Recently, through the Bipartisan Budget Act of 2018 (Budget Act), Congress made changes directly impacting hospices. Hospices should review the changes, outlined below, and consider how the change will impact them and prepare accordingly. The first change – allowing physician assistants to act as hospice attending physicians – is clearly a help to hospice patients, but the second change – penalizing hospitals for early discharges to hospice care – may not be beneficial.

Physician Assistants as Attending Physicians for Hospice Care

With this change in law, hospice patients will have a third type of provider that can act as their attending physicians and that third type is physician assistants (PAs). This is effective January 1, 2019. Currently, hospice patients can choose a doctor of medicine or osteopathy as their attending physician as well as a nurse practitioner (NP).

Only a physician may certify a patient as terminally ill, however, and Congress’ recent actions under the Bipartisan Budget Act of 2018 do not change this. It is expected that CMS will share information about PAs as attending physicians in the hospice proposed rule due out at the end of April/beginning of May. And, because there was no change in the law to allow any practicing provider type other than physicians to certify a patient, it is expected that PAs will have the same role and authority in hospice care as NPs. Stay tuned to this blog for additional information as it becomes available.

Transfer Policy for Early Discharge to Hospice Care

Under this new policy, hospitals will receive a reduced payment for patients who are discharged
early to hospice care. The implementation date is all discharges occurring on or after October 1, 2018. The details of what is defined as “early” and the consequences for such a discharge were not part of the Budget Act and are expected to be published in the proposed hospital rule for FY2019. This rule is usually published in April, and this type of early discharge penalty policy is not new to hospitals. Currently, hospitals are penalized with a reduced payment when a patient is referred to post-acute care entities such as long term care facilities and, in certain cases, home health agencies.

Many hospices are worried about the impact of this new policy and, as part of the law, MedPAC is instructed to conduct an evaluation of the effects of the policy change including the effects on:

(A) the numbers of discharges of patients from an inpatient hospital setting to a hospice program;
(B) the lengths of stays of patients in an inpatient hospital setting who are discharged to a hospice program;
(C) spending under the Medicare program under title XVIII of the Social Security Act; and
(D) other areas determined appropriate by the Commission.

The evaluation is to consider factors such as whether the timely access to hospice care by patients admitted to a hospital has been affected through changes to hospital policies or behaviors made as a result of the change. However, the final report on the evaluation is not due to Congress until March 2021 with preliminary results due March 2020. This is too long in the opinion of some hospices. Many are expecting to see later referrals to hospices with shorter lengths of stay immediately.

Again, hospices should consider how these two changes, particularly the latter, may impact them and prepare accordingly. HPS will provide more information when it becomes available.