"RVU was supposed to solve compensation problems, but I believe it has now become the problem because people are defining it in too many ways," says Northwell Health's EVP and Physician-in-Chief David Battinelli.
Editor’s note: This article appears in the October-December 2023 edition of HealthLeaders magazine.
A physician compensation model "must be tailored to what you want physicians to do," says David Battinelli, MD, executive vice president and physician-in-chief at Northwell Health and dean at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.
Prior to his current role, Battinelli served as Northwell's senior vice president and CMO. While working as CMO, he also served as the chief operating officer for the Feinstein Institutes for Medical Research. Other leadership positions he has held at the health system include chief academic officer and senior vice president of academic affairs.
HealthLeaders recently talked with Battinelli about a range of issues, including physician compensation models, his challenges as physician-in-chief, how physicians are involved in administrative leadership at Northwell, and physician engagement. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as the physician-in-chief of Northwell?
David Battinelli: Obviously, the size and complexity of the organization is a challenge. The additional complexity that most people don't know is that the physician-in-chief is also the dean of the health system's school of medicine. It is structured that way because the school of medicine is co-owned and operated by Hofstra University, which grants the degree, and Northwell, which executes most of the clinical and research enterprises of the school. So, at least half of my job is running the school.
To lead as the physician-in-chief at Northwell requires that I have a team of people at Northwell who help in all the domains that a physician-in-chief has at the health system, which includes the clinical enterprise, quality issues, and related issues that a chief medical officer would have in their responsibilities. The advantage is that I have experience in various roles such as academics and research, and as chief medical officer, which gives me a line of sight into who would be best to put into various positions so that things run as smoothly as possible for me as physician-in-chief and I can align the medical school and the health system in the clinical and research enterprise.
HL: You mentioned that the size and complexity of the health system is a challenge. How are you rising to that challenge?
Battinelli: The role of the physician-in-chief is oversight of the clinical and research activities in a 90,000-person organization. No amount of leadership at the top can compensate for the lack of local leadership. So an enormous responsibility of the physician-in-chief is to ensure strong local leadership. Talent acquisition, alignment, and selecting the right leaders at the various locations of the organization is critical.
Someone might ask how we run the health system's 23 hospitals. The answer is you have 23 good people leading those hospitals. Coping with the size and complexity of the health system requires scaling talent acquisition, alignment, and staff development across the enterprise.
HL: What are the main elements of Northwell's physician compensation model?
Battinelli: With 5,000 employed physicians, the good news is that we do not have 5,000 compensation models, but we do have a lot of them. The compensation model needs to be tailored to what you want people to do. So, our compensation model is variable, but there are some commonalities. Part of the commonality is the compensation models have a clinical component, there is a teaching component, and for somebody who is a primary researcher there is a research component.
Most of the compensation models are geared primarily toward the physician's primary job—whether it is clinical, education, or research. For those jobs that are blended, we blend the qualities of the compensation models into a single piece.
Where we are headed is moving away from primary incentives to models that make more sense for individual physicians. You can chase money and chase relative value units, or you can focus on how physicians are spending their time. This is opposed to grinding out the work and logging as many relative value units as you can until you burn yourself out. Having a stable job description and alignment is handled much better than chasing after a relative value unit model. Physicians are hesitant to align themselves with RVUs these days. Twenty-five years ago, the RVU was supposed to solve compensation problems, but I believe it has now become the problem because people are defining it in too many ways.
HL: How are physicians seeking to define RVUs in different ways?
Battinelli: Some physicians say they need academic RVUs. Others say they need research RVUs. Others say they need clinical RVUs. If it is a relative value unit, the clinical value has been pretty much worked out—you get a certain amount of money for a certain amount of work. But if a physician is doing research or academic work, it is more difficult to set an RVU—what would that value be?
David Battinelli, MD, executive vice president and physician-in-chief at Northwell Health and dean at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Photo courtesy of Northwell Health.
HL: How are physicians involved in administrative leadership at Northwell?
Battinelli: We have our Physician Leadership Development Program, which is an executive leadership program. We take physicians we have targeted as leaders and are likely to take jumps in their positions from six to 18 months. We firmly believe in physician leadership.
We have several physicians leading our hospitals. We have about 40 chief medical officers who are all physicians. Given the size, scope, and complexity of the organization, you need people with a clinical perspective as a physician to help non-physician leaders understand what is important to our physicians. It is not just money—money is important to everybody, but it is not more important than some of the other aspects of a physician's work.
HL: In addition to yourself, are there other physicians in the C-suite and at the vice president level?
Battinelli: There are other physicians at the executive vice president level, senior vice president level, and vice president level. In the C-suite, there is a substantial number of physicians. When I first joined Northwell in 2006, there were only two physicians in the C-suite, but there are many now.
HL: What are the benefits of having physicians serving in administrative leadership roles?
Battinelli: For better or worse, physicians are not the easiest group to communicate with. They are more likely to listen to physicians than non-physicians. It is similar to patients—patients from certain ethnic and racial backgrounds prefer a physician from a similar background because the patients feel these physicians understand them better. With physicians, they will take the same message from a respected physician leader better than they will take the message from a respected non-physician leader.
It is easier to promote alignment and engagement physician-to-physician.
HL: What are the primary elements of physician engagement?
Battinelli: I explain effective physician engagement and leadership in a few ways. One is you want people who are respected clinicians to engage physicians. Physicians are a tough group—they do not like to listen to non-physicians. They will listen to a doctor if they think that person is a good doctor.
Second, you need to have a certain amount of selflessness, meaning that the physicians you are communicating with have to believe that this is about them succeeding, not you succeeding. They are not against you succeeding, but they are against you succeeding without them.
Third, effective physician engagement requires good governing skills, meaning you must be fair, equitable, trustworthy, and possess integrity. Trust is probably the most important word—the decisions you are making as you are helping to align physicians must be in their best interest.
HL: In addition to serving as dean of the medical school, you have served in several other academic roles. What are the primary qualities of a good medical educator?
Battinelli: There are some people who believe your role as a teacher is to get students to do what you want them to do. The educators that I believe are most effective are the ones who are interested in inspiring people and helping people achieve what they want to achieve. With medical school students, you are dealing with adults. In that setting, a good educator supports and inspires rather than motivates and directs.
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Editor's note: This story was updated at 12:05pm on Oct. 18, 2023.
Christopher Cheney is the CMO editor at HealthLeaders.
KEY TAKEAWAYS
Move away from primary incentives to compensation models that make more sense for individual physicians. Focus on how physicians are spending their time.
Ensure that physicians know that they are succeeding, not just that the organization is succeeding. “[Physicians] are not against you succeeding, but they are against you succeeding without them,” says Battinelli.