Should you be flexible when privileging low- and no-volume providers?

With the rise of hospitalists, ambulatory surgery centers, and endoscopy suites, almost all hospitals find themselves confronting a growing number of low- and no-volume providers. At the same time, regulators have raised the bar regarding the need to link privileges with demonstrated current competence. The challenge is that low- and no- volume providers by definition do not provide enough evidence of their competence when caring for hospitalized patients.

One of the strategies hospitals commonly use is to grant low- and no-volume practitioners refer-and-follow privileges. Granting refer-and-follow privileges meets some insurance companies’ requirements for providers to maintain membership or privileges on a medical staff. This approach allows the hospital to not have to perform peer review, including OPPE and FPPE, because the provider is not authorized active privileges.

Although many hospitals find this approach helpful, it may not solve all of your low- and no-volume provider challenges. What about physicians who feel angry, insulted, or otherwise injured by the hospital reducing their privileges, making them feel the hospital is not physician friendly? This is not the outcome CEOs want for the primary care physicians who are an important referral source for the hospital, especially if their unhappiness makes them vulnerable to competitors recruiting away their referrals.

Another challenge arises due to the increasing number of women in medicine who seek to balance the demands of medical practice with the desire to raise families. Alternately, more fathers are taking an active parenting role and may require the same family leave time traditionally granted to women. When parents who have taken a number of years off to stay home with their children wants to return to practice, will they only be eligible for refer-and-follow privileges because they cannot demonstrate current competence? Will your hospital demand that they complete a mini-residency, even if these programs are hard to find and often require the physician to move to a different city? Such an approach is not physician friendly, and it creates barriers to physician recruitment and retention at a time of increasing physician shortages.

These examples make it clear that medical staff leaders and MSPs responsible for credentialing need to become more flexible and creative in developing new approaches for addressing low- and no-volume providers. One example of such flexibility is to offer low- and no-volume physicians dependent privileges, not independent privileges. Dependent privileges require another practitioner to participate in the care of patients. Examples of such participation include co-management of patients, mandatory consultation, or another physician assisting in surgical procedures.

For practitioners returning from time off to raise children, the need for dependent privileges will be temporary because the hospital should be able to gather enough peer review data for the practitioner to shift to independent privileges (assuming the peer review data is positive) fairly quickly. For primary care physicians who refer to the hospitalist program but don’t want to give up their privileges at this time, they will have few or no patients in the hospital, and so will generate little or no peer review data. They would continue to have dependent privileges until such time as they resume active inpatient practice and can generate adequate peer review data to demonstrate current competence. At that time, the hospital can grant them independent privileges. Using dependent privileges therefore becomes a flexible tool to accomplish the hospital’s goals of being physician friendly while protecting patients.

This approach is not perfect because it creates additional challenges. For example, how will physicians who provide supervision or co-management of patients with the low-volume provider be reimbursed for their services? They may be able to perform a consultation for which they could be reimbursed. Another option is for the consulting physician to receive the primary surgeon’s fee, and the low-volume physician to receive the first assist’s fee, or vice versa. It may be that the low- or no-volume practitioner must forego billing for their services for the first few patients they treat in the hospital to secure the assistance of another physician in the care of these patients. Whichever of these approaches your organization uses, it should place the burden on the applicant to obtain the necessary supervision or co-management services.

Another challenge is determining what role the low-volume provider will be allowed to play in caring for patients and how much supervision or co-management will be required. Once this is determined, ensuring that adequate supervision or co-management is carried out becomes yet another challenge.

The goals of a low- and no-volume provider strategy include creating a physician-friendly approach that allows the hospital to achieve its strategic goals for growth and physician recruitment and retention while ensuring safe patient care. As the examples discussed demonstrate, one of the keys to implementing a successful low- and no-volume provider strategy that goes beyond refer-and-follow privileges is to be flexible and creative.

For a more in-depth discussion of a step-by-step approach to low- and no-volume providers, you may wish to read The Greeley Company’s free White Paper, Low Volume/No Volume Practitioners: Best Practices for Competency, Privileging, and Strategy.

Richard Sheff, MD, CMSL, is chair and executive director of The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.