Medical Directorship of a Home Dialysis Unit
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1 Medical Directorship of a Home Dialysis Unit Thomas A. Golper, MD, FACP, FASN Vanderbilt University Medical Center Nashville, TN thomas.golper@vanderbilt.edu Potential Conflict of Interest Disclosure: Honoraria or consultation fees received from Baxter Healthcare, DaVita, Fresenius North America, Genzyme
2 Summary/Outline Overview Specific Medical Director Duties Compensation Performance
3 The intersection of money and quality of care is the responsibility of the medical director
4 Dialysis Facility Economics Revenue - Expenses = Net Income or margin Managing margins 1. Decrease operating costs 2. Increase service volumes (e.g. 4 th shift) 3. New services 4. Re-value current services (convince payer to accept your price raise) 5. Share in generated savings (capitation) 6. Earn incentive payments
5 Dialysis Facility Economics Revenue - Expenses = Net Income or margin Maximize Reimbursement Manage Modality Mix Improve Accounts Receivable Payer Mix Increase Patient/Referral Base Acute Contracts Non-Dialysis Services (lab, access,etc) Manage Labor Expense & Staff Retention Manage Inventory Manage Administrative costs & Overhead Effectively Limit Capital Outlay In 2004 almost the entire operating margin came from injectable drugs, less so 2004 to 2010 and after 1/1/11, it changes as we go to bundling so see Finances module
6 Dialysis Facility Economics Revenue - Expenses = Net Income or margin Maximize Reimbursement Manage Modality Mix Improve Accounts Receivable Payer Mix Increase Patient/Referral Base Acute Contracts Non-Dialysis Services (lab, access,etc) Manage Labor Expense & Staff Retention Manage Inventory Manage Administrative costs & Overhead Effectively Limit Capital Outlay In 2004 almost the entire operating margin came from injectable drugs, less so 2004 to 2010 and after 1/1/11, it changes as we go to bundling so see Finances module For more details see module on Finances of Home Dialysis: Facility and Physician Payments
7 The intersection of money and quality of care is the responsibility of the medical director
8 Medical Director s Duties McMurray Neph News Issues July 2000, RPA 1996 Applicable in 2010 Approve policies and procedures Make sure nurses are adequately trained Assure QI programs in place Assure that all physicians in the facility comply with all ESRD Network, state, and federal mandates applying to dialysis facilities
9 2008 Conditions of Coverage: Obligations of Dialysis Facilities To Receive Medicare Payments Major change is a shift to be far more patient focused and far less process focused Many new duties assigned to medical director and the governing body Empowers medical director in his/her relationship to the governing body to plan, organize, conduct, and direct the professional ESRD services of the facility Lots of ensures
10 New C of C for Med Director Some ensures Ensures quality assessment and improvement program (QAPI) is effectively developed, implemented, maintained and periodically evaluated Ensures that all clinical staff (including physicians) actively participate in achieving performance goals Ensures that each pt treated at that facility achieves the best possible outcome Ensures that staff are adequately trained Ensure better outcomes Ensures that P & P are adhered to by staff
11 Medical Director Qualifications Licensed physician in the state where services are provided Meets criteria of an ESRD qualified physician director (at least Board eligible in IM or Peds and with > 12 months experience or training in care of pts at ESRD facilities Professional staff member (bylaws)
12 Duties & Responsibilities Outpatient General Title 42 of Code of Federal Regulations Responsibility for the quality of delivered professional care Directing professional services Creation of standards, policy, procedure Conscientiously applying policies and procedures (enforcement) Member of governing body Official communicator between medical staff and executive board Separate and distinct from attending nephrologist
13 Administrative Duties 1 Assures written policies and guidelines including: Pt care delivery P & P manual organizational delineation and function of each category of worker Medical records maintenance Professional staff bylaws (+ credentialing) Pt and staff education programs
14 Administrative Duties 2 Communicable disease control Physical environment Fire, safety, emergency preparedness Assures CQI programs Initiates } Make this Participates empowering, Monitors inclusive, and fun Assures physician compliance with all network, state and federal mandates applicable to dialysis Establishes a practice goal within facility Supercedes competition Active dialogue with MAB and attendings
15 Administrative Duties 3 Oversee pt satisfaction affairs Incident reports Staff-patient relationships Liaison to affiliated provider institutions Nephrologist-patient relationships Overlaps with many of the previous descriptions
16 Administrative Duties 4 Examples of areas for unit-specific P & P Dialyzer reuse/reprocessing Anemia eval and mgt Dialysis adequacy measures and achievements Water standards Immunization/surveillance (Hep B, pneumovax, Hep C) Osteodystrophy mgt Access surveillance/mgt Pharmacologicals in facility Many, many more
17 Technical Duties Participate in selection of cost-effective treatment modalities and supplies offered Advise attendings in this regard Approves and oversees P & P, ensuring: adequacy of training of nurses and techs in dialysis science/techniques Water quality Dialyzer reuse/reprocessing Adequacy of dialysis Continuous coverage for medical/ technical questions to pt care staff and attendings
18 Medical Duties 1 Assures P & P for: Dialysis techniques, related medications Pt suitability (e.g., admission criteria) Other medical issues mentioned before Coordinates the comprehensive renal care team to ensure quality Dialysis care Nephrologic care General medical care Short-term and long-term care plans Modality selection education PD, HD, transplant, home dialysis
19 Medical Duties 2 Assure availability and P & P for: Dietary consultation } Social service Unit size does matter Financial counselor Assure appropriate execution of dialysis orders/prescriptions and day-to-day patient care by nursing and technical staff Assure attending physician education of and compliance with unit P & P CMS changes to visit frequency Where practice goal becomes helpful
20 Compensation, CMS, Safe Harbors, Chains, ER Docs and CEOs Hourly rate will be a safe harbor Only if fair market value and records kept Chains and CMS would like compensation to be hourly, like an ER doc (~$120) Makes it crystal clear (state of mind in fraud and abuse of self referral) RPA fought this, wanted the comparison to be that of a CEO RPA filed suit on 2005 Ruling did not support RPA s position CMS stopped pushing this Establish an hourly rate Precedents: medical legal fees, surveys, interviews, consultations
21 Agreements 1 Condition of participation in Medicare requires a medical director New conditions propose increased and more intense workload for med director Duties and compensation linked Clarify In-patients (acutes) vs. Out-patients (chronics) because duties differ somewhat For acute programs oversight is more short term and liaison is with hospitals Poor guidelines on acute unit med director roles
22 Agreements 2 Clarify language, especially oversee, supervise, or facilitate vs. ensure Obligations of owners/operators in assisting medical director Specifically identify the contracting parties (solo MD vs. practice) Length of agreement is not a trivial issue Non-compete covenant Comfort level
23 Agreements 3 Non-compete covenant Geography and length Benefits in lieu of cash compensation Office space, car, phone, supplies Fair market value for items not mandatory for doing medical director duties Compensation at fair market value
24 Regulatory Issues 1 Antikickback Statue Stark Prohibits the knowing and willful offer, solicitation, payment or receipt of any remuneration, directly or indirectly, overtly or covertly to induce or in exchange for the referral of any item or service for which payment is made under Medicare or Medicaid Felony with $25K fine and/or jail Safe harbor elements (personal services)
25 Key Components to a Successful Home Program Life Plan Stage 4 options education Integrated treatment strategy Unit organization* Standardized processes of care Quality measurement tools Staff education and development * Staffing types, patient:nurse ratios, services linked to patient numbers, medical certification, reimbursement Standardized protocols, flow charts Key quality characteristics for improvement, collect sufficient data points (courtesy of Marty Schrieber)
26 Home Dialysis Infrastructure Administrative Advantages/disadvanta ges of LDO affiliation Staffing Care delivery Secretarial support Space Supplies Pharmacy Billing Care delivery Primary care nursing Physicians Back-up dialysis Surgical support Radiology Clinic structure Technicians Dietary Social service
27 Infrastructure Considerations Barriers to overcome
28 Systematic Barriers Governmental CMS requirements about visits and reimbursements Reimbursement strategies favoring graft placement instead of fistulae Home care partner support Delays of accreditation/certification of new units Elimination of facility home training fees
29 Systematic Barriers Attitude/Philosophy of Large Dialysis Organizations (LDOs) Availability of state of the art equipment and solutions Delivery of products/supplies Pharmacy Business conflicts trump patient care LDO laboratory services do not accommodate home dialysis needs LDOs use data for commercial advantage rather than practical CQI Home Dialysis Clinic as an addendum to in-center hemodialysis Physical environment Staffing
30 Systematic Barriers Educational Issues Patient education about home therapies Physician education/training/experience in home dialysis Dialysis staff education/training/experience in home dialysis
31 Profile of a Successful Home Dialysis Medical Director Strong believer in therapy Directs home facility separately from in-center Comfortable and willing to address clinic concerns with referring nephrologists and surgeons Confidently markets the services and strengths of the Home Dialysis program to partners and others Actively involved in clinic CQI process Stays current on science and Best Demonstrated Practice Participates in staff education
32 Team Building for Home Dialysis Educating the staff to stay up to date with home dialysis is important Opportunities for sharing knowledge Free exchange of ideas re pt care Continuous QI activities infection rates and protocols morbidity and mortality core indicators (adequacy, anemia, albumin, Ca/P)
33 Medical Director Performance Review Pre-ESRD Candidates Census Training Issues Technical Issues Facility Report Card Trends in Hospitalization Mortality Statistics Complication Update (infection,catheters, nutrition,adequacy, Bone Disease, Anemia, etc.) QA Quarterly Mtgs QA Project Report Quality Tracking Verification
34 Statistical Process Control (SPC) in Continuous Quality Improvement (CQI) Focus on key quality characteristics Collect sufficient, useful, and precise data Plot data to examine stability Determine special cause vs. common cause variation Focus on key variables for intervention
35 Medical Director Checklist Review Policies and Procedures for: Outcomes Review -anemia -nutritional status -mineral and bone metabolism -dose of dialysis Quality Assessment Improvement Program (QAPI)
36 Medical Director Checklist Review Policies and Procedures for: Consultation with Dietitian Consultation with Social Worker H & P and death summaries Policies for Preventive Care Meetings with Vendors Patient Satisfaction Surveys Adverse patient occurrences
37 Medical Director Checklist Review Policies and Procedures for: Personnel Issues (training, hiring, discipline) Physician Nurses Technicians Administration Physician Rounding & Documentation Medical Staff Bylaws Vascular Access
38 Medical Director Checklist Review Policies and Procedures for: Required Unit Paperwork (surveys etc.) Review Board of Health Surveys Selection of Appropriate Dialysis Modality Short & Long Term Care Suitability for Transplant Referral Unit Physical Environment
39 Medical Director Checklist Review Policies and Procedures for: Dialyzer Reuse (Reprocessing) Infection surveillance and control Disaster Preparedness Equipment Issues Water and Dialysate Quality Government agency interactions MCO's, hospital systems etc. Specific Unit Based Problems
40 Meetings Continuing Medical Education RPA ASN NKF ASPN (Peds) ASDIN (Interventional) Annual Dialysis Conference ASAIO American Society of Transplant Physicians Medical Director Meeting Network Meeting
41 Tools That Help Medical Directors Medical staff bylaws Credentialing of staff nephrologists Job description Performance-based compensation vs. hourly rate Staff meeting minutes Time documentation This is the slide to remember
42 Question #1 The Medical Director must review Policies and Procedures for which of the following? A. Referral to cardiologists B. Referral to vascular access surgeon C. Referral to primary care internist D. Referral to transplant program E. All of the above
43 Question #1: Answer The correct answer is D. Referrals to transplant program
44 Question #2 Medical Director compensation is based on all of the following except? A. Time required to perform duties B. Experience/leadership skills C. Ability to bring in more patients D. Length of the non-compete covenant E. Geography limits of the non-compete covenant
45 Question #2: Answer The correct answer is C. Ability to bring in more patients
46 Question #3 The 2008 Medicare Conditions for Coverage greatest impact is? A. Process focusing B. Demanding ensures of medical directors C. Establishing credentialing of staff E. More aggressive engagement of the governing body F. Defining medical director s compensation
47 Question #3: Answer The correct answer is D. More aggressive engagement of the governing body
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