As the director of the hospitalist service at Philadelphia's Pennsylvania Hospital, Mindi Roeser, MD, ACP Member, frequently was asked to take on administrative work that went beyond her job description. She watched the amount of time she spent on direct patient care decrease, while time devoted to utilization management, quality improvement and documentation increased.
Eventually, Dr. Roeser cut back to half time as a hospitalist in order to become the 520-bed hospital's first physician advisor (PA). As she juggled both jobs, Dr. Roeser realized that hospitalists are ideally suited to fill the increasingly necessary PA position.
“Hospitalists have become (more) involved in quality initiatives and performance improvement projects. This kind of experience is really important to a PA candidate,” Dr. Roeser said.
A physician advisor's job description typically includes varying roles as advisor, administrator and educator. They assist in triaging patients to the appropriate level of care and managing length of stay, work with care managers on patient documentation issues, and act as liaisons between their physician peers and the hospital administration. They also often participate in key hospital committees (including utilization review, recovery audit, quality improvement), review payment denials and perform second-level appeals with third-party payers, and educate physicians on issues such as admission vs. observation, documentation and payer requirements.
PAs have become more important than ever in the last decade, as Medicare has tightened up on reimbursements to hospitals. Administrators have responded by hiring more PAs to ensure care delivery is in compliance with Medicare's Conditions of Participation, and by redefining the duties of existing PAs to focus more on the utilization review process.
Why hospitalists are ideal
“The ideal PA is someone young enough to understand documentation, experienced enough to know the rules, bold enough to go toe-to-toe with surgeons, and is satisfied with stepping out of patient care completely,” said Doug Folzenlogen, MD, ACP Member, director of a hospitalist service and part-time physician advisor at Adena Medical Center in Chillicothe, Ohio. “In my opinion, hospitalists most closely fit the requirements.”
A good hospitalist also has a solid understanding of coding and is a good documenter. These same skills are critical to successfully managing denials and appeals, which is a key responsibility of most PAs, Dr. Folzenlogen added.
Since present-day hospitalists have been taught to focus on length of stay and clinical documentation, Dr. Roeser said, they also already are trained in these other relevant areas.
Both physicians noted that diplomacy and communication skills are essential to an effective physician advisor, and these skills are common among hospitalists.
“A successful hospitalist works effectively and efficiently with social workers, resource managers, attendings, residents and other subspecialists,” said Dr. Roeser. The best physician advisors will have the respect of these clinicians and the ability to communicate with them about potentially contentious issues, such as whether a patient is ready for discharge, she added.
Many hospitals, including his, would benefit from having a full-time advisor, Dr. Folzenlogen said. But physicians who have the requisite skills, and also are willing to take on full-time physician advisor duties, can be hard to find.
Indeed, Drs. Roeser and Folzenlogen both added part-time physician advising to their existing hospitalist duties when they saw a need, but declined offers to be full-time PAs.
While they liked the regular work hours that are usual for PAs (no nights or weekends), neither wanted to give up the patient contact of their hospitalist job.
“We go into this business to examine, diagnose and treat patients. The PA position is largely looking at how others are doing the job you were trained to do,” Dr. Folzenlogen said.
Others may not like the uncomfortable conversations that are a necessary part of the PA job. “Arguing with insurance companies about why they should pay you is routine,” he said. “So is talking to your own physicians about their decisions without making it sound like you are second-guessing them.” Such conversations can be more emotionally draining than taking care of critically ill patients, he added.
Some, however, are won over by the job once they have done it awhile on a part-time basis. After 35 years in internal medicine and critical care, Michael Salvatore, MD, FACP, became a part- time physician advisor for the 130-bed Beebe Medical Center in Lewes, Del. Today he does the job full time and has been a speaker at the Medicare Recovery Audit Contractor (RAC) Summit and at National Association of Physician Advisors conferences.
“Each year the audiences get bigger at these conferences,” he says. “As health care changes, the demand for physician advisors increases.”
Dr. Salvatore's focus at Beebe is utilization, quality and documentation improvement, and appeals. “It's definitely a full-time job here,” he says. At other hospitals or with different responsibilities, the job could be part-time, he believes. “If the PA's job was limited to handling denials, then it probably could be done part-time, which would be ideal for someone who wants to continue in patient care.”
For hospitalists interested in entering the physician advisor field, Dr. Salvatore recommends gaining comfort with all aspects of hospital medicine, developing a rudimentary understanding of Medicare and Medicaid policy, and joining the hospital's utilization review committee to become familiar with important issues.
“Tell the administration you'd like to assist when the current PA is unavailable,” he suggests. “There's plenty of helpful information available…meetings, webinars…to prepare for the job. The problem for most physicians is finding the time.”
For anyone who dives in to the job full time, however, there are some time and schedule benefits. “It's still a 40- to 50-hour week, but my weekends are free!” said Dr. Salvatore.