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A Medical Director’s Perspective
Understanding the Physician Perspective
By Christopher Snyder, DO
“The first duty of a wise advocate is to convince his opponents that he understands their arguments, and sympathizes with their just feelings”
Samuel Taylor Coleridge, 18th Century English Philosopher
Effective interventional case management depends on trust and
relationships, but can at times seem closer to refereeing between
opponents. The medical director of case management is an advocate
for case managers, the medical staff and, ultimately, the patient. While
often times the opponent is a third-party payer, care must be taken to
prevent relationships with attending physicians from becoming
adversarial during the case management process. One major cause
of this potential adversarial perception is that many physicians
increasingly feel that they are on the defensive most all the time.
Understanding what contributes to this sense of “being under attack”
allows medical directors (and case managers) to better communicate
with and influence attending physicians. There exists a sound and
sympathetic common foundation of knowledge and experience upon
which to build lasting, positive relationships. This article examines
some major concerns shared by many practicing physicians, and
presents strategies to address and incorporate these concerns in
medical director-physician interactions. Doing so will increase the
medical director’s ability to succeed in accomplishing both his role in
supporting case management requirements and providing advocacy
with third party payers on behalf of physicians and their patients.
DOCUMENTATION
Medical documentation continues to grow in its importance to
healthcare transactions of all types, and expectations are both very
high and very specific. Several different parties review a patient’s medical
record during and after a care episode – case managers review charts
concurrently to the care being provided, payers review charts to determine
if and how much a hospital and physician will be compensated for
providing the care, and quality initiatives necessitate review and
abstraction of data. When the medical record replaces actual conversation
as the only communication of the physician’s medical judgment, its
importance is elevated further. It is critical that the documentation
effectively communicate the physician’s active plan of care.
Documentation is, in some ways, a dialogue between the physician
and the hospital – the means by which a physician conveys a patient’s
symptoms, diagnoses, treatment, and progress – and the tool used by
case managers to assure the patient receives the appropriate level of
care. Ultimately, it is also the tool by which the hospital is reimbursed for
the cost of providing care. A certain tension can develop in this dialogue,
and the physician’s and the hospital’s needs regarding documentation
can potentially be viewed as competing with each other.
Physicians are committed to healing or curing their patients and
are naturally inclined to document improvements to this end,
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demonstrating progress in the patient’s chart. Documentation showing
good progress creates pressure for discharge to a less acute level of care.
If a physician does not understand the nuances of the criteria for level of
care decisions, he/she may not recognize the impact of the
documentation. Consequently, when documentation “pushes” a
discharge or transfer too quickly, a patient may be readmitted soon after,
reflecting poorly on the physician’s quality of care, creating additional
(perhaps unreimbursed) costs for the hospital and potentially placing
the patient at unnecessary risk.
In order to be effective and credible,
a medical director supporting case
management will need to incorporate
these concerns into interactions with
practicing physicians.
Hospitals are similarly focused on caring for patients, and must
also ensure they have the resources to provide care in the future.
This requires effective documentation, as it directly affects hospital
reimbursement. Tensions and suspicions can develop because of these
different needs; hospitals may be perceived as solely focused on
reimbursement while physicians may be thought to not care about
documentation quality. Physicians, as well as hospitals, can be
aware of and caught in this tension. Ultimately, the most effective
documentation accurately and completely reflects the acuity,
clinical state and needs of the patient, and through this accuracy
provides optimal benefit to physicians, hospitals and patients.
THREATS TO AUTONOMY OF PRACTICE AND AUTHORITY
In any medical case, attending physicians are the authorities over
patient care and expected to lead the care team. They most often
possess the highest level of training, knowledge and skill. With their
level of medical training, they are not only often the most educated
clinician on the case but also the one most accountable for the patient’s
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outcome. Generally, physicians understand and are comfortable in this
role. Although most also understand the important need for guidelines
and accountability, guidelines that appear to be driven by anything
other than actual patient condition and prognosis raise serious
concern. Any restrictions on physicians’ judgment and ability to put
the patients’ interests first are viewed as ominous and threaten a
physician’s autonomy of practice. These restraints can and do come
from various sources:
Hospital
When case managers’ review and “management” of a patient’s
course of treatment is perceived as a restraint on a physician’s
autonomy of practice, this can especially impact trust and
communication between the medical staff and the medical director
of case management. Case management is a function of the hospital
administration. Administration is involved in the negotiations with
payers or clinical service lines regarding many of the guidelines and
perceived restraints on the practice of medicine, and can potentially be
viewed as an opponent for this reason. It is important to recognize this
filter through which case managers and the department may be
“heard” – that the case management department and its employees
may well be viewed as having more administrative power than a
physician. The feeling of powerlessness is uncomfortable for most
people, and is especially so for physicians who have the ultimate
accountability for patients
Patients
An engaged patient, proactive in his/her own treatment and
recovery, is always a delight for a physician. However, the advent of the
internet, pharmaceutical “direct-to-consumer” marketing, and endless
opportunities to view health “experts” and experiences on various
media sources, have created a significant challenge for physicians.
Armed with just enough information and understanding to be
dangerous, some patients are placing themselves in the position of
“overseeing” their doctor’s decisions rather than engaging in a
meaningful discussion about treatment – ready to ask questions and
learn. Physicians’ years of training and experience build effective
medical judgment, and when patients do not recognize or respect this
level of knowledge, it creates significant frustration for physicians.
Payers
Medicare and other payers continue to increase their reliance on
Evidence Based Medicine (EBM). The scientist inside a physician
understands the value of this approach to the science of medicine.
However, the experienced practitioner inside the physician sees too
heavy a reliance on EBM guidelines as the removal of intuition,
listening, past experience and unique co-morbidities that truly
distinguish an excellent physician – able to practice the art of medicine.
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Many have heard this condescendingly called “cookbook medicine.”
Strict guidelines, protocols and care pathways can feel like a “recipe” to
a physician with a patient who simply does not fit the parameters of
the “prototype patient.” Payers, however, see the consistency of these
protocols as a means to assuring a level of quality of care and
predictability of costs.
Moreover, over-reliance on this approach seems to threaten the
very reason many physicians chose to pursue medicine, and what they
love most about practicing medicine – the use of critical thinking skills,
the process of diagnosing and developing treatment plans, and helping
to heal challenging patients.
This tension also appears to launch a direct attack on several
things that are held sacred to physicians – that they will treat their
patients without respect to the type of insurance they hold.
Physicians are likely to resent any interference by third-party clerical
or financial staff members who have neither the medical
qualifications nor the first-hand knowledge of the patient, or who
appear to advocate for patient care decisions on the basis of financial
rather than clinical implications. This resentment can impede taking
appropriate documentation steps that could defuse a future
challenge or denial by a payer.
Compounding these tensions is the constant threat of litigation
regarding liability, negligence and malpractice threats. This ever-
present threat makes some physicians feel that practicing medicine
The goal of the medical director
should be the perception that
he or she is working to assure
that the medical staff has the
maximum autonomy possible
while providing accountability for
hospital quality assurance.
requires more calculated risk than the fulfillment of a passionate desire
to help people. Underlying these resentments, however, is the reality
that by following EBM guidelines, physicians will actually protect
themselves from future litigation
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Understanding the Physician Perspective (continued from page 15)
PATIENT AND SOCIETAL EXPECTATIONS
With more and more medical advances, expectations continue
to increase that a visit to the doctor will bring a full return of health.
The amazing capabilities of our healthcare system can be a
double-edge sword when it creates false hope and unrealistic
expectations for complete “cures.” This atmosphere puts enormous
pressure on physicians and families alike, and may lead to pressure
for unrealistic or medically inappropriate treatment.
Additionally, while the last few decades have produced great
leaps in our understanding of treating and preventing disease, there
has not been a corresponding increase in the level of responsibility
taken by many patients regarding compliance with treatments
plans, or healthful or preventive behaviors. For example, a patient
with newly diagnosed diabetes who is morbidly obese, alcoholic,
and smoking two packs of cigarettes per day may not ever have
easily managed glucose levels – despite the care team’s best efforts
at education and access to the best pharmaceuticals.
Emotional situations can also be intimidating, time consuming
and frustrating for physicians. Raw emotions, which are present in
most serious or end-of-life medical situations, often decrease the
patient and family’s ability to make difficult and timely decisions,
and can increase the pressure placed on the physician to create a
cure. Also in many such cases, conflicts arise between patients and
family members as these individuals struggle with decisions.
QUALITY REQUIREMENTS AND REPORT CARDS
The traditional view of what constituted a “good doctor” was
based strongly on patient experience – a physician who sees and
treats his patients as unique individuals, listening to and addressing
their unique concerns and particular ailments. The definition of an
effective physician, however, has radically changed through the
efforts of both payers and healthcare quality oversight
organizations. Today, physician report cards and quality data on
both physicians and hospitals are readily available.
Are the current measures adequately measuring the quality
of a physician’s professional performance? Do these measures
truly represent physician quality? Many physicians strongly
question the validity of the currently accepted measures. The
current measures have primarily been developed by payers and are
strongly based on charge captures, which are highly subject to
inaccuracies and the effectiveness of a physician’s documentation.
Physicians have little input or control over which statistics are used
to paint the picture of their quality of care. While such statistics as
mortality are important, these do not account for long-term
outcomes and quality of life for patients, particularly with chronic
diseases such as CHF (Congestive Heart Failure) or diabetes.
Additionally, most physicians are responsible for patients
across many different levels of care. Acute care is perhaps the most
resource-intensive settings, but is by no means the level of care in
which the physician can most influence the long-term quality of
life for his/her patients.
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STRATEGIES FOR MEDICAL DIRECTOR EFFECTIVENESS
In order to be effective and credible, a medical director
supporting case management will need to incorporate these
concerns into interactions with practicing physicians. This can take
several potential forms, from more formal “internal marketing”
regarding the how case managers can provide valuable partners in
such concerns as documentation and difficult social situations, to
informal incorporation into daily medical director-physician
interactions. The following are three specific strategies to
incorporate these practicing physician concerns for medical
director effectiveness.
Act as Physician and Medical Staff Advocate
to Hospital Administration
Physicians value an ally when dealing with problematic family
members, payers and administrative policies. Case managers can
effectively provide advocacy, and a medical director needs to be
perceived as a strong and credible medical staff ally. For example, a
medical director can help physicians understand the continual
changes in the healthcare environment and how those changes
impact interactions with the many constituencies to whom a
physician is accountable. The goal of the medical director should be
the perception that he or she is working to assure that the medical
staff has the maximum autonomy possible while providing
accountability for hospital quality assurance.
Provide the Voice for Medical Staff Concerns in Administrative
and Payer Discussions/Negotiations
By working with all of the healthcare team, a medical director
can ensure that all parties are being represented fairly and
communicating effectively. More important, a medical director has
access to payer and administrative negotiations, and can provide
voice and champion for medical staff concerns – especially where
those concerns align with case management priorities.
Develop Improved Data Metrics to More Accurately
Reflect Physician Practice
Medical directors working with case management are
uniquely positioned, through access to reporting tools and
interface with both physicians and administration, to develop
improved data measurement that more accurately reflects
physician quality practices. Improving metrics will be the outcome
of open communication between hospitals and physicians, and
medical directors provide the necessary link to create such a
positive partnership.
Christopher S. Snyder, DO, is Chief Medical Information Officer,
Utilization Medical Director, and Hospitalist at Peninsula Regional
Medical Center in Salisbury, MD. Dr. Snyder has been in his current
position for seven years. He was previously in Family Practice for five
years. Dr. Snyder earned his DO at Kirksville Osteopathic in Kirksville,
MO, and is board certified in family practice.