Podcast: What makes an effective physician advisor?

Steve Wright:

Welcome to another edition of our ongoing Optum360 podcast series, on topics related to hospital utilization review. I'm Steve Wright, I'm marketing director at Optum360. Our podcast today is about what makes an effective physician advisor. Physician advisors have such a significant impact on medical necessity and inappropriate reimbursement for hospitals. It's imperative you pick the right individual for this role and provide them with the proper tools to be most effective. I'm joined today by my colleague, Dr. Kurt Hopfensperger, who is a former physician advisor and is one of our subject matter experts, who helps develop successful physician advisor programs. Welcome, Kurt.

Kurt Hopfensperger:

Thanks Steve. Glad to be here once again.

Steve Wright:

Okay, so starting out, what specialties are appropriate as background experience for a physician advisor?

Kurt Hopfensperger:

Steve, I think I'm going to answer that from a little different perspective. I think that training and hospital experience are more important than specialty. A physician advisor should have significant expertise in the appropriate regulations, commercial payer policies, government and commercial appeals processes, and medical necessity documentation among other topics. Typically, a physician advisor will review cases in almost every area of clinical medicine, surgery, neurosurgery, orthopedics, pediatrics, OB/GYN, general medicine, et cetera. So, there is no medical specialty which by itself can prepare one for the physician advisor role. But having said that, probably the most common specialties in the role are internal medicine, family practice, emergency medicine, pediatrics, and general surgery. However, in my experience, superb physician advisers can be developed from almost every specialty.

Steve Wright:

Okay, Kurt. So, knowledge of things like regulations and payer policies gives a new physician advisor a leg up, but what personality traits are important so that provider organizations pick the right individual for that role?

Kurt Hopfensperger:

Once in a while a hospital might have a special situation with their medical staff or their other staff in which a very forceful aggressive personality is the best fit. But in general, most successful physician advisers have a high capacity for listening, reserving judgment until the entire argument has been made, and gentle persuasion. It's important to cultivate a relationship with the medical and the case management staff in which the advisor is seen as an expert, a coach, a mentor, and most importantly as a team member with the same interests as everyone else. That is putting patients in the correct status benefits everyone. And it goes without saying that excellent communication skills are necessary as well.

Steve Wright:

As you know, most people associate physician advisers with medical necessity case reviews, but can you talk a little bit about the breadth of duties a typical physician advisor can handle?

Kurt Hopfensperger:

The core of the physician advisor position is indeed reviewing the records of patients in the hospital shortly after they present, and making a recommendation about the patient's status. Depending on the hospital though, this role often expands to peer discussions with payer medical directors, hospital rounds, case management rounds, managing the appeals process, coaching physicians regarding medical necessity documentation and giving educational presentations to the medical staff. And beyond that, some physician advisors also work with the clinical documentation improvement department, engage in focused internal record audits, and many are involved with length of stay management projects. Physician advisors ultimately can help in almost any area of hospital operations. For example, we've had advisors identify and help remove barriers to timely discharge from the emergency room, and we've had advisors provide input to the commercial payer contracting process.

Steve Wright:

So, now we understand the breadth of what a physician advisor can do, but Kurt, what's the reality of how thin you can spread a physician advisors duties?

Kurt Hopfensperger:

It's very difficult to put a metric or a benchmark on how much physician advisor time any particular hospital needs. For example, you might hear a figure such as one advisor for every 200 beds, or one advisor for a certain amount of average daily census or discharges per month, and so on as good guides for this. But those estimates I believe are based on a narrow view of the advisor's role. It's been a pretty rare occurrence to find a hospital that feels it's overstaffed in the physician advisor department. The usual challenge is finding more time for existing advisors to help with additional areas. And actually artificial intelligence can be used to help address physician advisors time constraints by helping them read and analyze those patient records more quickly. But the very core minimal physician advisor responsibility should be the review of every patient in the hospital who's going to be in house for a significant time, say, at least one midnight, and whose case has failed inpatient screening by the case managers or by artificial intelligence tools.

Steve Wright:

So Kurt, if physician advisors are challenged to cover a lot of responsibility and case volumes, can you expand a little bit more on what types of tools a physician advisor needs to be most effective?

Kurt Hopfensperger:

Well, Steve, as I mentioned before, I don't think specialty and experience are the complete package. No matter how experienced a medicine physician is, for example, they perhaps haven't dealt with subtle complications of certain neurosurgical procedures, or know the risk probabilities of an adverse event given an intraoperative finding in those procedures. Nor can any physician keep up to date in research for dozens of medical and surgical specialties. And it would be a very uncommon hospital to have access to hundreds of journals, and also employ a dedicated full time research team to help their physician advisor with making the appropriate recommendations, based on that huge body of medical literature. If that medical research can be made available to a physician advisor in a simple time effective way, it pretty much instantly can improve their performance.

Kurt Hopfensperger:

Lastly, physician advisors need to take into account the real world results of both government audits and commercial denials, along with the final results of both appeals processes. That's where training and ongoing support come in. A physician advisor needs resources to provide regular training on government regulations and payer policies, so that he or she can fully understand how to impact compliance and proper reimbursement for the hospital. Also, as I mentioned, having access to a curated library of evidence based medicine focused on appropriate factors, not for diagnosis or treatment, but for patient status recommendations is important as well. Don't have physician advisors reviewing cases in which their expert professional opinion isn't necessary. Utilize sorting tools based on artificial intelligence to help decide which cases truly need a physician advisors time. That is what will make a physician advisor most effective.

Steve Wright:

That's great advice Kurt. Any final thoughts on finding the right physician advisor given that clinical shortages are happening?

Kurt Hopfensperger:

Well, it definitely can be quite a challenge to find physicians who have both the personality and the communication skills for the position. And who also have an interest in utilization review and an interest in learning a large amount of what might at first brush appear to be akin regulations and rules. On top of that seven day a week coverage along with holidays, is important because otherwise a hospital really has two utilization review process with undoubtedly different outcomes. One for when you have a physician advisor and one for when the physician advisor has gone. Finding appropriate training for physician advisers is also difficult, and losing one or two advisors to retirement, or change in hospitalist contracts, or leaving for other opportunities, or perhaps even just ineffectiveness, can really set back a utilization review program. A lot of hospitals hand off all of those burdens to remote physician advisor service companies, or they will arrange to have a physician advisor service company actually place one of their own advisors on site at the hospital.

Steve Wright:

So, Kurt, to summarize, it seems like physician advisors have a really challenging job, but the good news is, with some training and technology you can develop physician advisors to be very effective.

Kurt Hopfensperger:

Yes, that's right, Steve.

Steve Wright:

Well, that's all the time we have for today. Thanks, Kurt, for sharing your views and expertise, and I hope this has been helpful for our listeners. Please be on the lookout for additional episodes of our podcast and thanks to our listeners for their commitment to make healthcare better for everyone.