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PRESENTS

IN COLLABORATION WITH

EXECUTING A SUCCESSFUL PHYSICIAN ADVISOR PROGRAM:

A CASE STUDY

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The Physician Advisor (PA) role is relatively new in medicine, and many medical practitioners and administrators are not yet familiar with it. The PA is involved with many parts of hospital operations and acts largely as a consultant, facilitator, and team leader. In the hospital the PA could conduct reviews on care management cases to determine Level of Care (LOC), act as a resource for attending physicians regarding medical necessity, assist with denials and appeals as a subject matter expert or a peer-to-peer resource, or aid the Clinical Documentation Improvement (CDI) teams in program implementation and proper coding – among other possible roles.

An effective PA does not stand alone, and must be part of a team that approaches the challenges of modern hospital care with a transparent and adaptive strategy. This case study will examine one hospital that succeeded in implementing an effective PA program over a short time: A truly effective model for other systems looking to improve metrics and protect revenue.

INTRODUCTION

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At the forefront of the development of effective Physician Advisor programs is the team at Rochester General Hospital (RGH), which launched its’ PA program less than two years ago. At the time, RGH worked with a third-party contractor that outsourced Physician Advisor functions. Though the provider offered LOC reviews and denial management assistance, the program founders began to see challenges working with an outside contractor. The contractor communicated remotely with staff physicians and, as a result, there was little connection with the team and no integration within the culture of the hospital. Some physicians even believed the contractor to be a government agency when they received calls. Another challenge was the influx of payor denials, but no perceived accountability.

The challenges with the contractor led to an internal discussion at RGH to consider insourcing the PA program instead, rather than continuing the status quo. The leadership team was sold on the benefits of a strong PA program to implement clinical documentation improvement (CDI) and medical necessity. RGH’s leadership also wanted to reduce the number of denials and was open to considering a program that could appeal denials in an organized and effective manner. After making the case to the Chief Medical Officer and other internal stakeholders, an implementation plan was developed.

THE CHALLENGES

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The initial 3-year plan was to launch a PA program with 1.3 Full-time Employees (FTEs) and to grow as needed. The program would address one functional area at a time to prove the Return on Investment (ROI) for the organization. Once program worth had been demonstrated, a new area would be engaged. The first functional area would be denials and appeals, followed quickly by Clinical Documentation Improvement (CDI).

Using this staged approach, the PA program essentially became self-funded after the ROI justified increased investment from the health system for each new initiative. This proved to be a critical strategy in working with hospital leadership. Profit and operating margins were lean, and there was limited room for investment in new programs that could not clearly justify their financial worth.

Another key strategy was the decision to lead with analytics. The program founders realized that to demonstrate ROI effectively, they would need to measure and communicate goals and accomplishments in a common language with hospital leadership. The second hire into the new group was a specialist in medical analytics with a background in statistical analysis and reporting. This new addition to the program also had leadership experience which was instrumental in helping manage the changes necessary to implement the program.

After the Initial Investment , the ROI funds the next PA

initiative.

Initial

InvestmentPA

Program ROI of Initial Investment

THE DECISION AND PLAN

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BUILDING THE PROGRAM

• FOCUSING ON MEASUREMENT, METRICS AND ANALYTICS

• FINDING THE RIGHT PEOPLE

•STAFFING THE TEAM CORRECTLY

•EFFECTIVE TRAINING AND EDUCATION

•MAKING PAYOR RELATIONSHIPS A PRIORITY

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An analytics-driven approach is only as good as the technological tools available and processes applied. At the beginning of the program there was no method for tracking UR and performance metrics. Electronic health records (EHR) took free text inputs for Utilization Review (UR), notes, and CDI templates, resulting in no effective way to take data from these notes to generate metrics. The team initiated a large Information Technology (IT) project to update their EHR software in order to tag and track data elements taken from UR documentation. Using smart data elements within the software, they were able to build drop-down menus that offer users specific choices when updating records. These discrete choices made measurement and analytics easy, though up-front work was required to get the templates and processes built, and to make sure that appropriate criteria were referenced within the notes to justify patient status determination. This made it simple for the denials and appeals teams to double-check work in the event of a denial.

FOCUSING ON MEASUREMENT, METRICS AND ANALYTICS

BUILDING THE PROGRAM

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Num

ber o

f Dis

char

ges

Observation LOS > 2 MN2015 Q1 2015 Q3 2016 Q1

388403

370

217

9672

RGH has been successful at improving throughput and driving

down long observations using a better review

process.

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The right people are needed for a strong team, and a smart hiring strategy is needed to find those people. The RGH team recognized that a combination of skills and the right attitude would be necessary for success. The PA needed to have a friendly and approachable personality. Internal hires have been especially beneficial to the program because they bring invaluable knowledge of the hospital and have existing network of relationships. They are already known on the floor and respected by their peers. Additionally, an emphasis was placed on bringing in physicians with expertise in different practice areas. This provided a broad clinical knowledge base for the team to draw upon. Leadership aptitude was also important for new PA’s. The physicians that were brought on had solid clinical backgrounds. This was critical for physician to physician communication, where credibility is key. However, prior experience working in a PA role was not seen as necessary for success – and there have been no hires with PA experience brought onto the RGH team.

FINDING THE RIGHT PEOPLE

BUILDING THE PROGRAM

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But how many PAs and additional staff would be needed to build a successful team? Determining the FTE requirements involved considering hospital volumes, and specifically the number of charts per day that needed to be reviewed. RGH was seeing 300-350 chart reviews per month, and the program founders determined that an efficient and trained PA could perform a thorough chart review in 45 minutes. Chart reviews and other functions on the front-end of hospital care, including capacity for odd coverage hours, accounts for 2-2.5 FTE. Work with denials requires another 1.0 FTE, and education, CDI, coding, and DRG denials another 1.5 FTE. Currently RGH is running with 5.7 FTE in the PA role – including the medical director for the program. In addition to PA needs, the RGH program founders determined that the UR team needed to grow from 10 members to 22 to be truly effective and to be able to perform timely case reviews.

STAFFING THE TEAM CORRECTLY

BUILDING THE PROGRAM

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The RGH team needed to find ways to train and educate their new hires, and at the time there was no formal training program available. The RGH team had to develop its own approach to learning. The first resource was to attend conferences. The team attended those put on by the National Association of Physicians Advisors and the American College of Physician Advisors. They also paid close attention to the work being performed by the contractor that was working in the hospital at the time. By evaluating the existing audit process at the hospital, they could see where the process worked and where improvements could be made. Also, the team collected available literature on the functional areas of the hospital. This literature was included in a library that new members were assigned to review.

EFFECTIVE TRAINING AND EDUCATION

BUILDING THE PROGRAM

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0%

25%

50%

75%

100%

Denials as a result of referralOverturned Pending Upheld

9%9%

81%

7%

59%

34%

VendorRGHThrough effective use of peer-

to-peer opportunities, RGH has improved upon the rate of

overturned denials and reduced pending denials since taking this function over from the third-party

contractor.

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The team believed that they could achieve better program outcomes with improvements in the relationships with payors. They aimed to achieve this by building relationships. Speaking with the payor Medical Directors while the patients are in-house has been critical to getting on the same page regarding care. The team found that once patients were discharged, conversations with payors became more difficult due to the inherent hindsight bias that exists when looking at a past case from different perspectives. The team also found that by approaching their payor counterparts as peers and by respecting their points of view, a net benefit could be realized. An effort to close out cases sooner and more efficiently resulted in an overall improvement in revenue recovery when compared to the costs of engaging in long, expensive, and convoluted denials processes that put a drain on resources and soured the payor-hospital relationship. Driven by an effective peer-to-peer approach, the RGH team made quicker decisions and secured more case overturns.

MAKING PAYOR RELATIONSHIPS A PRIORITY

BUILDING THE PROGRAM

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Procedure, communication, and measurement are the keys to operation of the team. For example, the team recognized that Utilization Management (UM) and UR are 7-day processes, not Monday through Friday. Working calendars were restructured to 18 hour schedules 7 days per week. They also relocated UR services centrally instead of handling these operations individually in each hospital unit, with the PA office located near UR. This restructuring improved operations significantly by both making UR easier to operate and measure, and making it easy for the UR team to tap into the diverse expertise of the PA team. Once the team learned how different payors worked and what approaches to denials were more effective, streamlined procedures could be rolled out to the whole team. Utilizing peer-to-peer opportunities, sending clinical information out to payors with staff follow-up, and addressing denials proactively increased the appeal success rate from 30-40% to 72%.

Communication is crucial for an effective PA program. A PA needs to approach others - and physicians in particular - in a collaborative, non-confrontational manner. Physicians generally do not like being told how to provide care, and the PA does not want them to feel criticized. The RGH team members are currently honing their messaging style, and continue to work to be more approachable to both providers and fellow staff. The team also holds regular Thursday meetings to keep team members apprised of the state of the program, key metrics, and what projects are active. Program leadership also holds monthly lunch-and-learn sessions for the full team. These are generally formatted as a 30-minute presentation and another 30 minutes of round-table discussion. These sessions often result in spin-off projects to improve the overall program. For example, a recent session was a discussion on determining how to maintain contact with providers. A work group of PA and UR professionals is surveying providers, aiming to figure out what works best in the relationship and continuing to refine the process.

RUNNING A SUCCESSFUL PA TEAM

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In less than two years, the team has begun to deliver on what was promised to administration. Reimbursements are up, risk is being mitigated, a two-midnight program is in place, and denial management is being handled more efficiently. An early transition to ICD-10 went smoothly. There have been measurable changes for the CDI team. The new EHR tools allow for UR process measurement, and the UR professionals and PAs at the hospital have broadly begun to adopt the process. Payor relationships have improved and peer-to-peer reviews have improved significantly. The process of insourcing PA functions has progressed as well, and 95% of concurrent reviews are now handled by the team. Hospital administration has adjusted inpatient / observation predictions based on the metrics provided by the team. There are many metrics for success, but one of the most basic is dollars, and RGH has committed to continuing the PA program and devoting more resources to the program.

In 2014, Rochester General Health System merged with Unity Health System, adding two hospitals and changed their name to Rochester Regional Health. As a result, there are preliminary talks about what it would take to replicate the PA program results throughout the new system. Rolling out to multiple hospitals presents new challenges. For example, different EHR systems and different administrative structures need to be considered. Different organizations also have different strengths that should be emulated at other facilities if they can improve overall effectiveness. If prior success is an indicator, the RGH team will be up to these new challenges.

THE OUTCOMES AND FUTURES

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After launching the PA program in November of 2015, the RGH team quickly reduced the observation rate from a

38.3% 2015 average to 31% in 2016.

% O

bs a

t Dis

char

ge

Observation Status at Discharge11/30/2019 12/7/2019 12/14/2019 12/21/2019 12/28/2019 1/4/2020 1/11/2020

37.0%

38.0%

36.0%

35.0%

29.0% 29.0%

30.0%

THE OUTCOMES AND FUTURES

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Kalyana C. Kanaparthy, MD, FHMMedical Director, Physician Advisor Program, Director, MAT UnitRochester General Hospital585.922.4000

Matt Phillips, MBADirector, Physician Advisor ProgramRochester General Hospital585.922.4000

Yasser Said, MDPresidentIndusMente Phone +1 720.577.5915yasser@indusmente.com

Gabrial Carter M.S.F.V.P. OperationsIndusMente Phone +1 720.577.5915gabe@indusmente.com

SOURCES

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CONTACTS