Each year, millions of patients are serviced and evaluated in the hospice world of care. When a patient is admitted to receive hospice services, the patient must be certified as being terminally ill. According to Federal regulations, an individual is considered to be terminally ill if the prognosis is that the individual’s life expectancy is 6 months or less if the illness runs its normal course. This industry, although much needed and patient focused, is worth nearly $30 billion dollars annually.
Recently, the Federal government issued the Fiscal Year 2019 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements Final Rule. Of particular focus are the payment rates for those involved in this industry. However, one unique aspect of this rule revised regulations for providers. Specifically, the Final Rule establishes that as of “January 1, 2019, physician assistants (PAs) will be recognized as designated hospice attending physicians in addition to physicians and nurse practitioners.” While this might not be earth shattering, it does highlight some of the inconsistencies in the regulatory approach to hospice care by providers.
Shortage of Providers
The hospice industry is a critical industry in the United States. According to the National Hospice and Palliative Care Organization (“NHPCO”), hospice is “[c]onsidered the model for quality compassionate care for people facing a life-limiting illness, hospice provides expert medical care, pain management, and emotional and spiritual support expressly tailored to the patient’s needs and wishes. Support is provided to the patient’s family as well.” Further, the NHPCO stated that this type of care was provided to nearly 1.5 million Medicare patients in 2016 alone.
However, several organizations have studied the future of the hospice industry, including whether there will be enough providers to service the industry. According to the Journal of Pain and Symptom Management “[t]he need for hospice and palliative care is growing rapidly as the population increases and ages and as both hospice and palliative care become more accepted. Hospice and palliative medicine (HPM) is a relatively new physician specialty, currently training 325 new fellows annually.” To further the address this issue, the study reflected on whether there will be enough physicians to service the industry. The conclusion was startling. Specifically, the study concluded the following:
“Current training capacity is insufficient to keep up with population growth and demand for services. HPM fellowships would need to grow from the current 325 graduates annually to between 500 and 600 per year by 2030 to assure sufficient physician workforce for hospice and palliative care services given current service provision patterns.” Understanding that graduate medical education is funded by Medicare, it is impossible to know whether it is feasible to increase to these numbers. However, given the regulations allow PAs to be attending physicians, might this solution be another viable option for increasing providers in hospice?
Regulatory Confusion of Attending Physicians
The most recent change allows PAs to act as attending physicians for hospice patients. However, the current confusion in regulations does not allow this type of change to assist in the shortage issues, considering the increase in future hospice care. Specifically, a PA or nurse practitioner (“NP”), is allowed to be “attending physicians” for hospice patients. In short, this means if a patient is designated as terminally ill, their care may be managed by a PA or NP.
However, the unique regulatory structure still requires that a physician (M.D. or D.O.) certify or re-certify terminal illness. From a legal perspective, a patient cannot be admitted to hospice unless a physician certifies the terminal illness. According to the NHPCO, cancer, cardiac, and dementia are the three top prognoses. To further complicate matters, although both an NP and PA cannot certify or re-certify terminal illness, a physician or NP can perform the necessary face-to-face encounter to determine continued eligibility.
The impact of these changes on the hospice industry create a push and pull type of action. First, allowing PAs to act as attending physicians assists in the shortage. It will allow increased utilization of PAs in hospice organizations. Second, it still creates a regulatory structure in which hospice organizations must create operational strategies taking into account who can and cannot perform certain services at certain times. While the Final Rule could not address these issues, hospice organizations remain vigilant.