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What to do about low- and no-volume physicians

Credentialing Resource Center Connection, June 2, 2004

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Dear credentialing colleagues:

Allergists, dermatologists, family and internal medicine specialists, plastic surgeons, neurologists, and many other physicians no longer find it necessary to admit or treat patients in the hospital.

Credentialing professionals often refer to these physicians as low-volume practitioners and agonize over their reappointment. How can the hospital evaluate their competency? How can the facility meet the JCAHO's standards for "results of performance improvement and monitoring" without volume data? These physicians continue to apply for reappointment to the active category of the medical staff, but they are not truly active. Many of these physicians only want to be on the medical staff so that they can still participate in managed care contracting.

Credentials committees should consider the following:

1. Appointment issues must be kept separate from privilege issues. The first pertains to staff category, voting, and serving on committees. The later relates to competence and permission to treat patients. By-laws may be changed to deal with the first. However, the "competency equation" must be satisfied for the second. (See the March Credentialing Connection at http://www.hcpro.com/content/38133.cfm )

2. Not all low-volume physicians are the same. The following are typical of low- and no-volume applicants:

A. The provider treats a majority or all of his or her patients at another healthcare facility.  Evaluating their competency is much like evaluating a new applicant. Acquire references and volume and outcome information from the active site. For example, obtain references from that facility's chief executive officer, department chair, and director of medical records.

B. The physician is not clinically active at another hospital, but is active within the community, such as at an ambulatory center. They could clearly qualify for appointment to the staff (if permitted by the bylaws). Privileges would depend on evidence of competence in the specific area(s) requested. For instance, granting privileges to a low-volume allergist who wishes to consult for her colleagues, should be an easy issue. In this case, reference letters will suffice. However, it would be nearly impossible to grant privileges to perform complex surgery or treat complex medical cases to a physician who no longer engages in this type of work in any setting.

C. The physician has not practiced medicine for several years but wishes to remain part of the staff. These physicians occasionally make the mistake of requesting privileges.  Learn to "just say no" nicely.

When in doubt, fall back on a great credentialing principle: the burden is always on the physician to provide evidence demonstrating his or her competence -- no information, no processing, no denial.

The primary issue presented by low- and no-volume physicians continues to be that of patient safety. Don't grant independent clinical privileges unless the competency equation is solved.  Second, consider the issue of staff membership. In many instances, appointment without independent clinical privileges is a terrific solution.

That's it for today.

All the best,
Hugh Greeley
http://www.greeley.com/seminars/">http://www.greeley.com/seminars/

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