Wanting to Learn More about Hospice?

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!

Not Happy About this?  Check out our Advocacy Page and Act!

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