Case study
Using physician advisors as an agent for change
Learning objective:
At the completion of this educational activity, the learner will be able to:
- Identify the advantages and challenges of having physician advisors involved in performance improvement efforts.
Physician advisors (PA) are an important ally for case managers at many organizations when it comes to ensuring proper patient status. But one organization has greatly expanded the role of PAs to include performance improvement and as a result has seen improvements in everything from readmissions to length of stay.
Ven Mothkur, MD, MBA, LSSBB, the corporate physician advisor at the Franciscan Alliance, a 14-hospital health system based in Illinois and Indiana, says that the organization shifted from an outsourced group of PAs to an internal team of 13 PAs and five physician clinical documentation improvement (CDI) specialists over a one-year period in 2014.
"I think we’re quite traditional in some respects," he says. "The primary function of the PAs is to perform patient status reviews. But what makes the role unique is its emphasis on the PA as a leader in performance improvement."
In the past, PAs at the organization were very much in figurehead roles. That has since changed dramatically. Today, PAs at the health system are still visible leaders but are also engaged, active full-time staff members that serve as a bridge between the medical staff, case management, and the C-suite.
The PAs run daily interdisciplinary rounds and are essentially the physician representative for case management and utilization review, but they are also liaisons between the chief medical officer (CMO) and the chief financial officer (CFO), helping to translate corporate goals into actionable plans. This includes global efforts to improve continuity of care and work as part of multiple accountable care organizations.
When an issue crops up, the PA’s are in a position to investigate the challenge. For example, if the observation rate starts creeping up they may jump in and start asking questions.
"What’s happening on the ground? Is it an issue with a payer? Are they being too delayed in getting back with authorizations? Is it a delay in communication between the attending physicians and case managers? Is it a delay on the end of the physician advisor getting back?" says Mothkur.
This new, "mid-revenue cycle" position allows the PAs to focus on what’s going on in the organization as a whole and help make performance improvements in response.
The health system implemented the new PA program after looking at its outsourced PAs and the value they were bringing to the organization. "When we looked at the cost to benefit ratio, it was just not there," says Mothkur.
The health system realized that there may be a real benefit to having well-respected members of the medical staff take on this role working alongside their colleagues.
Today, the PAs at Franciscan Alliance perform regular status reviews and ensure that the hospital is running a tight ship on the front end, but they also keep an eye on all the organization’s dashboards, metrics, and trends and turn those numbers into performance improvements.
Making the shift to the new model required a multi-step process that began by taking a good look at the organization and its needs.
Below are the main steps an organization will need to take to begin a similar program.
Shifting the role of the PA
Step 1: Financially justifying the change. The most challenging aspect of allowing PAs to shift their focus is justifying the change to upper management. "You have to give as much of a financially justifiable ROI as possible to the CFO. They’re the ones who approve it," says Mothkur.
When analyzing data to determine whether changing the focus of PAs, consider all the soft returns on investment, such as decreases in the observation rate, fewer denials, more medical staff engagement, or a higher case mix index, he says.
Step 2: Assessing the need. What are the problems your organization wants to address and will they be best solved by a wholly internal group of PAs or a hybrid model?
Some organizations use internal PAs during the week and switch to outsourced PAs to handle calls on nights and weekends, says Mothkur.
"I think the first step in doing this is to look at where you have huge gaps," he says. One starting point might be to look at the organization’s gross revenue write-offs. If this number is beyond national benchmarks, there may be an immediate and readily apparent benefit to having PAs move in and address the problem areas you find.
Also look at your mix of physicians. Are they primarily employed or independent? It may be easier to gain compliance from employed doctors with educational initiatives while independent physicians may require more intervention from PAs to accomplish the same goals.
Also look for other areas that could use improvement. For example, if your denials are high then your observation rate is high, or you are having trouble with payers then PAs can help smooth over some of these problem areas.
The PAs at Franciscan Alliance have become the oil that keeps the machine humming. If the oil was not there, the machine wouldn’t be operating as effectively. "There are now gaps that are picked up, there is improved compliance, nurses are happier, CM is ecstatic, the CFO has answers to what they’re seeing in numbers, the CMO has a second in command," says Mothkur.
Step 3: Choose the right PA. Finding the right person to fill this challenging role can be difficult. "It’s a matter of identifying the right person who is willing to do it all," says Mothkur. But this person also has to be someone who has the respect of the medical staff, someone who is ready to move on from practicing medicine daily to an administrative role and is excited about the opportunity to make improvements at a hospital level.
This job is not for the physician who took the opportunity in the past to scale back and work remotely, he says.
"Our PAs have to come to the hospital, attend leadership meetings, sit in the medical staff office for lunch, just to be there," he says. "This is very much a full-time job. The docs that we’ve gotten into it say it’s harder than clinical practice."
Often the PAs work 50 hour weeks. They also have to have thick skin, because they need to push back against their peers in some instances.
"It’s hard to find someone like I just described," says Mothkur.
To make its selections, Franciscan Alliance asked the CMO, among others, to identify potential candidates who were well respected, possessed leadership qualities, and were potentially interested in leaving clinical practice. Also look for physicians who have an appetite for looking at data and analyzing numbers.
Step 4: Ensure proper training. Once candidates are identified, training should begin as quickly as possible, says Mothkur. In the absence of formal training programs, organizations often have to cobble together their own programs, which should involve the following:
- Getting the candidate introduced to and embedded in the case management and CDI departments.
- Linking PA with educational resources, such as professional organizations like the American Case Management Association, Case Management Society of America, ACDIS, or the American College of Physician Advisors.
- Ensuring familiarity with different payers and health plans and ensuring proper education on InterQual® and MCG® (formerly Milliman) standards.
- Encouraging PAs to attend conferences on related topics and to join industry list-servs where PA topics are discussed. "The training is really very much on-the-job training, learning as you go," says Mothkur.
Step 4: Follow up. After the initial adjustment period, determine how the PAs are performing by polling case management and other departments, including the medical staff. Don’t be surprised if the medical staff is a little agitated by PAs, after all the job can be and should be a little adversarial.
The relationship between case management and PAs should always be one of mutual respect. A good PA will have respect and empathy for the increasingly complex and evolving case management role. A PA should have the attitude of "how can I help you," says Mothkur.
"There is often a shared bonding [between the PA and case management] over war stories because you’re fighting the same payers," he says.
A functional and positive relationship can pay dividends.
Franciscan Alliance has not only saved money by using an internal group of physicians. The other benefits of this approach include a reduction in the following:
- Denials
- Inappropriate admissions
- Avoidable days
- Readmissions
- Observation length of stay
- Overall length of stay
And case management has an important ally to support them and to help drive organizational change. "For case management it’s about knowing they have this leader and champion standing behind them that they never had," says Mothkur.
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