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Hospice Trends: Hospice medical director drives growth, success
Physician employee can provide billable visits
By Larry Beresford
Throughout its history, hospice care in America has suffered from intermittently strained relationships with physicians. Hospices obviously depend on community physicians for referrals and to sign medical orders, while Medicare regulations define essential roles for the hospice medical director as a core member of the team. But inconsistent or insufficient medical leadership of some hospice teams, coupled with occasional conflicts and misunderstandings with referring physicians, have left a lingering perception in some quarters that hospice is "anti-physician."
Such negative perceptions can impede hospice’s continued success, but one of the best ways to counteract them is through the active involvement of a competent, collaborative, respected hospice medical director. A full-time or significantly part-time medical director can help translate, mediate, and facilitate communication between the team and community physicians, as well as elevating the hospice’s overall professional practice and adding a complementary set of competencies to the interdisciplinary team. Hospice care and medical practice have both become too complex for hospices to expect to thrive today with a retired, volunteer, or very part-time medical director.
Although the physician’s services and time can be expensive to the hospice relative to other professionals on the team, many hospices today are failing to take advantage of the potential to bill Medicare and other payers for the hospice physician’s direct patient visits and thereby offset much of the expense of expanding his or her role on the hospice team. Some hospice programs may not even be aware that a physician employee of the hospice can provide billable visits to patients, suggests Charles von Gunten, MD, director of the Center for Palliative Studies at San Diego Hospice.
Physician billing requires the hospice to obtain a billing number from Medicare and master its technicalities, using the same fee schedules that community physicians already use. However, there is one key difference: Visits by hospice-employed physicians are billed to Medicare Part A and pay 100% of the allowable fee schedule, in contrast with attending physicians, who bill Part B and are paid 80% of allowable fees. Direct physician services provided by hospice employees are not included in the hospice’s per-diem rate but count against the benefit’s aggregate per-patient cap, although that is not likely to be a problem for most hospices.
Upgrading the medical component
A new report issued in June by the National Hospice and Palliative Care Organization (NHPCO) in Alexandria, VA, provides insights into how to enhance the physician’s role in hospice — and how to finance that expanded role through billable physician visits to patients. "Providing Direct, Billable Physician Services to Hospice Patients: An Opportunity to Upgrade the Medical Component of Hospice Care" profiles several hospice programs that employ one or more full-time physicians on staff and keep them busy making visits to hospice and palliative care patients at home, in nursing homes and hospitals, or at the hospice’s inpatient unit. It demonstrates how hospices can add full-time physician involvement cost-effectively and outlines the regulations and mechanisms under which hospices can bill for their doctors’ services.
"We believe there is a strong relationship between a hospice’s physician capacity and census growth," says Stephen Connor, PhD, NHPCO’s director of research. Connor says this correlation is supported by the experiences of a number of hospices that expanded their medical director component and then saw their census rise, "But it’s not just about census; it’s about increasing access and enhancing quality."
Expanded involvement in the hospice team by a physician who possesses appropriate clinical and interpersonal skills can enhance the quality of the hospice’s professional practice, raise its profile in the community, and bring peace of mind to homebound hospice patients who are unable to visit their attending physician’s office for a medical examination. To top it off, Connor says, some hospices are now offsetting all or a significant portion of the costs of their full-time physicians’ salaries by billing for their visits.
VITAS Healthcare Corp. in Miami has pioneered the practice of hiring full-time physicians and keeping them active as integral members of the hospice interdisciplinary team. Hope Hospice and Palliative Care of Fort Myers, FL, employs nine salaried staff physicians to care for its census of 650 patients, with plans to hire a tenth. Hope Hospice credits its growth in part to the direct involvement of physicians on the team. San Diego Hospice, which operates significant research, training, and medical school programs through its Center for Palliative Studies, employs ten full-time physicians and four fellows. Pike’s Peak Hospice in Colorado Springs, CO, saw its patient census grow from 90 to 225 patients in the 2½ years after the hospice hired a full-time medical director.
The number of physicians working full- or half-time in hospice has grown in recent years, along with the number of physicians certified by the American Board of Hospice and Palliative Medicine. As the NHPCO report makes clear, the benefits of full-time hospice physicians are not limited to the very largest hospices. An agency with a census of 50 could justify investing in an active medical director at half-time or more, because such involvement has been shown to increase both referrals and length of stay. Then the medical director could devote part of his or her time to visiting hospice patients in their homes. It may even be possible for several rural hospices in a region to share the services of a dedicated hospice physician.
However, for some hospices, the first challenge is to recognize the value of expanding the physician’s role and overcome lingering, unrealistic fears that greater physician involvement on the team risks turning interdisciplinary hospice care into a medically dominated model. For those inclined to question how they could afford to pay the salary of a full-time or significantly part-time physician, the real question is: How can they afford not to, if they intend to grow and thrive in an increasingly competitive environment?
"I would assert that when there is a physician member of the team who regularly sees patients, it strengthens the entire team, giving access to a broader knowledge base based on the physician’s training and an additional perspective that’s germane in very important ways," says von Gunten. Physicians intimately understand the culture that is inculcated in all doctors by nature of their arduous training — a culture that has sometimes mystified and frustrated hospice nurses. "If you take it as a given that such acculturation exists, the best way to deal with it is to have someone who speaks both languages and can bridge the two worlds."
It is important to hire the right doctor, one who can be a team player, von Gunten acknowledges. "The issue of balancing disciplines on the team is a challenge to all hospices, and balancing the physician member of the team is no different. The best way to balance the team is to insist that all members of the team are strong, not to enforce the weakness of some members. Adding the right physician can also be very supportive to other members of the team."
Roles for hospice physicians
Hospice physicians typically see themselves as consultants to the named attending physician on palliative pain and symptom management issues, reporting back their findings to the attending. They should possess the skills and understand the etiquette of consulting, von Gunten notes. They may visit patients with difficult symptom management needs, newly referred patients just discharged home from the hospital, hospice patients coming up for recertification with questionable prognoses, and palliative care patients who are not yet hospice-appropriate. Hospices with their own inpatient units may have the medical director visit every inpatient on a daily basis. However, the hospices with the most successful physician components strive to have every hospice patient visited by the medical director or other hospice physician at least once, preferably within a few weeks of enrollment.
Other roles for hospice physicians include:
In fact, says von Gunten, with a good hospice physician there’s the danger of mission creep — the desire to involve the doctor in all sorts of administrative and promotional activities that will get in the way of income-generating home visits. On the other hand, one of the consequences of the growing professionalism of palliative medicine is that there are now physicians out there looking for hospice positions. They won’t be found by advertising for them in the usual places where hospices recruit nurses, such as newspaper want ads, but they can be reached where doctors typically look for jobs, such as in professional journals and through professional associations.
[Editor’s note: NHPCO’s new report, "Providing Direct, Billable Physician Services to Hospice Patients: An Opportunity to Upgrade the Medical Component of Hospice Care", is now available on the members-only section of its revamped web site (www.nhpco.org) and is offered on CD-ROM for those who are unable to download it. Non-members should contact NHPCO’s Marketplace through the web site or at (800) 646-6460 for purchase information. A seminal article on physician billing for palliative services by von Gunten and Frank Ferris, "Procedure/Diagnosis Coding and Reimbursement Mechanisms for Physician Services in Palliative Care" (EPEC Trainer’s Guide, 1999) can be found on the web site of the Center to Advance Palliative Care (www.capcmssm.org/content/130/index.html?topic=4), which also offers other helpful resources.
Hospice Management Advisor Columnist Larry Beresford is a freelance journalist based in Oakland, CA, specializing in hospice, palliative, and end-of-life care. A former editor of Hospice Management Advisor, he has produced other hospice newsletters, including Hospice Manager’s Monograph and Hospice News Service, and has contributed to health care trade magazines. In 1999 and 2000 he was Senior Writer and Editor for the NHPCO and then was the primary researcher and author of Hospital-Hospice Partnerships in Palliative Care: Creating a Continuum of Services, a report jointly issued in December 2001 by NHPCO and the Center to Advance Palliative Care. Beresford also is the author of the definitive consumer’s guide to hospice care, The Hospice Handbook (Boston: Little, Brown & Co., 1993). Contact him at (510) 536-3048 or firstname.lastname@example.org.]