Role of the Hospice Medical Director

Michael Paletta MD FAAHPMHospice of MichiganMaggie Allesee Center for Quality of Life

Overview

QualificationsOrganizational StandardsClinical StandardsCommunity RelationsEducation and ResearchSupervision & OversightAdministration / ManagementRegulatory responsibilities

Qualifications

Qualifications: Initial

MD or DO degree with license valid in state where hospice operates

Board certification by ABMS primary board, or DO equivalent

Experience in care of terminally ill* Demonstrated ability to work with IDTAble to collaborate with referring and

consulting physicians

Qualifications: Initial

Able to qualify for appropriate liability coverage

Administrative directors should have additional medical management experience, e.g.--

Budget process

Fiscal intermediary relations

Pharmacy issues

Qualifications: Ongoing

Completes orientation processContinues to meet requirements set out

in job descriptionSubmits to annual competency

assessment where applicableEarns at least partial % CME in H&PMAchieves board certification in H&PM

Qualifications: Certification

November 2012 is last sitting for exam toward H&PM certification for alternate pathway candidates

Eligibility for certification will thereafter require fellowship training

Practice standards will elevatePublic reporting requirements will add

visibility to physician credentials

Organizational Standards

Program requirements

Hospice medical director coverage must meet clinical and administrative needs and be proportional to census

Job description must fully describe and delineate roles and responsibilities

Organizational structure must support medical director’s role

Clinical Standards

Certification

Medical directors certify prognosis at admission

Section 418.22 of the Medicare hospice benefit stipulates that written certification of prognosis and eligibility be completed by both the attending (referring) physician and the hospice physician

Certification

The medical director is allowed to certify based on information collected by a nurse from the referring doctor

The RN may admit pending approval for straightforward cases; must consult with MD where uncertainty exists

Physicians are held responsible for acquiring clinical data needed to decide

Re-certification

Medical Directors recertify patient prognosis at appropriate intervals

The IDT conference is a forum for discussion, but, the responsibility attaches to the medical director

The medical director must ask for additional data (labs, records) if the prognosis remain unclear, and visit the patient when appropriate

Re-certification

If the medical director cannot in good faith affirm the prognosis to be 6 mos or less, the patient must be discharged

The physician may delegate, but is responsible for, the plan of transition from hospice care back to the primary care doctor

Face to Face Encounters

CMS now requires every recertification after 179 days of hospice care be preceded by a physician visit called the face to face encounter (FTFE)

FTFE is an administrative, not a clinical duty, and therefore falls under the per diem rate of the MHB. Physicians cannot bill separately for FTFEs

Face to Face Encounters

Persons seeking hospice care who had a prior episode of MHB service must also have a FTFE prior to admission.

Physicians who uncover a new medical problem during the course of a FTFE may bill under E&M codes for the portion of the visit that deals with that issue. The FTFE documentation must be separate and distinct from the E&M.

Care Planning

Medical directors manage pain and other symptoms in accordance with palliative standards of practice

They teach principles of palliative medicine to all IDT members when appropriate

They serve as liaison to community physicians for promotion of H&PM

Care Planning

Medical directors participate in the development and review of care plans as part of the IDT process

This requires:

Regular and full attendance at IDT

Availability to RNs during their visits

Willingness to contact referring doctors

Patient Visits

Medical directors visit patients in all applicable locations (home, ECF, hospital) when clinically appropriate and in accordance with a comprehensive plan of care

Daily visits for persons in GIPDocument visits in timely fashion and bill

M-A and M-B as applicable, using appropriate CPT codes

Clinical duties cont’d

Participate in performance improvement activities for their hospice

Manage pharmacy utilization for patients under their control

Participate in after-hours and weekend / holiday on-call duty to ensure 24/7 access to physician oversight

Participate in hospice ethics committee, if applicable

Community Relations

Advocacy

Medical Directors represent the values and mission of the hospice to the community

They educate community doctors on principles and practice of H&PM

Present at medical staff conferences and other medical education forums

Collaborate with ECFs that have hospice team relationships

Education & Research

E & R

Medical directors should enhance the clinical education of the hospice staff

They should join and participate in professional organizations related to H&PM

They participate in external medical and nursing programs in H&PM education

They may help develop and / or actively support research protocols in H&PM

Supervision & Oversight

Oversight

Administrative medical directors interview and approve hiring of doctors

Communicate expectations to physician candidates and be ready to answer Qs

Orient all new physicians, detailing their duties and responsibilities

Conduct competency and quality evaluations at least annually

Oversight

Hospice physicians may supervise RNs and advance-practice nurses (eg NPs) in their clinical duties

However, standards of practice are different for each discipline; physicians may not be familiar with nursing training and standards

Physicians cannot certify or testify about nursing standards

Administration & Management

Administration

Hospice MDs must have intimate knowledge of the Medicare hospice benefit, and have a feel for CMS policies & procedures

They must understand the policies of their fiscal intermediary (FI), and have a working relationship with their FI medical director

Admin & Mgmt

Administrative medical directors participate in developing yearly business plans for their hospice

They participate in the annual budget process for their program

They help develop and manage a pharmacy utilization plan

Admin & Mgmt

Medical directors help their programs prepare for survey by regulatory and accreditation agencies

They assist in response and negotiations with fiscal intermediaries and other third-party payors

They help establish physician credentialing processes for their hospice

Compliance

AMDs must contribute to program responses to:Administrative law judge reviewsPre-payment probesAdditional development requests (ADR)Targeted medical reviews (TMR)

Compliance

AMDs must assist program leaders confronted with (and share liability and culpability during):Recovery audit contractors (RACs) Zone program integrity contractors (ZPICs)Office of Inspector General (OIG) investigations

Endangered species..

“Doughnut doctors”Volunteer medical directorsUntrained, non-certified hospice MDsUnlicensed hospice MDsPaid medical directors with no dutiesECF / home care physicians

“designated” as hospice MD

Resources

American Academy of Hospice and Palliative Medicine

Center to Advance Palliative CareThe Cochrane LibraryNational Hospice and Palliative Care

OrganizationMichigan Hospice and Palliative Care

Organization

Questions / Comments

Michael Paletta MD FAAHPM

VP Medical Affairs / CMO

Hospice of Michigan