Physician Advisors: Supporting Patient Care Through Strategy and Education

Podcast Transcript

Dr. James K. Stoller:

Hello and welcome to Med Ed Thread, a Cleveland Clinic education podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hi, welcome to today's episode of Med Ed Thread. I'm your host, Dr. Tony Tazano, Director of Student health and and assistant clinical professor of surgery here at Cleveland Clinic in Cleveland, Ohio today. I'm very pleased to have Dr. Nick Liberton and Dr. Mina Girgis here to join us. Both are enterprise physician advisors for Cleveland Clinic. Nick and Mina, welcome to the podcast.

Dr. Meana Gerges

Thank you. Glad to be here.

Dr. Tony Tizzano:

Could each of you get us started by telling us a little bit about yourselves, what brought you to the clinic, your roles here?

Dr. Meana Gerges

Sure. Nick, would you like to go first?

Dr. Nicholas Libertin:

Yeah, absolutely. Very excited to be on the podcast. Thank you guys so much for inviting us on. So, a brief background about myself. I am an emergency medicine physician by trade, so board certified in that worked in Columbus for about a year or two and then came here at the clinic and have been here since 2016, I believe. So, you know, coming up on 10 years here, I originally just started as a staff physician and then became an enterprise physician advisor here with mena. Also, I serve as the vice chief of staff of Avon Hospital. So I'm involved in the MedExec board there, as well as the sepsis chair, pharmacy and therapeutics chair, and then the peer review committee chair as well. And that's basically a bit about me as far as hobbies and interests. I really, at this point in my life, it's all about my wife and my kids, specifically kids, sports. I feel like I'm an Uber driver driving all these kids around. But it's a fun time in. And when we aren't doing that, I like to travel. So we recently got back from a trip to Ireland.

Dr. Tony Tizzano:

Fabulous. Nick Cart and the kids around. Those were the days. Nina, what about you?

Dr. Meana Gerges

Well, I can relate. Much like Nick, I'm also a father of three little girls and we do a lot. So I can sympathize and empathize with Nick. I'm an enterprise physician advisor for Cleveland Clinic as well. Also a staff hospitalist. Been with Cleveland Clinic since 2013. Completed my residency at Ohio State University in Columbus, Ohio, where Nick also attended Ohio State. So we go back to Ohio State, but here we are working together again as physician advisors. I've been a physician advisor now for about four years. Have been also hosting and mediating our Cleveland Clinic Physician Advisor conference for the past few years in partnership with the American College of Physician Advisors. So that is now a national conference. Last year we had representatives from four countries and 33 states. Exceptional conference where we talk about a lot of, you know, what we're going to talk about today.

Dr. Tony Tizzano:

Perfect, thank you so much. So for our listeners, a rapidly growing number of physicians serve as advisors to their peers and institutions to cultivate and promote the leaders of tomorrow in case management, hospital utilization, clinical documentation, integrity, health systems, revenue cycle optimization and healthcare regulation. Their endgame is better patient care safety and improved access through mentorship and collaboration among healthcare teams. So Nick, please help us frame this topic because this was a little bit new to me as I first listened to it. I'd heard of it, but really couldn't use the words in a sentence. But tell us the role here for the both of you here at the clinic.

Dr. Nicholas Libertin:

Yeah, absolutely. So a physician advisor by trade, they wear lots of hats. Now at the clinic we tend to have a very robust program. So you know, we have, you know, typically you have at least a physician advisor per hospital. We tend, because we have such a large system that we consolidate that a bit, but we wear many hats, you know, here at the clinic. What that means is we are utilization management, you know, chairs of a lot of the committees there. We deal with denials on the back end, we deal with coding issues, we deal with peer to peers, with insurers and then even taking cases to the Medicare judge or the alj. We've taken cases and kind of work with our legal team there. So really lots of different hats that we work with. The society, as Mina mentioned that we are established with is the American College of Physician Advisors. That group was founded in 2014, really by a handful of physicians. It was kind of emerging specialty. The role of a physician advisor has always been done by someone in the hospital. It started to have, you know, a name price several decades ago, but really was in a society and that one has become and emerged the prominent society. It's now passed, I think 1,000 members as of 2023 and has really been kind of the gold standard as far as where we go for a lot of direction and where we are in organizations and dealing with some of the payers.

Dr. Tony Tizzano:

So this has become a really respected college. It performs a really important service to make sure things are coded properly so that we get appropriate reimbursement, they don't get stuck with bills, so on and so forth. So what are some of the core values, Mina, when you look at what's expected of physician advisors?

Dr. Meana Gerges

Yeah, that's a good question. So when you look at The American College of Physician Advisors. You can kind of think of it as the home for physician advisors nationally, kind of much like the American Academy of Family Physicians for family medicine physicians and other respective boards. It is really the newest kind of specialty in medicine. When I first joined as a physician advisor, people didn't know what a physician advisor was. Most people still don't know what a physician advisor is. But the awareness level, in just a matter of a few years has increased tremendously. It's becoming a lot more popular now. I think when you think of core values and what we want to do is we want to both tell the patient's story. So clinical documentation is imperative with what we do and be appropriately reimbursed for the work that we are doing and fight the denials both for not only for the health of the organization, but for the patients themselves and their financial health as well. So this is to be transparent, it's to be honest, and it's to kind of bring the good fight, so to speak.

Dr. Tony Tizzano:

Very good. It seems also for either of you that there's a leadership development role in what you do as well. Because by doing the things that you propose and doing them well and appropriately, as you say, that's a part of learning to be a leader and do the right thing at the right time for the right person.

Dr. Meana Gerges

That's right. You are absolutely right. I think we are a team of leaders in our respective spaces and what we do. And at Cleveland Clinic, there's just eight of us for the entire enterprise, at least here in Northeast Ohio, we've recently. We have a Florida group as well that's recently joined us. So we're now expanded a little bit, but we still do the bulk of the work here in Northeast Ohio. And we really, as Nick was alluding to, we're in every facet of the medical journey, from the ed where Nick lives to the inpatient space where I live and beyond. And we're in every part of that.

Dr. Tony Tizzano:

And so this is a service that you're providing for over 4,000 physicians. That's oversight and what have you?

Dr. Meana Gerges

That's correct.

Dr. Tony Tizzano:

What a monumental task.

Dr. Meana Gerges

And thousands more patients.

Dr. Tony Tizzano:

Yes, yes. I won't even hazard a guess at the number. So, Nick, have these efforts moved the needle for faculty, students, trainees in the health system?

Dr. Nicholas Libertin:

Yeah, so, I mean, a couple things that we do. So the first one is we have an elective for fourth year med students to give them exposure to this specialty. I also think it's an important elective too, to just really open their Eyes to this other side of medicine. Right. I think we can all agree that in our med school and residency we didn't get any lectures on billing, coding, denials, insurance companies, things like that. It's just this foreign entity that we're exposed to once we're attending physicians and oftentimes overwhelmed. Right. So that's one of the goals of the fourth year rotation, is to really show what we do and how we interact. So that's been launched probably a couple years back. The other thing is, doctor, two of our members, Dr. Sumana Nirasiman and Dr. Mike Taylor, have launched educational series with internal medicine residency here at the clinic as well as the surgical residency. And the hope is there is a little more kind of diving into the weeds of things like documentation, insurance denials, and they even go over things like statusing. And when we refer to statusing, to give you a background on that, is every patient in the hospital is in a hospital bed, is in a certain status. Now, you know, inpatient status tends to be higher acuity patients that are going to be there for multiple days. Observation status tends to be patients we think of as maybe a little bit lower acuity that are going to be there for less than maybe a day or two. And then there's other statuses, things like outpatient in the bed and extended recovery. We won't get too much into the weeds there. But the reason why this is important is we have to put patients in a status when we're placing them in the hospital. And this can have ramifications. The hospital gets reimbursed more for certain statuses like inpatient status. But more importantly, it's important to the patients. Right. Because I'm sure people have heard that certain things like being an observation status for prolonged periods of time, that they incur higher out of pocket costs. And then lastly, it can have regulatory implications. Right. So if we're putting patients in the wrong status, you know, cms, you know the center for Medicare Services. Right. Like they're auditing charts every couple of years at different hospital systems. So if we're doing things the wrong way, they can come back and they can pose sanctions, they can take back money from the facility. So it's very important. And I think that's a great project that Samana and Mike are undertaking.

Dr. Meana Gerges

I'd like to add to that. So based on statusing, what Nick just mentioned, it's actually a huge part of what we do. If patients are admitted and discharged in the incorrect status, there are certain payers that won't pay a single penny, regardless of what was done, regardless of how long the patient was in the hospital and how much charges were incurred. So all of that will fall back on the patient in the hospital. So it becomes vitally important. And as Nick alluded to, when physicians are coming out of residency, you know, they' gotten almost zero exposure to this kind of stuff. So they're learning this stuff after they.

Dr. Tony Tizzano:

Start on the fly.

Dr. Meana Gerges

On the fly. They're learning, you know, they learn how to keep patients alive and how to help heal, but they don't learn anything about business or billing or any of that kind of stuff that happens in the background. So that's a big part of what we're doing now. What Dr. Taylor and Sumana are doing in their space is what we're doing at Avon Hospital. We've gone as far as to assemble a team of educators to help educate our new hires and our existing hires. And it's continuous education. We're not just doing a one time thing. We've done grand rounds, we've done Wednesday lunch and learns, we've done one on ones, we've done group sessions and we're continuing to do that.

Dr. Tony Tizzano:

That's great because it's not until you have boots on the ground that you begin to appreciate the need for this sort of work.

Dr. Meana Gerges

That's right.

Dr. Tony Tizzano:

So what's the impetus for this for yourself, for example, to get involved in this kind of work?

Dr. Meana Gerges

Well, I think, number one, everything that I just mentioned, number two, it's new and exciting. It's something that we've never learned and we're not used to dealing with. But this is the world that we live in and we don't know how the other side works. And unless somebody tells us or we have some sort of education or listen to a podcast like this one, we don't know. So I think the impetus there is, number one, it's interesting. Number two, we're helping the patients, we're helping the hospital systems, we're helping the healthcare landscape in general. By doing what we're doing. The goal is to try to lead to a better health care environment, better healthcare system, more healthy. One especially, you know, when it comes to the money aspect.

Dr. Tony Tizzano:

Sure. So it seems that if you're having the appropriate status assigned to individuals as they move through the system, they come into the er, then perhaps they're in an observation, they get admitted as an inpatient, that it actually, when done well, might even facilitate access.

Dr. Meana Gerges

Absolutely, 100% would facilitate access. I think Nick can tell you a little bit Better about that. Him being an ED physician, he sees it every day. I see it as well. But we have patients that are boarding in the emergency rooms that have no hospital beds. There's nowhere for them to go.

Dr. Nicholas Libertin:

That's an important subject, right? Because sometimes we cohort certain patients in observation units, depending on the hospital. And every time you have to transition a patient from an observation bed to maybe a higher acuity bed, right. That requires cleaning, that requires time, that requires, you know, nursing handoff. We say as physician advisors, right? We try to put the right patient in the right status at the right time. And that is a. It's fluid, right? I mean, you know, some patient, when they get admitted to the hospital, might be in observation status and then something changes or they're going to be there for a prolonged period of time and require that more intense services than we initially thought. So that's why with us and the UM team that we work with, we're looking at these patients 365 days, you know, pretty much from 7am to, to 6pm we're constantly evaluating their status and seeing if we need to change it to make sure that we're putting the patients in the right status.

Dr. Tony Tizzano:

Great. So for either of you, you know, you mentioned that there's a senior elective so that, you know, trainees are starting to get a taste at the very kind of end. And not to mention the residents, why isn't this, you know, we lay this foundation for the basic sciences and disease and so forth, but this is such an imperative. You would think that we'd get started early because this is complicated to learn just from trying to learn coding all by itself. You know, to have this not all of a sudden come when you're all of a sudden hitting the wards and having to do it, and then you've got to go and submit the charge. Because as I understand it, if you don't do it well or you miss something, there's not a retroactive chance you can't go back and go back to the well.

Dr. Meana Gerges

Is that true with some payers? It's true with some payers. They offer no retroactive billing as observation if you discharge them the incorrect status. But when it comes to teaching residents and teaching, you know, physicians earlier on, you gotta, you know, you kinda gotta go back and think of what that journey was like. Our minds, at least for me, was certainly not on any of this kind of stuff, nor if somebody would have taught it to me, would I have really cared. I don't know if I would have cared My worry was about patients and patients health and how do I fix them, how do I keep them alive? What do I do if a code is happening, who do I call? There's so much that comes at you in medical school and in residency. However, I will say I graduated from Ohio State in 2013 and even back then when I was in residency, I had some pretty smart attendings that, you know, we would sit down in between patients and we would actually talk about what helps meet this kind of criteria and what is Milliman criteria. So I got exposed to it myself very early on and it piqued my interest. I think that's what kind of sparked my interest. Moving and to today, what kind of led to me saying, I want to get my master's of business administration in healthcare. I want to learn more about this. And I got involved in the, um, space to learn a little bit more. That was my personal journey. I don't think that, you know, just a, your normal run of the mill physician, regardless of specialty, is thinking about that. Yeah. So. And if they are, then they kind of have to carve out their own time to learn it and to do it. So I think that's why what we're doing here at the clinic is unique. We're kind of the first ones to venture into, well, let's see if we can squeeze it in. Let's see, you know, if we can expose these residents to this kind of stuff, if it'll make a difference.

Dr. Tony Tizzano:

It seems that perhaps, Nick, you would comment on this, that there'll come a day when we're weighed and measured by our ability to do this well, and it will be tied to perhaps salaries or what have you. You can be penalized if you do too much, but if you're leaving something on the table, you don't want that either. Everyone just wants to be fair and that this is trying to do this with integrity and put what should be put out there. Any thoughts?

Dr. Nicholas Libertin:

Yeah, I couldn't agree more. I think that's well put. Your emphasis when you're younger on your career is just getting better as a physician because everything's overwhelming and you're trying to learn. I don't know where in the hospital you need to go to get X, Y and Z, what floor is what floor and things like that. I mean, that's kind of your focus early on in your career and just learning to be a better physician. As time progresses though, you realize that this stuff is important. Right. I mean, we're seeing right now like a record number in the last couple of years of these hospitals getting shut down due to fiscal constraints. Right. And I don't see that changing this kind of stuff is what keeps us to have the ability to have safe staffing ratios and to maybe hire an extra physician or two in certain settings. When you talk about hundreds of thousands of patients that you're seeing a year, even just a change of 1 to 2% in your billing or coding can be the difference of keeping a hospital afloat. So it really, really does make a big impact. And I think that for me especially, it's been really gratifying seeing kind of the impact that we make as physician advisors of the clinic.

Dr. Tony Tizzano:

Well, I really like that perspective because as our listeners think about all this, they're thinking, well, this is just a way that hospitals can get as much as they can possibly get. But your point is, you know, we're keeping clinics and hospitals solvent so that they have someplace to go. Because if you're not fiscally solvent and stable, you may not be able to keep the doors open. And it's all of a sudden the decisions are made and you're closing and everyone's there, like, what, why, how?

Dr. Meana Gerges

I don't think a lot of people realize that hospital margins are so thin. I think they think it's a huge hospital system. A lot of hospitals are operating on a margin, like Nick said, by like 1%. It's very, very thin. So when you don't have this kind of stuff going on and proper physician advising, it's very easy for those, you know, smaller hospitals to close down. And you know, obviously that leads to less patient access, less healthcare, less delivery. It's not good for anyone.

Dr. Tony Tizzano:

Important food for thought. So for either of you, what lies on the horizon? What do you see as next for the role and for the College of Physician Advisors, the wish list?

Dr. Nicholas Libertin:

That's a great question. I think that the biggest thing I see as an opportunity for physician advisors is to work with, continuing to improve, to manage outcomes and costs. I think that what you're going to see here in the future specifically is the inaction of more value based care. So there's going to be more shared risk that we're seeing as a hospital in preventing patients from getting sicker or getting admitted to the hospital. And I think that you're going to see a shared risk model with that and more and more emphasis on value based care. So I can see physician advisors really stepping into that role and working. You know, the clinic, we're robust enough where we actually have a value based Care team, but not a lot of other hospital systems have that. And so I think that that when you start seeing some of these things that were passed five to 10 years ago, they're starting to take more and more into effect downstream with Medicare. I feel that is a huge future for the physician advisor role. And I think population health is going to continue to be something that we really look at and then obviously technology. Right. So I mean, I think a lot of the things we do as physicians, physician advisors, as a health system are going to be augmented by technology and it's going to occur at a faster pace than ever in the history of healthcare in America, certainly. So I think that those three things will continue to be important things to look out for for the physician advisor role.

Dr. Meana Gerges

I couldn't agree more. And growth. I also see the college growing exponentially as well.

Dr. Tony Tizzano:

Yeah. Considering where it was in 2014, I think you said to where it is now, it's on a logarithmic growth.

Dr. Meana Gerges

Yeah, absolutely.

Dr. Tony Tizzano:

So for either of you, are there any other thoughts or questions that I didn't pursue that you feel are important for our listeners to know?

Dr. Nicholas Libertin:

I would say another shout out. Like Mina had mentioned, our Cleveland Clinic Physician Advisor conference which is going to be in late October. We have a lot of great speakers that are lined up and if you're a member of the staff here, it's obviously free. If you're external, it's a very nominal fee and it's all remote and you can obviously learn more information about the career path. But then also it's I think an eye opening conference. And yeah, I mean it does a great job with it every year. So.

Dr. Tony Tizzano:

So would this help to give an idea of the services so that virtually any physician might enjoy going to this and take something away from it that's a value?

Dr. Meana Gerges

Yes, absolutely. This is a multi specialty conference. It is a national conference. It will be on October 29th again in partnership with the American College of Physician Advisors. It's an all day conference, excellent speakers. Would love to have you join.

Dr. Tony Tizzano:

Wow. Maybe I can come and give us some ideas for some more podcasts. I mean, it's always there, always.

Dr. Nicholas Libertin:

Well, that'd be great. Yeah.

Dr. Tony Tizzano:

Well, Nick and Mina, I really want to thank both of you. This has been a very thought provoking and wonderfully insightful podcast to our listeners. If you would like to suggest a medical education topic to us or comment on an episode, please email us@educationcf.org thank you very much for joining. We look forward to seeing you on our next podcast. Have a wonderful day.

Dr. Meana Gerges

Our pleasure. Thank you so much.

Dr. Tony Tizzano:

You're so welcome.

Dr. James K. Stoller:

This concludes this episode of Med Ed Thread, a Cleveland Clinic education podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to Med Ed Thread and please join us again soon.