To be a full-time physician advisor, an individual must give up their regular clinical medical practice.
When I became a physician advisor at Sherman Hospital in Elgin, Ill. in 2006, I was in practice as an internist and HIV specialist, along with six other physicians. We were our own corporation, and each of us equally covered all costs and shared revenue, as allowed by law.
The hospital administration asked me to serve as an independent contractor and work 10 hours per week as the physician advisor. To avoid any Stark Law violations, I kept a time sheet to prove I logged 10 hours per week of work. I made this work by starting early in my office, seeing my first patient at 8 a.m. instead of 9 a.m. like my partners. I then extended my lunch break and raced to the hospital during that time on Monday, Wednesday, and Thursday, and spent Friday afternoon at the hospital. Add that all up and it was 10 hours. It also allowed me to maintain my private practice patient volume and cover my share of expenses.
But the truth was that I worked a lot more than 10 hours. I got paged and emailed by case managers when seeing patients in my office, and answered their calls between patients. I wrote appeal letters on nights and weekends. And I will admit that I frequently checked the hospital census and read histories and physicals (H&Ps) and progress notes to ensure that patients were placed in the right admission status – and that there was documentation of medical necessity for ongoing hospital care, even when I was on vacation. When elements were missing, I contacted the case manager or physician and intervened. When rumblings started that the U.S. Department of Justice (DOJ) was looking into the medical necessity and admission status of implantable defibrillators, I spent a few weekends researching and developed a checklist for our electrophysiologists to use, to ensure we got it right.
But being in the early years of physician advisors, there was no professional society, as there is now with the American College of Physician Advisors (ACPA), with which to network and determine how many hours a physician advisor should work – and what duties they should have. So, I did what doctors often do: I took on all the duties that were asked of me, and I simply made it work.
Fast forward to today. Hospitals now recognize the value of physician advisors in the myriad of ways they can help, beyond determining admission status, now including length-of-stay optimization, clinical documentation, quality of care, readmission reduction, and so on. And with those extra duties comes the need for more than just a quarter-time physician for a 250-bed hospital. As a result, many hospitals are hiring physician advisors as full-time employees.
But in order to be a full-time physician advisor, an individual must give up their regular clinical medical practice. And that brings up the next dilemma: should the physician continue to work a shift or two a month, both to keep up their clinical skills and to maintain credibility with the medical staff? Some contend that once a physician advisor stops providing patient care, they become “just another administrator,” and cannot possibly be trusted. If the doctors see the physician advisor taking a shift as a hospitalist or in the emergency department, they will know the physician advisor is still “one of us,” and will listen to recommendations on status and documentation.
While that reasoning may have some validity, when I was offered a full-time position, I decided that it was not fair to my patients to continue working only one or two days a month. I would not be there for their illnesses, or when they needed health advice. I would have to relegate most of their care to other physicians, and would never want to be forced to choose which patients I “would allow” to continue seeing me. I still miss my patients.
But another issue needs to be addressed. Can a physician who only provides medical care a few hours a month maintain their competency as a practicing physician? Can a physician who works two hospitalist shifts a month assess and treat severe COVID-19 pneumonia as well as their full-time colleagues? How much time must be devoted to direct patient care to maintain one’s skills?
In a recent article in JAMA Internal Medicine, one of those questions was addressed. In a cross-sectional study of Medicare patients, using statistical methods that I probably learned in medical school but forgot, the authors found that physicians who worked fewer days as hospitalists per year had a statistically higher patient mortality rate than those who worked more days.
Now, to be clear, this one study does not mean that physician advisors should not continue to provide patient care. Although they controlled for many variables, the study does not control for all variables – but it does suggest that there is more to the discussion than simply wanting to maintain credibility with the medical staff. Perhaps there is a threshold amount of direct patient care that must be provided to maintain one’s skills and not result in an increase in adverse outcomes. The study also only looked at hospitalists broadly and made no attempt to assess clinical competence of physicians who perform procedures. Does a cardiologist who only performs cardiac interventions once a month have outcomes equal to the cardiologist who does them regularly? Certainly, there is no limit on what kind of doctor can become a physician advisor, with many pathologists, radiologists, cardiologists, and others excelling in the role.
There is also no data at all to demonstrate that a physician advisor who is not practicing clinically cannot maintain their credibility by keeping up to date on medical advances, maintaining their board certifications, and most importantly, maintaining collegial relationships with their colleagues. In the “old days,” if you were not taking calls and staying up for 36 straight hours, you were not part of the club. But fortunately, those days are long gone. In fact, a physician advisor can maintain credibility in other ways: offering education to physicians to help them avoid having their claims denied, developing forms and templates to help them with some of the mundane tasks, dealing with the insurance companies trying to deny their admissions, helping with developing continuity of care programs so their patients have better outcomes, and many other methods.
The decision to keep seeing patients while being a physician advisor is complex. If this data is correct, perhaps hospitals should always go all-in, and only use full-time physician advisors. Or perhaps hospitals should divide the duties up among several physicians so that each maintains a large enough clinical practice to remain competent while also having enough time to adequately perform their physician advisor duties.
As with many scenarios encountered every day in the life of a physician advisor, the answer to whether a physician advisor should continue seeing patients is: “it depends.”
Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic.