups and individuals wanting to leverage their
current dominant role
5. Groups that are falling apart anyway
12.
13. Create a check list and a decision flow chart
Gets everyone on the same page
Creates an evaluation process that is supportable to and
by the Board
Allows for quicker decision making
Process helps physician to understand future
expectations on the front end
Deals with sensitive issues early
What does it mean to be an employee
Objective approach to decision
14.
15. Who needs to be involved and why
Confidentiality to be managed/need to know
Physician demographics
Strategic fit definition
Options/packages for recruitment
Who makes decisions and how
Preferred time line for process
16.
17. Who approached who:
• If strategically important determine who is best to make first approach to
physician or work with physician(s)
• What is the strategic fit – competitive / expansion of services
• Do you understand physicians request (fishing or firm)
• Has physician approached others?
• Does the physician need to get more information (from who and by when)
• Explain the process and evaluation flow chart to physician as a Board requirement
• Explain who is involved with decision process
• Agree on confidential approach
• Stand still agreement
• Provide time line (and keep to it)
18. Local recruitment flow chart (sample)
Who Physician Decision
approached
Who? Strategic Need
What do we know
about this physician
Begin Due Diligence Define data to
be collected
Strategic or
VP Medical Affairs
business need
- Med Staff Plan Input
for specialty
- Practice volumes
- Service Lines
Hospital
Talk with dept.
UR/QA Data
management.
Medical Records
Objective/specific Nurses etc
Credentials
information Sleuthing
Information subjective
Prepare Preliminary
decision Report.
Yes/No
19.
20. Issues to be addressed in a discussion with
Physician:
What expectations are there for an employment agreement?
What will happen to the existing practice?
What about employees?
Are there assets that may be purchased?
Describe the process for dealing with these
issues.
21. Use a standardized approach for a confidential report -
prepare:
• Physician name, specialty, privileges, # years, practice location, community served,
other hospital affiliations, practice partners.
• Physician stated interest and reason for interest in employment
• Current volumes of referrals IP/OP, practice, individual physicians
• Internal UR/QA information trends
• Observations of CMO or VP Medical Affairs, others
• Credentials review
• Is there a cultural “fit” with existing practices
• Strategic need reasoning (if required)
• Recommendations for next steps (Pursue or Not)
22. Use of preliminary due diligence:
Obtain Senior Management input / Board approvals to
proceed
Note any limitations/issue needed to be addressed
Meet with physician
Communicate issues
Reconfirm process
Confirm interest
If interest still good, get a formal confidentiality agreement
and “stand still” agreement in order to get more information
from the practice.
23.
24. Full assessment - preparation
Decision NOT to proceed
Decision to Proceed with Step 3
Full assessment
Proposal and Negotiation Prepare Preliminary
decision support.
IF YES or Need More Info Yes/No IF NO
Prepare Confidentiality Agreement Plan meeting with Physician/s
Decision Explain Conditions that
and Employment Practice must occur to move ahead
meeting Projections Assessment
25. You must know what the business status is now:
Request a more detailed assessment of the practice to
include: (explain why needed)
Full operating statements
Bank statements
Patient volumes by service
Review of patient records
Payer contracts
Staffing, salaries and benefits
Retirement plans
IT capability
26. What are the expectations
Discuss a check list for asset types and preferred
actions
Lay out a typical employment package that
conforms to existing criteria for income / salary /
incentives
Suggest physician adds any additional thoughts
to be presented to the Board/Senior
Management.
27. Direct employment
Hospital
Subsidiary (foundation model)
Aligned group - Multi Specialty /Single Specialty
Practice/employee acquisition-physician
contractor
Joint venture on a Service Line
Most anything that is legal
28. Senior Management (or Board sub-Committee)
should approve any formal offers.
Present this decision authority with:
Physicians wish list
Current practice performance data and projected impact if hired
Overview of plan for practice assets and personnel
Cost assessment with proposed salary, incentives, benefits
Proposed contract of employment
Timeline for action
31. Challenges will include:
FMV for assets
FMV for income
Non competes
Hours and coverage
There will be System/Operational changes
Collaboration
New reporting
Avoiding impressions of favoritism
32. Income Construction and Limitations
Productivit Payer Billing/ Practice Hospital
y Mix Collections Expenses Performanc
e
Fixed Salary
W/RVU’s
Net Collections
Net Income
Physician has incentive to manage
Physician has NO incentive to manage
33. Meet with physician to discuss the offer:
Employment/Services agreement:
Terms and conditions
Salary / incentives
Acquiring Business:
Description of assets to be acquired
Formal valuation
Liquidation of other assets
Consideration of staff
Timeline for decision and action
34.
35.
36. If Acceptance:
Move quickly to signature
Employment agreement
Sale/transfer of assets
Agree and prepare a time table for action
Schedule announcements (eg: to practice staff)
Change provider numbers/notify payors
Close books on original practice
Rehire staff with new contracts
37. If Rejection:
Communicate reasons and possible issues
Is a counter proposal required/appropriate
Is there flexibility in the package without Board
input?
Agree to disagree ?
Be sure to part on good terms if no deal
It’s just business
38. Be open but confidential (emotions may come into play)
Explain how decisions are made
Use an objective and supportable approach
Understand the physicians reasoning
Collect both objective quantifiable data and subjective
(confidential) peer commentary
When agreement is reached move quickly to get contracts and
make the changes
If no agreement there must be clarity and part friends.
Editor's Notes
Thoughts of managing population health and capitated payments processes is supporting Hospitals move toward integration by getting the physicians as part of the team. Allows for the collection of data and the ability to modify behaviors to meet expected standards of care. All clinical issues within the hospital are to great extent governed by the physicians.
Physician employment is more than a trend it’s a tidal wave.
A recent Healthleaders Study revealed that 67% of those surveyed said they had received more requests from local physicians to discuss employment. Making such decisions on who locally you want to employ has the potential to be trouble unless you handle it right.
There is a lot to be done to ensure the process goes smoothly. So if you want the right outcome don’t wait for the autopsy.
The 5 Step Approach When exploring physician employment options, managers should consider the following questions: What is the mission-related purpose of the physician employment or practice acquisition, such as serving a medically underserved area, addressing the absence of specialists or practitioners in the hospital, or raising the hospital's profile? What steps have been taken to assess whether the employment or acquisition will fulfill that purpose, such as assessment of the physician's services, capabilities and qualifications? What type of compensation package is necessary? Has a third-party made a fair-market value assessment and is the compensation in the range of that assessment? Is there a cash-in/cash-out problem or will the professional service fees a hospital collects cover the proposed compensation package? If not, what is the justification for going ahead at a loss? What assessments and projections have been performed on the impact to the hospital or health system in connection with the employment or acquisition? Has that assessment been performed and considered separately from the setting of the compensation package? Has management reviewed the compensation package through, for example, a compensation committee, verified compliance with the hospital's guidelines, and affirmed its reasonableness? Will there be restrictions on the physician's practice at other institutions during and after employment? Does the arrangement include incentives to ensure the physician's productivity during employment? If so, have those incentives been structured in a way that is compliant with regulatory requirements; that is, they do not take into account value or volume of referrals? Is there a process for monitoring the progress or success of the employment/acquisition in relation to the stated mission? Is there a path for making necessary adjustments to the relationship if needed to achieve the stated goal? What is the exit strategy for the hospital if the relationship with the physician is not viable?
How many of you are in the midst of dealing with employment interest from local physicians? Many of you will be intuitively conscious of these issues but it pays to cover them….. Some docs are looking for a way out of difficult situations with the hospital being the insurance policy. While their motivation for employment may not match that of the future ideal employee it is up to you to know why you are being approached and plan with that in mind.
You will not want to just wing it. The consequences of missteps can be career limiting especially if you are dealing with high volume physicians. By preparing a formal approach, in which other decision makers have input, will allow you to get decisions faster and be responsive to the physicians. Suggest you look at creating a process flow chart to be sure you get all the steps and consider contingencies. Also others know what you are up to as you begin the process. Be sure to share the process with the physician and arrange an informal discussion on what it means to be an employed physician. If not already done arrange for the physician to talk with other employed physicians. Better now than later in the process.
A word to the wise Lose lips sink ships. But keep those who need to know…. informed
What kind of things do you need to know to create your check list and what variables are you likely to consider.
Some will approach you and there will be some that you will want to approach to explore what they are thinking. What is the reason you will contemplate a recruitment. Strategic growth, better manage a service line, build a primary care referral base? What do you know about the physicians intent…. This is crucial. Fishing, desperate or a real desire to focus on being a clinician. How will you initially advise the physician? Ask how much time have they invested in exploring their options and particularly employment. Supply some resources…… make no attempt to hide information… it will come back to haunt you and spread mistrust to other physicians If desire to proceed need to set some ground rules. Your preliminary report will want to have covered the first conversation with the physician to verify he/she is serious and has carefully considered the process. It will also cover what is generally known about the physician. This quick assessment saves time and money if there are obvious reasons why this transaction will not take place.
Build a picture of the physician and how his/her practice will fit into your system
Preliminary discussion Describe the process that you are required to follow with all local physician recruitment and how the decision will be made.
Use your check list and limit who is involved in gathering the information Put the description together to get approvals to go to the next step. Who will be your best resources…. Confidentiality remains key
Step Back…. Do you have in place an existing group practice? Will the hospital directly employ. Is the Hospital an investor in an aligned group? Will the employed physician be an employee in a solo practice. Some hospitals acquire the practice and the physician becomes a 1099 employee. Practice can be leased from the physician and operated by hospital.
Be sure you have answered the questions before they are asked. CYA You may be presenting more than one physician to the Board so follow the same process for each. Simplifies the presentation. Put each physicians information in a separate packet. Present. Who are you talking about What is known What does the doctor request If approved what is the plan for acquisition and employment Costs and projections Proposed contracts w/ salary structure
By standardizing your approach you can simplify your life There will be exceptions
Points of Pain will include money, control and ego
The whole process of paying physicians is undergoing a Change. Initially salaries were the norm and production fell, then the switch to practice expenses and the care of the uninsured/Medicaid was ignored. Followed by Work RVU’s and production of any kind ramped up. Now seeing more combinations that include quality and hospital goals …with production. You need to run the numbers What is the best use of the physicians expertise and time.