Ask Dr. Parker

“What advice do you have for physicians who aspire to lead value based care organizations?

Did you ever wonder how your Medical Director or Chief Medical Officer got her or his job?  Did you ever wonder if they received some special training or went to another graduate school to learn their skills?  Turns out most Medical Directors and Chief Medical Officers learn their skills on the job and climb the ladder of increasing administrative and leadership responsibility within their own organizations.

Let’s take a look at the career path of a “typical” Medical Director or Chief Medical Officer.  And for the purposes of this discussion let’s consider a Chief Medical Officer to hold a similar but higher office than the Medical Director with larger responsibilities, often at a network level.

The big picture: What does an accountable care organization need from a Medical Director?

For a healthcare organization to be successful in value based care, Medical Directors need to help build seven key capabilities.

  1. Quality Measures. The medical director needs intimate knowledge of how her organization is doing on all required measures, and she needs to be facile with the variation between groups of providers. She probably needs a “quality person” to ride herd on all the details, depending on the size of the organization.
  2. Utilization. For all contracts with upside and downside risk related to utilization, the medical director needs near-real time insight into where all the utilization is occurring and where important variations need to be addressed.  A strong data asset is required as a foundation for this analysis.
  3. Coding and billing. This topic is universally disliked by providers, but effective medical directors understand that undercoding leaves money on the table and overcoding risks incurring penalties and sanctions. The most successful medical directors have support from analysts and administrative staff who use an enterprise clinical data asset to identify and close documentation gaps.
  4. Care Management and Disease Management. Medical directors can use aggregated data and sophisticated algorithms to look across their population and identify not only very ill patients, but more importantly, “actionable” patients.  These are the patients who are most likely to benefit from patient education and services.
  5. Leadership, Medical directors and chief medical officers need to not only develop their own leadership skills, but be highly tuned in to the leadership strengths and weaknesses within their own organization, from the very top right down to the local level with individual practices.
  6. Governance. Medical directors and CMOs need to understand and participate actively in the governance structure of their organization, including key committees such as contracts, network membership and sometimes even credentialing.  These committees will also determine the financial structure of an organization, and medical directors and CMOs need knowledge and input in those processes.
  7. Analytics.  Successful ACOs or other healthcare organizations need wide and deep sources of data, including both claims and EHR data, that are timely, curated, and actionable.  Medical directors need to guide business intelligence teams in using this data to best serve the interests of their patients and providers.  Population health management program needs evolve over time, so medical directors need to stay up to date and engaged with the analytical program.  Medical directors and CMOs often serve as the necessary bridge between the clinical leaders and the IT leaders, and their collaboration is essential to the success of the organization.

Medical Director Responsibilities

Medical Directors work with the larger leadership team to develop organizational strengths in all of these capabilities, with direct responsibilities for some of them.  A Medical Director at an accountable care organization (ACO) or other healthcare institution is usually directly responsible for overseeing and bringing to life all of the attributes listed above and below. They will typically have responsibility for the following:

  • Quality: Improve overall organizational performance on quality measures, which are specified by value-based care contracts.
  • Utilization: In ACOs with risk contracts, understand variation in patterns of medical utilization, such as use of high-tech radiology, skilled nursing facility (SNF) days, ED use, and high cost drugs.  Once the “diagnosis” of overutilization is made, the medical director or CMO is tasked with defining and carrying out a “treatment plan” to deal with aspects of overutilization and accomplishing meaningful and measureable reductions.
  • Care Management: Develop and execute an effective care management program.  This requires the ability to work well with nursing leadership and nurse care managers.
  • Coding: Implement coding initiatives that ensure that contract PMPM baselines are correct and optimized.
  • Disease Management: Oversee any disease management programs, such as initiatives around heart failure, chronic kidney disease (CKD), diabetes, chronic obstructive pulmonary disease (COPD), behavioral health and end of life/palliative care.
  • Compensation Plans: Depending on the organization, have oversight of compensation plans for physicians and the ACO’s overall financial performance.
  • Network Strategy: Assist with decision-making around the ACO’s strategy for potential expansion with new providers or new services.
  • Relationships with Leadership: Inform and educate ACO leadership and the relevant Boards about aggregate physician performance on contracted measures.
  • Relationships with Key Stakeholders: Work effectively with other ACO healthcare leaders, such as Chiefs of Medicine, Surgery, Radiology and the hospital administration.
  • Leadership: Demonstrate Leadership abilities to manifest all the change required to get the aforementioned items completed!

The importance of learning on the job

Most physician readers of this piece will immediately recognize that none of the items listed above are taught in medical school or residency.  In a nutshell, most of these skills and aptitudes are learned on the job.  Some of the business skills can be learned in business school, but most of the required skills are highly specialized around medicine.

It is my opinion that business school skills are not easily translatable to the specific needs of a Medical Director.  I believe this is also true of Masters of Public Health curricula, which may have more relevant healthcare content, but again, not to the level of detailed knowledge required by a Medical Director or Chief Medical Officer.

So, in the absence of a formal curriculum, how do you develop the skills you need?

1. Gain Basic Skills

First, the potential Medical Director or CMO needs to learn the skills of being a physician.  Spend five to ten years at least learning how to be a really good physician.  This means not only understanding the needs of your patients, but the needs of other providers and the broader healthcare team.

Over time, most Medical Directors and CMOs reduce their patient care time as they increase their administrative time.  You’ll want to be a constant student of how your organization works well and where it could use improvement.

2. Gain Administrative Experience

As you study your organization, you may identify areas of particular professional interest.  Seek out opportunities in these areas to develop hands-on administrative experience.

  • Volunteer for committees that oversee improvement in the quality of care. Perhaps there is a committee working on algorithms for need for admission from the ED, or perhaps there is a committee dedicated to improving performance on quality measures.  Get on it and participate!
  • Take initiative to get involved with the financial business meetings of your practice group and/or hospital. This will allow you to learn by observing others, and it will help you decide what elements you see in others that you wish to add to your own toolkit.

3. Develop Emotional Intelligence

Recognize early that there are really two sets of skills to learn.  The first is related to a knowledge base about value-based care, such as the items listed in the Medical Director job description above.  But the second set of skills – probably more important – relates to what is often called “emotional intelligence”.

To be a leader, you will need earn the respect of your peers and co-workers, and you will need to assist them in thinking and acting in new ways.

There is some understandable debate as to whether leaders are born or trained.  My attitude is that if you are interested, if something inside you says “I think I could do this, I think I could be good at this, I think I would enjoy the challenge” than consider listening to that inner voice.  As my father would say, “If you want something, do something!”  Then take some steps in that direction and see if you like it and wish to go further.

Mentors can be very helpful.  I am a big fan of finding an older, experienced physician who might be willing to spend some time with you on an intermittent basis assisting you in your journey towards medical leadership.

4. Seek Outside Learning Opportunities

Courses about leadership may offer a kernel of truth here and there that are helpful.  Be open to learning about leadership in any way you can, including reading about other leaders you might find intriguing, such as President Lincoln or President Washington or whomever ignites your interest.

For some people, taking graduate level courses either in business or schools of public health may be useful.

Lessons about leadership know no boundaries.

5. “Are you pissing people off yet?”

My final lesson might surprise you.   It was shared with me once by an older, wiser Medical Director at a conference when I was a relatively junior Medical Director. “You can’t make an omelet without breaking some eggs,” he said.  He followed that up by asking, “Are you pissing people off yet?”

Of course, what he meant was that as a leader you are going to have to change the status quo.  By definition, changing the status quo threatens something for someone – and that “someone” is likely to be upset with you.

To reach a higher goal, you will need a thick enough skin to take the heat in the kitchen (if you will allow me to mix metaphors).

Hopefully, I have given you some food for thought about what it takes to embark on the journey to become a Medical Director and ultimately a Chief Medical Officer.  I would conclude by sharing my belief that the most successful Medical Directors and CMOs view themselves as lifelong students of learning with unending respect for patients and their peers.

March 7, 2019