Wanting to Learn More about Hospice?

PA's Can Now Serve as Hospice Attendings--

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

PAHPM needs your support!

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.

CMS has revised a rule to allow PAs to prescribe medications to our patients on hospice!

Please see the proposed rule change (in particular, see pages 40725-40726):


Please take time to comment by 9/27/19 and offer your support for the rule change, but also identify practical ways PAs can and are working with hospices every day, even with the regulatory limits we have faced for decades.

We have spoken to CMS and they need to hear that hospices can utilize us to help fill the gap in palliative and hospice providers:

--supporting hospice teams by working as providers who can help hospice physicians and nurses with acute symptom managment

--filling the role of doing face-to-face visits for hospice recertification--currently only advance practice nurses can do this (with the physician signing off on their work)--PAs have the skill and potential to do the same thing!

--align PA supervision to match the expectations of "NP and CNS collaboration with a physician" that CMS currently follows.  This will better represent how PAs are collaborating with physicians, especially given the changes in PA supervision statutes at the state level

We've heard from hospices themselves that they would like to employ us to do the above--both in urban and rural areas where they are short clinical providers.

CMS wants to hear practical ways we can work for hospice and with hospice. 

They need to redefine the role of advance practice providers (PAs and NPs) on hospice teams, and this is our opportunity to be heard!

Again--go to the rule change and see the comment links on the webpage!

COMMENT by September 27th, 2019 !

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!

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