Now that most health systems are aware of the profound, positive impact a physician advisor can make in the case management, utilization, and clinical documentation improvement (CDI) arenas, hospitals are scrambling to find the perfect candidate. This search inevitably begins with one question: “Hire from within, or recruit an outsider?”
I have frequently heard the argument for choosing an established physician, well-rooted within the ranks of the current medical staff. The individual is usually one whom has practiced for many years or even decades in the system, is well-known by providers in multiple subspecialties, and long has been immersed in the culture of the organization. Frequently, the choice is someone who is nearing retirement, and is happy to cut down on, or move completely away from, direct patient care.
While I am sure a physician fitting this bill could become an effective physician advisor, I strongly support the opposite end of the spectrum. With full disclosure – I am a physician advisor “foreign” to my adopted health system – I advocate searching outside the walls of your organization’s hospitals and clinics for your perfect match.
While clearly in place for a number of years now, many of the rules and regulations established by the Centers for Medicare and Medicaid Services (CMS) are still confounding and confusing to practicioners and administrators alike. Add to this the fact that new rules are issued and old rules are altered on a regular basis, and you are faced with an educational challenge that can seem unsurmountable. Clinicians clearly do not need to be line-by-line experts in CMS rule, but it is imperative they understand the basic tenants of appropriate status, medical necessity, and progression of care.
Similarly, the complex work of your system’s CDI and coding experts does not need to be intricately understood by your providers, many of whom still may be reeling from the change last year to ICD-10. But, the foundation of the work, the critical importance of the impact spread from quality reporting measures to denials management and reimbursement, must be appreciated and supported. With ever-increasing pressure on providers to see more patients faster while fostering positive patient satisfaction scores, utilizing “codeable” terminology in their documentation can easily fall to the bottom of the barrel of responsibilities, and even be ignored all-together.
Whether spearheading a new effort or continuing to guide down an established path, the conversations, spirited debates, written communications, and empathetic counseling required not only for the medical staff but also nursing, case management, social work, and administration at all levels, demands a hardy soul. Much of the information which needs to be shared, understood, and complied with will be met with incredulity, exasperation, and even anger. I believe there is no time for re-working oneself into the minds of others as an administrative expert in these frustrating rules as opposed to a sympathetic peer who REALLY agrees it’s all baloney. Similarly, while an established physician may have good intentions, I think it would be quite difficult for “one of the gals/guys” to remove themselves enough to adequately present and enforce the points necessary – knowing that the result will likely end in bad feelings and possibly even the end of some friendships.
An outsider has no such attachments to protect or fret over. While it is key to have a physician advisor in place to effectively confer with and share information as a peer to the medical staff, coming in as an “unknown” has distinct advantages given the lack of history or social ties. We can be as blunt, straight-forward, and strong-willed as we need to be. We can also bring in an element of humility, irreverence, and humor to our interactions which might be hard to find in a long-standing, highly-respected member of the established medical community.
I have personally experienced variations in testing of my mettle by physicians and physician groups within my new organization in the two-and-a-half years since I joined. As a health system which has a strong history of maintaining providers on staff from their post-residency years through retirement, my appearance on the scene not only as a newbie, but a newbie in a brand new role, was an anomaly. Making the rounds, introducing not only myself, but also the concept of “physician advisor” was met with gradations of welcome, suspicion, excited interest, and attempts at intimidation. I learned that when you start a professional relationship without a history, you can immediately set the mold into what you need it to be. Right from the start, I knew those who demonstrated the most push-back needed my guidance and direction more than any others. I also quickly learned who my true allies were, fellow believers in the work that needed to be accomplished, despite not completely understanding all that needed to be done. Starting with a clean slate, these relationships readily became apparent. Coming into the role with long-established customs and pre-set manners of interaction would have been yet another hurdle to overcome before the real work could be accomplished.
The physician advisor role is a rapidly-evolving and brash new organism with roots set down two decades (or so) ago and branches that show no sign of slowing down their spread. It is imperative for your health system to secure one and set to work if you have not already. I encourage you to resist the safe option of hiring a known pillar of the medical staff from within. Instead, broaden your search, extend your reach, and catch an intrepid doc who’s not afraid to ruffle a few feathers and set blaze to a new trail.
Juliet B. Ugarte Hopkins, MD, CHCQM