Hospital-physician Relationships Research Articles

Alignment in the Hospital-Physician Relationship: A Qualitative Multiple Case Study of Medical Specialist Enterprises in the Netherlands.

Policy-makers and hospital boards throughout the world have implemented different measures to create and sustain effective hospital-physician relationships. The 'integrated funding' policy reform in the Netherlands was aimed at increasing hospital-physician alignment and led to the unforeseen formation of medical specialist enterprises (MSEs): a fiscal entity representing all self-employed physicians in a hospital. It is unknown how hospitals and MSEs perceive their alignment and how they govern the relationship. This study explores the hospital-MSE relationship, and how governance styles influence perceived alignment in this relationship. A multiple case study of five non-academic hospitals in the Netherlands was performed. Data was derived from two sources: (1) analysis of hospital-MSE contracts and (2) semi-structured interviews with hospital and MSE board members. Contracts were analysed using a predefined contract analysis template. Interview recordings were transcribed and subsequently coded using the sensitizing concepts approach. Contracts, relational characteristics, governance styles and perceived alignment differed substantially between cases. Two out of five contracts were prevention contracts, one was a mixed type, and two were promotion contracts. However, in all cases the contract played no role in the relationship. The use of incentives varied widely between the hospitals; most incentives were financial penalties. The governance style varied between contractual for two hospitals, mixed for one hospital and predominantly relational for two hospitals. Development of a shared business strategy was identified as an important driver of relational governance, which was perceived to boost alignment. Large variation was observed regarding relational characteristics, governance and perceived alignment. MSE formation was perceived to have contributed to hospital-physician alignment by uniting physicians, boosting physicians' managerial responsibilities, increasing financial alignment and developing shared business strategies. Relational governance was found to promote intensive collaboration between hospital and MSE, and thus may improve alignment in the hospital-physician relationship.

The impact of economic and noneconomic exchange on physicians' organizational attitudes: The moderating effects of the Chief Medical Officer.

Hospital-physician relationships are critical to hospitals' organizational success. A distinction can be drawn between economic and noneconomic physician-hospital exchange. Physician senior leadership could be an important component of managerial strategies aimed at optimizing hospital-physician relationships. The purpose of this study was to investigate the moderating role of the quality of exchange with the Chief Medical Officer (CMO) in the relationship between economic and noneconomic exchange and physicians' key organizational attitudes. Self-employed physicians practicing at six Belgian hospitals were surveyed. Economic exchange was conceptualized by the concepts of distributive and procedural justice, whereas noneconomic exchange was conceptualized by the concepts of administrative and professional psychological contract. Our outcomes comprise three key organizational attitudes identified in the literature (job satisfaction, affective organizational commitment, and intention to leave). The moderating role of leader-member exchange with the CMO in these relationships was assessed. Our results showed a relationship between both psychological contract breach and organizational justice and physicians' organizational attitudes. The quality of exchange with the CMO buffered the negative effect of psychological contract breach and reinforced the positive effects of organizational justice with respect to physicians' organizational attitudes. Our results demonstrate that both economic and noneconomic aspects are important when considering physicians' key organizational attitudes. The reciprocity dynamic between physician and hospital can be enhanced by high-quality exchange with the CMO.

The impact of professional and organizational identification on the relationship between hospital-physician exchange and customer-oriented behaviour of physicians.

BackgroundHospitals face increasingly competitive market conditions. In this challenging environment, hospitals have been struggling to build high-quality hospital–physician relationships. In the literature, two types of managerial strategies for optimizing relationships have been identified. The first focuses on optimizing the economic relationship; the second focuses on the noneconomic dimension and emphasizes the cooperative structure and collaborative nature of the hospital–physician relationship. We investigate potential spillover effects between the perceptions of physicians of organizational exchange and their customer-oriented behaviors.MethodsA cross-sectional study was conducted on 130 self-employed physicians practicing at six Belgian hospitals. Economic exchange was measured using the concept of distributive justice (DJ); noneconomic exchange was measured by the concept of perceived organizational support (POS). Our outcomes consist of three types of customer-oriented behaviours: internal influence (II), external representation (ER), and service delivery (SD).ResultsOur results show a positive relationship between DJ and II (adjusted R2 = 0.038, t = 2.35; p = 0.028) and ER (adjusted R2 = 0.15, t = 4.59; p < 0.001) and a positive relationship between POS and II (adjusted R2 = 0.032, t = 2.26; p = 0.026) and ER (adjusted R2 = 0.22, t = 5.81; p < 0.001). No relationship was present between DJ (p = 0.54) or POS (p = 0.57) and SD. Organizational identification positively moderates the relationship between POS and ER (p = 0.045) and between DJ and ER (p = 0.056). The relationships between POS and II (p = 0.54) and between DJ and II (p = 0.99) were not moderated by OI. Professional identification did not moderate the studied relationships.ConclusionOur results demonstrate that both perceptions of economic and noneconomic exchange are important to self-employed physicians’ customer-oriented behaviours. Fostering organizational identification could enhance this reciprocity dynamic.

In the eye of the beholder: A qualitative study of mutual obligations and areas of ambiguity in the hospital–physician relationship

Hospitals and physicians have been working together for years in providing specialized health services. However, hospital–physician relationships are considered lukewarm at the best. We build on psychological contract theory to develop an in-depth understanding of how physicians (N = 15) and hospital executives (N = 15) in Belgium experience and interpret obligations in their working relationship. Our analysis yielded a rich understanding of mutual obligations and areas of ambiguity. Two major themes emerged from the analysis. A distinction should be made between administrative obligations (adequate support and responsive decision making) and professional obligations (clinical excellence and physician autonomy). Two areas of ambiguity could be identified reflecting both dimensions. An economic trade-off exists in the day-to-day interaction and therefore views on how the care should be organized differ. In addition, the extent to which medical decisions should take into account the corresponding impact on hospital finance varies.

Hospital-physician relations: the relative importance of economic, relational and professional attributes to organizational attractiveness.

BackgroundBelgian hospitals face a growing shortage of physicians and increasingly competitive market conditions. In this challenging environment hospitals are struggling to build effective hospital-physician relationships which are considered to be a critical determinant of organizational success.MethodsEmployed physicians of a University hospital were surveyed. Organizational attributes were identified through the literature and two focus groups. Variables were measured using validated questionnaires. Descriptive analyses and linear regression were used to test the model and relative importance analyses were performed.ResultsThe selected attributes predict hospital attractiveness significantly (79.3%). The relative importance analysis revealed that hospital attractiveness is most strongly predicted by professional attributes (35.3%) and relational attributes (29.7%). In particular, professional development opportunities (18.8%), hospital prestige (16.5%), organizational support (17.2%) and leader support (9.3%) were found to be most important. Besides these non-economic aspects, the employed physicians indicated pay and financial benefits (7.4%) as a significant predictor of hospital attractiveness. Work-life balance and job security were not significantly related to hospital attractiveness.ConclusionsThis study shows that initiatives aimed at strengthening physicians’ positive perceptions of professional and relational aspects of practicing medicine in hospitals, while assuring satisfactory financial conditions, may offer useful avenues for increasing the level of perceived hospital attractiveness. Overall, hospitals are advised to use a differentiated approach to increase their attractiveness to physicians.

Hospital-physician relationships: implications from the professional service firms literature.

The hospital-physician relationship (HPR) has been the focus of many scholars given the potential impact of this relationship on hospitals' ability to achieve socially and organizationally desirable health care outcomes. Hospitals are dominated by professionals and share many commonalities with professional service firms (PSFs). In this chapter, we explore an alternative HPR based on the governance models prevalent in PSFs. DESIGN/METHODOLOGY APPROACH: We summarize the issues presented by current HPRs and discuss the governance models dominant in PSFs. We identify the non-equity partnership model as a governance archetype for hospitals; this model accounts for both the professional dominance in health care decisions and the increasing demand for higher accountability and efficiency. There should be careful consideration of existing regulations such as the Stark law and the antikickback statue before the proposed governance model and the compensation structure for physician partners is adopted. While our governance archetype is based on a review of the literature on HPRs and PSFs, further research is needed to test our model. Given the dominance of not-for-profit (NFP) ownership in the hospital industry, we believe the non-equity partnership model can help align physician incentives with those of the hospital, and strengthen HPRs to meet the demands of the changing health care environment. This is the first chapter to explore an alternative hospital-physician integration strategy by examining the governance models in PSFs, which similar to hospitals have a high reliance on a predominantly professional staff.

Future Hospital-Physician Relationships: The Bundled Payment Option

Future Hospital-Physician Relationships: The Bundled Payment Option

HEALTH CARE MANAGEMENT Conference Paper Abstracts.

Academy of Management Annual Meeting Proceedings includes abstracts of all papers and symposia presented at the annual conference, plus 6-page abridged versions of the “Best Papers” accepted for inclusion in the program (approximately 10%). Papers published in the Proceedings are abridged because presenting papers at their full length could preclude subsequent journal publication. Please contact the author(s) directly for the full papers. ArticlesHEALTH CARE MANAGEMENT Conference Paper Abstracts.Published Online:30 Nov 2017https://doi.org/10.5465/ambpp.2010.54503723AboutSectionsPDF/EPUB ToolsDownload CitationsAdd to favoritesTrack Citations ShareShare onFacebookTwitterLinkedInRedditEmail AbstractThe article presents abstracts on health care management topics which include the role of managed networks as an organizational form in British health care, the management of hospital physician relationships, and racial disparities in patient care.FiguresReferencesRelatedDetails Vol. 2010, No. 1 Permissions Metrics in the past 12 months History Published online 30 November 2017 Published in print 1 August 2010 InformationCopyright of Academy of Management Journal is the property of Academy of Management and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.KeywordsABSTRACTSHEALTH services administration -- AbstractsHEALTH care industry -- AbstractsHOSPITAL-physician joint venturesDISCRIMINATION in medical care -- AbstractsDownload PDF

Price Transparency For Medical Devices

Hospital buyers of medical devices contract with manufacturers with market power that sell differentiated products. The medical staff strongly influences hospitals' choice of devices. Sellers have sought to limit disclosure of transaction prices. Policy-makers have proposed legislation mandating disclosure, in the interest of greater transparency. We discuss why a manufacturer might charge different prices to different hospitals, the role that secrecy plays, and the consequences of secrecy versus disclosure. We argue that hospital-physician relationships are key to understanding what manufacturers gain from price discrimination. Price disclosure can catalyze a restructuring of those relationships, which, in turn, can improve hospital bargaining.

Hospital-physician collaboration: landscape of economic integration and impact on clinical integration.

Hospital-physician relationships (HPRs) are an important area of academic research, given their impact on hospitals' financial success. HPRs also are at the center of several federal policy proposals such as gain sharing, bundled payments, and pay-for-performance (P4P). This article analyzes the HPRs that focus on the economic integration of hospitals and physicians and the goals that HPRs are designed to achieve. It then reviews the literature on the impact of HPRs on cost, quality, and clinical integration. The goals of the two parties in HPRs overlap only partly, and their primary aim is not reducing cost or improving quality. The evidence base for the impact of many models of economic integration is either weak or nonexistent, with only a few models of economic integration having robust effects. The relationship between economic and clinical integration also is weak and inconsistent. There are several possible reasons for this weak linkage and many barriers to further integration between hospitals and physicians. Successful HPRs may require better financial conditions for physicians, internal changes to clinical operations, application of behavioral skills to the management of HPRs, changes in how providers are paid, and systemic changes encompassing several types of integration simultaneously.

Hospital-Physician Relationships: Taking a Proactive Approach to Building Mutually Successful Relationships

Hospital-Physician Relationships: Taking a Proactive Approach to Building Mutually Successful Relationships

The Evolving Role of Third Parties in the Hospital—Physician Relationship

Hospital-physician relationships (HPRs) are a key concern for both parties. Hospital interest has been driven historically by the desire for the physician's clinical business, the need to combat managed care, and now the threats posed by single specialty hospitals, medical device vendors, and consumerism. Physician interest has been driven by fears of managed care and desires for new sources of revenue. The dyadic relationships between hospitals and physicians are thus motivated and influenced by the role of third parties. This article analyzes the history of HPRs and the succession of third parties. The analysis illustrates that the role of third parties has shifted from a unifying one to one that divides hospitals and physicians. This shift presents both opportunities and problems.

Hospital-Physician Relationships: Imperative for Clinical Enterprise Collaboration

The need for new venues for physician-hospital collaboration is significant and growing, especially between independent physicians and health systems. Often physicians and hospitals act independently of each other, even though maintaining and sustaining a productive relationship between physicians and hospitals is essential to good patient care and improving the health status of the communities we serve. The tension in physician-hospital relationships is a long-standing and widely acknowledged concern. The old model of hospital-physician relationships, governed by the rules of the organized medical staff structure, doesn't work in the current environment, which has grown increasingly complex as a result of economic, legal, and care-delivery changes. These complexities make relationship management challenging. Hospitals and physicians struggle to align behaviors to achieve cost and quality goals. The need has never been greater for hospitals and physicians to work together as a joint clinical enterprise to improve quality, reduce practice variation, and control the cost of healthcare. This article explores the challenges and some options for improving the physician-hospital relationship in the current environment.

A Local Solution for Hospital-Physician Relationships

I COMMEND THE feature authors on their thoughtfulness and diligence researching and writing about this critical link to provide excellent healthcare. Many of the concepts they present are universal and can be applied to all healthcare systems, but just as all healthcare is local, so are the tactics for solutions. We use our own frame of reference to filter what we see and hear. I have been a physician a private practice, an employed physician, chief medical officer, and CEO at the same hospital-physician integrated delivery system, the same town. There is no other hospital for over 25 miles. We have no specialty hospitals, ambulatory care centers, or joint ventures, but we do have critical needs recruiting and retaining quality physicians so we focus resources these areas. Each position I've held offers a very different view, and from each perspective the path to improving patient care is also very different. For example, 95 percent of our physicians are employed by or contracted with the system; many of my fellow physicians the upper Midwest find themselves a very different situation. The high percentage of physicians employed by the system by no means indicates that our physicians are any closer to achieving consensus with administration, and we must be intentional about aligning our organizational goals with those of the doctors. The same skills of communication, aligning strategies and goals, and decision making are needed our situation as are needed organizations with fewer employed physicians. SEEING THE BIG PICTURE I agree that administrators and physicians look at the world very different lights. The two professionals come from different viewpoints when considering, for example, the amount of time required to make a decision, the value of meetings, or how a message should be communicated. The skills that make an excellent physician-such as autonomy, efficient use of time, and the ability to make decisions rapidly on often incomplete or unknown information-are foreign to administrators who seek data, analysis, and a broad range of input before a decision is made. From physicians I hear over and over how long the organization takes to make decisions. The physician disdain for meetings as a waste of valuable time creates dissension, because decisions are formulated and made at the committee level. When administration does not engage the physician properly, or when physicians do not become engaged, decisions appear to be made without physician input. When such a decision is then implemented, physicians have no buy in and often even defy the decision. The methods suggested the feature articles will certainly aid these relationships. If physicians can be convinced to step back and see the big picture, better discussions will result. Recently one of our rural physicians complained to our CFO that we were delaying our decision on his building expansion. The CFO took the time to explain all of our capital projects that dwarfed the size of the expansion of his office and explained our process of prioritizing capital expenditures. He also explained the process of the business plan and return on investment. Once the physician better understood his project respect to other decisions he became much more patient. THE VALUE OF GOOD PHYSICIAN LEADERSHIP I could not agree more with the authors on the value of effective physician leadership. Physicians often have disdain for administrators who have never practiced medicine or taken call for patients. If physicians are asked for input, they prefer to explain clinical opinions to leaders who understand clinical medicine. Physicians also want to be educated by other physicians when implementing a new process. They certainly do not wish to be corrected or counseled by a nonclinician. Three of our top five executives are physicians, and we find that this helps the organization's relationship with physicians, but having such representation leadership is not a panacea. …

Hospitals And Physicians: Not A Pretty Picture

Hospital-physician relationships in the United States have deteriorated markedly in the past few years. An asymmetry of obligations to caring for the uninsured and inappropriate financial incentives have worsened the conflict between hospitals and physicians in many markets. Sadly, the resources and political bandwidth consumed by managing this conflict have been diverted from the fundamental challenge of providing universal health coverage--the root cause of much of this conflict.

Something old, something new: recent developments in hospital-physician relationships.

To describe recent developments in hospital-physician relationships in 12 metropolitan areas. We analyze qualitative data from a third round of biannual site visit interviews conducted in 12 randomly selected metropolitan areas from 1996 to 2001. The study interviewed 895 respondents during the third round of site visits, conducted in 2000 and 2001. As HMO enrollment and capitation contracting has failed to grow in local markets, hospital executives have returned to a strategic focus on improving relationships with specialists in pursuit of fee-for-service revenue. Yet, 65 percent of hospitals interviewed in 2000 and 2001 continued to own primary care physician practices, with ownership more prevalent in highly concentrated hospital markets. A majority (55 percent) of hospitals have decreased the size of these practices in the past two years. Interest in forming integrated delivery systems has waned. The potential for quality improvement through these organizations systems--by emphasizing primary care and coordinating hospital and physician services--has not been realized. The new emphasis on hospital-specialist partnerships may improve the financial status of hospitals and participating specialists in local markets, and may improve quality of care in selected service areas, but it may also increase health care costs incurred by employers and consumers.

Hospital-Physician Relationships: A Synergy That Must Work

FEW RELATIONSHIPS ARE as complex and dynamic as the hospital-physician relationship, and even fewer are as critical to maintain for the future benefit of healthcare delivery in the United States. Joseph Bujak and Chris Howard speak well to the complexities of this relationship and offer helpful suggestions as to how we might improve on them. It has been my privilege over the years to observe Bujak develop his theories on hospital-physician relations, and, with minor exception, I find myself in substantial agreement with his concepts and approaches. I believe his comments for the greatest part are reflective of the historical context of practicing medicine and medical staff relations. With that said, I make the following observations. Whereas physicians have historically been the people ultimately accountable for patient outcomes, recent practices and court cases seem to indicate a shared responsibility among the physician, hospital, and patient for those outcomes. This is especially true when catastrophic events occur that are often the result of defective system design as well as human error. A movement toward team approaches to patient care and individual patients' responsibility removes some of this burden from physicians but simultaneously makes physicians and others more interdependent. At the same time I believe the loss of this autonomy and control is one of the contributing factors to physician dissatisfaction. In a recent presentation to the American Hospital Association's Health Care Systems Leadership retreat, Lawrence Casalino (2003) cited the following as examples of the emotions and feelings that are being experienced in physician practices: general anger, discontent, distrust, breach of professional-society contract.... These and other factors are as much a result of loss of control or autonomy as of economic issues. We need to demonstrate more mutual respect between physicians and hospital leadership and build on our interdependency. Bujak's comment on the medical staff organization and structure are representative of the experiences many hospitals and medical staffs are having and does raise valid questions about the value of the medical staff to the individual physician and to the hospital. Many hospital executives and physician leaders are in fact evaluating new ways to bring greater relevancy to the medical staff structure and create greater value for all involved. His recognition of medicine being both a profession and a business is also valid, and recognition that physicians have legitimate economic needs that are driving many of their actions needs to be given serious consideration. Physicians also need to develop a better appreciation of the fact that hospitals must remain financially as well as healthy for the benefit of both patient and community and that erosion of hospitals' stability is in one's interest, especially the patients'. I mention healthy because too many healthcare organizations lose sight of their while pursuing their margin. This concern can grow even more as hospital margins erode while physician participation increases in specialty-owned hospitals and ventures that affect hospital earnings to the point that the repeated concept of no margin, mission becomes a reality. Casalino (2003) reported that in the area of physician-owned ambulatory surgery centers, 585 were created in the past two years...[as compared to] 166 in the prior eight years. Although one can argue the relative value to the healthcare delivery system of this trend, one must also acknowledge the potential negative impact on hospital missions and their relations with physicians with this type of activity. As Bujak also points out, all physicians are not alike when discussing strategies, and it is important that executives recognize that most physicians do evolve from an culture and as such are independent thinkers. What I do question is whether the expert culture is strong enough to overcome the group think or collective, which I believe can exist in physicians as well as executives. …

Building Hospital-Physician Relationships Through Servant Leadership

THE ARTICLES BY Joseph S. Bujak, M.D., and Chris Howard provide thoughtful and insightful commentaries on state of hospital-physician relationships and what my faculty often describe as the real world. Each in their own way describe how we have gone past covenental relationships that defined hospital-physician interactions in years past to dependence on contractual relationships in a world characterized too often by competition instead of collaboration. The complexity of hospital-physician relationships and strain that results are well described in these articles, particularly lack of trust; these consequences should have been easily predicted as a result of corporatization of healthcare (Anderson 1997). Furthermore, recent surveys from coast to coast have revealed a growing dissatisfaction among physicians with current practice environment. Older physicians are retiring early, and many physicians say they would not choose medicine again, nor would they recommend medicine to their children as a career (Merritt, Hawkins 2000). Physician dissatisfaction should not be surprising given unfavorable practice economics and what they perceive to be a decline in quality of practice environment. As incomes have fallen, many physicians have chosen to try to become equity partners in day-surgery centers, diagnostic imaging centers, and even hospitals that compete with very hospitals that have provided them a practice environment in past. In workforce, younger employees now often question why their fathers and mothers were loyal to institutions, for they have seen them laid off and forced into early retirement. Likewise, younger employees may not trust long-term relationships or institutional covenants to degree their predecessors did. This phenomenon affects younger physicians as well. These same physicians' expectations concerning lifestyle and income have not kept pace with inflation over last decade (Massachusetts Medical Society 2001). Complicating matters further, physicians have seen their practice costs rise, particularly for malpractice premiums. They have seen physician-patient relationship come under attack by managed care, and they have seen a growing consumerism wherein patients seeking affordable insurance premiums have shopped health plans and as a result ended physician relationships seemingly in exchange for a savings of a few dollars a month. Likewise, hospitals have felt that they are under assault with unfair competition from niche players in marketplace, many of which are working in partnership with physicians who used to provide nutrients to hospitals' bottom line. Many of these same hospitals, even though not-for-profit in nature, mimicked their for-profit sister institutions and provided ample opportunity for physicians to participate in joint ventures on equity arrangements. The hospitals also may have purchased physician practices, giving physicians a taste for sources of income other than professional fees. Professional values were too often sacrificed for short-term market advantage: What we say is not nearly as powerful as what we do or what we are perceived to be doing. RELATIONSHIP-CENTERED CARE Many of us in healthcare delivery community have invested in concept of patient-centered care, but I believe it is now time to argue for concept of relationship-centered care. Physicians need a hospital that can provide them with a climate that supports their efforts to bring healing to individual patients and populations of patients. It is not enough to be centered solely on patient for healthcare delivery. The healing environment requires a number of other healthy relationships (Tresolini and Pew-Fetzer Task Force 1994). Many physicians find themselves distanced from relationships with almost everyone else except patient, including their family, their peers, their faith, and even themselves. …

How to Improve Hospital-Physician Relationships

For healthcare organizations (HCOs), successfully partnering with physicians is the strategic imperative. A number of misperceptions and limiting beliefs compromise partnering initiatives. To pursue a more successful approach to partnering, it is important to understand some of the forces that are affecting the healthcare industry. The accelerating pace of change demands that healthcare leaders serve as change agents, evoking resentment from the majority of healthcare stakeholders. Demands for measured accountability and the shift of control from provider to consumer threaten the physician perception as "captain of the ship." Cultural differences between the expert culture of physicians and the affiliative culture of the HCO perpetuate feelings of distrust and compromise efforts to actualize interdependencies. Economic pressures and an unwillingness to make time to engage in dialog prevent the provider community from serving as a creative force in shaping its own future and restrict the ability to build the mutual trust that is necessary for the establishment of successful relationships. Measures that would enhance the likelihood of forming successful and lasting relationships include the following. Adopting an orchestration model would allow a flexible way to bring services to a community. It may be the only way to simultaneously integrate and specialize. Budgeting to reflect service-line functioning would allow the systematic integration of patient care throughput and provide a necessary metric for assessing clinical and operational performance. Segmenting the medical staff would allow the establishment of pluralistic relationships based on shared goals and values and allow change agents to lead to critical mass rather than consensus. Focusing on the customer would ensure relevance in the changing medical marketplace. Adopting a complexity science metaphor rather than continuing in a command-and-control, top-down organizational structure would enhance adaptability and help maximize human capital. Most importantly, forming relationships that center around shared purpose and values will lay the foundation for excellence and sustainability while restoring a sense of meaning, pride, and joy to the healthcare professions.

Restructuring Hospital-Physician Relationships for Future Success

Integrating physicians into the Healthfirst administration through employment sowed seeds of mutual understanding among these two groups that would benefit the system immeasurably over the next several years. The immediate future, however, saw only cultural upheaval between our hospitals and newly employed physicians, hospitals and nonemployed physicians, employed and nonemployed physicians, as well as specialists and primary care providers. Traditional physician-relationship-building efforts became difficult, if not impossible, to maintain. Essentially, administration was forced to scrap ten years of physician-development plans in order to reconfigure a relations effort that would maintain hospital support from all sides while restructuring the employed medical group. This article describes the evolution of Healthfirst's approach to maintaining effective physician relationships within our healthcare system and its affiliated entities over the past decade. Specifically, the article details the manner in which our system has evolved physician-relations activity to maintain an effective strategy during times of significant change in the healthcare industry.