The Alphabet Soup of Premier Health Utilization Management

By Robert Morrison, MD, associate chief medical officer, Miami Valley Hospital, Premier Health physician advisor

Caring for patients will always be the primary role of physicians, but delivery of health care is more complex now than ever. Getting the right care at the right time to the patient requires a plethora of specialized caregivers that not long ago were unheard of and unnecessary. As usual, you can’t tell the players without a scorecard, so here is a walk through the raft of people who are there to help you take care of your patients' needs in the hospital and beyond:

The Chief Medical Officer (CMO)

A CMO is a physician who is also a hospital executive and part of the leadership team. The CMO is responsible for the quality of care in the hospital and has domain over the Medical Staff Office, the Quality Department, and the Regulatory Department. This position is charged with ensuring patients get timely, evidenced-based care from the finest physicians available, and as such is involved in credentialing and privileging. The CMO works with the chief of staff and department chairs to maintain focused and ongoing professional practice evaluations, and is a member of the Medical Staff Quality and Executive committees. They are on-point when CMS, ODH, and Joint Commission surveyors come to the hospital. They also help define business strategy and direction for the hospital operations team, and work closely with the CEO and COO to implement that strategy.

The Associate Chief Medical Officer (ACMO)

The ACMO at Miami Valley Hospital is the “boots on the ground” physician executive out there every day in huddles and on the nursing units. The ACMO is responsible for length of stay, re-admissions, patient experience, and transitions of care. They are the face of the Executive Team to the staff, the patients, the families, and the medical staff. They are also the liaison between case managers, social workers, nurse managers, nurse directors, and providers. The ACMO is a facilitator, a problem-solver, and is a full member of the hospital leadership team. They constantly keep up with medical literature and attend clinical conferences to ensure best practice by the hospital and the system.

The Physician Advisor (PA)

The PA is concerned about every aspect of utilization of scarce resources. In the hospital setting, this includes utilization of space, time, people, clinical services, and supplies. The PA has an understanding of patient care work-flows, status assignment, utilization management, reimbursement, insurance issues, CMS regulations, denials management, standards of practice, length of stay, clinical documentation, coding, regulatory expertise, compliance, education, and informatics. Their global view makes them a valuable partner to physicians.

Case Managers (CMs) and the Director of Integrative Care Management (ICM)

Case managers are nurses who advocate for patients from admission to discharge, and sometimes after discharge. They work in the Integrated Care Management (ICM) Department and coordinate care; understand hospital processes; adhere to strict ethical and legal standards of care; manage length of stay; understand status (inpatient vs. outpatient); and work closely with all members of the team. The director has a matrix relationship with the CMO, the ACMO, and the PA that is critical to progressing patients through the health care system. Thirty years ago, nobody had heard of case management. Now, the hospital could not function without it.

Social Workers (SW)

Social workers are part of the ICM department and do way more than get your patient a bed in an ECF. They counsel patients and families, provide psycho-social support, and connect patients to community resources that will be needed after discharge. The Quebec Society of Social Workers states it best in their mission statement: “To restore balance in an individual’s personal, family, and social life in order to help that person maintain and recover his/her health and strengthen his/her ability to adapt and re-integrate into society.” What a high calling!

Clinical Documentation Specialists (CDS)

CDSs are nurses who read, assess, and review the patient’s medical record. They ensure the documentation reflects the patient’s severity of illness, intensity of service, and risk of death or an adverse event. They identify every condition that can be captured to paint the patient’s clinical picture correctly. They affect length of stay, reimbursement, cost of care, Case Mix Index, and DRG for the hospital stay. They translate clinical language into coding language, with huge benefits to our patients, the hospital, and the system.

The Center for Status Integrity (CSI)

CSI nurses read your notes and assist you by advising regarding the correct status, i.e. outpatient/observation or inpatient. They help determine the medical necessity of care in a hospital setting based on the severity of the patient’s illness, the intensity of service in the hospital, and the risk of death or an adverse event. They use evidence-based guidelines from industry-standard tools to help guide physicians to the correct level of care. They also write extensive reports to the commercial payers supporting the admission of patients, and participate in real-time and after-the-fact appeals of denial of coverage by the payers. Additionally, they work with the PA to rapidly escalate cases for secondary review, and they are an invaluable resource to the system for status determination, level of care, utilization management, and insuring fair reimbursement for hospitals and providers. This department’s functions are mandated by CMS, so CSI staff are experts in meeting the CMS regulations regarding status and utilization review.

The Utilization Management (UM) Committee

The UM Committee is required by Medicare under the Conditions of Participation in the Inpatient and Outpatient Prospective Payment Systems. This committee is chaired by the CMO, has oversight of all the players listed above, and is responsible for every aspect of care in the hospital: status management, length of stay, re-admissions, insurance issues, CMS and other regulations, and resource utilization. It is a physician-led group that reports to the Medical Staff Executive Committee. If you are looking for a committee to serve on that can affect every aspect of care for your patients, this is the one. It can function as a peer-review body that is only surveyed by CMS. The goal of this committee is to eliminate waste; optimize utilization; provide a protected venue to look at aberrant practice patterns; and improve the health of the hospital, which will improve our patients’ and community’s health.

There you have it – a dedicated team of professionals whose unified goal is providing excellent and efficient care for our patients and eliminating wasteful practices. Doing so ensures the continued health of our hospitals and the health system, so we will have state-of-the-art gleaming facilities that provide the highest quality care now, and in the years to come.

The next time someone in any of these positions calls you, sees you in a huddle, or talks to you on the floor, remember that their interests are the same as yours – they always keep patients at the center of their work. Thank them; manage them up to your patients and families; talk to them; take their advice in the spirit it is given; seek their help; be kind to them; be cognizant of their (often) difficult situations; and admire their ability to guide our patients through the quagmire that our health care delivery system has become.

Take care, and thank you for everything you do for your patients.

Robert Morrison, MD

Dr. Morrison (retired) served as the associate chief medical officer at Miami Valley Hospital and a physician advisor for Premier Health. 

Back to the July 2018 issue of Premier Pulse