Hospital MDs – Roles and Responsibilities; Credentialing and Privilege Granting

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

July, 2003

Physicians are absolutely needed for the viability and financial sustainability of a hospital.

Physicians are needed to make and to keep a hospital running in rendering health care services.

The physician’s advice is the primary driving force for patients to utilize the service of a hospital. At present, patients usually follow the advice of the physicians on where to get their health care services. The hospital’s attraction is merely a secondary force.

Thus, a physician force is essential in the establishment and development of a viable and financially sustainable hospital.

Important points for discussion with regards to the physician force are:

1. Roles and responsibilities of physicians in the hospital
2. Credentialing and granting of privileges to physicians in the hospital

Physicians accepted and admitted to a hospital play three major roles:

1. Physician-clinician
2. Physician-manager
3. Organization member

Responsibilities are dictated by the roles played by the physicians.

As clinician, physicians are responsible for the quality of medical services they render to their patients.

As manager, physicians are responsible for the quality of governance and stewardship delegated to them by the hospital administration over assigned units and/or programs.

As organization member, physicians are responsible for the quality of support they are expected to give to the organization or hospital.

Credentialing of physicians to be admitted and to be accepted to a hospital is done by the top management and this will be governed by the following factors:

1. Qualifications for the roles and responsibilities expected of a physician in a hospital (clinician, manager, organization member).
2. Potential to contribute to hospital’s viability and financial sustainability.
3. Potential to be integrated into and be compatible with the culture of the existing hospital and its management.
4. Potential to meet the expectations of the community for a physician in a hospital.

Note: There is no such thing as one universal credentialing system. It will be dependent on the requirements of the regulating agencies (DOH and PhilHealth); philosophy and policies of the board of directors; quantity and quality of physicians present in the community; and lastly, the expectations of the community. All these factors will also be dependent on what is existing at a certain point in time.

The so-called privileges or benefits granted to physicians in a hospital may mean one or more of the following:

1. To practice their profession within the hospital with or without being part owner of the hospital or shareholder.
2. To have a clinic space with or without cost.
3. To be part of a decking system for walk-in patients.
4. To be part of a decking system for patient referrals.
5. To be given medical and hospitalization benefits and discounts when they and their dependents become patients or clients of the hospital.
6. To be part of any other incentive, motivating, or privilege scheme provided by the hospital such as car park, dorm, internet services, etc.

The privileges or benefits given to the physicians usually serve 2 purposes:

1. To acquire and at the same time control the number and quality of physicians who will be part of the hospital and who will help run and develop it.
2. To serve as an incentive and motivating scheme for the physicians.

Again, just like the credentialing system, there is no such thing as one universal scheme of granting privileges and benefits to physicians. It will be dependent on the philosophy and policies of the board of directors; the prevailing trend and practices of other hospitals in the community; and lastly, the financial status of the hospital. The best scheme will be one that will best achieve the two abovementioned purposes at the same time achieving hospital viability and financial sustainability.

Here are some other issues that have to be considered by the top management or board of directors when they formulate policies on credentialing and granting of privileges to physicians:

(I shall develop these in the future.)

1. Physicians as shareholders or not for a private hospital (advantages and disadvantages)
2. Clinic space for free or not (advantages and disadvantages)
3. Classification of physician membership in a private hospital (active, courtesy, associate, etc. – advantages and disadvantages of classification)
4. Types of physicians to accept – generalists or specialists – advantages and disadvantages of generalists
5. Number of physicians to accept or to have – quantity over quality? quality over quantity?
6. How much medical and hospitalization benefit to give?
7. How to monitor contribution (financial and other type) of physicians to hospital sustainability?
8. How to monitor quality of care of physicians to clients/patients?

Physicians as shareholders in a private hospital
Advantages	Disadvantages	Notes on disadvantages
As part owner, they will be more committed to help the hospital (as long as they receive returns for their investment).	For physician-shareholders who look forward for their return in investment, there is a tendency to “overdo” in their management of patient.	Difficult to control because of the “individualistic” nature of physician’s decision-making.
More resources for capitalization.	Physician-shareholders have a tendency to get as much privileges and benefits from the hospital, which could be detrimental to the viability and sustainability of the hospital.	May be easy to control by a professional board of directors.
	If shareholding is a must for the privilege to practice medicine and the cost is big, this can hinder recruitment of quality physicians who cannot afford.	If shareholding is decided upon, either make it affordable or provide a scheme in which quality physicians who cannot afford will not be turned away.
	Physician-shareholders who are not professionally competent may use this route to practice medicine in the hospital and thereby inflicting harm on quality service.
Tendency: Make physicians shareholder for the advantages cited but try to control the disadvantages. Allow rooms for physician-nonshareholders to contribute to the hospital viability and stability. Physician-shareholders should still undergo credentialing system for competency to render quality medical services.

Clinic spaces for free
Advantages	Disadvantages	Notes on disadvantages
Attractive to physicians – makes it easier to recruit physicians to the hospital.	Will usually encounter problem of non-optimal utilization of the clinic. Presence of rent is so far the best strategy to maximize the use of clinic spaces provided by the hospital to the physicians.
Tendency: Clinic spaces with a reasonable and motivating rental cost.

Types of Physicians – Classify / categorize?
Advantages	Disadvantages	Notes on disadvantages
Provide incentive to the physician-shareholders
Tendency: All physicians who need a clinic space for their practice should be given a space.