Rural Hospitals: The Role of Physician Advisors When Help is Needed Most

Most rural hospitals do not have physician advisors but clearly need them.

Last week RACmonitor published an article written by John K. Hall, MD, JD, MBA, FCLM, FRCPC, titled “Rural Hospitals: Here Today. Here Tomorrow?” In this article he summarized the challenges existing today for these rural hospitals. He went through what the last few years have been like for them, and concluded that the fate of these hospitals looks grim, and the fate of their communities looks grave.

Over the past several months I have had the opportunity—and, in my mind, the honor—to work with two critical access hospitals in northeastern Indiana as a physician advisor. As I am finding out, most rural hospitals do not have physician advisors, but clearly need them.

Shoestring budgets may not allow them this opportunity and many of these hospitals are seen as fodder to bigger hospitals and hospital systems as they seek to acquire them to garner more patients to their fold. The intention of these smaller hospitals is to remain independent.

But it is a struggle.

Many of these hospitals, including one of the two that I work with, are county hospitals and the nearest healthcare facility for these rural areas. As we also know, the health of these rural area populations is poor. In addition, processes, especially utilization review (UR), may be broken, and become the focus of multiple denials from payers, significantly affecting finances. Many of these hospitals have dedicated, loyal staff and physicians and have recruited high-quality executives with larger hospital background and experience.

What’s it like to work with a critical access hospital? There is only one word that describes it for me is rewarding. As you may or may not know, there are certain metrics imposed on hospitals with this designation by Medicare, such as maximum census of 25, and average annual inpatient stays of no greater than 96 hours. As a physician advisor, most of the work is on the UR side, and there is much to be done there.

One project in particular has been to reduce the number of observation stays to 48 hours or less. Upon starting at these facilities, many observation stays were as high as 75 hours and more. Through the daily UR staff huddle, reviewing all observation cases, UR and physician education, Two-Midnight rule education, and much needed second level reviews, we have seen a more appropriate level of care determinations. Although we are early in the process improvements, we are starting to see these greater than 48-hour observations decrease. It’s a slow but positive result.

The last area to present here is a better denials management program as I help with peer-to-peers and written appeals. The payers are learning quickly that they don’t have such a big upper hand in bullying these rural hospitals.

In summary, I would implore rural and critical access hospitals to look closely at utilizing physician advisors. The initial investment will clearly result in more sustainable revenue retention.

Programming note:

Listen to Dr. John Zelem every Tuesday on Talk Ten Tuesdays for his segment, “Journaling John MD” on Talk Ten Tuesdays, 10 Eastern.


John Zelem, MD, FACS

John Zelem, MD, is principal owner and chief executive officer of Streamline Solutions Consulting, Inc. providing technology-enabled, expert physician advisor services. A board-certified general surgeon with more than 26 years of clinical experience, Dr. Zelem managed quality assessment and improvement as a former executive medical director in the past. He developed expertise in compliance, contracts and regulations, utilization review, case management, client relations, physician advisor programs, and physician education. Dr. Zelem is a member of the RACmonitor editorial board.

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