but doctor certified them

Thursday, December 13, 2007

But the doctor certified them…

I really wanted to get off the subject of the Medicare Hospice Cap today, but I couldn’t. There is one cap argument that I hear quite a bit that, while sounding fair and logical, fails to actually work. The argument in question is what I will term the “But the doctor certified them” argument.

As I said, this argument seems to make all the sense in the world, but I want to give two reason that it doesn’t really hold up to scrutiny. Here’s how it goes. Those fighting against the cap argue that every patient they have ever had on service was certified by their attending physician to meet the Medicare criteria of a six month life expectancy given normal disease progression. Who is the hospice to question the patient’s attending physician? Seriously, where does the hospice nurse get the power to tell the doctor that the nurse’s one time evaluation of the patient is more accurate than the opinion of the doctor who has been seeing the patient for years? If a patient’s doctor believes that the patient meets the medical criteria for hospice, why would a hospice argue?

That’s the “But the doctor certified them” argument, and it makes all the sense in the world. If a doctor certifies hospice appropriateness, then we shouldn’t question them. Right? Wrong. Let me give you two reasons that it doesn’t always work.

First, doctors are often too nice.

I know that the hospice community usually complains that doctors don’t want to tell patients bad news and therefore wait too long to make a hospice referral. While that is often the case, there is a less frequent and less discussed flip side of that coin. This issue, which hospices don’t complain about, is that often doctors will make hospice referrals because they know that hospice can help the patient. This referral usually comes after the family has brought the patient to the doctors office and told the doctor how hard it is to care for the patient. It is a long heartbreaking story from a tired and stressed family. The doctor vows to find them some help. Hospice is the help they find.

Many hospices have been paying marketing staff quite a bit of money to go convince doctors of the reality that there is nothing better than hospice care. If you have a patient living at home, hospice is the best care Medicare can provide for them. Some doctors have been listening to the marketers, so when they meet a hard case, they hand it over to hospice. Unfortunately, the doctor is thinking much more about the care that the patient needs than the patient’s prognosis. They sign the hospice papers to get them care without really thinking about what they are signing. They are doing what they can to help a family. It is a noble thing to do, but it is still a patient who isn’t actually appropriate for hospice.

Second, doctors get paid by hospices.

First, I’m not saying that something illegal is going on. This isn’t some nefarious under the table bribe we’re talking about here. Medicare requires every hospice to have at least one Medical Director. Everything I’m talking about here is done in the daylight, but it doesn’t make it right.

Hospices hire Medical Directors to do the things they need a doctor to do. Many of them also hire Medical Directors with the hope that those Medical Directors will refer their patients to the hospice. This is clearly an area where the line between good and evil is gray at best. I know from what I would consider a reliable source that one hospice pays one of their Medical Directors $4,000 a month for the one meeting that he attends. That’s $4,000 an hour. Do you think they expect “loyalty” from their medical director? No doubt! Do you think the Medical Director feels pressure to give enough patient to keep this gravy train coming? Probably. Could this lead the Medical Director to refer a few of his patients that he wouldn’t otherwise refer? Possibly. (The Office of the Inspector General has noted these types of issues and, in theory, is going to be cracking down on it.)

Even if you follow the OIG’s advice and pay a reasonable rate for the amount of work the Medical Director does, there is still a decent chance that the Medical Director is going to help you out. “Oh, Dr. Smith, census sure is down. If we don’t get some patient’s we may have to cut back.” Could that line encourage Dr. Smith to certify someone that is just a bit on the gray line? No doubt.

Again, I’m not saying that hospices shouldn’t have Medical Directors. They are an essential part of the hospice team. The fact that many hospices have one Medical Director for each team meeting they have (ie. a small hospice has team meeting weekly, so they have four Medical Directors that come once a month.) probably indicates that there is a benefit to having doctors on your payroll.


These are two examples of why doctor certification isn’t always to be trusted. Is this the core of the cap problem? Not even close! My point here is that the argument that we should be trusting doctors to make certification decisions without any oversight or system abuse indicators just doesn’t hold water. The patient’s attending physician is, in my mind, the only logical person to certify hospice appropriateness, but that doesn’t mean the system is perfect. Oversight is still necessary, and that was the point of the hospice cap from day one.


Christian Sinclair, MD

Great post HG.

I wonder how certification of physicians as palliative care specialists may impact this a bit. If more hospices are getting board certified & fellowship trained hospice docs, then the era of the community doctor to sign papers and attend an occasional meeting may be a thing of the past. I find some of the marketing about medical directors somewhat disingenuous, when for many hospices this can amount to a figurehead position, as opposed to medical directors who are actually making home visits and doing clinical care for the hospice and formally trained or highly experienced in hospice care.

I have heard of hospices with ‘paper’ medical directors that never prescribe opioids for their own patients. Somewhat of a disconnect in approaches to medicine there possibly?

I do realize that this pool is much smaller to grab from for hospices so hopefully more fellowships will be formed to train this type of physician. And I do realize there are a great number of hospice medical directors who volunteer their time and do not get paid as well as those who do this out of genuine concern and support for the hospice approach. So I am not saying that board certification = best doctor ever, but I think that helps.

Hospice Guy


Thanks for the comment. I probably should have put in the post that what you guys at http://www.pallimed.org/ are a whole different subject.

The problem is, as you said, Medical Directors who will actually make home visits (much less are certified as palliative care specialists) are hard to find. In rural america I would guess they are typically impossible to find. I believe that active trained Medical Directors are the future of hospice, but I don’t think the future will be here any time soon.

Wouldn’t that be cool though!