The Courage to Execute

Over the past year, we worked with organizations across the country on fundamental transformations: operational restructuring, redesigning compensation programs for physicians and advanced practice clinicians (APCs), engaging physicians in creating an organizationally specific compact, and financial sustainability efforts. Through this work, we saw two distinct patterns emerge.

Some organizations implemented solutions at 100%. Others created carve-outs, exceptions, and compromises that felt safer in the moment. The outcomes couldn’t have been more different.

The organizations that fully committed and fully executed? They didn’t experience the mass exodus leadership feared. They didn’t lose physicians in droves. Instead, they achieved stronger physician engagement, clearer performance expectations, and—critically—sustainable financial models. Physicians appreciated being part of a transparent process with consistent standards, even when the changes were uncomfortable. These organizations engaged providers in a team with staff and executives. They thrived on the “creative tension” that was present and enabled clarity in seeing the need to co-create. From this approach, they ushered in their own success.

The organizations that hedged? The carve-outs multiplied. Exceptions became the rule. Trust eroded. And within a year or two, they were back where they started—or worse—facing the same challenges with even less credibility to address them. Additionally, they faced initiative fatigue: pursuing initiative upon initiative without full completion or implementation of previous initiatives.

The difference wasn’t in the quality of the strategy. It was in the alignment of expectations, roles, authority, and courage to see change through.

Healthcare leaders often fear transparency. We worry about physician reactions to productivity data, comparative performance metrics, or financial realities. Therefore, we soften the message, delay the scorecard publication, or present partial information.

But here’s what we consistently observed: Physicians can handle hard truths. What they can’t handle—and won’t tolerate—is inconsistency, hidden agendas, and being kept in the dark about the financial sustainability of their own practice.

One client spent weeks developing a comprehensive scorecard for their newly formed provider compensation committee, complete with productivity benchmarks, quality metrics, and financial sustainability indicators. The providers on the committee had great ownership in what was being suggested. To them, it provided accurate data that would be reported with clarity and appropriate frequency. When the strawman scorecard was presented, with provider support, the CEO, rather than the physicians, was not satisfied there were “enough data” included in the report. While physicians objected, the decision got tabled and delayed, to the point where to this day, the scorecard hasn’t been finalized. What do you think the physicians serving on that compensation committee felt about any of their suggestions moving forward?

Contrast this with organizations that put the data out there that are endorsed by providers, as in the example above—warts and all. These organizations agreed upon market benchmarks, identified where performance (staffing, access, expenses, production, etc.) was not aligned. From there, they engaged in meaningful conversations related to the organizations’ financial exposure. Yes, these were uncomfortable discussions. But physicians respected the transparency and honesty and engaged in problem-solving rather than resistance.

Transparency isn’t just about sharing information; it’s about creating a shared reality that aligns your focus with the individuals who carry out that focus. When physicians understand their performance compared to peers, and when their practice’s sustainability is at stake, they become dependable and supportive partners in solutions rather than obstacles to change.

Of all the work we did in 2025, compensation alignment consumed the most time and generated the most anxiety for organizations faced with the task of redefining their pay plan. And for good reason, as compensation structure sends the clearest signal about what an organization truly values.

The challenge we see repeatedly is that organizations are so worried about losing providers if they align their comp and work output (whether production-, shift-, or hourly-based) that they tend to protect low performers, which also then constrains their ability to reward high performers as they have paid underperformers above an “aligned” level of compensation. In numerous cases, groups maintain compensation at median levels for physicians producing at the 25th percentile of productivity. This isn’t kindness—it’s organizational dysfunction. And it comes at a direct cost: limited dollars available to appropriately compensate the physicians driving 60th, 75th, or 90th percentile productivity.

This creates a vicious cycle. High performers feel undervalued and potentially reduce their effort. Low performers feel entitled to protection. The organization’s overall productivity suffers, financial pressure mounts, and the problems compound.

The solution isn’t complicated, but it does require courage:

• Align compensation with work output and, therefore, contribution and value to the enterprise.

• Set clear performance expectations and follow through when those expectations aren’t being met.

• Create a sustainable financial model that allows you to recruit and retain high performers, rather than a model that subsidizes those who are not reaching goals that lead to a sustainable organization.

One of our clients this past year faced this exact dilemma. They had physicians who were not working at expectations and threatening to leave if compensation were decreased (aligned to output). Leadership had to make a choice: accept an unsustainable financial position to avoid conflict or have the uncomfortable conversation about performance expectations and market realities.

They chose the latter. With strong physician engagement and transparent data, they implemented a new compensation program that rewarded performance and eliminated the practice of subsidizing underproductivity. Did they lose physicians? One. And that physician was exactly who needed to leave for the group’s health.

As you reflect on your own organization, ask yourself:

• Are we truly transparent with our physicians about financial realities and performance expectations?

• Do we engage physicians as genuine partners or are we checking a box?

• Does our compensation program reward the performance we need and stop subsidizing what we can’t sustain?

• When we implement change, do we commit fully or create carve-outs that undermine the effort?

• Do we have the courage to draw a line in the sand on performance expectations?

These aren’t comfortable questions, but they’re necessary ones.

If you’re grappling with any of these challenges—or if you’re ready to move from strategy to execution but aren’t sure how to navigate the change management process—I welcome the conversation. Our team at AMGA Consulting has spent decades helping organizations make the transition from knowing what needs to be done to actually doing it successfully.

Because at the end of the day, healthcare doesn’t need more strategies. It needs executives who can execute.

Fred Horton is president of AMGA Consulting, where he has spent over a decade helping medical groups and health systems navigate complex organizational transformations. With 30 years of healthcare leadership experience, Fred specializes in physician engagement, compensation strategy, and change management that actually works.