Embed Size (px)
Citation preview
BRIDGING THE GAP BETWEEN CONFUSION AND CLARITY IN HEALTHCARE
National Physician Advisor ConferenceNPAC2019
Novel Bridge Construction: Creating a Moonlighting Physician Advisor Program
Pooja Nagpal, MD FACP CHCQM-PHYADVPhysician AdvisorPhysician Advisor On-CallParsippany, NJ
Medical DirectornaviHealthBrentwood, TN
3
• Consider reasons to start an internal physician advisor moonlighting program
• Estimate the financial benefits of such a program
• Extrapolate the non-monetary benefits
Objectives
4
• 500+ bed academic hospital
• Internal physician advisor program started in late 2009
• One 0.5 FTE with no training, quickly increased to 1.0 FTE
• Case Management department with approximately 30 case managers (CMs), all doing case review along with other duties
• Use of MCG screening criteria
• Back-up with external physician advisor company
• Sparse Utilization Review (UR) Committee
• Separate denials manager
Background
5
• Still 1.0 FTE, better established with many more responsibilities including committee memberships, UR Committee Chair, trainee and new faculty education
• Still 500+ beds at one hospital, though one smaller hospital in the system with one 0.5 FTE physician advisor
• Still using external physician advisor company to cover gaps, but also covering the other hospital’s gaps within the same tier up to 125 cases/month
• Case Management department now with separate UR team of approximately 10 CMs at primary hospital who only do case review
Fast-forward to 2015
6
• Physician advisor average of 25 reviews/day, > 770 cases/month
• Medicare, Medicaid, Medicare Advantage, random payer unusual cases
• Physician advisor reviews all inpatients that did not meet 1st level screen, all outpatients every day for potential inpatient flip
Cases
7
• Weekends, holidays, days off, busy days, 2nd physician advisor’s days off
• Covers initial reviews and subsequent reviews, if needed
• Up to 125 cases/month for a set tier rate
• Overage case rate $210/case
• Estimated cost of $829,500 for upcoming year in overage cases
• Even if we went up to the highest tier coverage, the cost of that tier would be more than the cost of the overage we had at the lower tier, and we’d still have overage
External Physician Advisor Company Use
8
• Financial• Decrease external physician advisor company cost by eliminating overages• External physician advisor company did not look for surgeries on inpatient-only
list nor count midnights for transferred patients
• Compliance• Built-in UR Committee membership• Concurrent confirmation of Condition Code 44 by hospital-based physician
advisor
• Practical• More time for internal full-time physician advisor to attend to other
responsibilities• More docs that understand the process = better education for trainees and
physician assistants/nurse practitioners
Needs Met
9
• Goal to reduce $829,500 loss in expected overage costs to external physician advisor company
• Coverage needed:• 104 weekend days/yr• 30 days of vacation/holiday/CME for internal physician advisor• 2 weekdays/month for additional work• Plan to recruit 8 hospitalists
• 2 weeks on/off including weekends• On for 4 weekend days/month, so available only 4 weekend days/month• May not want to cover full weekend• Plan for 1 person per weekend day each month = 8 separate hospitalists taking 1
weekend day each
Business Plan
10
• Total Cost: $126,560• $90/hr plus fringe = $113/hr• Weekend shift
• 6 hours long = $678/shift• 104 weekend shifts x $678 = $70,512
• Weekday shift • 8 hours long = $904/shift• 30 weekday shifts x $904 = $27,120• 24 extra weekday shifts x $904 = $21,696
• Paid training (weekday)• 8 hours; $904 x 8 moonlighters = $7,232
• Overall Savings: $702,940• $829,500 expected overages – $126,560 moonlighting costs
• Expected ROI 5.5 : 1
Estimated Costs and Overall Savings
11
• At least 1 year of practice as an attending• Experience managing patients and orders
• History of working directly with CM/UR/physician advisor team• Returns calls promptly?
• Collaborative?
• 9 Hospitalists
• Urologist also asked for moonlighting hours
• Approval from Section Chiefs
Moonlighter Selection
12
• One-on-one time with full-time physician advisor, 8 hours total• Review 2-Midnight Rule, inpatient-only surgeries, and other payer
rules/regulations
• Develop working knowledge of MCG criteria
• Introduction to UR documentation system
• Real-time case review
• Attendance at PA/UR Team Bootcamp conference and completion of RAC certification
• Inter-rater reliability intermittently done with full-time physician advisor with case discussion if there were different decisions
Training
13
• Concurrent case review• Medicare, Medicare Advantage, Medicaid• All outpatient status cases• All inpatient cases that did not meet MCG on first level screen• Random payer unusual case
• Condition Code 44 decision, and concurrence if recommended by external physician advisor company
• Peer-to-peer (P2P) with attendings and insurance medical directors if immediately needed• P2P for denials handled by full-time physician advisor
• Mandatory member of UR Committee
Responsibilities
14
• 8-hour shifts on weekdays, 6-hour shifts on weekends
• Request for available dates sent one month prior
• First-come, first-served
• Attempt made to give equal shifts
• No double-dipping – cannot be working as an attending AND the physician advisor moonlighter during the same hours
• If moonlighter was the attending of record, UR team sends case to external physician advisor company
• Back up always the full-time physician advisor
Assignments
15
• $90/hr plus fringe• Had to be under the hospitalist moonlighting rate so as not to compete
with coverage
• Remote access; full H&P sent by secure email, short documentation requirement in UR system
• Monthly reimbursement amount e-mailed to moonlighter’s primary service line • Primary service paid the moonlighter and billed the CM department• Compensation was included in calculation for retirement fund matching
because moonlighters were under salaried positions for regular jobs
• New skill set for CV along with UR Committee membership
Compensation and Benefits
16
• Attendings who wanted to participate, but were not appropriate• < 1 year of practice as an attending
• History of being uncollaborative
• Some change to the moonlighting group• Attendings leaving for fellowship
• Requests to increase pay, provide additional pay for holidays
Expected Issues
17
• First few schedules sent to everyone, some became upset because they did not get all the shifts they wanted• Full schedule then became available only to UR team
• Moonlighters notified only of their own shifts
• Proactive attempts at getting pay increased• Moonlighters went to Section Chief
• Attempts at double-dipping
Unexpected Issues
18
• Moonlighters covered 4,121 cases that would have otherwise been overage to external physician advisor company
• Overage case rate approximately $210/case
• Cost would have been $865,410
• Moonlighting program cost/year: $149,958
• Savings: $715,452
• Actual ROI 4.8 : 1
Savings Over the Year
19
• Fully covered weekends, vacations, and holidays
• No missed case reviews, improved compliance
• Attendings more responsive to internal moonlighter group as compared to external physician advisor company calls
• Increased attendance/buy-in with UR Committee
Practical Benefits
20
• 4,121 total reviews
• 1,118 inpatient cases did not meet MCG • 568 confirmed as inpatient
• 550 changed to outpatient
• 631 outpatient cases flipped to inpatient• 607 observations
• 15 outpatients for recovery
• 9 bedded outpatients
Case Breakdown by the Numbers
21
• Approximate difference between inpatient vs observation reimbursement $4,400
• Net 1,199 cases as inpatient = savings $5,275,600
• Net 550 inpatient cases downgraded to obs = loss $2,420,000
• Savings $2,855,600
• Does not take into account inpatient-only surgeries confirmed by moonlighters that are higher reimbursement
• Does not take into account non-observation outpatients that were upgraded to obs with additional obs payment
Case Breakdown by Financials
22
• Medicare: 58%
• Medicaid: 13%
• UHC: 25%
• Remainder is a mix of payers
Payers
23
• Financial savings on par with expected business plan
• Captured more inpatient-only surgeries
• Increased job satisfaction for full-time physician advisor
• UR Committee compliance with increased appreciation of UR processes, documentation, financial outcomes
• Anecdotally, more collegiality between moonlighters with UR team and with colleagues – discussing cases, asking for assistance proactively
• More real-time, case-based teaching with teams
Moonlighting Program Successes
24
• Highly recommend that this be done if there is already an internal physician advisor that needs help
• Can be done across a health system with multiple moonlighters cross-covering
• Moonlighters can be from multiple specialties
• Can include P2Ps/denials
• Can track other metrics: impact on documentation improvement, case-mix index, decrease in denials, etc.
Parting Thoughts
