The medical director as educator: an interview with Elizabeth M. Gallup, MD, JD, MBA - The Evolving Role of the Physician Executive - Interview

Physician Executive, Sept-Oct, 1999 by Richard L. Reece

Q. IS THE ROLE OF THE medical director evolving or changing as we approach the millennium?

Gallup: The answer to that question is what they taught me always to answer in law school: "It depends." It really does depend on the entity for which the person is a medical director. It depends on their job description.

The role of the traditional medical director, who is a Dr. No and that's all he or she pays attention to, just saying no and watching the clinical performance, is evolving into being an educator to assist physicians to manage their behavior and change their practices based on comparative data. In addition, the medical director is more involved in looking at the costs of what's happening in the practices and in the IPA. In the past, medical directors didn't participate in the economics of much of anything. It was purely clinical. But it's evolving to more of a business as well as a clinical role.

Q. What about the legal liabilities of a Dr. No, a Dr. Denial, or a Dr. Darth Vadar, who denies treatment, says it's medically unnecessary, or contradicts the physician at the bedside? Is that a growing problem?

Gallup: Yes. That's one of the reasons that entities are evolving away from a Dr. No. When you say no, it increases not only the medical director's individual liability for which he or she ought to have professional liability insurance, but also the liability of the HMO or the IPA or the entity for which the medical director works. In fact, just saying no doesn't really work in changing behavior. It alienates the practicing physician from the medical director, the HMO, or the IPA whose role is to help the physician practice better clinical medicine that is more cost-effective.

The only time in our organization that we ever say no is when a physician refers a patient to a specialist who is outside of the network. The primary care physician has to have to have a really good reason. Many times he or she does. However, it's often that the physician forgot to check the referral specialist list. Our role as an IPA is to say yes and keep our denial rate low, but also to supply the Information about the network to help the physician make the appropriate referral behavior.

Q. Physicians have exhibited a profound distrust for managed care as evidenced by the American Medical Association's unionization. How does a medical director, who's on the management side of the fence, retain his or her credibility?

Gallup: There are a multitude of answers to that question. One is that it depends on who you are a medical director for--an HMO or an IPA. Regardless, you always have to make sure that you make decisions based on what is in the best clinical interest of the patient--not on what is the best economic interest of the organization.

Let me give you an example of what I mean. There are multiple HMOs in Kansas City that now demand that all X-rays are performed at specific facilities. That's because these facilities gave the HMOs a pretty good price.

But what about the poor patient? Most family physicians and internists can do chest X-rays, extremities, and flat plates of the abdomen in their office. So, now the physician has a patient in pain coming in, or maybe a patient in congestive heart failure, and the patient has to leave the physician's office to go to yet another facility, which in some cases is 20 miles away. The patient gets the X-ray and comes back and the physician reads it. That's not in the clinical best interest of the patient.

Obviously, the physicians aren't too fond of HMOs that require their patients to jump through so many hoops. That adds to the disenchantment of the physician, if you look at it from the clinical side of practicing. It's the medical director's job to make sure that quality is not sacrificed for efficiency.

The second thing is, if the medical director doesn't do a good job in educating the physician, then the medical director is just going to be seen as a Dr. No. Anytime somebody is told no, it makes them mad.

Thirdly, especially in the Kansas City market, the primary care physicians and, just now, the specialists have taken enormous economic hits on reimbursement because the hospitals have been very strong and have not been willing to negotiate. The HMOs, to try and make profits in an extremely competitive market, have tried to take their money out of the physician's pocket, which also leads to disenchantment and talk of unionization. We have an IPA here that has a strong relationship with a large HMO. We are striving to make the physicians and patients more satisfied and partner with the HMO to create efficiencies that actually increase quality.

Q. You wrote a book called How Physicians Can Avoid Surrender and Lead Change: Gaining Real Influence in Your Own Health Care Organization Before It's Too Late (ACPE, 1996). That has a military ring to it. Do you believe physicians ought to go into their corners and come out fighting? Be more assertive?

Gallup: It sounds more militaristic then it is. It promotes physician cohesion in acting as a group. That is the American way. If you want to exert influence, get a group of anybody--any type of group will exert more influence than an individual.