Performance appraisal critical to managed care

Neglect them at your own peril

Physician relations professionals take careful note: If, in your hurry to build primary care networks, you haven’t developed a physician performance appraisal process, you may be cutting off the hand that feeds you, warn the co-authors of a new book, Physician Performance Management: Tool for Survival and Success.

As health care systems continue their frenzy of buying managed care practices to ensure a steady supply of referrals, they run the risk of "inheriting" physicians who are at best not team players and at worst will cost the entire system capitated dollars because of poor practice patterns, says Christine N. Micklitsch, MBA, FACMPE, director of physician education and services at Fallon Community Health Plan in Worcester, MA.

"Physicians can be your greatest asset or greatest liability — if you don’t give them the proper tools to survive in this rapidly changing health care environment," Micklitsch says.

As managed care continues to penetrate healthcare systems, talented physicians who can keep capitated dollars will be essential. "Yet, if the performance of physicians is less than desirable, patients and payers are more willing than ever to ‘vote with their feet’ when services, care, or costs don’t meet their expectations," she says.

The problem, explains Micklitsch, is that when new physicians come on board, there may be an incongruent fit between their old way of doing business and the new demands of delivery under managed care.

For example, under the traditional fee for service reimbursement system, physicians could maintain independent control of risk and reward as well as profit and loss. But at the other end of the reimbursement spectrum, capitation places physicians at risk —and thus the health care system — with its fixed payment for a defined population over a specific period of time.

The new medical model calls for teamwork, collaboration, and communication — a framework well on its way to being a standard among other hospital staff. Yet, it confronts physicians’ beliefs that "their judgment and practice style with patients, colleagues, and staff should not be scrutinized," says Micklitsch. (For information on how to help physicians change, see story, p. 42.)

That’s where the performance appraisal process becomes invaluable, the authors say. Much more than an annual job review, the appraisal is part of a larger concept of performance management — a means by which organizations can state expectations, offer feedback, and measure and monitor physicians through the eyes of those closest to them, says co-author Theresa A. Ryan Mitlyng, MD, associate medical director, HealthSystem Minnesota in Minneapolis. "Ask for feedback from those individuals most likely to know the physician best," says Ryan Mitlyng.

Include feedback from the following:


"To physicians, the opinions of their colleagues are very important," says Ryan Mitlyng. Yet, they may not feel comfortable giving their feedback in an off-the-cuff fashion. "A formal review process allows you to solicit feedback in a less threatening way," she says.

Such feedback should include these questions: Is the physician willing to trade call? Work patients into the schedule? Accept new patients? Participate in meetings?

Include colleagues who practice in the same specialty, as well as those who have regular contact through referrals such as primary care. Don’t forget nurse practitioners and physicians’ assistants. "They will also have a view as to how well the physician can act in a mentoring or supervisory role," says Ryan Mitlyng.

Support Staff.

Because interactions with front-line staff — nurses, receptionists, medical office assistants, etc. — are the first encounters a patient has upon entering a health care setting, they are extremely important to the success of the practice, points out Ryan Mitlyng.

Yet, if a physician’s relationship with his or her staff is tense or turbulent, it can "rub off" on the patient.

"Dysfunctional physician behavior can have a very negative impact on the ability of the team to serve patients," she says. "Physicians need to exhibit the same respect and acceptable social behavior with their staff as they would expect from others."

To evaluate the emotional climate of the workplace, ask the support staff questions such as: Does the physician answer patient phone calls? Is he or she willing to work with patients when needed? Explain treatments or diagnoses clearly to patients so they do not have to call back.


It goes without saying that patients are the prime customers of any health care system, yet organizations may still take for granted patients’ loyalty to a physician.

To find out what patients really think of their physicians, use internal patient satisfaction surveys that contain questions about physician’s interaction, behavior, and communication. "Even though this data is very subjective, it can have significance if it is gathered from a large enough sample of patients [about 100 to 150] per physician," Ryan Mitlyng says.

By having the patients numerically rank their answers, scores can be compared to those of colleagues whose patients also have been surveyed. Another barometer of patient satisfaction is patient complaints. One complaint does not signify a trend; however, if a physician receives a large number of patient complaints over the years compared with a colleague, this could signal that patients perceive a poor quality of care. "This represents risk to the individual physician and the organization," says Ryan Mitlyng.

Work teams.

As physicians move from an independent model of care to an intra-dependent one, health care systems must assess their participation in teams, adds Ryan-Mitlyng. "How well the group functions as a team will determine the efficiency of the practice and the quality of the patient’s outcome," she says.

Such feedback would include: Does the physician arrive in the operating suite on time? How long do procedures take? Is the physician able to direct the team effectively?


"Administrators should provide physicians feedback on how much it costs to practice in the fashion chosen," says Micklitsch.

Such examples could include: What are the practice’s revenues, overhead, and patient mix? How long does it take for the patient to get an appointment? How many new patients are being served, and how many are leaving? What are the utilization of laboratory and radiology resources and the cost of drugs prescribed? What are the physician’s transcription costs? Average length of stay? Cost of physician’s staffing?

"The bottom line is that by keeping physicians regularly informed, they are more likely to feel accountable for their individual activities and contributions," says Ryan Mitlyng.