In January 2012, I became our hospital’s first full-time physician Advisor. I was tasked with three duties: write appeal letters, do status reviews, and chair our UR committee. Having written my own job description, I also started working on processes to improve our average length of stay (ALOS) of both admissions and observations. Trying to establish an effective ALOS improvement process was initially a muddle. 

Then in March of 2012, I attended a lecture, "Multidisciplinary Rounds," presented by Dr. Howard Stein the physician Advisor at CentraState Medical Center in New Jersey, ACPA Board member, and a national expert on physician Advisor multidisciplinary rounds. It was a career changing lecture that unmuddled me. I returned to our hospital and instituted the Delaware version of Jersey rounds. 

On the RAC-Relief user group, a physician advisor asked for advice on a recurring problem in her institution concerning patients and chemotherapy at the end of life.

The patient was an elderly gentleman with two primary cancers (lymphoma and lung) who was admitted with hemoptysis and obstructive pneumonia. The patient was told by an outside facility at university cancer center that his cancer is incurable but reportedly he "wants to continue the fight." The local oncologist ordered chemotherapy. As the physician advisor, he wrote, "discussed the futility of treatment and he is adamant that it is necessary for palliative purposes. The following morning, the patient has large episode of hemoptysis, codes and after brief resuscitation and intubation, the family requests comfort care only and passes away."

Here is the advice I gave her:

We have all been faced by these situations and there are many articles written about patients getting chemo during their last moment of life. I have found it is based on the doctor's religious/philosophical/economic view of life rather than the patient's. Some docs thinks it is murder to not try anything and everything (yes, one doc called me a murderer for confronting him in a situation like this), some believe in miracles, and some just want to harm the hospital by burdening them with the costs. Universally all these cases were with doctors whose communication skills with families were poor; they never asked what the patient wants. I find the person most traumatized is the RN that cared for the patient and was forced to administer the chemo. They rank it up there with giving Dilaudid to a drug seeker as the most unsatisfying part of their job (we sure worry about patient satisfaction; maybe thinking of employee satisfaction would also be a good idea.). Of course the patient ends up getting the treatment and dying; I wait a week or so then talked to the doc about it and explained the availability of hospice and the ethics committee. (We did not have palliative care at the time.) I wanted to start the conversation with "I told you so!" but I resisted and say "things did not work out for Mrs. Smith. I hope you realize that I was being a patient and a hospital advocate and was not trying to deprive a patient of necessary care." 

And finally, some of the most rewarding experiences I have had was when I told my patients that I thought it was time to stop chemo and work on the quality of the life they have remaining. Universally, I was thanked for being the first doctor to tell them what they really wanted to hear; they were tired of "we can try one more drug" because they knew it was not going to work.

The landscape of healthcare is in the midst of significant change, most physician advisors will agree. We hear the word “unsustainable” a lot these days – whether referring to healthcare’s percentage of US GDP, patients’ co-insurance and premium increases, shrinking hospital margins, rising pharmaceutical costs, the volume of the ALJ appeals backlog, or even (not so long ago) maximum RAC ADR requests hammering hospitals’ administrative resources.

The growth in the number of physician advisors in the past 10 years has been in large part due to the “level of care” decision. Is this hospital visit an outpatient encounter, outpatient with observation service, or inpatient? In 2005, the Hospital Payment Monitoring Program published guidance that Medicare cases should be screened for proper level of care and referred for secondary physician review if there was a mismatch between the screening criteria and the ordered level of care. The usage of screening criteria and physician advisor services became widespread and commonly accepted during that decade for this and other reasons.

Those of us hoping the Centers for Medicare and Medicaid Services (CMS) would change course under the barrage of criticism of the 2-midnight rule coming from the American Medical Association, the Society of Hospital Medicine, the Medicare Payment Advisory Commission and a wide variety of industry critics (including this writer) were disappointed that the 2-midnight rule remains intact in the 2015 Outpatient Prospective Payment System (OPPS) proposed rule (CMS-1633-P).

CMS has moved responsibility for auditing short inpatient stays from the Medicare Administrative Contractors (MACs) to the Quality Improvement Organizations (QIOs). While QIOs have experience in reviewing medical necessity for hospital services (including admissions) they have done this on a limited basis. One can’t help but wonder how they will prepare for a high volume of reviews by the proposed start date of October 1, 2015. Might the quality of their work deteriorate to the level of the Recovery Auditors (RACs)? CMS has directed the QIOs to review "a sample" of cases but the proposed rule gives no clue if there will be defined limits on additional documentation requests (ADRs) and what the ADR limits might be. The QIOs will report to the RACs those hospitals with a high level of billing errors and RAC reviews will be limited to these hospitals. RAC ADR limits will vary depending on the size of the hospital, its record of billing errors, and its response to QIO education efforts.

A few years ago, I found myself spending my days and nights reviewing charts while working with highly trained interventional cardiologists, hospital compliance officers, hospital attorneys and outside counsel from around the county in order to assist in their defense in the Department of Justice's (DOJ) national investigation on implantable cardiac defibrillators (ICDs).  The focus of the investigation was the requirements for billing for the implantation of an ICD according to national coverage determination (NCD) 20.4; the DOJ was concerned that hospitals and physicians did not adequately follow the NCD requirements when billing Medicare for ICD implantation. The hospitals and physicians contended that the NCD was outdated and it would have been malpractice if they were to have followed the requirements.  The DOJ took the position that they were not attempting to direct patient care but that hospitals and physicians were noncompliant since chart documentation did not meet the Medicare criteria for coverage.  For example, some charts were lacking documentation of an ejection fraction that was less than 35% or that the patient had ventricular tachycardia but it was not clear if it was sustained or if the patient was symptomatic.  These are just two examples of potential violations from the very complex resolution model created by the DOJ for this investigation. The investigation is still ongoing. 

I also assisted in the defense of a solo practice rheumatologist who was being asked to repay almost two million dollars (including damages) because she did not document the clinical need for Remicaide adequately per the requirements of LCD 25820 for Infliximab (Remicaide).

The reason for bringing up these investigations is a rather simple one.  I wonder how many practicing physicians out there are aware of the national and local coverage determinations (NCDs and LCDs) with which they are obligated to abide?  How many physician advisors are aware of the myriad NCDs and LCDs which their hospitals need to follow in order to have a compliant billing process and the documentation physicians need to provide to ensure compliant billing? 

According to an article published online by Modern HealthCare on April 28, the Senate Finance Committee has taken note of the massive backlog of appeals of Medicare payment denials and has proposed some fixes, including separating the clinical appeals from the technical ones and sending technical appeals to the Medicare Administrative Contractor (the MAC) and clinical appeals to the Qualified Independent Contractor (the QIC).

This sounds like a good idea, but I'm dubious about continuing to rely on the QIC because it has a history of rubber stamping MAC denials - resulting in the log jam at the Administrative Law Judges (ALJs) and contributing to the high ALJ overturn rate. The behavior of the QIC itself should be scrutinized before giving it more responsibility and power. 

Senator Wyden's proposal to charge a provider a refundable fee to appeal seems to be an impediment to due process. Hospitals already have to pay for the appeal itself, which could include third party appeals contractors and legal fees. It's especially unattractive to propose such a fee when there is no penalty to the RAC, MAC, or QIC for an unjustified denial that's subsequently overturned by the ALJ.

The American College of Physician Advisors (the ACPA) is a non-profit professional organization supporting physicians who choose the newly emerging medical specialty of physician advisor. The ACPA was founded in 2014 and has grown rapidly to over 200 physician and non-physician members.

The organization’s primary goal is the enhance the realm of the physician advisor through education, mentorship, and professional leadership, while increasing the recognition by hospital administrators of the critical role physician advisors play in enhancing and protecting revenue. It plans ultimately to bring to physician advisors the recognition and status associated with a new medical specialty.

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 1000^th COVID-19 patient as a system and I would like to share highlights on how we have achieved successful outcomes.

Our COVID-19 preparations and response are guided by three critical drivers: 

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

Today I’m trying to balance a million different tasks. Today I am scheduled for the normal activities of being a physician advisor including level of care reviews, peer-to-peer calls, and discussions with staff on queries that don’t make sense. But, on top of that I’m trying to encourage my hospitalist colleagues to apply for open physician advisor FTE, finish a presentation for a national meeting that’s due, write the clinical appeal letters due in the next week, practice for another presentation I am recording next week, and attend my system level physician advisor meetings scheduled today. Oh, and of course, since I’m working from home today, I should probably cycle through some laundry and dishes and say hi to my husband and kids. When I write it all down, it sounds like chaos. Living it, it feels like “normal.”

The task that gives me the most pause today is the presentation I am supposed to give on Saturday. Saturday is the graduation retreat for our internal medicine residents, and they have asked me to come and talk to them about wellness and career longevity. Specifically, they want to know more about how coaching works and how can they use their core values to help guide them like I keep talking about? At one point in my life, if asked to speak to students or residents, I would have been very purposeful about showing students the best parts of this life in medicine. But as I have gotten older, I’ve realized that there are enough other people telling them their amazing stories of patient connections, close saves, and diagnostic prowess. Besides, those are the “easy” moments to live in a lot of ways. The wins we have in our career make us feel great and can give us a renewed sense of hope and purpose. But, those moments don’t come every day. And what I want to tell them is how to live in between those moments. How do you find joy and purpose in the everyday? How do you find the career niche that looks like chaos on the outside to everyone else but is perfect for you? How do you take the theories and put them into practice in your own life?

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….