Role of the Hospice Medical Director

1. Role of the Hospice Medical Director Michael Paletta MD FAAHPM Hospice of Michigan Maggie Allesee Center for Quality of Life

2. Overview • Qualifications • Organizational Standards • Clinical Standards • Community Relations • Education and Research • Supervision & Oversight • Administration / Management • Regulatory responsibilities

3. Qualifications

4. 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 IDT • Able to collaborate with referring and consulting physicians

5. 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

6. Qualifications: Ongoing • Completes orientation process • Continues to meet requirements set out in job description • Submits to annual competency assessment where applicable • Earns at least partial % CME in H&PM • Achieves board certification in H&PM

7. 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 elevate • Public reporting requirements will add visibility to physician credentials

8. Organizational Standards

9. 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

10. Clinical Standards

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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.

17. 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

18. 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

19. 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 GIP • Document visits in timely fashion and bill M-A and M-B as applicable, using appropriate CPT codes

20. 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

21. Community Relations

22. 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

23. Education & Research

24. 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

25. Supervision & Oversight

26. 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

27. 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

28. Administration & Management

29. 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

30. 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

31. 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

32. Compliance AMDs must contribute to program responses to: • Administrative law judge reviews • Pre-payment probes • Additional development requests (ADR) • Targeted medical reviews (TMR)

33. 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

34. Endangered species.. • “Doughnut doctors” • Volunteer medical directors • Untrained, non-certified hospice MDs • Unlicensed hospice MDs • Paid medical directors with no duties • ECF / home care physicians “designated” as hospice MD

35. Resources • American Academy of Hospice and Palliative Medicine • Center to Advance Palliative Care • The Cochrane Library • National Hospice and Palliative Care Organization • Michigan Hospice and Palliative Care Organization

36. Questions / Comments Michael Paletta MD FAAHPM VP Medical Affairs / CMO Hospice of Michigan