Power Tactics, Role Playing and Leadership Opportunities for Physician Advisors Jeffrey Farber, MD, MBA Chief Medical Officer, Mount Sinai Care, LLC Introduction A Physician Advisor: • is a hospital-based physician executive who serves as a liaison between case and utilization management, health information management, treating clinicians, and administration; • is a content knowledge expert on government and commercial payer rules and regulations, clinical documentation, coding, billing, and publicly-reported, and severity-adjusted quality data; The Greatest Challenge for the Physician Advisor is Physician Engagement Power Tactics Behaviors one utilizes to influence: • Legitimacy • Rational persuasion • manages length of stay, throughput, efficiency, quality, and medical necessity and coding denials; • Coalitions • ensures compliance with Medicare’s conditions of participation, leading the Utilization Management Committee. • Consultation • Inspirational appeals • Exchange • Personal appeals What is Power? Power: One’s capacity to influence another’s behavior to be in accordance with one’s wishes. The ability to mobilize resources to achieve some end. • Formal: based on one’s position in the organization • Ingratiation • Pressure Matching Power Tactics to the Audience - Coercion and Reward - Legitimate: from position within hierarchy • Informal (personal) power encompasses: - Expertise (physician advisor knowledge base) - Referent power: if I like, respect, and admire you, you can exercise power over me because I want to please you. - Charismatic power: due to one’s attractive visions (based on personality and interpersonal style) Upward influence: rational persuasion Downward influence: everything except personal appeals and coalitions Lateral influence: everything except inspirational appeals and pressure Mount Sinai Medical Center, New York, NY Role Playing Scenario 1: Observation Unit Role Playing Scenario 3: Appeals Management Physician Advisor wants the organization to build an observation unit. Physician Advisor wants to engage a chairman to partner in working on front-line processes to reduce medical necessity short-stay admission denials. Background: Appeals Management Department was without physician leadership and had limited outreach to doctors. New Physician Advisor role in 2006, expanded to lead the department in 2007, and hired full-time and part-time physician appeals coordinators, eliminating the need to outsource appeals. Requires expertise in revenue cycle, payment models, quality, compliance, documentation, and coding. Power tactic for C-suite: rational persuasion. Focus on revenue integrity, reducing $ lost to denials, back-fill of inpatient beds with higher margin cases, readmission reductions, alignments with value-based purchasing and accountable care organization Power tactics for physicians: Rational persuasion: increased and more directed referrals, improved care coordination and patient satisfaction Consultation: I’d like your input on how best to handle admissions to the unit from the voluntaries Coalitions: Dr. Smith in cardiology thinks it’s a great idea Ingratiation: that was a great talk you gave at grand rounds. Role Playing Scenario 2: Clinical Documentation Power Tactics Legitimacy: Messaging directly from CEO and CFO as an organizational priority, including metrics on service line dashboards. Consultation and Ingratiation: Thank you for encouraging your faculty to work with us in crafting appeal letters. Partnering with us in finance will ensure revenue integrity when hospital and physician billing are aligned. Exchange: Partnering with us on improved frontend documentation will allow us to improve your service line’s case mix index (CMI) through improved documentation and electronic medical record templating. Physician Advisor wants a staff doctor to answer a clinical documentation query. Background: • Long-neglected clinical documentation improvement program that lacked a physician leader. Revitalized in 2007 with a physician champion. • Physician advisor expands the program across two campuses in 2008 and increases the clinician response rate to queries from 77% to 100%. • Rational persuasion: improved documentation defends the physician from medical liability allegations and enhances the physicians’ reputation through accurate comparative analytics and public reporting of severity-adjusted quality data. • Consultation: Dr. John prefers we contact him in this manner. What works best for you? MSH CDI Program Performance 19,000 100% 17,000 95% Future Directions 15,000 90% 13,000 Charts Reviewed (#) 85% 11,000 80% 9,000 75% 7,000 5,000 70% 2007 2008 2009 Total charts reviewed 2010 2011 Physician response rate 2012 Physician Response Rate • There are many emerging career-enhancing opportunities for physician executives in the physician advisor realm. • Thoughtful use of power tactics will assist the physician executive in mobilizing resources to achieve desired ends. • Successful physician executives should be skilled in leading and influencing not just down, but across and up in complex organizations.