From declining reimbursements and increasing denials to the ongoing shift of services from hospitals to outpatient settings, healthcare is experiencing significant transformations. Compounded by nursing shortages, physician retirements, clinician burnout, and escalating costs for medications and devices, hospital executives are now more than ever forced to reassess traditional approaches, including the way that staff is utilized.
Non-patient facing activities have increasingly moved out of the hospital setting, aided by increasingly sophisticated technology, and hastened by the COVID-19 pandemic. Consequently, there is a pressing need to assess the benefits of outsourcing services, enabling hospital staff to concentrate on patient care. Utilization review activities are a worthy place to start, beginning with the role of the physician advisor.
The rise of the physician advisor
Nationwide, hospitals are increasingly employing physician advisors to ensure efficient and effective hospital operations. While the origin of the physician advisor’s role is uncertain, their numbers have grown substantially. The American College of Physician Advisors, a national physician-led organization with more than 1,200 members, underscores the significance of this role. While medical directors of various service lines have existed for years, their duties are limited to oversight of their specific area of expertise. While physician advisors perform a myriad of duties, they often assist with issues of medical necessity, utilization, and documentation across all hospital areas.
However, the intricacies of the physician advisor role are not typically taught in medical school or residency programs. Furthermore, a physician cannot simply be appointed to the position and be expected to perform these tasks effectively and compliantly. It also is not a role that can be “bestowed upon” a senior physician who has decided to reduce or discontinue clinical practice but still wants to be involved. Physician advisors must be carefully selected, properly trained, and receive adequate executive support with ongoing education.
Moreover, hospital needs must be properly assessed. While some hospitals may suffice with one or even a fractional full-time equivalent, there’s no on-size-fits-all solution. Every hospital is unique. While the hospitalist movement has expanded, many hospitals continue to rely on community physicians to manage patient care during hospitalizations. In such instances, rather than engaging with a select number of physicians, the physician advisor may be faced with interacting with a larger number, most of whom are in and out of the hospital before daytime staff arrive. The coverage for specialty programs further compounds this issue, such as when multiple cardiology groups on staff escalates the physician advisor’s workload.
Some might assume that a teaching hospital would be the optimal setting for an effective physician advisor program, however academic medical centers usually have more complex patients along with constant turnover of medical students, residents, and fellows, all of whom need ongoing orientation and supervision to ensure proper utilization of services and documentation. Additionally, teaching hospitals receive a significant volume of patients transferred for specialized care, warranting additional efforts in coordinated care, screening, and triage.
The payer mix also contributes to the need for physician advisor oversight and input. Each payer develops their own rules for prior authorization, determination of admission status, admission notification time limits, length of stay approval, post-acute care transfers, and so on. The growing trend of Medicare beneficiaries to Medicare Advantage plans and states adopting Managed Medicaid as the only option for Medicaid recipients has added layers of work.
Determining the scope of the physician advisor role
The various tasks assigned to a physician advisor can be daunting. To maximize impact, it is important to prioritize their efforts on areas where they can leverage their personal relationships with other physicians.
One such area is the optimization of length of stay, where the physician advisor attending multidisciplinary rounds can hear about the roadblocks to moving patients through the continuum of care. Issues like limited access to physical therapy evaluations, the inability to get a stress test or MRI for a patient, insurance company demands, and patients questioning their discharge plans can be addressed by the physician advisor. These rounds are also the perfect place to determine if the patient is in the right place within the hospital. Patients are often outfitted with telemetry monitoring ordered on admission as a precaution, but that leads not only to increased nursing costs but also the risks of false positive alarms and reduced mobility by the patient. Addressing inappropriate telemetry use is another role where the physician advisor can help improve outcomes both clinically and financially.
Denials management is another area that is often performed off-site and can be outsourced to organizations that can use their national data and experience to argue the inappropriateness of the denial more effectively. While this work can happen remotely, the physician advisor can serve as that intermediary at the hospital, being able to understand the root causes of these denials and work with the physicians and other staff to prevent future denials.
Documentation challenges also demand the physician advisor’s attention. Be it the changes to the coding of evaluation and management visits or the proper terminology needed to code specific diagnoses impacting the myriad of quality and risk adjustment programs, the physician advisor is best positioned to provide that guidance to their colleagues, both in real-time on the medical units and at department meetings. The clinical documentation staff, many of whom are remote, often face hurdles effecting change and having that physician support is invaluable.
Finally, one of the most common yet least productive roles of the physician advisor is addressing the patient’s admission status. Whether it involves reviewing new admissions to decide between inpatient admission or outpatient placement with observation services or discussing the case with an insurance company’s medical director, this recurring task, while essential, may not always require involving the physician advisor. In fact, as they get acclimated to the documentation habits of their own physicians, they tend to develop an unconscious bias and perhaps allow inpatient admission when an auditor would not support that decision. These cases are often time-sensitive, and if the physician advisor is unavailable, cases can be missed, resulting in the wrong status for patients.
As hospitals evaluate the roles and responsibilities of their physician advisors, it is important to consider where their medical knowledge, experience, and ability to interact with the medical staff can be best utilized. They need to explore the options to address those other needs, ensuring the physician advisor’s effort are maximized to enhance efficiency in patient care and hospital operations.
Ronald Hirsch
Ronald Hirsch, MD, is vice president of physician advisory services at R1. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians.
