The U.S. Centers for Medicare & Medicaid Services has proposed a rule that would allow physician assistants (PAs) to serve as attending physicians for hospice patients. However, due to current regulatory restrictions the PA may not be an employee or contracted with the hospice. 

If made final, the rule would allow PAs, acting within their scope of practice and hospice policy, to make orders for medications or services for patients. Current regulations allow only physicians and nurse practitioners (NPs) to make such orders. 

“The role of physicians and NPs as hospice employees and contractors is clearly defined in the hospice CoPs; however, the CoPs do not address the role of PAs,” CMS indicated in the proposed rule. “Therefore, we believe 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.”

The complication exists because current Medicare Conditions of Participation (CoPs) do not define the role of PAs. CMS currently doesn’t consider PA services as being part of the Medicare Hospice Benefit. 

Consequently, the CoPs do not contain provisions to address PA personnel requirements, co-signature issues, or a designation as to whether PA services would be considered core or non-core, which according to CMS would be necessary for a hospice employee or contractor.

The attending physician would consult with the hospice interdisciplinary team and furnish care for conditions determined by the hospice as being unrelated to the terminal prognosis. If the patient has an attending physician relationship prior to electing hospice, that physician can continue to serve the patient in that capacity during hospice.

Hospice organizations said they were encouraged the move.

“This CMS proposal would close a loophole in current Medicare regulations that limits drug prescribing for hospice patients to only physicians and nurse practitioners (NPs), even though Medicare law and regulations allow PAs to also serve as those patients’ attending physicians,” John Richardson, chief data and quality officer for the National Partnership for Hospice Innovation (NPHI), told Hospice News. “NPHI agrees and strongly supports the proposed change and we look forward to working with CMS to expand the role that physician assistants play in hospice care.”

CMS is seeking comments on the rule through Sept. 27. In particular they seek feedback on the following questions related to the role of non-physician practitioners (NPPs) in hospice, whether NPP services should be considered core activities, how NPP services should be supervised, co-signature rules, and personnel rules. 

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