Your hospital probably has a chief medical officer (CMO) or vice president of medical affairs (VPMA) who attempts to manage a myriad of relationships in the organization – bridging the gap between the physicians and the dreaded administration, providing management-level insight to department chiefs, sitting in on clinically related department meetings and dealing with issues of credentialing and peer review dictated by licensure.
What about quality improvement, though? What about clinical documentation supporting utilization? What about overseeing billing and coding? A physician could be useful in all of these roles, yet in most hospitals, just one MD sits on the executive board with administrative leadership. We continuously hear that we need to improve clinical documentation to support utilization and improve quality of service.
Engaging the medical staff in new efforts is always a challenge, especially in clinical documentation. With a transition to more physician performance-based payments in the imminent future, coupled with the RAC audits and public reporting for health systems, interests are aligned and immediate change is needed. What is a vehicle for this change?
The silver bullet could be a physician advisor (PA). This new specialty has emerged as a complement to your CMO or VPMA to assist with all the problems that some executives might not have the time nor the specialized skills to address.
A PA specifically is focused on utilization management (UM), quality improvement and documentation. In fact, it is detrimental to have the PA involved in disciplinary actions because he or she should be viewed by the medical staff as a trusted resource and expert for advice.
In order to manage utilization effectively, the PA partners with care management and understands billing and coding. Hospitals that have implemented a PA effectively believe they have found the closest thing to a comprehensive solution for utilization management and compliant billing. Employing a PA has other upsides too.
As the role has gained recognition, a group called the National Association of Physician Advisors (NAPA) has formed. Dr. Mark Michelman spoke at a recent NAPA meeting and highlighted advantages to bringing on a PA; in his experience, some of these advantages include:
- Decreased LOS
- Decreased avoidable days
- Decreased denials
- Decreased costs
- Improved documentation
- Improved use of resources1
So, what is a PA’s role? The effective PA is an expert in chart audit and, again, a useful partner to care management. Physicians do not learn this skill set in medical school – the hospital must be willing to invest in education and training for the individuals who fill this role, even if they hire a PA with training. A PA’s duties should include:
- Chart audit as the central focus
- Partnering with care management for documentation of medical necessity, severity and intensity of care
- Partnering with quality officers
- Leading a utilization management function
- Serving as an expert on clinical criteria (Milliman/Interqual/other)
- Acting as a liaison to medical staff
- Participating in key committees (UR, RAC, etc.)
Not just any physician can or should become a PA. PAs must have certain personal characteristics; they should command the respect of physicians and departments, and possess the ability to lead. PAs are tasked with leading staff in improvements in UM and quality, especially as they are impacted by documentation and evidence-based medicine. Yet the PA cannot be perceived by care management, hospital personnel or even medical staff as an intimidating figure. The PA must be approachable, especially for the care managers who utilize the PA as the first “go-to” person when they are unable to obtain appropriate admission orders.
The PA also must be available when a clinical documentation improvement specialist and coder cannot get a response from a query. Therefore, the PA must be amicable and welcoming to these staff members, ensuring complete transparency and keeping open lines of communication.
However, the PA cannot be afraid of conflict. During implementation of the PA role, the medical staff may push back. Utilization always will carry with it some conflict when it is perceived as part of the hospital’s financial focus. However, the correlation between quality and documentation is evident. Poor utilization will impact individual physicians through potential denials and payer profiles.
Dr. Jeffrey Farber recently highlighted the benefits of having a good clinical documentation improvement program led by a physician. At a NAPA meeting, Farber said such a program:
- Improves communication between physicians;
- Enhances reputation of physicians through accurate data analysis;
- Ensures appropriate reimbursement for physicians and hospitals;
- Helps the medical staff analyze their patient populations;
- Defends the physician from medical liability allegations;
- Informs healthcare data, ratings, profiling, government /insurance audits; and
- Improves the overall quality of care.2
The PA isn’t just another FTE; he or she will help instill a fundamental cultural change in a provider setting. Implement a PA properly and begin to see the “silver bullet” take effect – and solve problems before they become serious issues.
Find out more at the ninth annual NAPA Leadership Summit on Optimizing the Role of the Physician Advisor, March 22 and 23 in Orlando.
About the Author
Elizabeth Lambin, MHA, is a partner in PACE Healthcare Consulting. Elizabeth has more than 20 years of C-suite level hospital executive management experience. Most recently, she was the CEO/Market President for Tenet Healthcare’s Hilton Head Regional Healthcare. Elizabeth holds an undergraduate degree in Business Administration, Cum Laude and a Master’s in Healthcare Administration from the University of South Carolina.
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- Mark Michelman, MD, MBA, vice president of medical affairs, Morton Plant Mease Healthcare System, Clearwater, Fla. Southeastern Physician Advisor Symposium: The Scope and Practice of an Emerging Profession, Jan. 27.
- Jeffrey Farber, MD, medical director of clinical documentation improvement and appeals management, Mount Sinai School of Medicine, New York City, Southeastern Physician Advisor Symposium: The Scope and Practice of an Emerging Profession, Jan. 27.