08/14/2019

CMS Proposes Expanded Role for Physician Assistants in Hospice CoP

The National Association for Home Care & Hospice (NAHC) released this article this week discussing Physician Assistants in the Hospice Conditions of Participation (CoPs).

The Bipartisan Budget Act of 2018 (BBA 2018) included a provision permitting physician assistants (PAs), beginning January 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 and physicians, and was long supported by various stakeholder groups, including NAHC and the National Hospice & Palliative Care Organization (NHPCO).

Subsequent to passage of the legislation, the Centers for Medicare & Medicaid Services (CMS) confirmed 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 orders for drugs 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 NPP (non-physician practitioner) 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?

Thoughts or comments on this proposed change may be directed to Anne Shelley, Director of Regulatory Affairs for Home Health and Hospice at ashelley@leadingageohio.org or to Theresa M. Forster at tmf@nahc.org. (National Association for Home Care & Hospice)