Is there a medical director in your agency’s future?
Maybe so, says home care physicians group
The time is right for the home care industry and physicians to realize they are on the same team, instead of regarding each other with antagonism and suspicion, according to the American Academy of Home Care Physicians.
One way to achieve that a way the Academy hopes the Health Care Financing Administration will soon mandate is by having a physician actively involved in your hospital-affiliated agency as medical director.
To that end, the Columbia, MD-based AAHCP has developed a program to train physicians for the role of home care agency medical director. And the AAHCP plans to approach HCFA in the future with a proposal to require all agencies to employ physician medical directors.
The AAHCP, whose stated mission is "to promote the art, science, and practice of medicine in the home," has about 1,000 members, says President Peter A. Boling, MD, associate professor of internal medicine at Virginia Commonwealth University’s Medical College of Virginia campus in Richmond.
Boling has been at the forefront of recent efforts to get Medicare to increase reimbursement for physicians who make house calls. Boling acknow ledges that the history of mistrust between doctors and home care agencies has contributed to the lack of physician involvement, but reimbursement also has been a big issue perhaps the biggest.
"Physicians need to make house calls to be efficient in home care," he says, "but the reimbursement fee structure under Medicare has been so discouraging to doctors, most have steered away from it."
Boling says the national reimbursement rate under Medicare is "between $50 and $60 for the most commonly used services. That’s fairly low. When you add travel, time with the patient who has complex problems, that’s 45 minutes at that level of care. Most doctors need $90 a visit to make it a financially viable activity, especially if they are office-based and pay a staff."
Led by Boling, the AAHCP recently proposed to HCFA a restructuring of the fee schedule under Medicare for doctors. "In 1998, if HCFA approves what we have sent forward, we stand to have a level of reimbursement that would actually encourage doctors to participate in home care by making house calls."
Boling says the proposal includes "comprehensive codes that never before existed to describe the sickest of the sick patients doctors are examining at home."
Training home care agency medical directors
Boling also was key in developing the training program for medical directors. "Through a national survey of primary care physicians in 1990, we found that 11% had participated as advisors or consultants to home health agencies," Boling says. The study was conducted with the assistance of the American Medical Association and the American Academy of Family Practitioners, and was published in 1992.
"We had 1,161 responses from family practice physicians and internal medicine physicians. The results indicated a high frequency of involvement by doctors in the process of home care in some capacity."
The study, and Boling’s own experiences as a member of House Calls, a Richmond-based team of three doctors, three nurse practitioners, a social worker, and a secretary that manages the care of 150 chronically homebound patients a year, led him to conclude that training would be needed.
In its two years of existence, more than 400 doctors have attended the 21¼2-day seminars, Boling reports.
The program is designed for small enrollment (120 per session) because "it is highly interactive, with a lot of cross-learning in the groups," Boling says.
Doctors receive 17 hours CME credit for attending, and Boling says the $900 fee is reimbursable.
"Cost of participating is actually an allowable training expense for the Medicare program," says Boling. "The agency can actually sponsor a medical advisor to attend the seminar and receive reimbursement for the cost."
Training certification also is in the works, Boling says. "We are going to be offering a certification program with exam leading to validation from the Academy that this person has the knowledge and skills as a medical director of a home health agency."
Boling emphasizes that all sessions are taught jointly by doctors with long experience in home care and other home health professionals. "It’s not just a bunch of doctors talking about stuff they don’t know," Boling says. "For example, we turn our quality improvement and rules and regulation track over to people from home health agencies because they know it better.
"The first session covers such home health basics as how an agency is organized, how it works, the rules and regulations," Boling says, describing the seminar. "And we have a sensitivity and interpersonal skills component, training doctors on how to be members of a team and being a liaison with other doctors in the community." Also covered are ethics, quality improvement, fraud and abuse, and Stark law issues, Boling says.
The second day is more clinical. "It begins with a plenary session with an inspirational speaker," Boling explains. "Then participants choose seven of 14 two-hour seminar options: wound care, respiratory therapy, terminal cases, nutritional care, AIDS care, etc."
Boling says the Academy sees a pressing need now for more physician involvement in home care. Historically, many doctors have eschewed home care because of time demands, compensation issues, and "the availability of nurses in the home who could be extensions of physicians," Boling says. But that is changing.
"Now we have started to use home care more aggressively, enrolling very sick patients in the process, employing sophisticated technologies in the home, and using home care as a vehicle to provide postacute services. Of course, shortened lengths of stays in hospitals are a factor."
Boling says some regulatory issues that plague agencies these days, such as claims denials or allegations of fraud, might be avoided if doctors become actively involved.
Don’t just go for the bucks
The key word is active. Hospital-affiliated agencies should not consider a physician a potential candidate for a medical director’s position based solely on referrals, Boling warns.
"Hospitals have to identify which of their physicians are most actively involved in home care. An agency will know who makes most referrals, but the trick is to identify doctors who are motivated to improve the quality of care. If you seek one solely on the basis of who makes the most referrals, and thereby supports your business, then you’re liable to pick someone who won’t function reliably as medical director. Sometimes doctors who make high referrals are great. They really know and like home care. But others who are making referrals because they are too busy at the office, well, that just doesn’t work."
Two important factors that must be considered in involving doctors with your agency, Boling says, are fair compensation and training. "Doctors need guidance about what they are supposed to do."
But above all, Boling advises, "Don’t get one just to fill the pockets of the agency."
[Editor’s note: Peter A. Boling, MD, is author of a newly published book, The Physician’s Role in Home Health Care (New York: Springer Publishing; 1997). It may be purchased for $46.95 by contacting the publisher at (212) 443-4370.]
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