ARTICLE IN BRIEF
Financial viability can make or break a neurology department in an academic medical center. In the first summit for neurology chairs, organized by the AAN, neurology chairs shared their frustrations and solutions for addressing the challenges of the job.
The pressures of leading an academic neurology department today are not for the faint of heart, one neurology chair at a major academic center told a group of attendees at the first summit for neurology chairs convened by the AAN in March.
“We are responsible for patient care and clinical productivity; service to the institution including committees, panels, and hospital medical staff; and for orchestrating the education of our students, residents, and fellows,” John D. England, MD, FAAN, professor of neurology and chair of the neurology department at the Louisiana State University Health School of Medicine in New Orleans, said. “It's a ruthless environment and if you don't look out for your department, no one will.”
Indeed, he said, success boils down to this oft-quoted business adage, “No money, no mission.”
In round-table and panel discussions, presenters and participants alike voiced these themes: The neurology chair must be a financial steward and manager, a business leader, a fundraiser, negotiator, and all-round go-between between clinical staff and hospital administrators. And mastery of these roles could make or break a neurology department in the larger academic medical center.
“Neurology departments and their financial viability are important to all of us,” said the AAN Education Committee Chair A. Gordon Smith, MD, FAAN, the incoming chair of the department of neurology at Virginia Commonwealth University, and one of the summit organizers. “While not all neurologists practice in academic settings, all of us are academic neurologists at one point in our career.”
The meeting had been organized, he said, to identify opportunities to support the shared departmental missions of education, research, and care delivery. The chairs had prioritized their top concerns from a list of 13 issues sent before the meeting. [For more about the meeting, see “Nearly 100 Chairs Attend the First Summit.”]
Financial viability was a universal concern. Toward that end, Dr. England cautioned chairs who were operating in the red: “Don't run your department into a deficit — it's a sure way to get removed.”
Dr. England urged them to negotiate and to seek formal contracts. “As I tell my young faculty members, the most certain way to not get a contract is to not ask for one,” he said.
Dr. England negotiates for education, research, and service dollars from the school of medicine and other institutions, and explained how important that is in order to cross-subsidize members of his department, especially his general neurologists who are not as well reimbursed as most subspecialists for their services.
“They could see patients seven days a week and still not meet their salaries in revenue,” he said. “You need to demonstrate the value of neurology to those you are asking for support from and you need to provide the service and demonstrate the importance of neurology as a specialty destination.”
Dr. England also stressed the need to quantify “downstream revenue,” one of the most frequently echoed sentiments at the summit. These data, which include items such as neuroradiology and laboratory orders, surgery, and other referrals, are needed to make the case to hospital administrators for the transfer of resources to neurology. Indeed, it was the number one issue — chosen most often from the list of 13 choices of topics by the 61 chair respondents to the pre-summit survey.
These data, which strengthen the argument for financial support, are not always available from administrators. At breakout sessions, some chairs shared their strategies and successes, while others voiced frustration at not having access to the data from administration at their institutions.
WORKING WITH HOSPITAL ADMINISTRATORS
“Relationships with hospital administrators can be challenging,” said David M. Greer, MD, FAAN, chair of neurology at Boston University School of Medicine and chief of neurology at Boston Medical Center. “They are often non-physicians in suits and can seem to be out of touch with what's important clinically. It's easy to be antagonistic, but you need to build these relationships,” he advised. “They make an investment in the chairs, and it's important to understand that they are not your enemy; if you start with that kind of attitude, you are not going to make it.”
“They want you to be successful,” he added. “It's all about having effective communication, and having your department understand that it's best to establish mutual goals with the hospital, as well as the medical school.”
“We need to look at downstream revenue very carefully,” said Carlo Tornatore, MD, chair of neurology at Georgetown University Medical Center. In managing his department, he said he follows the advice of his grandmother, who counseled him at an early age by saying, “The world is a cruel place, no one is going to take care of you — you need to take care of yourself.”
To this point, he predicts that in the next few years, patients are going to be driven out of large institutions, health care will be decentralized, and facility fees will go away.
CODING AND BILLING
“We need to focus on the low-hanging fruit: coding and billing,” Dr. Tornatore said. “In our department, we found that there was a lot of leakage of revenue with incorrect billing. Centralized billing is completely unreliable and lacks a feedback loop.”
He advised attendees to get a revenue cycle manager, as his department did, and to focus on high-yield codes such as those for chronic care management and transitional care management. One strategy the revenue cycle manager introduced was low-tech: laminated blue cards that instruct faculty on how to code properly for these higher revenue CPT codes. The department was able to recoup over $300,000 dollars a year by bringing in an expert who was able to focus on correct coding for neurologic services.
S. Andrew Josephson, MD, FAAN, professor and chair of neurology at the University of California, San Francisco School of Medicine led a breakout session on the subject of maximizing billing. “Increasingly, financial models in academic departments regarding clinical income are dependent on productivity and therefore, billing and coding,” he said, “and as a result, chairs are increasingly focused on this aspect of clinical care.”
He pointed out that the AAN is continuing to work on identifying coding and billing best practices for academic and community groups alike and disseminating them broadly. “There are specific challenges unique to academic departments including shared note writing with house staff, large inpatient services, and management of funds with health systems and research enterprises,” he said, adding that sharing best practices among chairs will be a key step going forward.
SOURCES OF REVENUE
Neurology departments are also searching for new sources of clinical revenue and ways to diversify their business opportunities. Several speakers focused on adding service lines such as interventional neurology, infusion services, stroke centers of excellence, and telemedicine services. Dr. England noted, for example, that he successfully negotiated a contract for teleneurology services to the Louisiana State Penitentiary, a maximum-security prison farm in Louisiana known as “Angola.”
Claudia F. Lucchinetti, MD, FAAN, chair of neurology at Mayo Clinic in Rochester, MN, said: “Neurology and neurosurgery at Mayo work closely together in an integrated collaborative model to provide subspecialty service line care for patients with brain tumors, epilepsy, spine disease, and neurovascular disorders.”
Frances E. Jensen, MD, FACP, FAAN, chair of neurology at the University of Pennsylvania, said that using advanced practice providers (APPs) productively across service lines is important. Asking the audience for a show of hands as to how many employed APPs yielded a near unanimous response. But only a few people raised their hands when she asked how many used APPs maximally. “There is a gap there,” she observed, explaining that each professional needs to operate at the top of their license for maximal efficiency.
RECRUITMENT/THE NEUROLOGY PIPELINE
A common concern — tied for second place in the survey — were trepidations about the neurology pipeline, recruitment, and future of research funding. “I am particularly concerned about the future of neuroscience research,” said Natalia Rost, MD, MPH, FAAN, FAHA, chair of the AAN Science Committee. “In the current academic environment, there are scarce resources for the development and support of robust research programs at the department level.
“Neurology department chairs are possibly the most influential segment within academic neurology,” she continued, “with a broad impact on the educational, research, and clinical practice standards in the field. At the same time, they are faced with the multitude of challenges including but not limited to the ever-changing health care environment, research funding cuts, and neurology work force issues.”
Dr. Rost said she hoped that the summit would encourage more dialogue that would ultimately lead to developing tangible solutions in support of the future of academic neurology. These include developing strategies to help departments assist faculty to be successful in research, finding pilot funding, improving chances for success through mentorship, and ways to negotiate with our institutions to maximize recovery of indirect costs, Dr. Rost said.
“Recruiting a diverse faculty according to their activities and subspecialties, and also by race/ethnicity and gender, and retaining them are critical,” said Dr. Smith. The chairs also discussed how to recruit and integrate hospitalists into the department, how to recruit pure clinicians into the department to help meet the clinical demands, and how to use outreach to increase diversity in faculty recruitment and in the training pipeline.
“While education is in many ways our central mission, it is underfunded at most institutions,” Dr. Smith said, “and there is often inadequate financial support available for medical educators. Neurology department chairs often have to find creative solutions to adequately fund their teaching faculty.”
Indeed, participants shared many creative ideas about how to approach their numerous challenges. Two recurring themes, Dr. Smith observed, were the need for better data and the opportunity to build a community between chairs to share experiences and solutions, both objectives with which he believes the AAN can help. “My hope is that the summit will be the beginning of an enduring initiative to support academic departments of neurology in collaboration with the American Neurological Association [ANA] and the Association of University Professors of Neurology [AUPN],” Dr. Smith concluded.
NEARLY 100 CHAIRS ATTEND THE FIRST SUMMIT
What worries your neurology chair most? On the first Monday in March, fortuitously wedged between two Nor'easters, I flew to O'Hare to find out. There, at an airport hotel, the first Neurology Chair Summit was being convened to brainstorm ideas and share solutions for issues threatening neurology departments. Nearly 100 of the nation's 140 or so adult neurology chairs were in attendance.
The concept, which had had been considered for some time by the AAN, gathered steam in June of 2017 at a joint Science and Education Committee meeting. Within two months, a work group had been formed, chaired by AAN President Ralph Sacco, MD, MS, FAHA, FAAN, chair and professor of neurology at the University of Miami Health System.
The 12-member team comprised nine other chairs including the AUPN President Karen C. Johnston, MD, MSc, and ANA immediate past President Barbara G. Vickrey, MD, MPH, FAAN, as well as the AAN Science Committee Chair Natalia S. Rost, MD, MPH, FAAN, FAHA, and Education Committee Chair, A. Gordon Smith, MD, FAAN. The work group met frequently and together developed a list of potential topics of interest. They then polled department chairs to see which of 13 topics — comprising multiple challenges — were most dire, so they may be able to discover innovative solutions to the problems they face.
All in all, participants came away expressing the hope that this summit was the beginning of many more collaborations. Dr. Sacco, for one, agrees. As he was riding the airport shuttle en route to the summit, he sat with two neurology chairs from the same city, who had never before met. “This encounter exemplifies why we wanted to host this meeting,” said Dr. Sacco. “We wanted to bring chairs together to share best practices and work collaboratively to come up with solutions for the problems facing all of us in academic departments.”
—Orly Avitzur, MD, MBA, FAAN