What, Exactly, Is a CMO?

As a young internal medicine physician and employed core faculty member for an ACGME internal medicine residency, my focus was two-fold: I wanted to provide the best and most up-to-date care for my patients and teach the most basic as well as most complex care to my interns and residents.

In undergraduate and medical school, I planned to become a community-based family medicine physician and have an old-fashioned private practice. Clearly, my plans had pivoted from that original plan.

After three years of serving in my initial role, I was elected to serve as the vice-chair, and then four years later, I was elected as chair of the department of internal medicine at my hospital, a large level 1 trauma center. As chairperson, I worked closely with the chief medical officer on many aspects of my job, which included privileging, quality and outcomes, and physician behavior, to name just a few. I knew that the CMO worked on these issues but had no idea what else the role entailed.

After a year of chair work, I was asked to serve as the medical director of the employed medical group. This evolved into serving as president of the medical group and then into a new role of chief clinical officer (CCO) for a geographical area that initially covered three and then five hospitals. I was responsible for overseeing the medical group as well as the physician leader of each hospital.

At this point, I really began to think about what the title of the hospital physician leader meant and what roles were filled by this physician leader. Four times during my time as CCO, I have served as “interim” CMO or “interim” vice-president of medical affairs (VPMA) for a hospital site. This work developed my understanding of what the role of the CMO means now, given the changing nature of healthcare in America.

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The role of the CMO changed significantly in the last two years of the COVID-19 pandemic. As we enter the post-pandemic era, we can expect further evolution of the position with new technology and methods making their permanent mark in the healthcare sector. As a physician leader, the CMO will be tasked with preparing for the next crisis while at the same time dismantling the crisis mode that their staffs have been living for the past two years.

THE ROLE OF THE CMO

For purposes of this discussion, the CMO is seen as equivalent to a VPMA. Generally, larger and more complex hospitals have a CMO; smaller hospitals tend to have a VPMA. The smallest hospitals, such as critical access hospitals, usually have a medical director. The amount of time spent administratively by the physician leader is usually correlated to the size of the hospital, with the CMO having the most dedicated time, the VPMA less, and the hospital medical director the least.

In about 25% of hospitals, there is a CMO and VPMA, with each having specific duties and the VPMA usually reporting to the CMO. With changing hospital economics and increasing responsibilities of leaders, the number of hospitals with both leaders has decreased.

Physician administrators are either full-time administrative, part-time administrative and part-time clinical, or part-time administrative and part-time retired clinically. The split roles of clinical and administrative can be challenging for both the physician leader and the other members of the administration.

In my first physician leadership role, I was to spend 50% of my time as a clinician and 50% of my time in administration. What I found was that this became 80% and 80% respectively. Patients and office staff need the doctor when they need the doctor! Administrative meetings and issues arise at various times and rarely follow the clinic time for the physician.

For the CMO or VPMA who has split schedules, communication, flexibility, and understanding of all parties are the keys to success. I have asked the VPMAs on my team who are 50:50 to try to have a set schedule and have each hospital leadership team know what can be expected. In addition, during clinical shifts, they should allow for grace.

An added level of challenge arises when the clinical employer is a group other than the hospital-owned medical group, such as a contracted anesthesia group or contracted emergency medicine group. Again, communication and planning are keys to success. The challenges are present but can be overcome with these steps.

THE CMO AS CLINICIAN

The CMO having an active clinical role is not a must, but it does benefit the CMO. In the past, the clinical work may have been seen as a distraction. There seems to be a trend in CMOs considering patient care as a positive attribute of the job. Seeing patients may give the CMO credibility with other members of the medical staff. It can also provide the CMO with empathy regarding what the physicians are dealing with in the hospital, such as throughput and EMR issues.

Also, in more cases than not, the clinical work is what the physician leader went to medical school to prepare for as opposed to learning to be an administrator. Doing work that they have been trained for and may be more familiar doing promotes mental well-being.

Finally, clinical work may provide the CMO with a sense of accomplishment. In today’s complex healthcare system, solving a problem rarely results in a quick outcome in one encounter. Treating blood pressure or removing a gall bladder is a task that can be completed.

AN EVOLVING ROLE

The role of the “traditional” CMO (or VPMA) has certainly changed. In the traditional sense, the CMO role was not well-defined; more than likely it was part-time or fewer hours than at present, and filled by a senior physician who was more likely part-time or full-time retired clinically. CMOs were well-trained in a medical specialty but less so (or not at all) in the role of the CMO itself.

Many CMOs led by influence rather than data and tended to get by with an engaging personality and a sense of camaraderie with physician peers. They were usually engaged members of the medical staff, were well-liked, and had been respected in their clinical roles prior to being the CMO at the same hospital. Their responsibilities tended to focus on facilitating the work of chief of staff and department chairs, on peer review, and on credentialing and privileging. Finally, the CMO had responsibility for a “building” or one location of the health system.

Over the last few years, what is needed and expected of the CMO or VPMA has changed substantially. At the root of the change is the fact that hospitals and physicians need alignment with goals of safe and high-quality care at a lower price. The physician leader must understand all levels of the organization, from finance to strategy to supply chain to patient access and more.

The CMO must be willing to suggest or make changes in the standard “way it is done” and serve as a liaison between physicians and other executive leaders of strategy, finance, IT, and operations. In times of financial strain for hospitals and health systems, the CMO is the physician leader for mergers and acquisitions at the hospital level.

Today’s CMO is a transformational executive. The term “transformation” is essential in current healthcare. The CMO is responsible for leading culture change, spearheading physician acceptance of performance improvement and case management goals, and coordinating utilization, quality and safety, credentialing, and physician practice evaluation. As healthcare steps deeper into value-based care and value-based reimbursement, the CMO emerges as the physician leader.

Physician staffing is at critical levels in many specialties across the country and the world. These shortages became even more pronounced during the pandemic and continue now in the post-pandemic era. The CMO is the chief physician recruiter and should participate in screening and interviewing all candidates. Feedback from physician applicants is more positive when the CMO is present and engaged.

In addition to recruiting new physicians from outside hospitals, it is essential that hospitals, when able and appropriate, support graduate medical education (GME) programs. For these programs, the CMO should be the executive who leads graduate medical education either formally, or more commonly informally, by influence and with support and respect. Whether direct or indirect, the CMO’s influence over GME is essential, not only for future recruiting but also in the daily work of the residents in the hospital.

Since the pandemic, the CMO has had a new informal title: chief physician communicator. This communication includes updates, education, and crisis alerts about such issues as COVID-19, monkey pox, influenza, swine flu, polio, and tomato virus, to name a few, along with constant updates about masking rules and vaccine availability and requirements. Information on new physicians, new technology, shortages of supplies and drugs, and constantly changing rules and regulations is available to markets faster than ever before.

With all these communication needs, the CMO must have a strategy. In the past, communication took place at department or medical staff meetings, or with a sign taped to the physician’s lounge door, and occasionally with a hard copy mailing to the physician’s home or office. Today, meeting attendance is low, and the dissemination of information is inconsistent, so the approach must be multifaceted and include email, texting, signage on TVs and screens in multiple locations, and even paper mailings. The CMO is responsible for gathering and sharing information by whatever means deemed to be most effective.

There is certainly a higher-level set of expectations for today’s CMO. Physician leadership training is necessary, and the CMO should be trained and be a teacher and trainer for other physicians. The CMO promotes physician burnout awareness and physician suicide awareness and is a coach and mentor for medical directors and other young physician leaders.

Data is a key to success. The CMO needs to be a data/metric expert in all areas, including quality reporting, length of stay, and using the electronic medical record (EMR) to its fullest extent. The CMO is the main hospital EMR champion or at least one of the core champions who puts a focus on clinical documentation to maximize appropriate coding of medical illness. The CMO serves as the physician advisor or a direct resource for the physician advisor for case management and throughput.

Legal issues in healthcare have become more complex than ever before. Physicians, and specifically the CMO, must understand physician compensation, wRVU structure, fair-market value issues, relationships between hospitals and employed physicians, contracted physicians, and independent physicians.

Newer issues such as ACO waivers and joint venture technicalities are added to older, yet still important, areas of healthcare law, such as Stark laws and anti-kickback statutes. HIPPA compliance and audits remain a daily conversation, as does the recovery audit contracts (RAC) process.

Today’s CMO is involved in strategy, which is now a core part of expectations. There needs to be a physician leader involved in discussions about when to buy a surgical or orthopedic robot, what newer oncology procedures should be used at the hospital, and which vendor has the best price as well as the best quality. The list of these types of issues is endless, but having an engaged and knowledgeable physician leader is invaluable in today’s healthcare world.

Culture management remains a core competency of CMOs. The CMO is the liaison between the medical staff and administration and must be able to effect culture change and lead by influence. This may be the most difficult part of the job today. Success requires the trust of the medical staff and exceptional interpersonal and communication skills. Attempting to effect change with too heavy a hand can backfire and cost the CMO their credibility. Maintaining this balance is a daily struggle, yet it is of utmost importance.

FOUR ESSENTIAL COMPONENTS

With so much on the CMO’s plate, it may be best to summarize the job by its four components:

• Clinical operations, such as C. diff management, CAUTI, CLABSI, and all hospital and individual physician quality metrics.

• Case management/throughput, including length of stay and utilization management.

• Medical staff relations, such as OPPE/FPPE, credentialing, med exec liaison, officers/chairperson liaison, and behavior issues.

• Hospital clinical strategy, including collaboration with the hospital president, finance, nursing, and supply chain.

During the last several years, a new role has emerged in the area of physician leadership: chief clinical officer (CCO). The CCO tends to be at larger systems and markets/regions with more than one hospital and a medical group and ACO/CIN. Some have called this position a “supercharged” CMO.

The CCO oversees multiple hospitals, medical groups, population health entities/CINs/ACOs, and ambulatory care locations. Rather than interacting with individual physicians or on individual hospital units, the CCO focuses on strategy, physician and practice acquisitions, as well as hospital/system mergers and acquisitions. In other words, the CCO is the “chief physician executive.”

Often, the CCO serves as a liaison between health systems, health departments, and local government entities in health concerns, essentially serving as the external physician “voice.”

In addition to the CMO, the CCO is the chief physician recruiter, an overseer of graduate medical education, and potentially, the research-accountable executive ensuring compliance on medical research activities.

As with the CMO, the CCO role will continue to morph over time with the demands of the present state of national healthcare, as well as the needs of each hospital, groupings of hospitals in a market or region, and of a health system itself.

Excerpted from The Chief Medical Officer’s Essential Guidebook , edited by Mark D. Olszyk, MD, MBA, CPE.