By Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM 

A hospital cannot survive in today’s health care environment without a strong physician advisor (PA). This highly skilled professional must have competence in a diverse set of skills which includes; broad based clinical knowledge, understanding of regulatory compliance mandates, and how clinical documentation is directly related to coding and billing integrity.

PAs must also demonstrate skills in communication, diplomacy, finance, empathy, respect, and humility. Very few job descriptions contain the education, experience, and expertise required by physician advisors.

PAs have been colleagues in my practice of case management for the past 23 years. In my early years as a hospital case manager, I recall sitting for an hour every month with my first physician advisor and a stack of charts. We reviewed our denial letters from the payers and reviewed the charts making joint decisions about whether our hospital would appeal the denial, or that we agreed with the payer and would not appeal the case. This excellent physician rounded with our case managers and reviewed charts of current patients that the case managers felt could be discharged safely, and if he agreed he would have the crucial conversation with the attending physician. This was no small feat in the days when attending physicians and surgeons ruled the hospital and the case managers held little if any sway. Even this rudimentary model of the physician advisor’s role required the knowledge, temperament, and political finesse that was not taught in medical or business school. 

Our model of case management at the time was one I don’t currently promote because it included case managers taking on additional and necessary work primarily because “they were already in the chart.” This work included continuous documentation improvement and quality chart audits, which included audits of physicians’ penmanship (really). Our PA supported our work and, as we learned new skills, he also learned and continuously provided the backup we needed to be effective. Our outcome measures, at the time, were minimal but consistent with today’s throughput benchmark, in that length of stay was a benchmark that needed to be met. 

The PAs I have worked with recently are certainly more technologically savvy and can and do avail themselves of the many educational programs available to them to advance their knowledge. However, in my view the key elements of a successful physician advisor have not changed.

PAs are agents for change. While performing a myriad of duties for the hospital, PAs are out in front leading the hospital through the ever-present transformation of health care. This requires diplomacy, as well as tact. The PA may run interdisciplinary rounds, act as the representative for the case managers at the executive level, run the Utilization Management Meetings, and act as a liaison between the hospital president, chief medical officer, and the chief financial officer (CMM, 2016).

PAs have a broad clinical knowledge base. Hospitalists and pulmonary/critical care physicians are ideal candidates for the role because they are knowledgeable about many different disease states and they are comfortable discussing these conditions with other physicians (Huff, Fee, Clesi, et al, 2014). Clinical conditions that can safely be treated at a lower level of care continue to increase and the physician advisor can inform her colleagues of the detailed plan for care coordination developed by the case manager and the interdisciplinary team. Conversely, if there is a subtle change in the clinical picture such as a drop in HCO3 or a change in vitals that the case manager did not detect, the PA can advocate for additional hospital time for the patient and teach the case manager and other team members why this is necessary. 

PAs are excellent communicators. The ability to interact with all members of the health care team, sometimes even the patient, is essential. The rationale for decisions must be explained succinctly and accurately. The ability to persuade an insurance company to provide a needed benefit for a patient can impact the course of that patient’s recovery. The conversation with an attending physician as to why it is not acceptable to keep the patient longer in the acute care setting, is equally important as the conversation with the insurance PA as to why another patient needs to stay longer in the acute care hospital. 

PAs are collaborators. They quickly learn the team dynamics and the strengths of the case managers. Inherent in the collaborative work between the PA and the case managers is a bond of trust. This is essential to achieve the environment of continuous improvement that the PA fosters.

PAs are available. Allowing for a full and effective coverage of the PA is often missed when hospitals plan and budget for one or a team of PAs. In addition to providing back up when he or she is out, the PA must be available to answer questions about compliance concerns, such as Condition Code 44 or addressing issues of patients’ status. The PA needs to be available to ensure discharges, when appropriate, actually occur. And available to discuss a case with an attending physician, or an insurance physician, and to maintain continuous process improvement for care coordination managed through case management.

It has been my privilege to work with dedicated, committed, and innovative PAs over the past 23 years. Their focus is not exclusively compliance, documentation, utilization management, and revenue cycle; On the forefront of their practice are patients and how to better serve them in the right place, with the right care, and at the right time.