Partners Who Don't Pull Their Weight: Here's the Solution

It's a common complaint: One physician is slacking off while everyone else runs between patients, fields calls after hours, and squeezes in staff meetings. Do you have a colleague who isn't working as hard as everyone else? Who either doesn't bring in enough revenue, or refuses to be on call as often as they should? Or perhaps he or she doesn't take part in your practice's community outreach efforts.

Introduction

Exasperated group members are frequently reticent about confronting the offender, especially if the doctor is a venerable senior partner who is decelerating toward retirement.

"They are loath to take steps," says Judy Bee, a partner in the Practice Performance Group in La Jolla, California. "I don't know how many times we've started working with a medical practice and we are given a clear agenda, but we get there and they say, 'It's about Harry. You have to get him to behave.'"

Younger physicians can be a source of ire, too. Perceptions of indolence, it turns out, are generational. You can have a 65-year-old doctor "who has worked his practice from dawn until dusk, and he gets angry when younger doctors don't like to do that," says Judy Capko, the founder of Capko & Company, in Thousand Oaks, California. However, she points out, the attitudes and goals of younger physicians tend to be entirely different, and expecting the same single-minded devotion from them is "totally unrealistic."

Solving the problem means addressing 2 areas: figuring out an appropriate solution, and dealing with the recalcitrant physician.

What's Causing the Problem?
To handle the dilemma successfully, you have to identify the problem you're trying to solve, says Bee. For example, is practice income suffering because a physician's limited hours make it impossible to expand the patient base? "If you have someone who isn't taking the volume and the rest of the doctors can't handle any more, there won't be enough business to hire another doctor," Bee says. Or, maybe patients are complaining because they can't get an appointment. "That's a killer," she adds. "It's going to hurt the practice."

In the best scenarios, the practice already uses a compensation formula based on productivity, fixed expenses, and variable expenses, both experts agree. This indirectly -- and objectively -- addresses work ethic. Part of the physician's pay is determined by patient visits or a comparable measure, such as relative value units. Doctors who see more patients earn more money.

Fixed expenses represent the portion of operating costs that are shared equally, regardless of how much the physician works. "That penalizes the doctor who isn't really serious about a big practice," Bee says. A physician who is not earning enough to comfortably cover fixed expenses might question the wisdom of maintaining unprofitable work habits. Variable expenses are also determined by productivity -- busier physicians pay a bigger share because more staff time, office space, and supplies went into the care of their patients.

Younger members of a group practice that had been founded in the 1960s may be frustrated if the practice relies on an outdated compensation formula. Back when the practice was "awash in money," the bills were paid, and profits were distributed equally, even though the founding physician was working harder than everyone else, Bee comments. "Then managed care comes into view, and you may be working hard, but the amount you're paid for each case is smaller. Also, the senior guy has aged, and he wants to slow down." Younger physicians, who never experienced the boom days, resented the older physician's percentage, and they kept leaving. "If you don't change the mechanism, you have serial turnover, and that is expensive," Bee notes.

Even so, a carefully crafted formula does not offer a total solution. Another staff member might be necessary, whether that is a midlevel provider, a part-time physician, or a full-time physician. "Aside from an adequate supply of patients, that new employee requires compensation, and the money needs to come from somewhere," Capko says.

However, you cannot simply offset underperformance with a salary adjustment because that could violate the physician agreement, and that agreement, which must be examined before action is taken, might go back decades.

Develop a Cohesive Approach

Though a daunting prospect, you must have a frank discussion with the physician who is dodging a share of the duties, regardless of seniority. "The senior doctor shouldn't carry more weight than the other partners. We should all be even stakeholders who are looking out for the common good of the practice," Capko says.

Advance preparation is essential. "There's a certain baseline cost for carrying a doctor, whether 10 or 20 patients are being seen. You need to gather a lot of data to see what the financial impact of this physician's routine is on the practice," Capko says. Determine what you need the underperforming physician to do, discuss the best way to lay out your position, and present it as a united group.

The group spokesman should be someone this physician greatly respects. Although some practices engage a management consultant as a facilitator, "You have a much better chance of succeeding if a physician expresses the group's viewpoint than if the consultant is given the role of dealing with this. Otherwise, the doctor who feels challenged is just going to attack the consultant. He or she is not going to see that the doctors agree with that consultant unless that's voiced," Capko says.

Don't Make It Personal

Steer the discussion away from the physician's behavior and focus on the long-term health of the practice. Capko recommends something like, "You have been the foundation of this practice. We owe you a lot. But this practice -- your practice -- is struggling with some issues, and we need to address these for the future." Then you can delineate your concerns. If, for example, the compensation formula does not adjust for productivity, the group should press for a change. Or, if rooms are standing empty and support staff is marking time due to the physician's erratic schedule, talk about what that unpredictability costs the practice. Suggest that the doctor's appointments be compressed into specific periods so the facility can be used most efficiently.

It's not unusual for a contract to say that physicians decrease or drop call once they have been with a practice for a specified time and reach a certain age. Still, taking on more help is sensible because everyone else is "tap-dancing as fast as they can," Bee observes. She offers the following proposal: "We would like to buy you out so that you get the profit you helped generate, and we're going to enter into an employment contract where we can agree on so many sessions a week or a month. Let's come to terms that allow you to be around, see patients, and help us with your wisdom."

Explain that the practice needs a system in place as each physician heads toward retirement. "Bring the conversation around to the best way you can be productive as a group. It's a way of doing it without offending the doctor. You want that doctor to be involved in the decision. That's the only way you have the best outcome," Capko says.

What if the doctor is a newer addition? "One of the reasons we get into this situation is we don't set up expectations in the first place," Capko says. "We don't say, 'we expect you to be seeing 20 patients per day or generating this much revenue.'" Every new agreement should include the physician's standard schedule, and if the practice has more than 1 site, whether he or she will move between them.

However, if that information wasn't in the agreement and a physician is not as industrious as you had hoped, you have to renegotiate the schedule. Note that you can work together to define what must be done and make the blueprint fair to all parties. "Your goal is to get a commitment from that doctor," Capko says. "Usually, they're earning the right to partnership, so this is like a trial period." Make it clear that partnership is not going to happen if the practice's needs are not met.

Sometimes a physician will be unwilling to change and will quit, possibly without notice. "Then you have to go back and say, 'Wait a minute; let's develop a plan that works for both of us,'" Capko concludes. "You have to prepare for that and make sure you aren't violating the contract."