Physician alignment is not going away anytime soon as a top CEO concern. In fact, the deeper we dive into health care transformation and the ongoing push into outpatient care, the larger it looms. Physicians make 80 to 90 percent of the decisions that drive where dollars go. That holds true if you are living on the first or the second curve of the new delivery system or even swimming around somewhere in between. Physicians may be a dissatisfied bunch coming to you with offers to buy their private practices, but they are still a very big, important bunch. And many physicians have changed in fundamental ways.

Opting Out: Why all the physician interest in hospital employment over the last several years? Many don't know how to navigate the complex changes under way and aren't interested in taking up the task. The most commonly cited reasons are wanting a sense of security, reimbursement uncertainty, and a desire for a better work-life balance. Running a private practice is filled with hassles, fueled by government regulations, rising prices, new technology demands and overwhelming paperwork. I'm sure you can sympathize.

The fact is that many physicians have just had it. Older physicians never heard the phrase work-life balance, but now it has gained importance. Soon it will be a "must have" as opposed to a "nice to have" in medical practice terms of employment. And as the millennial demographic comes to dominate the clinical workforce, it will become common practice.

The phenomenon of widespread physician burnout is well-documented. A study by the Mayo Clinic found that almost one in two doctors suffered at least one symptom of burnout and felt the effects of emotional exhaustion. Emergency physicians, internists, neurologists and family medicine doctors reported the highest rates. Burnout raises concerns about quality of care and leads to treating patients as objects as opposed to human beings, which obviously leads to all sorts of problems in the new world.

I know this sounds dangerously like the softer side of management and leadership, but working with employed physicians on the fundamentals that can make practicing medicine feel truly worthwhile and provide professional satisfaction may be one of the most important building blocks of physician alignment.

The Physicians Who Opt In: Then there are the physicians who are ready and willing to embrace the changing landscape. Physician practices lead more than half of the 367 accountable care organizations reported at one count. About 115,000 doctors now practice within an ACO. Many of these form affiliations among practices rather than full mergers. According to public statements and written accounts, many do not see the need to affiliate with a hospital. In fact, they view hospitals as a challenge to controlling the cost part of the new value equation. And some have joined forces with insurers.

Some analysts see the rise of the more entrepreneurial physician groups as a welcome counterbalance in health care. They envision these newcomers as a positive force in controlling overall health care costs by forcing all hospitals in a given market to compete on price and quality for referrals and other cooperative arrangements.

Uncertainty hangs over almost everything, but the current outpatient environment brims with new types of players and new demands.

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