Wanting to Learn More about Hospice?

PA's Can Serve as Hospice Attendings--

But the Centers for Medicare & Medicaid Services (CMS) Did Not go Far Enough!

Thanks to all who helped us provide comments to CMS this September regarding their proposed rule changes that will affect PAs in a number of ways, but in particular our ability to serve as hospice attending.  We are now awaiting the final rule after CMS completes its review of comments.

Thanks to our partners at AAPA and the National Coalition for Hospice and Palliative Care, CMS heard our concerns about limits to our ability to prescribe medications to our patients on hospice.

Click Here for PAHPM’s Official Comment and Response to the Rule

Click Here to see the specific CMS text addressing the rule change and the points on which CMS is asking the public to comment.

Highlights of Comments from what PAHPM and our Partners shared with CMS:

  • PAHPM agrees with CMS’s proposal “to revise § 418.106(b)(1) to permit a hospice to accept drug orders from a physician, NP, or PA. We propose that the PA must be an individual acting within his or her state scope of practice requirements and hospice policy.” 

HOWEVER, we disagree with limiting to just non-hospice drug orders, as is indicated in the text.  PAs, as NPs should not be limited and should be able to care for patients fully, able to provide hospice drug orders relating to their hospice/terminal condition.

  • PAHPM respectfully disagrees with the proposal to specifically limit reimbursing PAs with whom hospices may want to employ or contract
  •  PAHPM believes that PAs can provide meaningful involvement with hospice by providing complex symptom management and care for patients and families
  •  PAHPM believes PAs can be integral members to help run hospice interdisciplinary teams
  • PAHPM believes PAs should be allowed to do face-to-face visits for recertification just as our NP colleagues currently do

We know a number of you also shared your own comments with CMS and encouraged others to do so--for that, a big THANK YOU!

We will continue to keep you updated and even now, are partnering with our Coalition Partners and AAPA to be prepared to bring to reality PAs following patients on to hospice and fulling caring for them and being full partners with and on hospices across this country.  More will need to be done at the national and state level, and we thank you in advance for helping keep this momentum going!

As it stands now. . .

In early 2018, Congress passed the Medicare Patient Access to Hospice Act which allowed the Centers for Medicare & Medicaid Services (CMS) to change the regulations to recognize physician assistants as designated hospice attendings effective January 1, 2019.  

What does this mean?  

PAHPM, along with AAPA have been in direct contact with CMS to help clarify what this change will mean for PAs.  CMS has clarified that while the statute was changed to allow PAs to be hospice attending, there are still separate discretionary Conditions of Participation (COP) rules and regulations that guide hospice actions and these were not changed.  One particular COP, 418.106(b) Standard: Ordering of drugs, states:

Only a physician as defined by Section 1861(r)(1) of the Act, or a nurse practitioner in accordance with the plan of care and State law, may order drugs for the patient.  

If the drug order is verbal or given by or through electronic transmission— 

  1. It must be given only to a licensed nurse, nurse practitioner (where appropriate), pharmacist, or physician; and  
  2. The individual receiving the order must record and sign it immediately and have the prescribing person sign it in accordance with State and Federal regulations

CMS has stated that this COP can be changed at the discretion of CMS and the Administrator--ie. we do not need another bill to change this.  They will start that process this year, and PAHPM and AAPA will be working closely with them to follow through on this.

One other change that was not made was the wording for who can certify terminal illnesses.  This still will fall to our physician colleagues with hospice.  The law as written, also did not allow PAs to be included as those that can do face-to-face visits during the recertification periods on hospice as our advance practice nurse colleagues currently can with approval from a physician.  This will likely require a new statute or bill to change the law, and again, PAHPM will continue to advocate for PAs. 

Bottom Line:

What CMS says we can do for now:
--as a hospice attending, PAs will be able to be the one provider that that patient can see, along with the hospice team
--we will be part of the "hospice" interdisciplinary care team and can provide guidance
--we will be able to order equipment and services for them

What CMS says we cannot do for now:
--while we can make medication recommendations and guide hospice, we cannot order medications to treat patients for symptoms related to their hospice diagnosis
--we cannot certify for terminal illness
--we cannot do the re-certification visits, "face-to-face" visits that hospices employ NPs and MDs to do

Note, each state has it's own statute and limitations for hospice.  Some mirror CMS regulations, others do not and may be more limiting.  We are working with AAPA to help understand what barriers exist for PAs to practice under the new CMS guidelines in their own states.  

For question regarding restrictive hospice language in your state, you can contact Erika Miller at emiller@aapa.org as noted in the link below.  You may also try reaching out to your state's hospice association--many states have one.  

See the AAPA page with Hospice FAQs.

Keep an eye out on this space for updates and further guidance!

More work to do!

Needing resources on how to care for patients on Hospice?

Visit some of these resources here.   Members, more to come on this website!

End-of-Life Resources --Collection of content from AFP on End-of-Life Care and Resources

The Hospice Referral

The Role of the Family Physician in the Hospice Referral and Management of Hospice