Podcast: Requirements for a Successful Physician Advisor Program

Kevin Butler:

Welcome to another edition of our ongoing Optum podcast series on hospital utilization review. Today, we'll be discussing how a well supported physician advisor program can help hospitals recover from COVID-19. I am Kevin Butler, Product Marketing Manager for Optum. With me today is Dr. Kurt Hopfensperger, Vice President of Provider Relations and Education at Optum, and a former physician advisor. Welcome, Kurt.

Dr. Kurt Hopfensperger:

Well, thank you, Kevin.

Kevin Butler:

So Kurt, from your conversations with client hospitals, how did COVID-19 affect hospital revenue integrity?

Dr. Kurt Hopfensperger:

COVID affected hospitals in several ways. Before there was the initial surge of COVID cases, hospitals already began limiting their elective admissions because they had to prepare for distancing of patients and staff, they had to prepare for respiratory isolation, they had to educate their staff on this new infection and they had to plan for possible increases in capacity. But these elective admissions included surgeries, which tend to produce more revenue than medical admissions and when COVID cases started to spike, a lot of hospitals continued this reduction in non COVID admissions.

Dr. Kurt Hopfensperger:

Another factor was that patients also seemed to believe that visiting a hospital would increase their chances of contracting COVID and that further limited hospital admissions, even emergency room visits, for common medical and surgical problems, and patients also delayed elective surgeries on their own. This summer, the emergency seemed to lessen and some hospitals, however, still remain cautious and they only slowly resumed elective surgical procedures. Now in the fall, we're seeing another rise in cases and we're again, seeing elective surgical volumes dropping in many states.

Kevin Butler:

Hospitals have taken, in some cases, a very aggressive approach toward responding to COVID-19. We've seen the increase in telehealth, we've seen some shifts in how hospitals are handling their basic operations. As hospitals cope with the financial consequence of COVID-19, have they overlooked any solutions?

Dr. Kurt Hopfensperger:

Well, if admissions and particularly these high revenue elective surgery admissions, are down because of COVID, I think it's critical that hospitals continue to make sure they're receiving correct reimbursement for the existing admissions and continue to contain costs. That requires, as you can imagine, correct coding and billing and requires a high-functioning and efficient utilization review program. I know from talking with a lot of hospitals that they've furloughed some of their utilization review staff as patient volumes declined, but I would exercise caution not to cut too far.

Dr. Kurt Hopfensperger:

Hospitals still are facing a lot of challenges with commercial denials and length of stay challenges, readmissions, discharge planning and some hospitals struggled to address these pre-COVID, often because they didn't have enough utilization review or case management personnel. So if a hospital is furloughing staff purely on a proportional basis with reductions in patient volume, that means those issues, commercial denials, length of stay, et cetera, which have a significant impact on revenue, can still remain under-addressed. It almost goes without saying that applying a compliance status review process to all patients in the hospital just remains as important as it always has been I think.

Kevin Butler:

You mentioned utilization review. Can we talk a little bit about physician advisors? Now are physician advisors more or less important now in light of COVID-19?

Dr. Kurt Hopfensperger:

In my opinion, they are more important now. Let's first start with COVID-19 itself and patients presenting with COVID-19 infections. The status inpatient versus outpatient observation of some of these patients is going to be obvious. Unfortunately, a patient who presents with or develops an acute respiratory failure, there's not going to be a lot of question about that. But, we're still learning a lot about the non-respiratory aspects of COVID. For example, we're learning about some of the cardiac manifestations and neurologic manifestations and I think because of that, a lot of patients are going to require an expert review by a physician advisor to make sure that that inpatient or outpatient status is determined correctly.

Dr. Kurt Hopfensperger:

Another thing I see is that, though as UR staff may have been furloughed, those remaining UR staff are going to reach out to their physician advisors, whether they're remote or onsite at the hospital, for even more guidance and even more support.

Dr. Kurt Hopfensperger:

I've also seen reduction in some physician advisor numbers at hospitals, because some physician advisors have returned to clinical practice temporarily to help with a surge in those COVID cases. And that of course makes the remaining physician advisors more important in their roles than they were before. And I think a little bit paradoxically the reduction in patient volumes that we have seen from elective surgery and elective medical admissions being reduced, is actually probably going to expand the physician advisor's role into more of a medical director of utilization and quality rather than just being used as a resource for case reviews.

Kevin Butler:

So it sounds like physician advisors can really have a big impact on utilization review as hospitals begin to emerge from some of the challenges that they've been facing and in some cases are still facing, but I know no function operates in a vacuum. What kind of support do hospitals have to provide in order to empower their physician advisor program to really contribute meaningfully?

Dr. Kurt Hopfensperger:

That can be a challenge. Hospitals have to give their physician advisors tools so they can make their decisions based on facts rather than just basing it on personal opinion. If you just rely on individual judgment or individual physician knowledge, that's essentially a recipe for potential inconsistency. And so a physician advisor program needs to have access to a very large library of journal articles and textbooks, especially in areas outside of the specialties of those physician advisors, because they need to research risk factors and they need to provide support for those physician advisor recommendations. So if this library is available and is accessible, physician advisors then won't be spending a huge amount of time researching these issues, but this library needs to be kept constantly updated so it can really provide a fact-based foundation for those decisions, again, rather than relying on physicians to use their personal opinion of cases. And hospitals, I think also need to make sure that their physician advisors have access to current regulatory training because the regulatory environment does change fairly often.

Dr. Kurt Hopfensperger:

That would also include what are the requirements and what are the best practices for being on or chairing a utilization review committee. And this training really should come from experienced physician advisors. And it also should include practical advice on such areas as building relationships with the medical staff and building relationships with medical directors at the various payers. I think hospitals also should make sure that their physician advisors have access to all the data that they need for this oversight. For example, physician advisors need access to the hospital's pepper data and their observation rate reports and clinical breakdowns and payment data and rates of use of Condition Code 44. And what are the failure rates of their internal screening tools used by case managers such as MCG or InterQual and what is the inter-rater reliability for example of case managers and what's going on with the appeals process? Physician advisers need all that data so they can identify improvement opportunities and they can also look at trends in operations.

Dr. Kurt Hopfensperger:

And I think the final thing I want to comment on is that hospitals really need to establish from the top, the expectation that every case goes through the same process, regardless of the payer or regardless of the time of day or the day of the week. Inconsistency can lead to inaccuracy. And so hospitals need to commit to seven day a week physician adviser coverage, whether that's through an internal program or through the use of remote advisory services,

Kevin Butler:

Kurt, that sounds like quite a bit of information and quite a bit of different factors that physician advisors need to keep in mind. I would think that would be a bit overwhelming. Is there a place for artificial intelligence in empowering a physician advisor program?

Dr. Kurt Hopfensperger:

Well Kevin, I think overwhelming is a good term. I mean, some of the issues that physician advisors face, reading fatigue, having read tens of thousands of words in a medical record every single day, having to use opinion instead of having access to evidence-based medicine, potential inconsistency of reviews as we mentioned earlier, different specialties, different practice experience, different backgrounds among the physician advisors at a hospital. Sometimes there's a problem with self-denial of cases that really should be supported as inpatient. Sometimes the workload is just too high, too many cases to review, which goes along with reading fatigue and also not knowing which cases are a high priority for review. That can be a real problem as well. And physicians are people. They make mistakes occasionally even in high functioning physician advisor programs. So I think that artificial intelligence, machine learning and natural language processing can help with these problems.

Dr. Kurt Hopfensperger:

For example, machine learning can very quickly review patient records and it can stratify or score these records for inpatient likelihood based on the medical facts. And that way, physician advisors really only have to see the cases they actually need to review. They don't have to see cases where their expertise and knowledge won't really be that important. And when they do review these cases, natural language processing can really accelerate that review because it can read the case. It can apply these evidence-based medical criteria that are specifically focused on inpatient or outpatient status. And then it can highlight in the record, the important high-risk and low-risk factors for that inpatient status as well. And what we've seen actually at Optum is that it can increase review efficiency by up to 30% for physician advisors. Now it doesn't replace physician judgment, but it lightens that kind of rote drudgery work involved in reviewing cases. And I think then allows physician advisors to use their time and their knowledge more effectively.

Kevin Butler:

So Kurt, you talked about being able to support a physician advisor program. What do you see as the key benefits that hospitals can derive if they take the time and commit the effort to providing that support?

Dr. Kurt Hopfensperger:

Utilization review does a very effective job on the majority of cases in a hospital. It can correctly classify with the use of many screening tools, most cases that come into the hospital, but there is a significant minority of cases that enter a hospital that really would benefit from an expert physician advisor review. And that benefit has a lot of downstream effects. Not only can the patient status be obtained accurately, but also for example, the patient has the correct copay. They may or may not qualify appropriately for example, for a skilled nursing facility benefit. It also has effects on hospital metrics such as length of stay and mortality rates and readmission rates, et cetera. So I think a well supported physician advisor program that's operating on a base of evidence-based medicine, really fills that gap between the UR process that is driven by case managers and utilization review personnel, which of course correctly identifies most cases, and this significant minority of cases that makes such a critical difference to a hospital's financial wellbeing and their metrics, and also makes such a significant difference to patient satisfaction as well as patient copays and their financial responsibilities also.

Kevin Butler:

Well Kurt, you've given us a lot to think about. Thank you very much for joining us.

Dr. Kurt Hopfensperger:

You are welcome. Thank you, Kevin.

Kevin Butler:

And thank you to our listeners for tuning in today. Please be on the lookout for additional episodes of our podcast. Together, we can make healthcare better for everyone.