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