Hospital to Health Plan and Back Again – A Physician Advisor’s PerspectiveAnita Patel, MD The traditional days of physician’s only role of providing clinical care has evolved over time. This has occurred due to several factors but ultimately, it needed to happen. The US has a complex healthcare model which can be incredibly challenging to navigate. We have multiple payors such as private, public as well as uninsured payors. The current payor system has roots in the US Marine Hospital Services which in 1798 deducted pay from seaman to cover hospital care (Healthcare Economics and Policy: Henderson). Their intent was to keep the labor force healthy and working. Subsequently, the business of healthcare coverage has developed into a multibillion business. Many of us received very little or absolutely no healthcare business lectures during medical school or residency. In practice, I only knew about insurance as it seemingly placed barriers between my orders and the patient’s receiving care. Endless phone calls trying to get things prior authorized. I have been told business classes are now being offered in medical school and there are even medical schools who offer a MD/MBA dual degree which is a good thing. In 2005, while working as a hospitalist, I was offered the part time utilization management medical director role at my hospital. Prior to this, I had no idea this role even existed or what utilization management meant. I took on the role and took on any duties the case managers asked me to do. This involved reviewing charts and talking to fellow physicians regarding documentation. I wrote out appeal letters and even talked to the “insurance person” about cases. The “discussion of cases” was my first exposure to the peer-to-peer process. During this time, I found the role difficult to describe and would tell people I worked in “Administrative Medicine”. I continued practicing clinically before eventually deciding to work on the health plan side. Going from the hospital setting to a corporate setting was a bit of culture shock. Instead of interacting with clinical staff all day, I was working with corporate staff in an office setting. It was a more formal atmosphere with the goal of running a business. I was now the “insurance person” rounding in the hospital. It was harder for people to avoid my gaze since I knew many of them. Although I was still performing the UM activities I began in the original role, they were in a different and much broader capacity. Fundamentally, the priorities stayed the same as when I worked on the hospital side, patients come first. I went from a setting of healthcare delivery to a setting of providing healthcare coverage; both important aspects of the healthcare system. I enjoyed my time on the plan side. We had a lot of camaraderie within my team similar to what I experienced working in the hospital. We implemented projects that helped high- risk seniors get case managers inside the home. The team even streamlined processes to help alleviate reimbursement headaches for our providers. After spending years on the plan side, I am back to the healthcare delivery side of things. The role of the physician advisor has grown tremendously, even the title has changed from medical director to physician advisor. I no longer struggle to find the words to define or explain my role when speaking with other healthcare workers. Heck there is even a society! Historically, the administrative staff in both the hospital systems and health plan systems have seen physicians as strictly clinical. Through the recent years, I have seen the transition of the administrative folks allowing physicians to sit at the table and provide input which can help both businesses improve quality and efficiency. There is utility for physicians on both the healthcare delivery and health plan side. They bring important clinical and operational input to an industry which provides clinical care for patients and ultimately benefits our society. I am excited to see what new roles develop as the involvement of physicians grows in scope. Dr. Patel is an Internal Physician Advisor II at Common Spirit Health |