Published in the May 2018 issue of Today’s Hospitalist
JUST A FEW YEARS BACK, the role of physician advisor—someone to handle observation status determinations, medical necessity reviews, peer-to-peer phone calls about denials with health plans, and documentation and discharge plans with other doctors—was seen as a good late-career option, a way to ease experienced physicians out of clinical care and leverage their collegiality with medical staff.
But the fast-growing field has outgrown that stereotype, says Sarguni Singh, MD, a hospitalist at the University of Colorado Anschutz Medical Campus in Aurora, Colo. Dr. Singh, who has 0.3 of her FTE carved out as a physician advisor, is one of a team of physicians there who are pushing the advisor role beyond reviews and peer-to-peers into redesigning hospital systems.
“We’re young and we’re motivated.”
~ Sarguni Singh, MD
University of Colorado Anschutz Medical Campus
She is eager to figure out what research to publish to start establishing evidence for the field’s results. She sees the position eventually leading to system utilization management and chief medical officer slots. And she is less than three years out of residency.
“We’re young and we’re motivated,” Dr. Singh points out. “Those are great qualities to have in what I see as a new physician leadership role.”
Outsourced to in-house
Physician advisors have been around for more than a decade. But their ranks continue to grow due to aggressive Medicare recovery audit contractors (RACs), constant debates over how to apply the two-midnight rule and—according to many physician advisors—increasing denials from commercial payers.
At the same time, there is a huge range in how hospitals manage those demands, with many hospitals continuing to rely on outsourced companies for physician advisor services. Via Christi Health, an eight-hospital system in Wichita, Kan., is one of them. Chief medical officer and hospitalist Samer Antonios, MD, says he used to take on many physician advisor chores himself, but that’s no longer possible since he became CMO.
While one doctor in his system will help by looking at status determinations when case management is on the fence, most secondary reviews and peer-to-peers go through a contracted outsourced company, says Dr. Antonios.
He’s asked that organization to “try to minimize the number of docs at the outsourced company we deal with. But that doesn’t happen, so we lose the ability to develop educational relationships with physician advisors.” While Dr. Antonios would like to bring advisors in-house, he doesn’t have the bandwidth right now to get such a program off the ground.
“We’d like to minimize the number of docs at the outsourced company we deal with. But that doesn’t happen.”
~ Samer Antonios, MD
Via Christi Health
Blessing Hospital in Quincy, Ill., still uses an outsourced company for some backup, says hospitalist Mary Frances Barthel, MD, chief quality and safety of ficer. But that’s only for about a dozen cases a month, typically on weekends. When she joined Blessing in 2011, she realized that the doctors in the hospital were avoiding that company’s phone calls.
“They learned the phone numbers the company would call from and just not answer,” she recalls. She now oversees four part-time advisors who—along with Dr. Barthel— handle most reviews and calls in-house.
One of them—the director of the observation decision unit—deals exclusively with observation status determinations, while another deals with RAC audits. The other two advisors began sitting down a year ago with doctors whose patients are in the hospital for more than 10 days to discuss alternative placement and discharge planning.
But those two physicians are so part time that they don’t have any FTE time carved out. The advisors who head the observation decision unit and do RAC audits each devote between 0.1 and 0.2 FTE to those roles. With such a part-time presence, Dr. Barthel ends up doing many of the concurrent status reviews herself.
“The other four advisors are all rounding, and those decisions are all being made between 8 a.m. and noon every day,” she points out. While having someone working a 0.5 or even 0.8 in the position would be ideal, “we have not had a candidate like that.”
Pushing beyond reviews
But at the University of Colorado, the role played by the in-house physician advisors is much more structured. Each 0.1 FTE for Dr. Singh and her advisor colleagues corresponds to a half-day per week they’re scheduled. (In addition to Dr. Singh’s 0.3, two other physicians—one of whom is a vascular surgeon—each works 0.2 FTE on utilization review and case management, while a fourth physician works part time on clinical documentation improvement.)
“You need to track who’s doing the peer-to-peers and what outcomes they have.”
~ Juliet B. Ugarte Hopkins, MD
ProHealth Care
Instead of dividing the work among them into secondary reviews and peer-to-peers, “we’re all basically doing the same job at different times,” Dr. Singh points out.
“We all wanted enough exposure to unique cases with insurance companies.” The three advisors also equally divide what she calls “high-yield committee meetings,” as well as meetings with inpatient medical directors and on complex discharges. Further, they each attend conferences and symposia at least twice a year.
Given that level of engagement, Dr. Singh and her fellow advisors have pushed well beyond reviews and denials into system redesign. They have streamlined, for instance, the process the hospital uses to accept outside transfers. They’ve also pared back hospital medicine admissions so that more patients now are cared for by their primary surgical or proceduralist team.
“If the only role for a physician advisor was to do second-level reviews and peer-to-peers, I wouldn’t do it,” she says. “We’ve interpreted this as a very broad role that we can tailor to each of our larger interests.”
Full-time advisors
At Virtua, which is headquartered in Marlton, N.J., hospitalist Erik DeLue, MD—the medical director of Virtua Voorhees and the director of physician utilization review for the entire Virtua system—points out that the physician advisor program there is not only in-house, but full time.
He now oversees two (soon to be three) full-time advisors. One deals exclusively with Medicare reviews, while the other position was created less than a year ago to handle commercial payers. (The third advisor being brought on will also concentrate on the commercial side.) Dr. DeLue says he uses this rule of thumb for staffing physician advisors: “one advisor to support every 15 or 20 hospitalists you have.”
At ProHealth Care, a two-hospital system in Waukesha County, Wis., former pediatric hospitalist Juliet B. Ugarte Hopkins, MD, also works as a fulltime physician advisor. Dr. Ugarte Hopkins, who is membership chair of the American College of Physician Advisors, a professional and certifying group, sees herself as proof of the field’s ongoing evolution.
“Physician advisors started out with outsourcing, then evolved into hospitals finding someone within their own ranks,” says Dr. Ugarte Hopkins. “We’re now moving toward hospital systems looking to hire people like me who have made this a full-time career for the long haul.”
Understanding a hospital’s culture
According to Dr. Ugarte Hopkins, hospitals with internal physician advisors have many advantages. First and foremost: having personal relationships with the clinicians with whom they interact and understanding the hospital culture.
“It’s not just getting a specific status or regulation covered, but bringing in quality and clinical documentation improvement as well,” she points out. “You just don’t have those when it’s outsourced.”
Dr. Singh agrees that hospitalists are well-positioned to take on advisor roles. That’s because “we’re usually on the receiving end of system inefficiencies,” she says. “Historically, physicians haven’t invested the energy to figure out how to craft a system that works on the front line.”
And then there are financial benefits from bringing advisorships in-house. Virtua’s Dr. DeLue notes that Medicare margins continue to trend downward, and hospitals need to hold onto every dollar they’re due. Bringing the physician advisor program in-house has been, he says, “a fantastic investment.”
Key metrics to track
ProHealth’s Dr. Ugarte Hopkins
points to another new devel
opment in the field: tracking
key metrics like overturn rates,
something her system began doing only last year. Many payer contracts, for instance, still stipulate that only attendings, not advisors, can do peer-to-peers with health plan medical directors.
“If a denial isn’t overturned, the hospital has to move on to an appeal after the patient is discharged,” she says. “You need to track who’s doing the peer-to-peers and what outcomes they have.” If physician advisors can get 80% of health plan denials overturned, but that’s the case for only 15% of the calls with attendings, “you need to think about looking at your contracts to see if a physician advisor can do them all.”
You also need to break down denial rates by payer, Dr. Ugarte Hopkins adds. With some payers, the majority of denials are overturned in peer-to-peers. But in others, almost none are.
“If those are eventually overturned in the appeals process, that’s a lot of work the payer is putting the hospital through,” she says. “That’s another situation where your contracting office should reach out to the payer to see why denials are always upheld during initial discussions but then are eventually overturned.”
And while many hospitals put a lot of effort into managing denials, “we don’t necessarily have good data to help us manage payer-specific or even diagnosis-specific trends.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Tough conversations
DOCTORS MAY SHY away from opportunities to work as physician advisors, worried that they’ll be embroiled in too many tough conversations with either health plan medical directors or their own colleagues.
Mary Frances Barthel, MD, chief quality and safety officer of Blessing Hospital in Quincy, Ill., points out that private payers seem to be increasing their denial rates, almost as if they have a certain quota of claims they want to deny. But many times, she notes, the peer-to-peer conversations she has with health plan physicians are simply “passing along information, so they’re not really debates. Once I relay documented information that they’re not aware of, I’ve had very good success overturning denials.”
Sarguni Singh, MD, a hospitalist and physician advisor at the University of Colorado Anschutz Medical Campus in Aurora, Colo., says the tougher conversations can be with colleagues in her medical center who may be extending a patient’s length of stay longer than necessary.
What’s required, says Dr. Singh, is diplomacy. “The key is trying to identify what you and the other doctor have in common in terms of goals of care for that patient—and figuring out the right time to have the conversation.” Sometimes, she adds, “you need to acknowledge that certain rules and regulations don’t make sense and let the other doctor vent a little.”
But sometimes, says Juliet B. Ugarte Hopkins, MD, a former pediatric hospitalist who’s now a full-time physician advisor for the two ProHealth Care hospitals in Waukesha County, Wis., you do have some hard conversations. Some of those are to bring about a necessary change in the hospital culture.
“Some hospitals have a very strong culture of keeping patients because patients want to stay, not because they need to be there,” she says. “Or there’s a cross-coverage culture where one doctor won’t discharge another’s patients over the weekend, so those patients stay longer than they need to.”
But she’s also had to speak with doctors about changing how they interact with case managers and clinical documentation specialists. “I completely appreciate why it frustrates doctors to have to use such information to make decisions,” Dr. Ugarte Hopkins says. “But that doesn’t mean it’s OK to be rude or belligerent.”
In such conversations, she thinks it’s an advantage to be younger and to have not practiced clinically within the health system where she’s an advisor.
“Many health systems turn to a man or woman who’s been a doc there forever and is ready to retire,” she points out. “But being a physician who’s well-known and well-liked can be a disadvantage when you have to have a tough conversation. You’re much more used to being strictly collegial.”
Physician advisor: Who’s the right fit?
AS CHIEF MEDICAL OFFICER of the five-hospital Via Christi Health system in Wichita, Kan., hospitalist Samer Antonios, MD, would love to find a colleague willing to take on a substantial physician advisor role. But when he’s tried to gauge colleagues’ interest, “it’s been lukewarm.”
He’s also sure that working as a physician advisor wouldn’t be right for many hospitalists. “They need to understand legislation and Medicare regulations and be willing to do extensive chart reviews,” Dr. Antonios points out. “They also need to have what can be awkward phone calls with health plan medical directors, and some people are just not into that.”
“It’s not for adrenaline junkies.”
~ Erik DeLue, MD
Virtua
Erik DeLue, MD, the medical director of Virtua Voorhees in Voorhees, N.J., and the director of physician utilization review for the entire Virtua system, oversees two (soon to be three) full-time physician advisors. He thinks that successful candidates are probably those who excelled in their college debate clubs.
“For them, it’s a sustainable career,” says Dr. DeLue. “It’s not for adrenaline junkies, so ED doctors might have trouble making the transition.” For those who do want to make sure that doctors and hospitals are paid appropriately for the work they do and can navigate documentation and discharge planning, “it’s like finding the right strategy in a chess game.”
He also believes that the best physician advisors are, not coincidentally, the best hospitalists.
“They’re able to understand and defend a case, and they can maintain excellent relationships with the medical staff,” Dr. DeLue explains. He points out, however, that many doctors in their early and mid-careers may not want to take on a full-time advisor’s role and walk away completely from clinical work.
But that’s just what Juliet B. Ugarte Hopkins, MD, did in 2014 when she became the sole full-time physician advisor for the two-hospital ProHealth Care in Waukesha County, Wis. Dr. Ugarte Hopkins credits burnout in her previous position as medical director of a pediatric hospitalist program for spurring her to look for something completely different.
“We were always short-staffed, and I have four children,” she notes. “It became more and more difficult to balance my work and home life while working 12- or even 18-hour shifts.” Instead of continuing that grind, Dr. Ugarte Hopkins now works Monday-Friday, 8 a.m. to 4 p.m.
That new schedule was such a change that her children were “shell-shocked for a bit,” she says. “They’d say, ‘You’re having dinner with us again? Why are you here another weekend?’ They were used to me being gone for long shifts.
