Developing an in-house physician advisor program - utilization management companies supported by teams of physician advisors

A study in 1989 by the Institute of Medicine Committee on Utilization Management [1] stated there were more than 1,000 utilization management programs nationwide. The result of all these independent programs has been a lack of standardization in both the review process and the medical criteria used to govern decisions on medical necessity.

Many programs use nurse reviewers to initially handle the case, with complicated or difficult cases being referred to a physician advisor for decisions. As the complexity of cases under review continues to grow and new medical technology is added, there is an increasing demand for fair and well-informed decisions. The physician advisor's role, in part, becomes that of final decision-maker in evaluating appropriateness of admission, in judging the efficiency of services in terms of level of care and place of service, and in seeking appropriate care alternatives for selected patients. In addition, the physician advisor must have sound knowledge of the appropriate length of stay for a given diagnosis or procedure and of complications that may warrant an addition to the initial length-of-stay assignment.

The role of the physician advisor is not simply that of supporting the nurse review function, but more of negotiator and educator with practicing physicians. Additionally, the physician advisor acts as liaison between the utilization management company and the provider community in understanding and shaping more efficient and cost-effective medical practice.

Staffing and Schedule

Probably the single largest decision to be made involves the physician advisor staffing level. Most companies have developed track records that will provide the basic information for such a decision. Among the important points of information needed are:

* Number of calls per day.

* Daily distribution of incoming calls (morning/afternoon/evening).

* Daily distribution of calls (Monday through Friday).

* Type of calls (medical/surgical/psychiatric).

* Average time per call.

The number of calls per day and the percentage of them involving physician referral (typically 10-15 percent, according to a RAND Corp. study) [2,3] should give a basis for the total work load per day in a precertification and concurrent review utilization management environment. This information, along with tracking of time and day of incoming calls for referral, should provide a good picture of when physician advisors will offer the most effective service. The experience of most utilization management companies indicates that the majority of calls to attending physicians take place during the afternoon hours, when the attending physicians are usually available in their offices. In addition, the greatest work load seems to fall on Monday, Thursday, and Friday, consistent with the highest level of activity in hospital admissions and discharges (excluding emergency cases).

The next decision is whether an in-house physician advisor staff is warranted, as opposed to phone access advisors. Nurse reviewers are responsible for identifying and referring cases requiring physician review. Most people can agree that an in-house physician advisor offers a far higher level of efficiency and timeliness in dealing with basic casework than does a phone-based network. An inhouse physician advisor eliminates lost time and opportunities. The inhouse advisor also adds consistency among reviews and professionalism for the company represented.

Another consideration is between the use of one full-time physician advisor, typically no longer in practice, and several part-time physician advisors who are still active in practice. Typically, a full-time physician advisor would perform reviews 40 hours per week, whereas part-time physician advisors work a minimum of 20 hours per week (usually arranged as half-day shifts on a Monday through Friday basis). The biggest advantage of a full-time physician advisor is his or her ability to make a complete commitment to utilization management, unencumbered by ongoing obligations to a peer group with which he or she shares a need for mutual community support. The disadvantage is a loss, in some cases, of up-to-date knowledge of current trends and practice patterns.

Physician Specialty Selection

Many utilization management companies prefer in-house physician advisors trained in family practice or internal medicine. Because of their broad knowledge and experience, these specialists can offer an informed opinion on a wider variety of cases without seeking additional consultation. Naturally, this benefit will vary on the basis of individual experience and training. Typically, physician advisors should have at least three to five years of practice experience to support their medical education and residency training.

We have found that a two-tier approach to subspecialty referrals works best. Our first level of referral consists of pediatricians, general surgeons, and Ob-Gyn physicians. Our general practice in-house physicians have found that 80-90 percent of their questions can be answered by this group of specialists without the need for further subspecialty help. However, when a second-level subspecialist is called to support a decision, a network of physicians who understand the goals and policies of the utilization management company should be in place.

The growth of psychiatric review services has mandated that many utilization management companies offering psychiatric and substance abuse review services have a psychiatrist in-house along with their medical/surgical physician advisor staff. The recent growth in mental health costs to 15-30 percent of some employers' total health care costs [4] and the complexity and duration of many psychiatric cases amplify this need.

A major consideration in having physician advisors is the rate at which they are utilized for case review. Because of the significant expense of physician support time, an evaluation of the most efficient use of their time is imperative. One cost-efficient consideration is use of in-house physician advisors (typically on an hourly wage) for as many case reviews as possible, saving referrals for a phone-based physician advisor or a subspecialist (typically reimbursed on a case-by-case basis) for selected cases only. This may be accomplished best by limiting outside referrals to cases prescreened by either the in-house physician advisor or a review supervisor. However, if the reason for the outside referrals is "bottlenecking" or long delays by the in-house staff, reorganization or an increase in in-house staff should be considered.

Recruitment Strategy

Local and state society journals, local and regional newspapers, recruitment firms, and networking are all good sources in developing an advertising campaign. A well-written ad in the right medium can significantly increase the number of responses and provide greater selectivity of candidates. Follow-up interviews for qualified candidates should be conducted. Personal interviews permit a better look at candidates, allowing more indepth evaluation and adding information useful in determining the best corporate fit.

A questionnaire can be developed and sent to physicians selected as being most appropriate for the position. This is helpful in outlining their qualifications and determining their hours of availability for phone referrals. Their responses also represent confirmed interest in the position. Responses from the questionnaire provide a group of physicians from which to make choices and to identify physicians who may not be ideal for the position but may be willing to function as phone back-up.

Credentialing

An important part of any physician advisor recruitment program is strong commitment to high-quality personnel. The basic requirement is broad certification in a recognized medical, surgical, or psychiatric specialty. Board certification by the American Board of Medical Management and/or the American Board of Quality Assurance and Utilization Review may offer a significant addition to clinical board certification.

Major areas for credentialing attention should include:

* Confirmation of board certification.

* Confirmation of current valid license.

* Review of any state or federal sanction.

* Review of malpractice history.

* Review of hospital privileges status.

* Professional association affiliation.

* Personal references.

The result of the above inquiries should provide a better picture of the physician and his or her professional history. The credentialing committee of the utilization management company must ensure that physicians performing review have a history of good judgment in their own medical practice and meet the highest professional and personal standards in dealing with patients and peers. If utilization profiles are available, they may be used to identify physicians advisors with cost-effective track records.

Another characteristic to consider in a physician advisor candidate is previous experience in quality assurance and utilization review. A growing number of physicians have some level of exposure to these areas through state PRO organizations, hospital-based review committees, and various levels of experience with the insurance industry. Although this previous experience may offer some insight into the broad world of review, it may offer very little insight into the practice of utilization management from the private insurance review viewpoint.

Legal and Legislative

Considerations

The current status of utilization management in terms of malpractice activity and legal liability is still undetermined. Cases are being presented daily, with no clear delineation of responsibility having been established. Many utilization management companies review cases in multiple states, and current legislation lacks interstate consistency. Although no obvious resolution of this confusion is in sight, a few general rules should help most physician advisors avoid the majority of problems:

* Follow good medical judgment.

* Follow accepted medical standards.

* Gather all facts before making a decision.

* Speak and listen to the attending physician.

* Negotiate a compromise if no other solution is possible.

* Allow for appeal.

* Follow predetermined corporate policy.

If a sound corporate policy is adopted, using the legal and risk management services currently available to most large utilization management companies and administered by compassionate and knowledgeable physician advisors, most problems can be avoided. Many companies carry an "errors and omissions" policy as well as corporate malpractice for their physician advisors. Although lawyers may recommend private malpractice insurance with a specific rider for utilization management activity, the value of such an adjunctive policy is yet to be determined, and the cost versus benefit relation may be questionable.

Because physician advisors review the private case records of patients not directly in their charge, they should be held to a confidentiality agreement as part of a standard contract. In addition, most contracts should specify the degree of employment or affiliation that is shared between the physician advisor and the utilization management company. In cases of corporate liability, this may become an important issue with part-time physician advisors acting as independent contractors.

Budget

Operational costs will generally fall in the following major categories:

* Salary

* Office Expenses

* Phones

Although we reimburse in-house physicians on an hourly basis, there are other options, such as a fixed salary amount. Some flexibility should be built in to accommodate increased business or activity. On-site parking, although it can contribute to costs, should be considered. This is especially true in metropolitan areas where convenient parking may not be readily available. Providing this benefit greatly enhances the attractiveness of the position.

Employment can increase salary expense by as much as 30 percent. This may be an important consideration in deciding whether to opt for a full-time or part-time physician staffing approach.

Additional budget considerations include office expenses, such as phones. In drafting the budget, you may want to include an allocation for phone referrals that occur when the physician advisors are not on-site or when the expertise of specialists is needed. Charges for phone referrals can be controlled somewhat by limiting them as much as possible until in-house physicians are available.

Training

Once the selection is made, you may want to arrange for all of the physicians to participate in a day of orientation and preliminary training. This is a good opportunity to present an overview of the company and to familiarize them not only with your business and philosophical approach but also with their roles. It may be helpful to provide them with copies of criteria as well as programs, policies, and procedures and to explain the development and application of each of these items. Goals and expectations for the physician advisors should be established, and they should be given guidelines to be used in carrying out their responsibilities.

Our services are fully computerized, which made it necessary to provide training in how to access and enter relevant case information. A brief session can be designed to teach the basic skills that will be needed. If they are reluctant to acquire typing/computer skills, other options are available for capturing the input from their case reviews.

State-of-the-art communication systems provide the vital link for all telephone-driven managed care companies. Heavy telephone usage requires a sophisticated network of telephones. Physicians will need to be familiarized with various phone maneuvers and capabilities. We found that having physicians observe nurses as they conduct phone reviews greatly increases their understanding of our services, the nurses' role, and not only how cases are reviewed but also what transpires before the physician advisor is involved.

As might be expected with any new program, the need for initial support should be anticipated and arrangements made to have staff available to answer questions, assist with technical problems, and provide any other help needed. After the program is up and running, you may want to schedule regular meetings with the physicians to discuss mutually identified concerns that can improve processes and effectiveness. Although the time this requires may be significant, we have found the physicians adapt quickly to change and are able to function independently in a very brieftime.

Work Space

Ideally, physicians' offices should be near those of nurse reviewers. This encourages greater interaction between the two groups. Case referral is the primary objective of an in-house program, but the availability of physicians for information exchange is advantageous.

In designing the physicians' work space, equipment requirements will need to be identified. Where operations are computerized, case access will not only streamline the referral process but also allow the physicians to enter their own documentation, thus eliminating paper trails or errors that can occur in verbal exchange of information. Phone lines installed into their offices will need the same capabilities as those of the nurse reviewers. This allows the physicians to use features, such as intercom and conference calling, that may desirable in performing case reviews.

Physicians have found it helpful to have their offices stocked with reference material, such as a client listings, policy and procedure manuals, dictionaries, medical texts, journal, and periodicals, that keep them informed of new technologies, techniques, and utilization patterns occurring throughout the nation.

Reports

By working closely with physicians, it is possible to continuously improve processes and to address any concerns that may be identified. Measurement systems must be established, and meaning data must be gathered that will enable the analysis of overall effectiveness. Careful analysis of the resulting reports ensures that optimization of the physicians' efforts in the review process is occurring. The value of this step is not only excellence of service but also improved overall performance.

Some of the key areas of the analysis and report are:

* Expectations:

Industry Norms. What is generally regarded as a desirable level of physician involvement in case reviews?

Corporate Goals. What are expectations relative to industry norms?

* Tracking of effectiveness, i.e., percentage of changes resulting from physician intervention in denial of admissions, reduction of hospital days, level of care, or place of service.

* Percentage of cases referred to physicians by nurse reviewers.

* Percentage of cases requiring phone calls to attending physicians.

* Total number of physician reviews directly related to specific areas, i.e., medical/surgical, psychiatry, case management, etc.

* Percentage of referred cases that do not require physician intervention. (This is an added value that may be missed when evaluating program effectiveness.)

Conclusion

The development and incorporating of in-house physician advisors is quickly becoming the industry standard among utilization management companies. Improvements in professionalism, effeciency, and cost containment far exceed the increased cost of operations compared to off-site physician advisor services. There is a need to actively recruit high-quality physician advisors with established training and experience, the highest practice standards, and sound medical and personal judgment.

Physician advisors must be considered members of the review team, working in tandem with nurse reviewers and attending physicians to ensure the best possible outcomes. This process can be reinforced through strong initial training in utilization management, along with ongoing updates on changes in medical practice and medical technology. Active feedback from nurse reviewers and establishment of performance standards will allow for effective performance evaluations and identification of areas for improvement.

References

[1] Field, M., and Gray, B. "Should We Regulate 'Utilization Management.' Health Affairs 8(4):103-12, Winter 1989.

[2] Meyer, H. "Prayer to Use Protocols to Assess Treatment Plans." American Medical News Dec. 9, 1988, pp. 1-3.

[4] Blue Cross and Blue Shield Association. "Controlling the Cost of Psychiatric and Substance Abuse Benefits." Benefit Cost Control Report, No. 1, July 29, 1988, pp. 1-8.

Grant D. Lawless, MD, RPh, is Medical Director and Dorothy B. Holt is Professional Services Director, Health Related Services, Inc., Pittsburgh, Pa.

COPYRIGHT 1991 American College of Physician Executives
COPYRIGHT 2004 Gale Group