Ensuring Access and Continuity of Care for Medicare Beneficiaries Who Receive Medical Care by PAs

Ensuring Access and Continuity of Care for Medicare Beneficiaries

Who Receive Medical Care by PAs
(Home Health, Hospice, & Skilled Nursing Facility Care)

The Senate Finance Committee, the House Committee on Ways and Means, and the House Committee on Energy and Commerce exercise jurisdiction on Medicare legislation and provide oversight on the Medicare Program.

H.R. 1178, the Physician Assistants Continuity of Care Act, allows physician assistants, as delegated by a physician, to order home health, hospice, and skilled nursing facility care for Medicare beneficiaries, and allow PAs to provide hospice care to their patients who elect Medicare’s hospice benefit. The bill does not change the current structure of the physician-PA relationship or PAs’ scope of practice. H.R. 1178 was introduced by Rep. Ed Towns (D-NY) on February 16, 2007, with Rep. Phil English (R-PA) as an original cosponsor. Introduced by Sen. Kent Conrad (D-ND), S. 1605, the Craig Thomas Rural Hospital and Provider Equity Act of 2007, would allow PAs to order home health and hospice care for Medicare beneficiaries. Introduced by Sen. Susan Collins (R-ME), S. 1678, the Home Health Care Planning Improvement Act of 2007, would allow PAs to order home health care.

Medicare coverage was originally extended to physician assistants (PAs) through the 1977 Rural Health Clinic Services Act. Congress acknowledged that PAs had the education and skills needed to provide a wide range of primary care physician services to Medicare beneficiaries living in areas experiencing a shortage of physicians. Congress’ aim was to extend medical services to rural Medicare beneficiaries. Subsequent Congresses steadily expanded Medicare coverage for services provided by PAs. In 1997, the 105th Congress passed the Balanced Budget Act (BBA). The BBA made it clear that medical services provided by PAs, as allowed by state law, are covered by Medicare in all settings at one uniform rate.

Unfortunately, the former Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) decided that the BBA’s Medicare provisions regarding coverage of services provided by PAs did not apply to home health care, hospice care, or skilled nursing facility care. As a result, PAs are currently not allowed to order home health or hospice care services for patients who are Medicare beneficiaries. PAs are also not allowed to order post-hospital extended care services in skilled nursing facilities or provide hospice care to beneficiaries who elect the hospice benefit. It is unconscionable that Medicare beneficiaries who routinely receive care from a PA and who elect to receive the hospice benefit are not able to receive hospice care provided by their PA.

PAs jump through hoops to obtain physician signatures on Medicare orders for home health, hospice, and skilled nursing facility care. The physician, however, is not always available, and access to needed care is delayed. The coverage problems disrupt continuity of care and decrease the availability of care, especially in medically underserved communities. The inability of PAs to provide hospice care disrupts continuity of care at a time when the Medicare patient is most vulnerable.

The American Academy of Physician Assistants recommends that the 110th Congress enact H.R. 1178, the Physician Assistants Continuity of Care Act, enabling PAs to order home health, hospice, and skilled nursing facility care for Medicare beneficiaries, and allowing PAs to provide hospice care to their patients who elect Medicare’s hospice benefit. (H.R.1178 provides broader Medicare coverage of services provided by PAs than S. 1605 and S. 1678.)

The 1997 BBA broadly authorizes PAs to deliver physician medical services if allowed by state law and delegated by the supervising physician. The law makes it clear that state law, not federal coverage policies, determines the conditions of PA practice. However, since HCFA determined that the BBA provisions regarding PAs do not apply to certain sections of the Social Security Act, such as certifying the need for skilled nursing facility care and home health services, it is necessary to enact a technical correction to clarify Congress’ original intent through the 1997 BBA.

In the absence of the technical correction to counter the coverage decisions, beneficiaries face unnecessary delays and denial of medically necessary care covered by Medicare.