By Jeni Miller
As modern healthcare continues to unfold and advance, new procedures and even positions often are put in place to best serve professionals and patients. One role that has been enhanced in recent years is the physician advisor (PA). These professionals are known as the liaisons between physicians and the administrative side of hospital operations. It is no surprise they rub shoulders regularly with hospital case managers.
“PAs help to support hospital operations through utilization management and efficient use of resources,” explains Elias Loukas, MD, medical director for case management at Dartmouth-Hitchcock Medical Center. “We help ensure that CMS mandates are held accountable to, especially in the nebulous landscape we’re in at times.”
Loukas’ colleague, Justin Krawitt, MD, medical director of utilization and clinical documentation in the hospitalist section of Dartmouth-Hitchcock Medical Center and president of the NH-VT chapter Society of Hospital Medicine, adds “a lot is borne out of CMS conditions of participation requiring physician oversight into utilization.”
“All hospitals require utilization review, and a PA is a liaison who supports that from a medical, legal, and ethical standpoint,” he says. “It’s important to have good support to help navigate and deliver efficient, high-quality healthcare, which we’re required by design to employ through CMS mandates.”
That “physician oversight” is the crux of the physician advisor role, as these advisors are medical doctors with patient care experience who also have undergone extensive training to understand the ins and outs of compliance, CMS, utilization review, and more.
PAs work together with case managers, but also use their clinical skills to provide support to their physician colleagues who may not be as well-versed in all things administrative.
“PAs have a unique expertise to educate their colleagues, and this has an impact on how care is delivered and how patients progress while hospitalized,” explains Krawitt. “They work with case managers and social workers to troubleshoot barriers to discharge, but clinically they reach out to physicians, or even to nursing home directors regarding barriers they may have.”
Many of these consultant-liaisons have performed extensive research of CMS guidelines, read up on materials from the American Case Management Association, and may even hold membership with the American College of Physician Advisors. Loukas explained “we have diverse groups of PAs including hospitalists, an ED physician, a cardiologist, and a thoracic surgeon, and they all still do clinical work. Everyone knows who we are, and that helps boost buy-in for providers.”
In any case, says Krawitt, “the PA bridges knowledge from the case managers to the physicians to ensure that patients are cared for and hospitals are reimbursed. We’re really advocates for all of these entities, and that’s very important both to patient satisfaction and to the bottom line of the hospital. They say that it takes two years to make a good PA, and five to six years to make a great one. There are so many rules and regulations with CMS that PAs need to shadow for a long time.”
Not all hospitals have a thriving physician advisor team (yet), and it takes time to build the kind of team that Krawitt and Loukas have developed at Dartmouth-Hitchcock Medical Center. After a hospital takes the first step toward prioritizing a solid PA team, much can be done to make the group a success and a help to their fellow healthcare professionals.
“Sometimes, ‘PA’ can be confused with ‘physician assistant,’ so we call our physician advisors ‘medical directors’ and have expanded their role,” says Krawitt. “All of our PAs support utilization management, care management, and clinical documentation improvement. Each also have specific sub-specialty areas of expertise. We have a designated liaison to different departments, surgery anesthesia, OB/GYN, pediatrics, critical care, and all are on rotation on an on-call role for acute decision-making seven days a week.”
However, it is not enough for the group to be deployed into the right places or roles in the hospital. They also need to be highly respected.
“Our group has been well supported by Dartmouth-Hitchcock because we’ve demonstrated excellent return on investment that far supersedes basic compliance,” explains Krawitt.
Loukas adds their team has “spent a good amount of time building up investment and engagement with providers and building relationships with colleagues across the institution. A good team depends on how well you interact with colleagues, and being a strong part of the overall program, being transparent and accessible, problem-solvers. We help take care of their patients, and that adds a level of credibility and acceptance. It’s worth it to cultivate this.”
Of course, relatability is not the only building block. The team also needs to support the goals of the hospital and ensure excellence.
“Dr. Loukas and I have been building PA programs that support compliance and move the institution toward best practice,” notes Krawitt. “The programs pay for themselves in spades when done correctly, and truly the financial return is extraordinary for institutions. The ROI in terms of quality, reimbursement (both revenue capture and loss mitigation), [and] physician engagement has really been a model of success. It’s true that the margins that a PA can help support are mystifying.”
Physician Advisor Meets Case Manager
Of all the many relationships the PA must cultivate in the hospital setting, the connection with hospital case managers is perhaps one of the most important.
“Case managers should [meet] with PAs as much as possible,” shares Krawitt. “The PA can be their advocates for patients and a bridge between physician and patients, and case manager and physician. We’re here to support them, partner with them, and learn from them.”
Krawitt gives the example of how important it is for case managers and PAs to work together seamlessly for the benefit of the patient — and what can go wrong when they do not.
“A patient can have a perfect surgery, but still leave the hospital very disgruntled if their case management piece is not delivered successfully,” he explains. “The PA and case managers work together to smooth transitions and processes, since patient satisfaction can be highly dependent on their last few hours or days in the hospital.”
Program on a Smaller Scale
The Dartmouth-Hitchcock PA program can help inform similar pursuits at other hospitals. But how can case managers still realize the benefit of a robust PA program at a smaller hospital?
“Even smaller hospitals can look at insourcing, making an investment in a PA that works actively and has a clinical role in the hospital,” says Krawitt. “They should try to get somebody on the ground working with case managers, someone they respect, know, and trust, who’s in the trenches with them.”
Loukas adds that “utilization management nurses are the unsung heroes in hospitals,” so it makes sense that joining forces with a PA would be a brilliant move for case managers who really strive for excellence in caring for patients and helping achieve their hospital’s goals.
“Having a PA with clinical expertise to make decisions on medical necessity can be invaluable,” said Krawitt. “Then, the case manager can ensure that the patient will still get care elsewhere if there’s not medical necessity at an acute care hospital and ensure they’ll find the optimal place for that patient. This is how PAs can work with case managers and social workers to ensure the best possible outcomes for patients.”