Physicians and organizations: for whom the bell tolls.

As a physician who has developed physicianorganization arrangements (POAs) that benefit physicians as well as promote viable delivery systems, I have raised numerous questions about their role within the healthcare industry and, more importantly, about their incentives for those considering alignment. Howard Zuckerman's article on the subject explores the various facets of this system, and by doing so offers a closer, yet unbiased, view of POAs. Currently, the merits of POAs are recognized more by their organizers than by their physician participants. The reason for this is twofold: First, the healthcare industry continues to support nonaligned practices such as diagnosisrelated groups (DRGs) and fee-for-service, and second, physicians prefer the autonomy that these practices afford them. However, as managed care continues to engulf the markets, and capitation arrangements continue to increase, the demand for alignment becomes greater. The first, and often most difficult, question is why and how to organize. Although more physicians are becoming aware that alignment is imminent, they are unaware of its implications and challenges. The transition from independent practice to alignment is usually characterized by radical changes for physicians. Physicians need to realize that this shift in responsibility will bring forth changes in their autonomy, governance, system of risk and reward, and level of trust. As illustrated in Figure 1, there is a relationship between the physician's level of autonomy and trust, and the type of healthcare setting with which he or she is willing to align. The figure also shows that practitioners with high autonomy and low trust are antagonistic and are likely to act with independence. In an independent practice, physicians are autonomous; therefore, the system of risk and reward depends only on their own management and decisions. Trust in an independent practice environment is not an issue but becomes pivotal as physicians determine their willingness to align with an organization. In POAs, physicians must accept the decline of their autonomy and must increase their level of trust because some organizations require physicians to participate in governance. As a result of this structure, physicians not only become part of the decision making but also are subject to the risks and rewards of the entire organization. However, different organizational arrangements require different levels of commitment. According to Zuckerman, sustaining a successful POA "often .... calls for careful selection of the participants and management." Because POAs are being formed to compete in the healthcare arena, I agree that the selection process for both physician leaders and participants should be thoughtful and exact. Selected participants must imbue quality management principles and reduce variations in medical care. The search for the right physician who will lead and organize other physicians toward a common goal is a complex and laborious task. The selected physician leader must gain the trust, support, and cooperation of the participants, and recruit nonaligned physicians who are fiercely autonomous and distrustful of their colleagues. Lack of documentation of physician efficiency and practice patterns becomes a major obstacle in this search. Hospitals, which traditionally maintain records of these patterns and outcomes, fail to provide more substantial information that will help determine a physician's qualification, and predict his or her suitability and success within an organization. Another avenue worthy of examination in the search for the right POA participant is the hospital's medical staff. Traditionally, the medical staff is the only organization common to a majority of physicians. Although the group encourages physicians to interact, it usually does not produce physician leaders who possess skills that are required to promote physician organizations. One of the problems with the medical staff is its election process that relies more on popular vote than on qualification. …