Posted: 5/13/2020
Medstar Health is a healthcare system that spans central Maryland and the District of Columbia. As Physician Advisor for MedStar Good Samaritan Hospital, I am so proud of Medstar Health and how our system of 10 hospitals has been able to manage capacity and redeploy personal and equipment during this pandemic. We recently discharged our 1000th COVID-19 patient as a system and I would like to share highlights on how we have achieved successful outcomes.
Posted: 5/06/2020
Original printed by RACMonitor.com on May 1, 2020
Posted: 4/18/2020
As I write this, we are likely in the midst of our COVID-19 peak in New Jersey. Most of the inpatients in my hospital are COVID-19 pneumonia patients with almost all available ventilators being deployed. Personal protective equipment (PPE) is very limited. The medical staff volunteers have been placed in COVID-19 teams which include a primary care doc, an infectious disease doc, and a pulmonary doc per floor. This preserves PPE and reduces risk to the physicians.
Posted: 4/07/2020
I work in a solitary community hospital in a relatively rural area of South Carolina and for us, the Covid 19 pandemic is a bit different than what people in places like New York are dealing with. It’s still stressful, just in a much different way. My family is either involved in healthcare or education, both of which are hugely impacted at this time.
With the school system shut down, our teachers are working to try to provide educational materials for the children stuck at home. Many of these children do not have families who are actively engaged in their education and food security is a major issue. My daughter got in trouble for adding healthy snacks to many of her students back packs to take home prior to this because her principal told her that she could not do it for every student so she was not allowed to do so for the ones she knew in particular were not eating except at school. Many of the children in Title One schools have limited or no access to the internet and the teachers worry on a daily basis about what is going on with their students, in many cases knowing that the parents are not following up on the work they are sending home to the students.
Most of the schools are still providing meals for pretty much anyone who shows up and says they have children. Thousands of meals are being sent home to cover breakfast and lunch. School busses are being used to set up delivery sites or in some cases, provide home delivery for many of the rural areas. Teachers across the country are finding ways to connect with their students either remotely through technology or through appropriately socially-distanced in person visits. You see examples on the news every day of teacher parades by their students’ neighborhoods, teaching from the porch through the glass door, or many other examples of trying to keep connections to their students. At least the school system has continued to pay their salaries even though they are not at school in the normal sense.
Currently, our hospital has two confirmed COVID-19 cases admitted and a few others waiting on testing, but suspected. Certainly not overwhelming the system yet but the peak in South Carolina is not expected for a few more weeks. Our current issue has nothing to do with being overwhelmed but rather the lack of volume. Current hospital census is 50% of normal with no elective surgery and an Emergency Room seeing 40% of the normal volume. Our system owns a large number of the physician practices and those are off by 30-60% depending on the type of practice. Overall, the revenue is currently down by 40% and has not bottomed yet. Outpatient revenue is down even more which has a higher profit margin so the bottom line is that there is no bottom line.
Starting next week, we will be furloughing a significant number of employees. We currently have two nursing units (64 beds) closed due to lack of volume and the remaining floors are not close to capacity. The daily news conferences from the State have people talking about how hospitals are not furloughing front line people in direct patient care roles. This may be a true statement, but they are certainly being down-staffed from one to three shifts per week. The stress of knowing that they do not have a secure income weighs heavily on the staff, adding to the concerns that they know they will be exposed and have a significant risk of carrying the infection home. Even our administrative team is taking time off without pay. With the expectation that this will likely extend into at least mid-May, our employees are very concerned about how they will pay their bills with a significant reduction in income. Many have depleted their paid time off. And, even though the hospital has agreed to advance up to 80 hours against future time, it would mean months before they actually worked off the time and they have to hope that they don’t actually get sick if, or when, we see a surge.
On a personal note, I am writing this from my home office having been exiled to work from home for two weeks now. I miss the daily interactions with the Case Management staff and even the opportunity to interact with the medical staff to discuss issues over lunch or at least to allow them to vent about what discharge planning problem we had or why the patient with no payer could not go to an inpatient rehab facility. I left clinical practice just over six years ago after doing every other night call for over thirty years as an OB/GYN to take on my current role as Medical Director of Case Management and Physician Advisor and never looked back. I have found my place in life as this has really been my dream job. I actually enjoy dealing with the payers and regulatory issues. The downside of becoming intricately involved with hospital revenue cycle is that I logically understand the necessity of adapting to the significant decline in revenue. But, at the same time, I understand the impact we have on the lives of those employees affected by the furloughs and down-staffing.
We will get through this and hopefully, months from now, will have appropriate therapeutics or vaccines to prevent a recurrence of the steps we are currently taking to slow the progress of this pandemic. Stay strong and hopefully avoid the infection. Also, remember that we expect a lot of the women and men that serve on the front lines in our facilities, often without recognition and currently perhaps without a dependable source of income. You can’t hug them but you can tell them they are appreciated. One last thought for all you physicians out there, the best comment I have heard lately was one person from one of the hard-hit areas saying what they really needed was nurses, not doctors, because nurses where the ones actually caring for the patients and all the doctors did was write orders. Maybe that is why we have nurses week and doctors day.
R. Phillip Baker, MD
Medical Director Case Management and Physician Advisor
Self Regional Healthcare
Greenwood, South Carolina
Posted: 8/24/2019
One question posed at the 2019 National Physician Advisor Conference was: “What will Physician Advisors do if the concept of Inpatient vs. Observation goes away?” R. Philip Baker, MD, Medical Director of Case Management at Self Regional Healthcare responds with his thoughts.
The role of the Physician Advisor is rapidly evolving into an integral part of the modern hospital’s armamentarium in dealing with the rapidly changing healthcare environment. Once relegated to status determination to be sure that each patient was in the correct status while in our facilities to ensure the correct reimbursement, that is now becoming a minor component of the contribution the Physician Advisor makes.
Posted: 3/17/2019
I don’t know about you, but my brain was fried by Wednesday afternoon when NPAC2019 concluded. With two hours of pre-conference sessions, 16 presentations over two-and-a-half days, six Best Practice Breakfasts each morning to choose from, AND over a half-dozen Dine with Docs dinner options, there was SO MUCH TO LEARN and so many people to meet!
Posted: 2/10/2019
A note from the blog editor: I asked one of our resident documentation experts, Dr. Erica Remer, to share what she has experienced in her career when it comes to the greatest challenges in educating physicians about their documentation, and how she successfully manages them. Here’s what she has to share!
Posted: 1/20/2019
As you all know, the venerable Dr. Steven J. Meyerson has passed his ACPA blog to me. Well…I am going to go one step further.
In 2015 and 2016, Dr. Meyerson shared his blog with guest posters from the ACPA Board of Directors and Advisory Board. Then, in 2017 and 2018, the contributions trickled away. This correlates with the development and cultivation of the ACPA monthly newsletter. There are a limited number of folks on our boards and after all, this is a volunteer, non-profit organization! All of us have primary employment keeping us busy, and there are only so many hours in the day. Whatever the reason, for virtually all of the last two years, Dr. Meyerson’s thoughts have filled this blog and we all have learned a great deal. Thank you, Steve, for your dedication!
Taking the reins this year, I am renaming this blog and opening it up to all ACPA members for submissions. Our strength does not lie within a few individuals, but in the greater collective of all of our experience and lessons learned. I 100% believe that physician advisors who have been doing this work for just a few months have terrific points to make about countless issues which we can all benefit from and consider carefully. Additionally, our field is evolving into so many nuanced iterations involving Clinical Documentation Improvement, revenue cycle, pediatrics, and even outpatient quality/utilization, it’s imperative we start hearing from those trail-blazers, as well.
JOIN ME, PEOPLE!
Don’t be shy! Type something up, any topic at all related to the work you do, any length, and send to me at [email protected] with “ACPA blog” in the subject line. Please make sure to include your name and credentials as you wish for them to appear, your title at work, and your employer. This isn’t a once-a-month thing like the newsletter, so keep checking back to see what’s new!
Posted: 1/07/2019
I’ve been writing the ACPA blog for nearly 4 years now, and it has been an honor to be able to present my musings and provide physician advisor education through this platform. I hope my readers have found my submissions a useful source of ideas and information, but now it’s time for me to pass the torch.
Posted: 10/11/2018
Opiate addiction is a serious problem that has been responsible for tens of thousands of deaths in this country. Pharmaceutical companies like Purdue, profiting from the sale of massive quantities of opiates, had launched aggressive marketing campaigns to convince physicians (like my self at the time) that opiate addiction was unlikely as long as you were treating pain and that there was no maximum dose. We were taught to increase the dose until pain was relieved. The country was flooded with oxycodone. Addicts, both self inflicted and iatrogenic, eventually lined up at “pill mills” where crooked doctors sold prescriptions for cash and many millions of doses disappeared into the black market.
Posted: 9/21/2018
As readers of this blog may be aware, I have written from time to time on the proper use and the abuse of InterQual (IQ) and MCG admission criteria, which assist in determining when a hospitalized patient should be placed in an outpatient observation bed or when the patient should be admitted as an inpatient. This is an important issue for several reasons: Since nearly every U.S. hospital utilizes one of these two proprietary products, it’s important that they use their tools correctly. Confusion about status can result in improper billing, which can in turn lead to denials, recoupments of previous payments, and the additional cost of rebilling. In some cases, denials come after the window for rebilling has expired and the hospital gets paid little to nothing for the services it provided.
Posted: 8/25/2018
I never really understood how my “square peg” of work as a geriatrician was supposed to fit into the “round hole” of evaluation and management (E/M) CPT coding with its five levels each of new and follow up office visits and detailed lists of elements that had to be in the record to justify each level of billing.
Posted: 7/26/2018
I have written several articles on one of my pet peeves (and likely one of yours): the manner in which some managed care and government reviewers deny inpatient admission/payment based on failure to meet screening criteria while failing to allow secondary review by a physician to override objective criteria.
Posted: 6/06/2018
On May 30, President Trump signed into law the bipartisan “Right to Try Act” which offers people with advanced and terminal illnesses who have failed all available treatments to have access to experimental drugs that might help if the drugs have passed Phase 1 FDA trials. 40 states have enacted similar laws. The federal law expands access to those people living in the 10 states that haven’t passed such laws, but does not add much else that’s new.
Posted: 4/24/2018
One of the many complaints physician advisors have about managed care organizations (MCOs) is payment denials based on inappropriate use of admission screening criteria.
Posted: 3/20/2018
Managed Medicaid plans in Maryland (including Amerigroup, Jai Medical, Priority Partners, UHC MCO, and Maryland Physicians Care) have been denying payment to hospitals for emergency department (ED) treatment of minor medical emergencies. And on March 15, NBC Nightly News reported that Anthem/Blue Cross Blue Shield is doing the same under its new “avoidable emergency room” policy in 6 states: New Hampshire, Missouri, Kentucky, Georgia, Indiana, and Ohio – “ and this could expand.” But if patients are not to go to EDs unless they are having a “true emergency,” NBC anchor, Lester Holt, asked, “How are they to know?”
Posted: 2/10/2018
In an article in the February ACPA Newsletter, Drs. Hirsch and Banker debate (to over simplify a bit) whether total knee replacement (TKR) should be performed as outpatient and admitted only if they require a second midnight of hospital care (Dr. Banker) or whether the Centers for Medicare and Medicaid Services (CMS) has granted more leeway in admitting these patients compared to other outpatient surgery based on comorbidities and the expectation of the need for post-operative skilled nursing care (Dr. Hirsch).
Posted: 3/01/2018
Having listened to the recording of the February 26, 2018 Open Door Forum (ODF) (I was unable to listen live) several issues remain unresolved.
Posted: 11/03/2017
he Centers for Medicare and Medicaid Services (CSM) has taken total knee arthroplasty (TKA or total hip replacement) off its Inpatient Only List (IOL) effective January 1, 2018.
For those who don’t know, the Inpatient Only List is a list CMS publishes of operations and procedures that must be performed while the patient is an inpatient at a hospital. Those procedures not on the list should be performed in an outpatient setting (outpatient hospital or free standing surgical center) unless admission can be justified under Medicare’s admission regulations.
Orthopedic surgeons have frequently kept their TKA patients for 2 nights after surgery as a routine practice and this wasn’t a problem when all TKAs were done as inpatients. But patients having outpatient surgery are expected to leave before the second midnight. If they stay longer, they should be admitted when there is an acute clinical reason (such as a complication of surgery) for keeping them a second night. This wouldn’t apply if the second night was for convenience; they would remain outpatients.
There has been a lot of chatter on the list-serves about how hospitals and physicians should react to this change. Some of this consternation seems to be a kind of shock triggered by such a seismic change, but we must remember that above all we are required to abide by Medicare regulations as best we can interpret and follow them.
The solution is actually rather straight forward: Under this new rule, TKA should be treated like any other outpatient surgery from a status and billing perspective. In other words, the procedure should be performed as an outpatient unless the physician can justify and document an expectation of a 2-midnight stay or a second night in the hospital is actually needed.
What about patients with multiple comorbidities who are at higher risk of complications? Sorry. Having comorbidities doesn’t qualify for admission unless the comorbidities are causing a recovery that is more complicated than usual and that a specific issue related to that comorbidity prevents safe release from the hospital. In some cases, however the surgeon can admit if there’s a documented treatment plan that encompasses 2 midnights of medically necessary post op hospital care. That’s exactly the way it is for all outpatient surgeries.
In the case of TKR, for those surgeons who don’t believe their patients are ready for discharge before the second midnight, I think it would justify admission if the surgeon documented that the patient "hasn’t sufficiently recovered from surgery to be managed at home because of…" pain, nausea, inability to ambulate, need for nursing monitoring of X, etc. These may not be “inpatient diagnoses” per se but they would explain why a surgeon believed that a post op patient “isn’t ready to go home" and that they have admitted the patient because they “require a second night of post operative care in the hospital.” I don’t know if that would fly with auditors, but hopefully it’s the truth - and the that docs won’t abuse such a tool to continue with their old ways.
For those post ops who are ready to jump out of bed, congratulations, they should be out before the second midnight and would remain outpatients.
The principle, as always, is "Do the right thing for the patient."
Posted: 10/13/2017
It all started with emergency department (ED) patients who couldn’t be fully evaluated within the usually brief ED time frame. With full waiting rooms and open front doors, hospitals had to make room for new emergency patients, often by moving those still being evaluated to another location. Before the days of observation units these patients were typically placed in “holding areas” or med/surg beds as outpatients mingled with inpatients, where their “ED evaluation” continued, but now at the pace of an inpatient rather than the frenetic pace of the ED. The Centers for Medicare and Medicaid Services (CMS) defined this as “observation care” but initially did not reimburse for it. Lacking the ability to be paid for room and board for outpatients in beds, hospitals could bill Medicare Part B for diagnostics and other Part B services but had to swallow the cost of providing outpatient bedded hospital care outside the ED.
