New Considerations for Developing a High-Performing Hospice Medical Staff

Beginning January 1, 2011, face-to-face recertification visits with hospice patients will no longer be simply good practice. The Centers for Medicare and Medicaid Services ("CMS") has implemented certain provisions of the Patient Protection and Affordable Care Act of 2010 and regulates that such visits become mandatory.


Face-to-face encounters may not occur earlier than 30 calendar days prior to the start of the benefit period for which it applies. Certifications may not occur earlier than 15 calendar days prior to the start of the benefit period for which it applies. A required face-to-face encounter must occur prior to its associated certification.

This requirement will better enable hospices to comply with hospice eligibility criteria, and to identify and discharge patients who do not meet those criteria. How to best comply with this regulation will be a determination made upon specific circumstances of each hospice's medical staff, including:

•      variability in clinical commitment of current staff, including nurse practitioners
•      nonclinical commitments that may include administration, teaching, and research
•      productivity data to analyze MD capacity to absorb additional volumes

Several points to keep in mind as you develop a plan to comply with the requirement:

• The face-to-face encounter by the hospice physician or the NP for the purpose of gathering clinical findings to determine continued eligibility for hospice care is NOT billable. The face-to-face requirement is part of the recertification process, and therefore is an administrative activity included in the hospice per diem payment rate.

• The certification or recertification of terminal illness is not a clinical document, but instead is a document supporting eligibility for the benefit and is considered an administrative activity of the hospice physician.

• Providing reasonable and necessary non-administrative patient care services during the face-to-face encounter is billable: If a physician provides reasonable and necessary non-administrative patient care, such as symptom management, to the patient during the visit (for example, the physician decides that a medication change is warranted), that portion of the visit would be billable.

• Billing for medically necessary care provided during the course of a face-to-face encounter should flow through the hospice and be billed as physician services under Part A, as the hospice physician or NP who sees the patient is employed by or, where permitted, working under arrangement with the hospice (for example, a contracted physician).

• If there is a billable portion of the visit, hospices must maintain medical documentation that is clear and precise to substantiate the reason for the medically necessary services separate from the face-to-face encounter related to recertification. Documentation of the face-to-face encounter and any other medically necessary patient care services provided during the visit can be included in one note. Visit documentation should, of course, clearly support any billable services that were provided.

• Medically necessary care provided during the course of a face-to-face encounter by an NP can be billed only if the NP has been designated as the patient's attending physician.

• There is no requirement that the visit must take place in the patient's home---- it could take place in practitioner's office.

• Electronic signatures are permitted on hospice certifications and recertifications. Narrative and the face-to-face attestation are parts of the certification or recertification and may also be signed electronically.

• Use of telemedicine to perform the visit is not permitted.

• Attendings cannot do the face-to-face visit without becoming a "hospice physician".

Much to consider, to be sure. 

An APCO Developing in Asheville?

In a recent post (read here), I commented about the exemplary results of Asheville, North Carolina in the DAI Community Palliative Performance Profile. To learn more, we interviewed Janet Bull, MD, VP of Medical Services for a not-for-profit hospice (Four Seasons) serving the Asheville area.

Some excerpts:

"We are very heavy in physician staffing, and think that is a good real positive," with the physicians mainly out making billable visits to hospice patients and serving as attendings or consultants on about 80 percent of patients enrolled in hospice care, she explains. "They actually paid for themselves last year."

Essential to the palliative care program's success was being clear on what kinds of patients it would see -- or not see. Dr. Bull continues, "We learned early on that we can't be all things to all people. We didn't want to be a chronic pain service or post-acute, post-surgical consultants. We wanted to stay focused on serious, advanced illness, generally for patients with three years or less to live. At Four Seasons, we are all about delivering quality care and looking at measurable outcomes. We take our patient and family satisfaction surveys very seriously.The program emphasizes continuity of care across care settings. From the get-go, we saw patients where they were, and we followed them from one setting to the next."

Integrating the hospice and palliative care departments was also a priority. "Many organizations bump up against the problem of palliative care being viewed as a step-child to hospice. Here we value the great things palliative care brings, and how it complements hospice," Dr. Bull says."We consider ourselves one big team, whether palliative care or hospice, with a lot of interface between the two. Patients can flow both ways between these programs. We used an explicit strategy of building the connections between the two. Some employees serve both programs, and we share resources and administrative tasks, integrating them whenever we can," she reports. "Often at staff meetings we'll have presentations by palliative care leadership or providers, explaining their work to hospice staff. We focus on education, both internally and externally, explaining the differences between hospice and palliative care, and how they complement each other. We inform patients that hospice offers many more services than palliative care."

Seems to me that what we're seeing in Asheville is the early development of an Accountable Palliative Care Organization, led by a chief palliative care officer for the community. Surely, there are other factors contributing to Asheville's performance, but just as surely one cannot underestimate the value of a strong and well-developed medical staff of HPM specialists.

Emerging Role of Palliative Medicine Physicians is Straining Hospice Relationships

I've been intrigued recently by the spate of articles and seminars concerning themselves with the relationships between physicians and hospitals. Of course, hospital-medical staff relationships have been contentious for years, and consultants advising hospital executives on the most effective ways to align physician objectives with hospital goals is hardly a recent development. So, what do I find intriguing? That similar concerns are surfacing with greater frequency among hospices and palliative medicine physicians, as hospices build their medical staffs and expand the role of physicians within the hospice's clinical and administrative activities.

What we're seeing can best be described as role drift, where there is a disconnect between what the physician sees as his/her role, and what the executives and/or other clinical staff see as the physician's role. Such role drift is magnified in those palliative care organizations where resources are strained. I don't mean to oversimplify, but one will generally find fractious relationships in organizations where the HPM physician does not have:
-Clear roles, responsibilities, expectations and accountabilities
-Well-established performance measures and standards
-Performance management system that tracks performance and offers feedback.

I'm curious to hear your experiences, and what methods you've used to build a high-performing hospice medical staff.

Building a Hospice and Palliative Medicine (HPM) Medical Staff

A former colleague with many years of hospital executive experience recently accepted a position as the chief executive of a mid-sized, not-for-profit hospice (115 ADC). Upon review of employee staffing, she noticed that the hospice had half-dozen "arrangements" with physicians (with varying commitments but all under 15 hours per week) to provide largely unspecified clinical and administrative services. She asked if medical staff planning customary in hospitals had applicability and relevance for hospices. Of course, I replied, the "planning process" has great relevance, although there are several differences in scope and scale.

To prepare a Hospice Medical Staff Development Plan, we follow a systematic five-step process:
Step1 – analyze HPM professional fee billings and Activity/Effort reports and job descriptions for physician roles,
Step2 – conduct interviews with key stakeholders (including all physicians practicing HPM in any capacity and commitment),
Step3- compile Hospital and Community Palliative Performance Profiles using Dartmouth Medical Atlas,
Step4 – review Hospice strategic plan and contracts/agreements between the Hospice and physicians,
Step5 – using Responsibility Charting process, define professional expectations, metrics, and accountability.

Through this five-step process, we gain insights that address the most common questions posed by hospice executives (administrators and physicians) about medical staff development: To what extent may nonphysician providers be used to meet additional clinical demands?When will additional physician staff be needed, and what are the anticipated time requirements to recruit these individuals?When should recruitment occur given practice ramp-up time and total recruitment budgets?Are there sufficient resources and the political will to build a hospice-sponsored HPM physician group?In what communities and health provider sites do we place physicians to meet our organization’s strategic objectives?

Are there other questions regarding building of a medical staff on your minds? I invite your comments on what challenges each of you face in building a hospice medical staff?

Hospice Medical Staff Development Plans

Trained as a hospital administrator, and having worked in hospital executive positions, I've seen the power of careful and timely hospital medical staff planning in furthering a hospital's commitment to its community's health. Effective medical staff development offers other benefits to the hospital, not the least of which, I've found, is that a link will be created between the physician recruitment campaign and the hospital's strategic plan and its growth objectives.

So, I've wondered frequently since my career headed into the palliative care field, would medical staff development plans (MSDPs)for hospices produce similar benefits? My experience suggests that they would. As hospices move beyond their traditional role of serving terminally ill patients who have elected to use the hospice benefit, and toward a leadership role in shaping end-of-life care throughout their communities, the role of the hospice’s physician staff is being redefined. Hospices are evolving into advanced palliative care organizations in which care spans organizational and professional boundaries, while integrating physician services into a traditional nurse-centric organization, and simultaneously adopting a collaborative model. Such a convergence will, unsurprisingly, strain an organization’s resources and its roles.

At their best, MSDPs are an objective quantification of community need on a palliative care basis. The challenge, we've learned, is identifying a standard for staffing of programs. In developing a plan, we consider the following:
-Variability in clinical commitment of current staff
-Presence and clinical role of providers such as NPs and PAs
-Presence of academic practices that may include teaching and research
-Productivity data to analyze MD capacity to absorb additional volumes

So what can a Hospice MSDP offer to the executive leadership of a hospice?
An assessment of community practice around end-of-life care to identify improvement opportunity, and to translate community needs into physician staffing requirements and associated financial commitments. An assessment of the hospice's current capacity, the identification of competencies that are likely to accelerate growth, and the creation of practice opportunities that attract talent and fill competency gaps. Armed with this information, hospice executives are solidly positioned to make a difference in the palliative care practices within their community.

I'm confident that other hospice execs have had related experiences. I'm curious to learn your feedback.