AAPA Responds to Expiration of CMS Public Health Emergency

Requests Some Flexible Policies Remain in Place

May 2, 2023

By Dorsey Griffith

The public health emergency (PHE) declaration, put in place by the federal government during the COVID-19 pandemic, temporarily lifted several outdated policies that prevented PAs from practicing to the full extent of their education and experience. The increased flexibility in practice regulations allowed PAs to enhance their critical role in caring for patients during an unprecedented national health emergency.

With the PHE expiration on May 11, the Centers for Medicare and Medicaid Services (CMS), has made permanent some of the regulatory relief measures, but not others. In a letter to CMS Administrator Chiquita Brooks-LaSure, AAPA requested that certain PHE policies become permanent and others be discontinued or amended.

PA Care in SNFs and Hospitals
Specifically, AAPA has asked CMS to continue to recognize PAs to perform the comprehensive healthcare visit to patients in skilled nursing facilities (SNFs). PHE provisions authorized the delegation of these “physician-only” visits to PAs if there was no conflict with a state law or facility policy. AAPA argues that there is no justification for re-instituting the outdated rules restricting PAs from performing this particular service. AAPA argues that the pandemic-related challenges SNFs faced would have been far worse if PAs had not been allowed to deliver care, increasing access at a time of extraordinary strain for SNFs.

Similarly, AAPA is asking CMS to continue to authorize Medicare hospital patients to be under the care of PAs, a decision that would improve care delivery efficiency. While PAs are allowed to determine the necessity of a hospital admission, write the order and perform the patient’s admission history and physical, CMS traditionally requires hospitalized patients to be under the care of a physician.

Noting that there is no known difference in quality or outcomes when care is “under the care of” a physician or PA, AAPA argues that “authorizing a patient to be under the care of a PA would provide the same collaborative and coordinated care as has been traditionally provided in hospitals without imposing arbitrary administrative burdens.”

Direct Supervision
During the PHE, CMS allowed physicians to meet direct supervision requirements via audio/visual (real-time, interactive) communication. The policy flexibility was granted to minimize COVID-19 transmission, meet patient needs for timely care and facilitate the performance of telehealth services during the pandemic. While AAPA appreciated the flexibility, the organization was and remains concerned about such a policy as it relates to PAs and nurse practitioners (NPs). Medicare provisions allow medical services performed by one health professional in the office setting to be submitted and reimbursed under the name of another health professional, the practice known as “incident to” billing. In these cases, PAs or NPs perform the care but the service is attributed to physicians.

Specifically, AAPA argues that “incident to” billing practices prevent accurate identification of the type, volume and quality of medical services delivered. “This lack of transparency has a negative impact on patients understanding who is providing their care, workforce policy considerations, Medicare data collection and PAs/NPs,” the letter states.

Authorizing direct supervision requirements by audio/visual communication for PAs and NPs, AAPA argues, would exacerbate existing transparency problems. AAPA suggests that this type of direct supervision only be allowed for health professionals who are not authorized to bill Medicare for their services.

Behavioral/Mental Health Care
The need for behavioral/mental health care services has never been greater. PAs are trained and qualified to treat mental and behavioral health conditions and have the national certification, state licensure and authority to prescribe psychiatric medications. Medicare, many state Medicaid programs and certain private, commercial payers cover this care when provided by PAs. However, some private, commercial payers with plans under the purview of Medicare do not. These include Medicare Advantage, Medicaid fee-for-service, managed care, CHIP and other plans offered on the Federally Facilitated Exchange.

Encouraging all payers who provide a plan under Medicare’s purview to eliminate prohibitive policies “would align the behavioral health policies under these plans with Medicare, and ensure beneficiaries covered by such plans have more qualified options available to them,” AAPA states in the letter.

Flexibility during a PHE
AAPA deeply appreciates the flexibility of federal policies put in place to manage the pandemic and meet patient demand for care. But some hospitals, because of the requirements and processes mandated by their internal policies, did not take advantage of these flexibilities. AAPA asks CMS to institute an explicit policy for use in a future PHE that allows facilities to temporarily waive their own policies and bylaws to align with federal emergency flexibility policies and asks CMS to encourage states and accrediting agencies to waive such constraints as well during public health emergencies.

AAPA has invited Brooks-LaSure to discuss with the organization its observations and recommendations related to the PHE.

For more information, contact Michael Powe, AAPA’s Vice President, Reimbursement & Professional Advocacy.

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