Address growing problem with credentialing

Difficulties arise in obtaining needed data

With the advent of hospitalists, credentialing and privileging for medical staff members who no longer care for inpatients is a growing challenge for many organizations.

The problem is that physicians may want to retain active medical staff membership with privileges, but they no longer want to be involved in committee activities. Also, at the time of re-credentialing, there is nothing on which to judge the physicians' competence since they haven't cared for any inpatients and no data are available.

This problem has intensified in recent years as primary care physicians spend less and less time in hospitals, says Alice Gosfield, a Philadelphia, PA-based health care attorney who works with organizations on issues including medical staff credentialing. "There is no single answer to this dilemma, but it is increasingly a problem," she says. "It is especially problematic since many managed care organizations look to medical staff membership and privileges as a safeguard for quality."

It is less of a problem for integrated delivery systems that employ physicians through affiliated entities directly, because they are evaluating what they do in their offices more than in stand-alone hospital settings, Gosfield explains.

There is a misconception that the National Committee for Quality Assurance (NCQA) requires all physicians who are credentialed by an accredited health plan to have privileges. "This is not true," says Gosfield. "NCQA says that if you have privileges, you must maintain them in good standing."

Hospitals face potential liability exposure if they hold physicians out to the public as being members of the medical staff and fail to evaluate their current competence, adds Gosfield.

Some hospitals have established separate membership categories without clinical privileges. "Other hospitals have actually decided that they will seek to look at the physicians' activities in their offices if they are to be considered members of the medical staff. This is a very small minority of institutions," says Gosfield.

Low volume of inpatients

As primary care physicians became able to care for much sicker patients in their offices, their hospital admissions decreased, says Frederick P. Meyerhoefer, MD, a consultant based in Canton, OH.

For many physicians, volume of inpatients decreased to almost zero, making it difficult to document the physician's continued ability to care for hospitalized patients, particularly as the acuity of these patients increased.

"As a result of this shift in where and how patients were treated, a physician's reliance on the hospital as the place where the sicker patients were cared for was altered," Meyerhoefer says. "Patients that the physician had previously admitted to the hospital for care could now be provided excellent treatment in the physician's office."

This contributed to the further development of the budding hospitalist program, which initially was meant to provide in-house coverage for the hospital and the admitting physician, with the primary care physician maintaining the responsibility for the care of the patient.

"It fairly quickly headed toward true specialty status as the hospitalists began developing as a true specialist with expertise in inpatient care," says Meyerhoefer. "Due to frequent resistance from private practicing physicians, a hospitalist program has now commonly been embraced as a strong adjunct to the care provided by the primary care physician."

As practicing physicians realized the worth of the hospitalist program and became confident in the services provided, they increasingly have voluntarily given up some, or all, of their privileges — including the right to admit patients. This has increased the hospital's responsibility, under its custodial oversight for the inpatient, to provide constant and appropriate medical care for its patients, says Meyerhoefer.

"As yet, there is no universally recognized method for handling these privileging issues involving no privileges or very simple privileges, with or without admitting privileges," says Meyerhoefer. "Hospitals and medical staff leaders are struggling with meeting the needs of the patient and balancing the concerns of possibly affected physicians."

To allow physicians who may not have recently exercised the use of privileges that have continued to be granted over the years or have been voluntarily relinquished also raises the question of one standard of care for all patients, adds Meyerhoefer.

"None of these privilege concerns have affected the current necessary credentialing requirements for any physician granted membership to the medical staff," he says.

Some physicians still attach a major part of their identity to their hospital staff membership and privileges, but others recognize that the overall practice of medicine has changed and acknowledge their role as ambulatory care specialists, just as the hospitalists are now becoming recognized for their expertise in managing the hospital patient, says Meyerhoefer.

As soon as the medical staff and hospital board grant privileges to any physician who does not have current clinical data supporting those privileges, it crosses the boundary of its fiduciary responsibility, says Meyerhoefer.

If any hospital-specific privileges are granted, the medical staff and hospital must be able to support the granting of the privilege with objective evidence of current clinical competency to exercise the privileges and manage inpatients, says Meyerhoefer. "This is the critical sticking point of allowing physicians to have medical staff membership with privileges," he says. "There is yet no clear answer."

There are creative ways of approaching this issue by looking to data that managed care plans maintain, pay-for-performance program data, or NCQA certification programs for diabetes, cardiac and stroke, says Gosfield. "But few hospitals have moved in that direction," she says.

Medical staff can only be granted privileges to do things for which the hospital has evaluated their competence in some capacity, says Gosfield.

"What that would be depends on the data they have available to them," says Gosfield. "If they do site visits or record reviews or look to other kinds of data, they could be given privileges to manage that kind of care."

They also can be given privileges "more of a social nature," says Gosfield, such as visiting patients, questioning them, and doing vital signs. "The real issue is that they should be given privileges only to do those clinical services which they are actually performing in the hospital," she says.

To obtain performance data for the credentialing process, have physicians sign releases for the information, and seek it from the parties who hold it, says Gosfield. "Look to report cards in the community, or go into their offices and do record reviews on your own," she says.

The other dilemma is that in most states, the organizations who may hold the necessary information are not obligated to provide it for another organization's credentialing unless it is generally made public, adds Gosfield.

Creative solutions needed

"Health care organizations are trying to come up with solutions to this evolving issue," says Fay A. Rozovsky, JD, MPH, a Bloomfield-CT-based consultant.

Here are some possible solutions:

• Using a courtesy-style privilege, with care providers not expected to take part in committees or attend meetings.

This could include all the "perks" associated with other medical staff categories, such as CME credits, library access, voluntary attendance at medical staff committee meetings, and reserved parking. "Whether or not these members have any political rights such as voting rights or membership on medical staff committees is a determination to be made by the medical staff," Meyerhoefer says.

For this type of category, the medical staff is not vouching for any current clinical competency of the physician, says Meyerhoefer.

"The push back on this approach is that as long as a hospital grants an appointment, it is holding that care provider out as having met established standards," says Rozovsky.

Thus, the bylaws, rules, and regulations of the medical staff need to be changed to accommodate this new approach while being certain that these changes conform to CMS, JCAHO, and AOA requirements, Rozovsky says.

• Performing a limited review of the physician's practice patients in some specific diagnostic categories.

"This would accord some credence to clinical competency to these physicians without granting hospital privileges," says Meyerhoefer. "However, this has not been met with great enthusiasm by the practicing physicians."

• Including procedures in ambulatory care settings or other hospitals when verifying performance thresholds.

As it becomes more difficult for care providers to meet the bylaw-required thresholds at the hospital, "outside" performance can be used as a surrogate, says Rozovsky. The danger is that the "outside measures" may not be data equivalents, and that is an issue that must be examined closely, she says.

"One thing is certain," says Rozovsky. "Before making any changes, health care organizations must be clear that the revised process will be compliant with applicable state law, the CMS Conditions of Participation, and accreditation requirements."

[For more information, contact:

Alice G Gosfield, 2309 Delancey Place, Philadelphia PA 19103. Telephone: (215) 735-2384. Fax: (215) 735-4778. E-mail: AGGosfield

Frederick P. Meyerhoefer, MD, 1261 White Stone Circle NE, Canton, OH 44721. Telephone: (330) 966-6717. E-mail:

Fay A. Rozovsky, JD, MPH, The Rozovsky Group, Inc./RMS, 272 Duncaster Road, Bloomfield, CT 06002. Telephone: (860) 242-1302. Fax: (860) 242-1075. E-mail: Web:]