Evolution of the Physician Advisor: A Current Perspective

The value added by physician advisors was recognized as both regulatory and financial.

Recently, I was prompted to recall how many years I have worked as a physician advisor, as well as the number and types of reviews performed over those years. Engaging in this exercise made me think about my journey as a physician advisor, and where I see the road leading in the future.

In earlier years, as a hospitalist with an inclination toward utilization management, I was often asked to justify hospitalizations from a level-of-care standpoint, answering questions such as “How sick is the patient?” and/or “What types of interventions are needed/being employed to stabilize the patient?” Through initial incarnations of the “peer to peer,” I often negotiated continued coverage for a hospital stay with insurance medical directors at the nursing station. Notably, as I had these in-hospital debates, many of my colleagues were also having the same debates with the Recovery Audit Contractors (RACs).

Then, in 2013, we entered the era of the two-midnight rule. Understanding the rule became its own advanced curriculum course. The discussion shifted from focus on level of care to a refocus on the provision of hospital services crossing over two midnights. Defining medical necessity for hospital services became a sticking point to debate. After all, what you feel is medically necessary may differ from what I feel is medically necessary, especially when considering clinical backgrounds and regional standards of care. Nonetheless, physician judgment, with all of its complex considerations, remained a primary determinant for the Centers for Medicare & Medicaid Services (CMS).

A triad of physician judgment, hospital services, and two midnights ultimately provided structure for the two-midnight rule. Unfortunately, despite years of discussions, debates, and clarifying documents, the rule is still misunderstood within certain circles. We know this is even a problem with government contractors adjudicating according to pre-rule practices.

As a consequence, the role of the physician advisor itself became solidified in healthcare institutions. The physician advisor was the subject-matter expert employed to guide utilization management (UM) departments toward finding the most appropriate status determination for a hospital encounter, “as soon as possible and as much as possible.” Whether in-house or from an outside agency, health systems sought physician advisor expertise to reduce their audit risk, in addition to defending against denials. Value added by physician advisors was recognized as both regulatory and financial.

Not long after the advent of the two-midnight rule, we began to witness the rapid growth of managed care plans. Those occasional discussions with payors’ medical directors at the nursing station were now regular occurrences, in the context of increasing payor denials. The peer-to-peer review became a showdown of sorts, between provider and payor. And in many cases, the physician advisor was the best “contender” to represent the hospital in this proverbial ring of debate. The physician advisor could prepare the merits of a hospitalization, reference evidence-based criteria used by the payor, and engage in arbitrarily timed discussions more readily than the busy clinician actively rounding on hospitalized patients. Undoubtedly, use of the physician advisor in this capacity resulted in improved reimbursements from overturned denials.

Over the years, the physician advisor, who had become a regulatory and revenue integrity force with whom to be reckoned, had now become a clinical documentation integrity/improvement (CDI) champion as well. There was natural alignment between the physician advisor and the CDI specialist. Clinical documentation impacts a variety of hospital metrics, from quality to status determinations. Terms such as case mix index, diagnosis-related groups, geometric mean length of stay, and more have been added to the physician advisor vernacular and fund of knowledge.

More broadly, the physician advisor also began to play a role in the hospital continuum of care for a patient, and the larger scope of population health. Serving as a liaison between medical staff and the C-suite, the physician advisor in many institutions has also become a physician leader, if not an executive leader. I see examples all the time of a physician advisor becoming a chief medical officer (CMO), and/or a CMO functioning as a physician advisor.

The rich history and evolution of the physician advisor role is why it was important for the American College of Physician Advisors (ACPA) and our National Physician Advisor Conference (NPAC) team to choose the theme “Exploring the Spectrum: Leadership through Collaboration and Diversification” for NPAC 2022.

Physician advisors continue to rapidly grow and diversify through a variety of collaborative efforts. NPAC 2022 categories for presentation include Professional Leadership, Regulatory and Financial Strategy, CDI, Pediatrics, and, now, Evolving Roles for the Physician Advisor. Much like pediatrics has become a physician advisor area of specialty, we expect the same to happen for other areas, such as behavioral health, pharmacy, and more.

The future is bright for the physician advisor, and I hope everyone will join us in Austin, Texas from April 11-13, to look through the prism and explore the spectrum together at NPAC 2022.