DataWatch. Administrative Medicine: A New Medical Specialty?

Transcription

1 DataWatch Administrative Medicine: A New Medical Specialty? by David A. Kindig and Santiago Lastiri The growing complexity of the health care system in the United States and the importance of balancing cost effectiveness with quality and access has led to increased attention to the management and managers of health care institutions. Within this environment physicians primarily engaged in administration are increasingly playing an important role. There is limited information about the characteristics of this group. The American Medical Association (AMA) Masterfile contains the category of administration in its published statistics; the number of individuals in this category has grown from 11,715 in 1968 to 13,828 in This number represents a smaller percentage of total active physicians (from 4 percent to 3 percent over that time period) because the total number of active physicians has grown more rapidly. Several studies have examined various characteristics of physicians in administration.2 All of these past studies are limited in that they are dated or only examine one component or employment setting of physicians in administration. The study presented here was designed to obtain current information on the characteristics of physicians engaged in administrative activity to better define and understand this group and to better plan appropriate programs for physicians needing and wanting further managerial education to carry out their complex tasks. Study Methods The data for this study were obtained through twenty-minute telephone interviews of physicians across the United States whose primary professional activity was administration. A sample of 2,393 physicians was drawn from the total population of 13,500 physicians listed in the AMA Masterfile in July Primary professional activity in the Masterfile is based upon the greatest number of hours worked per week David A. Kindig is professor and director of Programs in Health Administration at the University of Wisconsin s School of Medicine. Th rough a number of private and public posts, Kindig has maintained a strong commitment to improving access to medical care in underserved areas. Santiago Lastiri, who earned a medical degree from the University of Hidalgo, Mexico, is currently a predoctoral student in health policy and management at the University of Wisconsin.

2 DATAWATCH 147 in various categories as self-reported by physicians in the Physician Professional Activities (PPA) Questionnaire. Of the 2,393 physicians chosen, we were able to complete 878 interviews, which represents 71 percent of the eligibles. Basic characteristics such as age, sex, specialty, geographic location, board certification, and federal versus nonfederal employment were taken from the AMA Masterfile tape. The 878 respondents were essentially identical to the entire 13,500 total population on these characteristics with the exception of federal employment, which involved 21 percent of our respondents and 13.4 percent of all physician administrators in the AMA Masterfile. The interview instrument solicited information on: title of administrative position; nature of the organization or institution worked for; number of previous administrative positions; number of years in current and past administrative positions; percentage of time devoted to administration and to clinical work; managerial education; membership in the American Academy of Medical Directors (AAMD), a national profes- sional organization of physician administrators; and perception and attitudes toward the role of physicians in administrative positions. Results The basic characteristics of physician administrators in our sample are presented in Exhibit 1. They tended to be slightly older than the average active physician, and a larger than average number were male. On the average, physician administrators had been in administration for over eighteen years, and had held their current positions about seven years. They worked slightly fewer hours per week than those reported for all physicians, and spent nearly two-thirds of their time in administrative activities. Approximately one-fifth of their time was devoted to patient Exhibit 1 Basic Characteristics Of Physician Administrators Average age 54.2 years Percentage male 91.2% Average no. of years in administration 18.6 years Average no. of previous administrative positions 2.3 positions Average years in current administrative position 7.2 years Average no. of hours worked/week 54.2 hours Percent time devoted to administration 64.9% Percent time devoted to patient care 20.5% Percent board certified 72.6% Percent AAMD membership 13% Federal employment 21.5%

3 148 HEALTH AFFAIRS I Winter 1986 care. In our sample 18 percent indicated spending less than 40 percent of their time in administration. The only explanation that we can give for their inclusion in the original sample is that their time allocation had changed since the time of their last PPA questionnaire, which could have been several years ago. They are included in our results since they did not differ by age, sex, type of organization, or specialty from the rest of our sample. A larger percentage of the physicians in the sample are board certified than is true of all active physicians. Exhibit 2 indicates the proportions of physician administrators in the sample by specialty and in relation to the percentages of all active physicians in the country. Many of the clinical specialties show ratios lower than 1.O. However, psychiatry has twice the proportion of administrators with respect to all active physicians in that specialty. In addition, public health, general preventive medicine, occupational medicine, aerospace medicine, pathology, and physical medicine all have ratios higher than one. This is not unexpected, given the increased administrative activities associated with these specialties. Geographic location of physician administrators was also analyzed. They appeared to be distributed uniformly across the states in relationship to the number of physicians in a given state. The only significant exception to this appeared to be in California, which had a lower ratio of physician administrators to all physicians, and Maryland, Texas, and Wisconsin, which had higher ratios. With regard to annual professional income, 3 percent reported less than $50,000 per year, 20 percent from $50,000-$74,999,34 percent from Exhibit 2 Specialties Of Physician Administrators General practice/family practice General internal medicine Other medical specialties Pediatrics General surgery Obstetrics/gynecology Other surgical specialties Psychiatry Public health General preventive medicine Occupational medicine Pathology Anesthesiology and radiology Aerospace medicine Physical medicine and rehab. Others No. of Percent of Ratio of physician physician Percent of all MD admin. to administrators administrators active MDs all active MDs a

4 DATAWATCH 149 $75,000-$99,999, 21 percent from $100,000-$124,999, 11 percent from $125,000-$149,999, and 11 percent greater than $150,000. The weighted mean for all professional income among the physician administrators in our sample was $110,374. This figure varied in relation to type of organization, title, and public versus private setting. The mean is comparable to the mean net income of $108,400 reported by the AMA in 1985 for all practicing physicians.3 Exhibit 3 shows the distribution of physician administrators by type of organization. The majority of these physicians were in hospitals (30 percent), educational institutions (24 percent), and government agencies (23 percent). Other organizations with physician administrators included group practice or clinics, health maintenance organizations (HMOs), health care corporations, industry or manufacturing, nursing homes and home health care agencies, insurance companies, and research institutions and foundations. Exhibit 3 Type Of Organization Of Physician Administrators Organization Number Percent Hospital Educational institution Government agency Health care corporation 46 5 Group practice or clinic 39 4 Industry or manufacturing 38 4 HMO 12 1 Other 66 8 Total Exhibit 4 shows the public and private sector distribution of physician administrators in the three different types of organizations that have the largest percentage of those physicians. In hospitals, 54 percent of physician administrators were in the private sector and the remainder in the public sector. Of the thirty-one federal physician hospital adminis- Exhibit 4 Number Of Physician Administrators In Public and Private Organizations Public Organization Total Private Federal State Hospital (54%) (12%) (13%) Educational institution (37%) (1%) (58%) Government agency (44%)

5 150 HEALTH AFFAIRS I Winter 1986 trators, twenty-five were in the Veterans Administration and four in the military. In educational institutions, 37 percent of physician administrators were in private institutions and 63 percent in public, with most of the public portion in state-level schools. Physician administrators in government agencies were found at all three levels. In addition, we found that 71 percent of physician administrators in hospitals were in institutions of less than 250 beds, and 45 percent were in hospitals that were part of a multihospital system. Exhibit 5 describes the average percentage of time that physician administrators devote to administration, clinical work, and other activities. Other in this survey is the time remaining after clinical and administrative activities and is assumed to include primarily teaching and research. There were substantial differences in average percentages of time devoted to administration in the major categories of organization. HMO physician administrators dedicated more of their time to administration (90 percent) than physician administrators in the other organizations. Physicians in educational institutions spent the least amount of time (56 percent) in administration. Clinical activities ranged from 27 percent in group practice to 6 percent in health maintenance organizations. Other activities ranged from 24 percent in educational institutions to 4 percent in HMOs. When asked to cite the primary reason for choosing an administrative career, 39 percent indicated a desire to have broad impact on health care delivery and to assure quality of patient care, 11 percent cited new opportunities and challenges, 11 percent indicated that the organization needed someone to do the job, 13 percent indicated a general enjoyment of management, and 7 percent indicated that they had the expertise and talent. Income security was identified by 3 percent and dissatisfaction with patient care by 4 percent. Regarding graduate education in management beyond the medical degree, 9.8 percent reported obtaining a master s of public health degree (MPH) an average of seventeen years ago, 1 percent reported earning a master s in business administration degree (MBA) an average of 8.2 years Exhibit 5 Percent Of Physician Administrators Time Devoted To Various Types Of Activities Organization HMO Government agency Health care corporation Industry or manufacturing Group practice or clinic Hospital Educational institution Administration 90% Clinical Other 6% 4%

6 DATAWATCH 151 ago, 1.9 percent reported receiving other master s degrees an average of 11.3 years ago. An additional 16.2 percent of the sample reported nonmanagement masters or doctorate degrees obtained twenty-three years ago on average. Physician administrators were also asked their views on whether formal graduate coursework or a graduate degree in management was advisable; 21.5 percent indicated that such education should be required and 62.1 percent indicated that it was advisable. Academic areas listed as the most important to study included: computer applications (13 percent), personnel and labor relations (10 percent), accounting and finance (10 percent), strategic planning (10 percent), quality assurance (7 percent), and management of physicians and other health professionals (7 percent). When asked whether the need for physician administrators would increase, decrease, or stay the same in the future, 75 percent indicated that the need would increase, 11 percent indicated that it would decrease, and 11 percent indicated that it would stay the same. Of those indicating an increased need, 27 percent said the primary reason was the need for physician involvement in the decision-making process. Other reasons included the more complex business orientation of the current system (19 percent), new alternative delivery systems (14 percent), and increased political pressures and government control (10 percent). Characteristics of AAMD members were compared to those of the total sample to see if there were differences in those physicians who had indicated interest or expertise in management by membership in this group. The major differences noted between the two groups were that AAMD members were slightly- older; had more previous administrative positions in their careers; and devoted a higher percentage of time to administration than their counterparts. In addition, physicians in AAMD were more frequently found in private organizations (hospitals, group practices, health care corporations, HMOs) and less in educational institutions and state and government agencies. AAMD physicians were more likely to have titles as president, vice-president, CEO, and medical director of health corporations or institutions than the sample as a whole. Currently a similar survey of AAMD membership is being carried out and comparisons with these data will be undertaken.4 Implications For The Future Of Administrative Medicine Profile of administrators. The results of this survey provide the only current and comprehensive description of U.S. physicians who are primarily engaged in administration. Many are surprised to learn that the AMA Masterfile lists 13,500 physicians in this category even though their annual reports have listed approximately this percentage of total

7 152 HEALTH AFFAIRS I Winter 1986 active physicians since the current method of reporting professional activity was introduced in Since so many physicians who do engage in administrative activity continue in other activities such as patient care, teaching, and research, it seems appropriate to use the AMA approach of hours devoted to an activity as a good way to categorize a primary professional activity. The current sample is the most representative yet studied since it does not deal with only a single organizational type such as hospitals or group practices or some other characteristic such as membership in a particular organization. The basic characteristics of the sample as a whole do not contain any unexpected findings; the facts that physician administrators are slightly older, predominantly male, and still practicing a limited amount of medicine have face validity. It will be interesting to observe whether the average years in a current administrative position decrease if the demand for such individuals increases in the future and turnover becomes more rapid. With regard to organizational type, the results differ from those reported by Slater for AAMD members in 1979, with slightly fewer in hospitals and considerably fewer in medical groups and HMOS.5 On the other hand, many more are reported in educational institutions and in government organizations. The fact that our sample contains more federal physicians than the total in the AMA Masterfile indicates that the percentages in government reported here are probably greater than the actual ones and must be taken into account in interpreting the results. Of particular interest are the substantial numbers in state and local government, presumably in state health departments and local public health agencies. Time spent in administration. The percentage of time in administration varies from 90 percent in HMOs to 56 percent in educational institutions. It is not unexpected that those in educational institutions, group practices, and hospitals would have lower average amounts in administration because of the clinical activities usually associated with administration in these settings. The relatively high percentages of clinical time in these organizations confirm this impression. Educational institutions have the largest percentage of time in other activities, which almost certainly reflects the teaching and research mission of these organizations. The reason for the low percentage of time in clinical activities and the very high percentage in administration in HMOs is not clear; it may be due to the small number of respondents or due to many individuals being associated with newer organizations with substantial development activities. The figures that are unexpected are the relatively high percentages of clinical and other activities in governmental organizations and the high percentage of other activities in health care corporations. The finding that 18 percent of respondents are now spending less than

8 DATAWATCH percent of their time in administration but are listed in the AMA Masterfile. with administration as their primary professional activity raises questions about the movement of this group of individuals in and out of administrative positions and the frequency of changes in percentage of time in administration. We would expect that the time in administration would increase with the number of years in administration, the level of position in the organization, and larger organizational size. We have collected data on the previous three administrative positions of our respondents and will be analyzing and reporting separately the results of the career progression of physician administrators. AAMD membership. The 113 or 13 percent of physician administrators who are members of the AAMD in our sample is similar to the national distribution; the 1985 AAMD membership was 1,700, which would be 12.6 percent of the 1985 AMA total of 13,500. Even though membership in the organization is voluntary, it would be expected that individuals who pay dues to belong to an organization devoted to medical management and have participated in managerial continuing education would have characteristics indicating more extensive managerial activity. The higher representation in medical groups and hospitals probably reflects the origin of the academy in the group practice sector and the relative emphasis of managerial development in private and noneducational institutions. Reasons for choosing administration. One of the most striking differences from the past literature is the reason for being in administration. When Goss reported in 1962, most physicians found administrative activities unrewarding and only did them because they had to.6 In contrast, only 18 percent of individuals in our study gave reasons of dissatisfaction in clinical practice, no one else being available, or income security as the primary rationale for administrative activity. The majority appears to be in administration for positive reasons such as impact on health care delivery, new opportunities and challenges, and managerial enjoyment and talent. Educational requirements. We were surprised at the large number of respondents who indicated that formal graduate coursework or advanced degrees were advisable or should be required by physicians in managerial positions. Relatively few of them possessed such degrees and many of the degrees reported were MPH degrees earned almost two decades ago that did not have a uniformly high concentration on management. It is noteworthy that the few with business administration degrees had earned them within the last decade on average. Anecdotal evidence indicates that increasing numbers of physicians are engaging in formal managerial education, either as continuing education or in MBA or health administration degree programs. Over the past decade, the W. K. Kellogg Foundation has assisted in the development of nontra-

9 154 HEALTH AFFAIRS I Winter 1986 ditional masters degree programs for clinicians at the University of Wisconsin, Harvard University, the University of Colorado, and New York University. The University of Wisconsin School of Medicine offers a degree in administrative medicine, a thirty-credit professional degree that integrates managerial and business courses with courses in medical administration. The response to our question about which academic areas would be most important to learn about showed a balance between business subjects such as strategic planning, accounting and finance, and computer applications; and health-related subjects, especially quality assurance and management of physicians and other health professionals. Ruelas and Leatt point out that physician executives will have different educational needs depending on the nature of their position and role and the principal issues facing the particular organization.7 Of the three predominant types of organization represented by the respondents, one can certainly imagine differences in role and educational needs of physician administrators in hospitals, educational institutions, and government, Detmer has made the distinction between the physician-manager who is a full-time executive with no clinical responsibilities and the clinician-executive who spans the boundary between the full-time administrators and the full-time clinicians. While MBA training without health care or significant medical integrative content may be appropriate for some full-time managers of corporations or large institutions who happen to be physicians, we believe that most physician administrators and medical directors will benefit from the combination of business and administrative medicine training that parallels their professional roles. Administrative tasks. This survey did not contain questions regarding the roles and tasks that physician administrators perform. However, other researchers have addressed this issue. Slater defined eight basic tasks that at least 70 percent of his AAMD respondents claimed involvement in: determining or improving medical practices used in patient care; dealing with problems or differences between physicians; evaluating physician performance in the organization; advising and motivating physicians; recruiting physicians to the organization; improving the quality of patient care; dealing with external medical organizations and societies; and improving professional knowledge and skills.9 Colligan and Berglund indicate that the administrative role of physicians includes setting group policy in medical matters, assuring quality control, assuring peer review, assuring that medical records meet standards, establishing relationships with referring physicians, assuring that medical practice is in accord with ethical principals, and taking leadership in controlling patient care costs.10 Starr indicates that the rise of corporate medicine will restratify the profession of medicine. He suggests that organizations of

10 DATAWATCH 155 physicians in groups may be able to exert collective action to influence decisions when both medical and economic considerations are relevant. Shortell has compared physician participation in hospital governance and hospital administration in investor-owned multihospital systems with that in other hospitals.12 While the investor-owned systems had more physician involvement in government through membership on the board or board committees, they were less likely to have physicians as salaried administrators and to have fewer medical staff committees. Shortell concluded that increased physician and medical staff input will be required to make the managerial and ethical decisions needed to balance the tension between health care as an economic good and as a social good. The respondents in our study seem to confirm these views not only by predicting an increased need for physician administrators but by indicating that the reasons for the increased need were primarily the need for physician involvement in the decision-making process and the issues created by the more complex and business-oriented health care system. There is every indication that the numbers of physicians involved in administration will increase in the future. The American College of Physician Executives (ACPE) h as b e g un to explore the possibility of formal recognition of the specialty of medical administration or administrative medicine. A certifying exam has been developed with the assistance of the National Board of Medical Examiners and has been administered twice. Fellowship in the ACPE is awarded to physicians who pass the exam and who have demonstrated excellence in clinical practice and in administration. There are currently 258 fellows of the ACPE. A committee of the college has been formed to pursue the possibility of formal recognition as a specialty or subspecialty board.13 While some remain skeptical that there is unique professional content in administrative medicine, others point out that this discipline is certainly as unique as several of the more recently approved specialties of family practice and emergency medicine. In terms of numbers alone, there are more physicians whose primary professional activity is administration than in the specialties or subspecialties of radiology, ophthalmology, neurology, dermatology, cardiology, urology, and otorhinolaryngology. Whatever the outcome or formal recognition of this specialty, we believe that the importance of physician administrators in the health care system will increase more rapidly than their numbers, and that their role will be critical in achieving a necessary balance among economic efficiency, quality of health care, and the ethical issues of access and rationing.

11 1% HEALTH AFFAIRS I Winter 1986 This study was conducted through a grant from the W. K. Kellogg Foundation. The authors would like to acknowledge the assistance of Robert DeVries at Kellogg; Roger Schenke of the AAMD; Gene Roeback for the American Medical Association Department of Data Release; Harry Sharp, Diana Bott, Diana Durand, and Jane Niece of the Wisconsin Survey Research Laboratory; and Cindy Dunne for assistance in peparing the manuscript. NOTES 1. Physician Administrators, American Medical Association (July 1985). 2. Mary E. W. Goss, Administration and the Physician, Journal of Public Health (February l962): ; Miriam T. Dolson, M.D.-Administrators are Older, Earn More Money, Run Bigger Hospitals; Survey, Modern Hospital (February 1969): %-98; Carl Slater, The Physician Manager s Role: Results of a Survey, in The Physician in Management, ed. Roger Schenke (AAMD Publication, 1980), 57-69; John S. Lloyd and Nancy L. Shalonitz, A Profile of Today s Medical Director, reprinted from The Hospital Staff, vol. 9 (American Hospital Publishing, Inc., February 1980); and Arthur Young and Co., Physician/ Administrator Survey (American Medical Association, 1984). 3. AMA, Socioeconomic Characteristics of Medical Practice (1985): Katherine Montgomery and Roger Schenke, personal communication, Slater. The Physician Manager s Role. 6. Goss, Administration and the Physician. 7. Emnique Ruelas and Peggy Leatt, The Roles of Physician-Executives in Hospitals: A Framework for Management Education, Journal of Health Administration Education (Spring 1985): D. E. Detmer, The Physician as Corporate Practitioner and Corporate Leader, presented at 1984 National Forum on Hospital and Health Affairs, Duke University, 1984, Slater, The Physician Manager s Role. 10. Robert D. Colligan and Elizabeth Berglund, Changing Roles of Physicians, Nurses, and Administrators, Medical Group Management (July-August 1985): Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), Stephen M. Shortell, Jeffrey A. Alexander, and Michael A. Morrisey, Physician Participation in Administration and Governance of System and Freestanding Hospitals: A Comparison by Type of Ownership, MIME0 (September 1984). 13. Frank Riddick and Richard Wilbur, personal communication, 1986.