Whether clinical, regulatory, or social, we have all been touched by the COVID-19 pandemic in a multitude of ways.  With a focus at the bedside or more globally performing chart review, the enormity of morbidity and mortality witnessed within our health systems must be recognized as the profound stressor it was or still is.  

Even if no longer practicing clinically, physician advisors around the country are facing immense pressures to keep their care/utilization management, revenue cycle, and Clinical Documentation Integrity teams up-to-date.  The flip side is just as important to keep in mind – the colleagues for which we serve as champions are treading water in the persistent deluge of information.  Simply keeping track of everything we send their way via e-mails, rapid-fire huddles, and informal touch-base sessions, is a predicament.  Taking one step forward and expecting expedient integration of new information and understanding of altered processes can ultimately prove to be a bridge too far.

This month marks a first for the American College of Physician Advisors (ACPA). It’s the very first time we are using our logo to demonstrate celebration and support of a movement. That movement is Pride.

In 2014 when ACPA was formed, our logo was created by our first president, the late Dr. Ronald Rejzer. His vision intended to translate how physician advisors are at the center of the intersections of utilization management, clinical documentation integrity, compliance, and leadership. While the original version was in shades of yellow and green, a few years later it evolved into the blue and orange iteration so many have come to know. Each of the “petals” or leaves of the ACPA clover can be expanded upon to incorporate our whole scope of work.

Compliance encompasses revenue cycle, billing, and regulatory expertise. Of course, utilization review includes the Medicare Conditions of Participation, but also the incredibly strong collaborative relationship between physician advisors and their case/utilization management teams. Even clinical documentation integrity – with the “I” formerly standing for “improvement” – has grown into much more than diagnosis capture for billing’s sake, and more and more physician advisors are becoming involved with CDI initiatives and education. Leadership is a no-brainer, all you have to do is step back and take note of how many of our members produce quality educational content for the greater community month-over-month, not to mention bringing pediatric physician advisors and their specific challenges to the forefront in the last few years when previously, they were almost unheard of.

Leadership is precisely why our logo stands for more than ACPA this month. While Pride taking place in June is often attributed to the Stonewall Riots which took place on June 28, 1969, the history of Pride involves queer activism across a broad spectrum and the simple insistence since the 1950s that sexual identity should not be a catalyst for discrimination or harassment. I believe physician advisors are leaders within their health systems when it comes to advocating for quality in patient care, and equally should advocate for EQUALITY within our global community.

Make no mistake, I know this one small gesture of solidarity by the ACPA for one month out of the year is not going to change the world. My hope is to provide just one more flicker of a flame to illuminate the cause, encourage visibility, and express support for our members. If you find yourself aggravated or even incensed by our rainbow colors this month, I encourage you to reach out to me via the Contact Us section of our website. All requests for anonymity will be respected as messages will come to me secondarily without identifying information attached. Feel strongly that another movement, celebration, or cause should be similarly spotlighted by our College in the future? Let us know which one and why in the same fashion.

“When we speak we are afraid our words will not be heard or welcomed. But when we are silent, we are still afraid. So, it is better to speak.” – Audra Lorde, writer, civil rights activist, self-described “Black, lesbian, mother, warrior, poet”

"Openness may not completely disarm prejudice, but it's a good place to start." – Jason Collins, first openly gay athlete in U.S. professional sports

“History isn’t something you look back at and say it was inevitable, it happens because people make decisions that are sometimes very impulsive and of the moment, but those moments are cumulative realities.” – Marsha P. Johnson, activist for gay and transgender rights, self-identified drag queen

Starting my term as president for the American College of Physician Advisors is a somewhat surreal accomplishment.  It’s also had me feeling particularly sappy while thinking about those who have influenced or supported me along the way.  Success and achievements mean nothing if you can't help others grow into themselves.  While I begin to plan out all the ways I and the ACPA can support future healthcare leaders, I'd like to send thanks out to those who did just that for me. 

• Dennis Lynch was a social studies teacher, my varsity basketball coach at Rolling Meadows High School in Rolling Meadows, Illinois (GO MUSTANGS!), and a verifiable asshole.  He was abrasive, argumentative, rude, and stealthily taught me more than the sophomore U.S. History curriculum ever did.  While appearing to try and break my teammates and me, he succeeded in building our sense of conviction. 
  
  Denny took the chip he saw on my teenaged shoulder and pushed me to build it up into a fortress of belief in myself and my abilities.  By graduation, this “jerk” made it clear I could manage any challenging personality or nay-sayer who came my way.  One of the happiest coincidences in my life is that my mother, then an inpatient oncology nurse, found herself caring for him at the end of his life.  She asked if she could disclose his condition to me and he agreed.  It’s not often you get a second chance to tell someone how much they impacted your life.  And, as I understand it from his family, he had a huge grin on his face when I called him an asshole in my letter.  Thank you, Coach Lynch.  Thank you for encouraging me to keep my body strong and my convictions stronger in preparation for whatever life throws at me.
  
  
• The summer before starting college at the University of Illinois at Chicago, I took a job with the Public Works Department in Des Plaines, Illinois.  The job would involve mowing soccer fields, painting baseball diamond lines, weeding flower beds, and unwittingly playing a part in what was likely the first exposure to sexual harassment avoidance my co-workers ever had.  

  
  It didn’t take too long to figure out I was the first female ever to join the team.  The next couple of weeks were filled with maneuvering through subtle resentment by a dozen men who were NOT pleased about taking down the soft porn posters decorating the shop.  Looking back, I can only imagine the heroic conversations and demonstrations of understanding and cajoling my supervisor – who’s name I unfortunately can no longer recall – had to accomplish.  He was patient and kind and in retrospect, I can see he was a champion for women’s rights as a whole.  Through his efforts behind the scenes which were unseen by me, he convinced a bunch of middle-aged men to accept and even get along with a GIRL in their workplace.  This experience is just one of many which shaped me and I have him to thank for it being something I learned from instead of something I ran from.
  
  
  
  
  

(This article was originally printed by RACMonitor.com on 7/23/2020)

Dear Hospital Administrator/Provider Who Believes You Comprehend How Terrible the No-Visitor Policy Is:

Last week, I underwent a relatively minor surgery.  The podiatrist warned me on no less than three occasions – the original office appointment when decision to operate was made, in the pre-op suite, and post-op before discharge – that I would experience more pain than would be expected given the nature of the procedure.  But, I was still pretty surprised to find my prescription for Norco included 30 tablets.  Thirty!  For a simple laser excision of a less-than dime-sized lesion?

I’d also been told to take two tablets four hours after discharge and “not hesitate” to take it every four hours while awake for the next 24 hours, even if I wasn’t really having any pain.  Oh, and I could take Ibuprofen at the same time, too.  Hmmmmm….  

Just when I start to feel jaded, I’m handed a nice surprise.

Once again, I found myself performing a frustrating chart review. It involved a young patient who presented to the hospital for a scheduled outpatient procedure. The procedure took place without complication, and she recovered without incident over a few hours. She was medically ready for discharge to home but when it was time to go, she said she was scared to be home alone. The physician was called, and she requested a bed for the patient to spend the night. No IV fluids, no meds, no special precautions, she slept soundly all night. After breakfast the following morning, she headed home in her own vehicle.

Sigh….

I composed a letter to the physician via our electronic medical record. You know the drill: “Dear Dr. You’re Killing Me Softly. Please remember that patients should only be hospitalized when it is medically necessary. If a patient does not require hospitalization but expresses concern about discharging to home, please contact the case manager….” Within 15 minutes, my phone was ringing and it was the doc!

Astonished, I proceeded to have a prolonged conversation with her about the scenario and her feeling of helplessness when addressing the situation. Somehow, she genuinely had no idea that case managers were available to assist the patient with making arrangements for discharge, such as contacting friends or family or even arranging for assistance at home out-of-pocket. She expressed how she very much did not want to put the patient into the hospital overnight, but thought her hands were tied, especially with all of the health system’s focus on customer service and positive Press Ganey scores.

Going forward, that physician will hopefully avoid unnecessary hospitalizations with the new information she’s learned. Not only will there be a benefit to the hospital, but to the patient, as well. As for me, I feel re-energized knowing that when I reach out to docs, it’s not necessarily to deaf ears, and shouldn’t routinely be considered something they already know but choose not to act on.

What simple, no-brainer info do you think YOUR physicians know but just don’t put to use? Might want to take a second look at those assumptions.

Having almost reached the ripe old age of forty-four, I find myself at the opposite end of a peculiar spectrum. At the beginning of my career as a pediatric hospitalist, I knew I was at the bottom of the food chain within the revenue cycle of the hospital system. Without a routine variety of high-priced procedures and diagnostic testing to be had, and a veritable windfall of patients covered by that stellar payer, Medicaid (ILLINOIS Medicaid, at that,) it was made clear throughout residency and beyond that Pediatrics was a zero-sum game at best, when it came to financials.

But, no matter. The name of our game as pediatricians is keeping kids healthy, alleviating their fears, and getting them out of the hospital as quickly as possible if they land there. My glory was in eking out a grin from a wary toddler with my artful performance via unicorn hand puppet. Wearing novelty t-shirts depicting internal organs as characters snuggling up for a group hug was a defining character trait that some felt was problematic. But, I was unapologetic. If you hold a medical staff meeting on October 31st, expect your vice-chair of pediatrics to arrive sporting a fuzzy cat ears headband and whiskers drawn on her face. It’s that simple.

Now, as a physician advisor, my involvement with patients is indirect. I review charts for hours on end and discuss clinical scenarios with doctors, case managers, and social workers without ever laying eyes on the topic of conversation. While my concentration remains on the health and safety of the patients, there is another focus at play, which is not so easy to see as patient-centric.

Assuring compliance with the rules and regulations of governmental payers not only lacks a sense of whimsy, but can be seen as downright insensitive. When it comes to medical necessity in relation to hospital care and length of stay, the rules we need to follow are relatively clear. Custodial care in the hospital will not be reimbursed. Pursuing outpatient testing before discharge to save the patient a drive back to the hospital will result in a financial loss to the hospital. Keeping a patient hospitalized for three midnights when only one was medically necessary could lead to a huge bill for the patient from the Skilled Nursing Facility when CMS reviews the stay years later. And, “soft admissions” from the emergency department for custodial care under the guise of failure to thrive or malnutrition potentially takes a bed away from a patient who truly requires acute hospital care and management. Lamenting over what is “fair” or makes sense won’t change things. Resist the urge to be apologetic. We have to abide by the rules, and figure out the best way to care for our patients within those constraints. It’s that simple.

In my former role, some hesitated to take me seriously because of my appearance. Today, I am acutely aware of the opinion of some that I am no longer a “real doctor” because I work in an administrative role. This was expected when I exchanged a dark call room for an office with a window, but it may be jarring for some entering the field. As physician advisors, we are often the harbinger of news or assessments that no one wants to hear. We need to stay focused on the reality that many do not consider: inefficiently-operated hospitals do not remain open. And, what greater disservice could we deliver to our patients than not being available to care for them?