WASHINGTON, D.C. (August 13, 2019)—The Bipartisan Budget Act of 2018 (BBA 2018) included a provision permitting physician assistants (PAs), beginning Jan. 1, 2019, to serve as hospice attending physicians. This change affords patients whose primary care practitioner is a PA to receive the same continuity of care that has been available for patients served by nurse practitioners (NPs) and physicians, and was long supported by various stakeholder groups, including the National Association for Home Care & Hospice (NAHC).

Subsequent to passage of the legislation, the Centers for Medicare & Medicaid Services (CMS) confirmed to NAHC that while PAs would be permitted to serve as hospice attending physicians, until changes were made to the Hospice Conditions of Participation (CoPs) at 418.106(b), hospices would not be permitted to accept medication orders from PAs since the CoP specify that hospices may only accept drug orders from NPs and physicians. Following is a previously issued summary of the role of PAs under hospice and under home health developed by NAHC.

As part of a recently issued proposed rule governing physician payment for CY 2020, CMS is proposing to amend Section 418.106(b)(1) to permit a hospice to accept drug orders from a physician, NP or PA. Under the provision the PA must be an individual acting within his or her state scope of practice requirements and a hospice’s policies. CMS is also proposing that the PA must be the patient’s attending physician, and that he or she may not have an employment or contractual arrangement with the hospice. CMS indicates that physicians and NPs have explicit roles as hospice employees and contractors defined in the CoPs, the CoPs do not address the role of PAs; nor does statute include PA services as being part of the hospice benefit. Therefore, CMS believes that it is necessary to limit the hospice CoPs to accepting only those orders from PAs that are generated outside of the hospice’s operations.

CMS has, as part of the proposed rule, request public comment on the following questions:

  • What is the role of a non-physician practitioner (NPP) in delivering safe and effective hospice care to patients? What duties should they perform? What is their role within the hospice interdisciplinary group and how is it distinct from the role of the physician, nurse, social work and counseling members of the group?
  • Nursing services are a required core service within the hospice benefit, as provided in section 1861(dd)(B)(i) of the act, which resulted in the defined role for NPs in the Hospice COPs. Should other NPPs also be considered core services on par with NP services? If not, how should other NPP services be classified?
  • In light of diverse existing state supervision requirements, how should NPP services be supervised? Should this responsibility be part of the role of the hospice medical director or other physicians employed by or under contract with the hospice? What constitutes adequate supervision, particularly when the NPP and supervising physician are located in different offices, such as hospice multiple locations?
  • What requirements and time frames currently exist at the state level for physician cosignatures of NPP orders? Are these existing requirements appropriate for the hospice clinical record? If not, what requirements are appropriate for the hospice clinical record?
  • What are the essential personnel requirements for PAs and other NPPs?

NAHC is examining the proposed change to address PA responsibilities as hospice attending physicians and seeking input from member stakeholders on the questions raised by CMS as part of the proposed rule.