Healthcare Financing and Strategies for Innovation Related to End-of-Life Care

Volume to Value–Will this change also impact hospice?

Value based reimbursement is actively making its way into various healthcare environments. By December of 2018, Medicare aspires 50% of reimbursements will be connected to value. 1 Hospice agencies may be ahead of the game, as studies show increased family satisfaction with care and quality of dying with hospice use. 2,3 And, starting in 2015, hospices were required to initiate the “Consumer Assessment of Healthcare Providers and Systems hospice survey,” which includes questions about quality performance. 4

Should hospice care be one sector of healthcare that is only non-profit?

I talked with a number of experts in the field of hospice care and management, and all agreed that dying people should not be vulnerable to profiteering. Many agree that the rest of healthcare should remain capitalistic, and include private and public ownership.

The emergence and continued rise of for-profit hospices in the United States has garnered much attention. Of primary concern are the claims of “cherry picking” patients—for-profit hospices have been found to have a significantly higher number of patients on their census known for having longer lengths of stay, which leads to higher reimbursement from the Medicare Hospice Benefit (MHB). 5 Certainly, non-profit hospices also need to be held accountable, but this is about the intention. Should care of the seriously ill and dying center around making a profit?

Increasing access to hospice and an aging population

APRNs ability to sign terminal certifications for hospice eligibility has potential to increase the number of people receiving hospice services. 6 Increasing access to hospice care leads to increased cost to Medicare via the MHB.

And with an aging population, and increasing numbers of people living with dementia, which is the most expensive diagnosis for hospice care…

“Average per-person hospice care payments for beneficiaries with Alzheimer’s disease and other dementias were 10 times as great as for all other Medicare beneficiaries ($1,976 per person compared with $193 per person).” 7, p. 56

…we foresee a financial crisis ahead for Medicare even without increased access to hospice.

So, How Can We Sustain?

Currently, there is a “Medicare Annual Aggregate Cap” for hospices, and if exceeded, the agency must give money back to Medicare. 5 This cap and/or the daily patient reimbursement from MHB could be reduced to further save Medicare dollars.

Innovation through concurrent care models integrating palliative and hospice care philosophies hold promise for saving money and improving quality care.8 The stakeholders involved (patients/families, healthcare providers & administrators, insurance companies & other payers, policy makers) will need to come to some agreement for this care model to succeed. 9

Presently, palliative care services receive inadequate reimbursement (and no reimbursement for some of the specialized interdisciplinary services, i.e. social workers and chaplains). 9 However, hospitals are saving significant amounts of money with inpatient palliative services, even when the cost of the entire palliative care program is subtracted. 9, 10

“This study found that palliative care consultation was associated with a reduction in direct hospital costs of almost $1700 per admission ($174 per day) for live discharges and of almost $5000 per admission ($374 per day) for patients who died.” 10, p. 1789

And, there is the hope that value based care will save money (i.e. less tests, expensive and aggressive treatments, and medications ) and allow clinicians more time with patients. This may be a double-edged sword. If clinicians, for example, decrease daily patient contacts from 30 to 15, who will provide care to the other 15? Yet, if things do not change, excellent providers may leave. I just talked with a physician friend who is planning for early retirement—she lost her passion for medicine because of a system that demands a high quantity of documentation and limited time to spend with patients. I have heard this similar response from many nurses.

APRNs in Hospice and Palliative Care—Part of the Solution

“Multiple studies have shown that nurse practitioners provide high-value primary care, comparable in quality to that of physicians.” 11,12 Palliative care physicians are already in short supply, and this shortage is anticipated to worsen. 13 APRNs (currently limited to nurse practitioners (NPs) and clinical nurse specialists (CNSs)) can achieve certification as “Advanced Certified Hospice and Palliative Nurses” through the “National Board of Certification for Hospice and Palliative Nurses.” 14 Thus, supporting APRNs to function independently at their highest scope of practice, within a model of interdisciplinary teamwork, will assist in solving the percolating, soon to boil over, problem of inadequate numbers of practitioners to meet the imminent healthcare needs of the aging and chronically ill.”12


1U.S. Department of Health & Human Services. (2015, January 26). Better, Smarter, Healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value. Retrieved from

2Shega, J., Hougham, G., Stocking, C., Cox-Hayley, D., & Sachs, G. (2008). Patients dying with dementia: Experience at the end of life and impact on hospice care. Journal of Pain and Symptom Management, 35(5), 499-507.

3Teno, J. M., Gozalo, P. L., Lee, I. C., Kuo, S., Spence, C., Connor, S. R., & Casarett, D. J. (2011). Does hospice improve quality of care for persons dying from dementia? Journal of the American Geriatrics Society, 59(8), 1531-1536.

4Widera, E., & Talebreza, S. (2016). Variability in hospice care at the very end of life. JAMA Internal Medicine, Editorial, pp. 1-2. Published online February 8, 2016.

5Aldrige, M. D., Schlesinger, M., Barry, C. L., Morrison, S., McCorkle, R., Hurzeler, R., & Bradley, E. H. (2014). National hospice survey results: For-profit status, community engagement, and service. JAMA Internal Medicine, 174(4), 500-506.

6Melvin, C. (2008). Hospice referral: What takes us so long? International Journal for Human Caring, 12(3), 24-30.

7Alzheimer’s Association. (2016, March). 2016 Alzheimer’s disease facts and figures. Retrieved from

8Mor, V., Joyce, N. R., Cote, D. L., Gidwani, R. A., Ersek, M., Levy, C. R., Faricy-Anderson, K. E., Miller, S. C., Wagner, T. H., Kinosian, B. P., Lorenz, K. A., & Shreve, S. T. (2016). The rise of concurrent care for veterans with advanced cancer at the end of life. Cancer, 122, 782-790.

9Cassel, J. B., Kerr, K. M., Kalman, N. S., & Smith, T. J. (2015). The business case for palliative care: Translating research into program development in the U.S. Journal of Pain and Symptom Management, 50(6), 741-749.

10Morrison, R. S., Penrod, J., Cassel, J. B., Caust-Ellenbogen, M., Litke, A., Spragens, L., & Meier, D. E. (2008). Cost savings associated with US hospital palliative care consultation programs. Archives of Internal Medicine, 168(16), 1783-1790.

11Naylor, D. M., & Kurtzman, E. T. (2010). The role of nurse practitioners in reinventing primary care. Health Affairs, 29, 893-899.

12McLean, A. (2015). Turmoil in primary care: Is there hope for teamwork? Arizona State University, Scholarly Writing.

13Lupu, D. (2010). American Academy of Hospice and Palliative Medicine Workforce Task Force, Estimate of current hospice and palliative medicine physician workforce shortage. Journal of Pain and Symptom Management, 40, 899-911.

14Hospice and Palliative Credentialing Center. Advanced Certified Hospice and Palliative Nurse (ACHPN®). Retrieved from (














Impacts of technological innovations, and implications for data and privacy related to hospice care

I believe most of us continue to be astonished at the rapid growth and ability of technology. Self-driving cars? Talking watches? Computers that can fit in your pocket?

Keeping pace with technology in the healthcare arena is challenging; however, it is imperative in order to further increase care quality, cost-effectiveness, and innovation.

Specific to hospice care, numerous innovations have been studied and are underway.

Telecommunications, telehealth, video conferencing

People with chronic and/or terminal illnesses frequently receive support from family caregivers, and the need for support often increases in the final months to days of life. Caregiving is stressful due to physical, financial, and emotional demands, and may lead to decreased social support/interaction, missed days of work, and increased morbidity (i.e. physical illness, anxiety). 1,2

Telehealth technology including “video, web-based, telephone-based and telemetry/remote monitoring” has been used to help caregivers through “education, consultation, psychosocial/cognitive behavioral therapy, social support, data collection and monitoring, and clinical care delivery” (p. 1). 3 Outcomes are significant and positive for caregivers, including improved mental health (i.e. decreased stress and feelings of isolation), and enhanced comfort/satisfaction with telehealth. 3

Hospice patients also may benefit from videoconferencing technology, i.e. allowing “attendance” to special events such as births, when the person is homebound. 4


Telehealth in rural areas

The collection and sharing of data is crucial, and cooperation among leaders in policy creation and healthcare is needed. For example, telehealth technology has potential to enhance care delivery and quality to persons receiving palliative and hospice care in rural areas. However, a proactive evaluation of the environment and technology, rather than a trial & error approach, is recommended. 5 Technological barriers need addressed (i.e. inconsistent access to cell phones and internet) along with political barriers (i.e. justification for dollars spent in the context of numerous healthcare needs in both urban and rural areas). 5 The use of telehealth technology to support patients and caregivers in remote areas is promising with findings of increased quality of life and improved mental health of caregivers. 3

Electronic Medical Record & Cloud Computing

Considering current technology, it seems remiss that necessary protected health information (PHI) is not available or readily accessible when patients are admitted to hospice.

For example, an older patient may reside in Arizona during the winter and live in another state in the summer. He returns to Phoenix after being hospitalized out of state for heart failure exacerbations and receiving a new cancer diagnosis. He is now hospitalized for pneumonia and admitted to hospice. Outside of the rare instance of a highly organized family member who carriers all health records in a paper binder, it can be challenging or impossible to obtain out-of-state notes in a timely manner. Sometimes the record request form is sent with no response (in my experience this does not occur with local hospital requests but has happened with local provider requests). Other times, the patient or family does not recall the name of the out of town provider—in which case a request cannot be made.

“Technology may prove useful in resolving some of the difficulties posed by the need for interstate compliance with various state health privacy laws” (p. 22). 6


Cloud computing has many potential benefits.

“By enabling easy adoption of feature-rich EHR systems, modern IT architectures can facilitate the federal government’s expressed goals of enhancing patients’ access to their medical records, improving data exchange, and reducing healthcare costs.” (p. 165). 7

And it can be designed to honor federal and state PHI privacy regulations. 7 However, it does not necessarily solve the problem of inter-provider and interstate EMR accessibility. Synergy across all EMR software providers is critical to streamline data, allowing convenient access to information at each patient intersection with healthcare.

Some hospice agencies have struggled to find the balance between EMR documentation, and maintaining staff and patient/family satisfaction. One hospice in Portland, Oregon found success by switching from laptops using browser-based applications to iPads using cloud-based software. 8 Staff satisfaction improved with ease of use, portability, and increased time to interact with patients & families related to decrease in documentation time (i.e. laptop connectivity issues led to staff taking notes and then documenting later on their personal time while the iPad allowed real-time documentation without a negative impact on relationships/engagement). 8 A significant reduction in expenditures on technology, training, and hardware also was reported with this change. 8

In summary, there is an abundance of data that requires effective and consistent packaging (EMR/software) and storage (cloud).

As current hospice Following/Attending providers, APRNs are already positioned to be interdisciplinary leaders & educators, and exemplify positive attitudes toward technological change in hospice care.


1Rumpold, T., Schur, S., Amering, M., Kirchheiner, K., Masel, E. K., Watzke, H., & Schrank, B. (2016). Informal caregivers of advanced-stage cancer patients: Every second is at risk for psychiatric morbidity. Support Care Cancer, 24, 1975-82.

2Boyczuk, A. M. & Fletcher, P. C. (2016). The ebbs and flows: Stresses of sandwich generation caregivers. Journal of Adult Development, 23, 51-61.

3Chi, N. & Demiris, G. (2015). A systematic review of telehealth tools and interventions to support family caregivers. Journal of Telemed Telecare, 21 (1), 37-44.

4Interim Healthcare. (May 23, 2014). How technology can improve hospice care for patients and caregivers. Retrieved from:

5Kuziemsky, C., Jewers, H., Appleby, B., Foshay, N., Maccaull, W., Miller, K., & Macdonald, M. (2012). Information technology and hospice palliative care: Social, cultural, ethical and technical implications in a rural setting. Informatics for Health and Social Care, 37 (1), 37-50.

6Pritts, J. L. (2007) Federal efforts to impose uniformity on state health information privacy laws. Health, Law & Policy, Spring, (20-23)

7Schweitzer, E. J. (2012). Reconciliation of the cloud computing model with US federal electronic health record regulations. Journal of the American Medical Information Association, 19 (161-165).

8Ashling, R. (2016). Advancing home hospice care through technology. Long Term Living, Jan/Feb, 14.

Video Credit

Priority Health. (2014). The future of health care technology. Retrieved from:





Private Sector Innovation and Policy Advancements

This post will discuss influences of the private sector on innovation and policy advancements related to hospice care.

According to Longest, private sector programs have potential for persuasive and positive change. Private sector influence may include “health promotion by places of worship, community-based organizations, civic groups, and businesses” (p. 6). 1 However, the private sector also has potential for negative change.

As the hospice movement was established in the United States in the 1970s, care was largely provided by non-profit agencies with cancer as the predominant diagnosis. Then, in the 1980s, Medicare initiated reimbursement for hospice care (please see ‘The Historical and Contemporary Role of Institutions and Actors & Statutory and Regulatory Mechanisms’ for a more detailed overview of the Medicare Hospice Benefit). Significant changes have occurred since—there are more for-profit hospice agencies than non-profit (see Table 1), 63.4% of hospice patients have non-cancer diagnoses with dementia and heart disease as the most common,2 and hospice Medicare spending has risen drastically from $205 million in 1989 to $2.9 billion in 2000 to 13.8 billion in 2011.3

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Table 1. “Growth in Medicare-Certified Hospice Providers” (p. 7)

With these developments, numerous concerns have arisen surrounding the quality of hospice care, Medicare fraud, and challenges in prognosticating death (non-cancer diagnoses are significantly more difficult to determine life expectancy of 6 months or less).

The private, for-profit, hospice sector has been scrutinized in recent years. Studies have shown that private hospices:

–Make more money than non-profits

–Cost Medicare more money than non-profits

–Provide less staff training

–Give less charity care

–Have longer length of stays

–Provide more visits by licensed practical nurses (LPNs) or nurse aides and less visits by registered nurses (RNs). 3,4

How do these differences impact quality of care?

Some have found statistically significant differences between non-profit and for-profit quality indicators, with for-profits scoring worse overall.6 Yet, others argue that the line between for-profit and non-profit hospice care is not that clear. “While for-profit status is a relevant inquiry, the corporate governance structure, overlapping directors, and cross-sector alliances and partnerships may have more to do with how hospices behave” (p. 451).5 For example, a physician can now be the medical director for a nursing home as well as the medical director for a hospice agency. Thus, there is potential for this particular nursing home to biasedly refer, even pressure, patients to this one hospice.

A positive influence from the private sector as it pertains to the advancement of policy for increasing advanced practice registered nurse (APRN) scope of practice is the Robert Wood Johnson Foundation’s (RWJF) support of research in the advancement of nursing. The RWJF is a private foundation seeking to benefit the public, which includes the support and encouragement of a “diverse workforce of nurses who work to their full potential.”7

Watch this exciting RWJF video outlining the importance of nursing to the future of healthcare in the United States, including the goal for full practice authority for all nurses:

As APRNs advance policy and gain the ability to certify patients for hospice, they will need to be exceptionally careful to maintain the overarching goal of nursing—to provide the best care for the patient. APRNs need to remain involved with other policy advancements honoring this goal. For instance, disseminating ongoing research on how hospice reimbursement and healthcare models impact care quality.

APRNs are key providers and drivers for the provision of excellent, compassionate, and holistic care to the dying.


1Longest, B. B. Jr. (2010). Health policymaking in the Unites States (5th ed.). Chicago, IL: Health Administration Press.

2National Hospice and Palliative Care Organization. (2015). Retrieved from:

3Jacobson, J. (2014). The effects of the profit motive on the hospice movement: Will quality of care be compromised? American Journal of Nursing, 114 (9).

4Cabin, W., Himmelstein, D. U., Siman, M. L., & Woolhandler, S. (2014). For-Profit Medicare Home Health Agencies’ Costs Appear Higher And Quality Appears Lower Compared To Nonprofit Agencies. Health Affairs, 33 (8).

5Halabi, S. (2014). Selling hospice. Journal of Law, Medicine & Ethics, pp. 442-454.

6Cabin, W. (2014). Nonprofit Quarterly. Is This as Good as It Gets? The False Promise of Risk-Based Medicare and For-Profit Dominance of Care. Retrieved from:

7Robert Wood Johnson Foundation. (2015). Joint Statement on the Institute of Medicine’s Progress Report on the Future of Nursing. Retrieved from:







The Influence of Public Sector Institutions and Policies

The public sector’s influence on healthcare policy associated with hospice care, particularly issues with access and provision of end-of-life care to the uninsured and disabled, is substantial and crucial. As discussed in a previous post, Medicare contains the Medicare Hospice Benefit (MHB). MHB is an option if the person has Medicare Part A and relinquishes Medicare coverage for any treatment related to the terminal illness (Alzheimer’s Association, 2015).

Those with disabilities, especially those younger than 65, often need assistance from the public sector (i.e. Social Security Disability Income (SSDI), Medicaid) to obtain the care they need, including quality end-of-life care.

Advanced Practice Registered Nurses (APRNs), working within a healthcare team, are leaders in the provision of exceptional hospice care to people disabled by various types of dementia.

Dementia impacts the lives of many people, as the person with dementia develops increasing cognitive disabilities resulting from the progression of dementia, and requires increasing amounts of caregiving. Here are some examples of different types of disabling and terminal dementias:

Older people

Age is the greatest risk factor for developing Alzheimer’s disease and most other types of dementia (Alzheimer’s Association, 2015). Also common is Parkinson’s dementia / Lewy Body Dementia (Lewy Body Dementia Association).

Down Syndrome

People with Down Syndrome have a greater risk of developing Alzheimer’s as they age- 75% of those age 65 and older have Alzheimer’s (Alzheimer’s Association, 2015).

Younger people

Among the most common types of dementia impacting people under 65: Early-onset Alzheimer’s and Frontotemporal dementia (FTD) (if you aren’t familiar with FTD, watch this video:

Two APRNs and a SW assisted the FTD community to learn about hospice and when is it time to consider hospice care for people with FTD (The Association for Frontotemporal Degeneration, 2011). APRNs are on the forefront of determining hospice eligibility in this population.

Since people with FTD are typically under age 65 and not yet receiving Medicare, health insurance coverage can be a challenge. Without private insurance that has a hospice benefit and without Medicare, this group has been at risk of being uninsured for healthcare including hospice care. As of 2010, FTD and other early-onset dementias were added to the compassionate allowances to expedite social security disability income (SSDI). (Official Social Security Website). After two years on SSDI, the person is automatically enrolled in Medicare parts A & B, thereby having the option of the MHB (Official Social Security Website).


Veterans are at an increased risk for developing dementia due to post-traumatic stress disorder (PTSD) and other military-related risks (i.e. head injury and depression) (Alzheimer’s Association, 2014).


Photo credit:

As my work focuses on hospice and palliative dementia care, I have encountered many patients who are veterans, and some have a history of PTSD. Some hospices’ provide special services to veterans, such as pinning ceremonies to honor the person’s life and service. This can be considered part of the MHB as volunteers facilitate these ceremonies.

Specialized training is required for staff to provide excellent care to veterans with dementia, particularly those with PTSD. APRNs are well suited to lead the care team and educate staff. For instance, the veteran with dementia and PTSD may experience frightening long-term memories that become current reality. This may present with hallucinations and delusions consistent with a mental return to war. There also can be significant challenges in caregiving, especially with personal care, as this triggers a self-protective reaction. Unfortunately, this understandable self-protection can harm caregivers who are at risk of being punched, bit, and squeezed. APRNs and other nurse leaders are pivotal in teaching comfort and bathing techniques to promote safety, comfort, and uphold dignity; and prescribing appropriate medications consistent with the evidence and/or best practice for this vulnerable population.


According to a contact at the Hospice and Palliative Nurses Association, who is experienced in healthcare policy specializing in advanced practice registered nurses scope of practice issues, as well as knowledge of hospice policy, the primary challenge to APRN hospice certification is changing federal legislation. Organized medicine is one of the barriers with concerns of APRN effectiveness and recognition of the critical importance of resource management. This is a current topic of interest as Medicare is scrutinizing hospice agencies with the goal to decrease fraud. Some hospices have been fined millions of dollars for admitting patients who clearly did not qualify under Medicare hospice criteria (Healthcare Finance, 2015).

Reasons for fraud are many, with a primary concern being proper identification of hospice eligibility. Outside of cancer diagnoses, the ability to prognosticate life expectancy is difficult. Heart disease, lung disease, and dementia are highly variable in their progression. Studies show that using the current Medicare criteria to determine hospice eligibility in people with dementia are not accurate, however, other tools have not shown much improvement (Mitchell, Kiely, Hamel, Park, Morris & Fries, 2004; Mitchell, Miller, Teno, Kiely, Davis, & Shaffer, 2010).

There is no research to indicate that MDs/Dos are better at prognosticating life expectancy than APRNs.

Note: I have recently become aware of how important it is to use the comprehensive term APRNs rather than one group, i.e. NPs, when discussing policy change. Even though nurse practitioners are the primary APRN group working in hospice care at this time, this could change in the future, i.e. expansion of the CNS role and it would be a smoother transition if the wording in existing legislation included the CNS within the broader APRN language.


Alzheimer’s Association. (January, 2015). Medicare’s hospice benefit for beneficiaries with Alzheimer’s disease. Retrieved from

Alzheimer’s Association. (2015). 2015 Alzheimer’s disease facts and figures. Retrieved from

Alzheimer’s Association. (June 17, 2014). Alzheimer’s Association journal compiles key research for the first time on military risk factors for dementia. Retrieved from

Alzheimer’s Association. (May, 2015). Down syndrome and Alzheimer’s disease. Retrieved from

Healthcare Finance. (October 5, 2015). Guardian Hospice to Pay $3 Million to Settle Medicare Fraud Allegations. Retrieved from

Lewy Body Dementia Association. What is LBD? Retrieved from

Mitchell, S. L., Kiely, D. K., Hamel, M. B., Park, P. S., Morris, J. N., & Fries, B. E. (2004). Estimating prognosis for nursing home residents with advanced dementia. Journal of the American Medical Association, 291:2734–2740.

Mitchell, S. J., Miller, S. C., Teno, J. M., Kiely, D. K., Davis, R. B., & Shaffer, M. L. (2010). Prediction of 6-month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines. Journal of the American Medical Association, 304 (17).

Official Social Security Website. (2010). Compassionate allowances conditions. Retrieved from

Official Social Security Website. Disability planner: Medicare coverage if you are disabled. Retrieved from

The Association for Frontotemporal Degeneration. (2011). Hospice and end-of-life. Retrieved from




The Historical and Contemporary Role of Institutions and Actors & Statutory and Regulatory Mechanisms

Who are the Key Players in Policy Creation?   

Government Players

  • The Administration: The President, The Presidential staff, & Political appointees,
  • Civil Servants (public employees), &
  • Congress

The Administration is considered to have the strongest influence with agenda setting, Civil Servants offer alternatives to The Presidential agenda and may have more power over policy implementation, and Congress is the hub of agenda setting and alternatives (Kingdon, 2011).

Other Key Players

  • Special “interest groups,
  • Researchers,
  • Academics,
  • Consultants,
  • Media,”
  • Political party/election groups, &
  • The Public (Kingdon, 2011, p. 45).

A Brief History & Current Outlook on Medicare

Medicare (amending the Social Security Act of 1935) was signed into law by President Lyndon B. Johnson in 1965, thereby ensuring universal health coverage for people age 65 and over in the U.S. (Centers for Medicare and Medicaid Services).

Medicare is funded solely by the Federal Government, and the financial strain on the federal budget will increase as approximately 10,000 of the 76 million Baby Boomers are turning 65 every day over a 20 year period (Kessler, 2014).

Primarily due to the aging of the American population, Social Security, Medicare and Medicaid spending are rising and current “spending policies are likely to prove financially unsustainable” (Longest, 2016, pp. 62-63).

The Medicare Hospice Benefit (MHB)

Medicare is the primary insurance provider for hospice care – In 1982, hospice was introduced to Medicare Part A “under the Tax Equity and Fiscal Responsibility Act” and the MHB was enacted in 1983 (Milone-Nuzzo, Ercolano, & McCorkle, 2015, p. 730).

The goals of hospice care include the provision of comfort-focused care through symptom management rather than curative treatments to persons deemed (by two physicians) to have 6 months or less to live (Milone-Nuzzo, Ercolano, & McCorkle, 2015). The MHB pays a daily rate for the hospice agency to provide DME and other supplies, medications, and interdisciplinary care (nursing, medical, psychosocial, spiritual, and volunteer support) provided at the person’s residence (private home, assisted living, nursing home, etc). Thus, the dying process became a financial opportunity and public policy issue with the growth of hospice companies, both for-profit and not-for-profit.


Statutes/Laws and Regulations/Rules

The legislature in each U.S. state has enacted a Nurse Practice Act (NPA) into law that also establishes a Board of Nursing (BON) with oversight to regulate and interpret the NPA (National Council of State Boards of Nursing).

As Federal Law, Medicare ultimately governs each NPA. Therefore, until the MHB is amended, the BON cannot change the current statute that disallows Advance Practice Nurses to sign hospice terminal certifications.

Key Players Involved in Medicare’s Statutory Requirement for Physician Terminal Certification


Hospice Medicare Beneficiaries

Advance Practice Nurses

American and State Nurses Associations

Institute of Medicine

American Medical Association


A Real-Life Story Involving Key Players (identifying information altered)

Bob is the Medical Power of Attorney (MPOA) for his 86 year-old wife, Edna, who has advanced Alzheimer’s disease, congestive heart failure (CHF), and severe arthritis. After Edna has been hospitalized multiple times for CHF exacerbations, multiple falls, and delirium (unmanaged pain, screaming, hallucinating, hitting her caregivers), the physician in the hospital talks to Bob about hospice. Bob chooses to elect the MHB for Edna (hospital physician and hospice physician sign the hospice admitting terminal certification) and feels the choice of aggressive comfort care fully aligns with what she would want for herself. Upon admission, the hospice nurse practitioner, nurse, and social worker sit down with Bob and ask him how he is doing, inquire about Edna’s life, clarify goals of care, and establish trust. Edna’s medications are streamlined, her pain is managed, and her distressing delirium is treated symptomatically with a soothing environment and medications. Bob shares tearfully with the hospice team, “Edna has been through more than she should have endured. The hospital became like torture to her. Thank God she finally has peace and looks comfortable.” The guilt he felt was palpable as he acknowledged being pushed through the healthcare system. But he didn’t know where to turn.

Questions to ponder until the next post:

What if Edna’s primary care provider (physician or nurse practitioner) had talked to Bob earlier about goals of care and hospice? What are the potential emotional and financial savings?

Can electing the MHB save Medicare money, particularly by avoiding undesired/unnecessary hospitalizations and overuse of medications?

Is it fair and sensible that a nurse practitioner can manage the care of hospice patients but cannot sign them onto service?

Are physician groups, such as the American Medical Association (AMA), the primary opposition to this issue? Is it remotely possible that this is more an issue of haphazard editing, i.e. leaving the word physician in certain parts of the statute and adjusting to include nurse practitioners in others?


Centers for Medicare and Medicaid Services. Retrieved from

Kingdon, J.W. (2011). Agendas, Alternatives, and Public Policies, Updated (2nd ed.). London: Longman Publishing Group.

Kessler, G. July 24, 2014. Do 10,000 Baby Boomers Retire Every Day: Fact Checker. The Washington Post. Retrieved from

Longest, B. B. Jr. (2010). Health policymaking in the Unites States (5th ed.). Chicago, IL: Health Administration Press.

Milone-Nuzzo, P., Ercolano, E., & McCorkle, R. (2015). Home care and hospice home care. In B.R. Ferrell, & N. Coyle (Eds.), Oxford textbook of palliative nursing, (4th ed. pp. 727-739). New York, NY: Oxford University Press.

National Council of State Boards of Nursing. Retrieved from



The Ethical Impact of Healthcare Policy and the Role of Ethics in Policy Decision-Making

The ethical principles of autonomy, beneficence, justice, and nonmaleficence should lead healthcare policy decision-making (4).

A current policy change needed to promote justice and fidelity: “Authorize Nurse Practitioners (NPs) to certify Medicare patients for hospice care” (2).


“All individuals deserve access to quality care at the end of life” (Ref. 5, p. 1)


“…Loyalty, fairness, truthfulness, advocacy, and dedication to our patients…the            concept of keeping a commitment and based upon the virtue of caring” (Ref. 3, p. 2).

In 2003, NPs were first granted the opportunity to accept the designation of hospice “attending physician” when updates to the “Medicare Prescription Drug Improvement and Modernization Act of 2003” created changes to the “Social Security Act (42 U.S.C. 1395x(dd)(3)(b)) ” (1) However, leaving only “physician” language in parts of the update resulted in an unjust regulatory policy (2). The nurse practitioner (NP) community is impaired by the inability to sign patients onto hospice service due to the Medicare requirement that physicians must sign admitting terminal eligibility criteria.

Currently, an NP can have an established relationship as a patient’s primary care provider, along with the ability to bill Medicare for many services since 1998 (2). Yet, at a critical health juncture, the patient must be evaluated by another provider, possibly unknown, in order to obtain hospice care, adding both financial and emotional costs (2). From an “egalitarian perspective of justice,” both the patient and the NP could benefit from a policy change allowing equitable access to hospice services (Ref. 4, p. 296).

Nurse practitioners are ideally positioned to facilitate transition to hospice services and fully capable of determining eligibility.

Many patients in nursing homes receive care from NPs, who may be the first to recognize when it is time for hospice care in this older, ailing, and frail population. And I can hear the exclamations of “balderdash!” from the increasing numbers of NPs specializing in palliative care who are utterly qualified and perfectly positioned to foster a smooth transition from palliative to hospice care.

Furthermore, it is vital to contemplate the pressing issue that ethnic minorities and rural communities have the lowest hospice utilization rates, partly due to access barriers (5).

“Allowing nurse practitioners, who are often the primary health care providers in  rural areas, to participate in the certification process may result in more and earlier referrals to hospice care, providing increased access to services” (Ref. 5, p. 175).

NPs working in various practice environments (i.e. primary care, hospital, specialty clinics, long term care, palliative & hospice) are well suited to engage in conversations about end-of-life wishes, advance directives, and palliative and hospice care. NPs are qualified to determine hospice eligibility. Considering healthcare’s future of doing more with less while caring for a rapidly aging, increasingly chronically ill population, it is imperative to act now and maximize our available resources. This includes allowing NPs full scope of practice and eliminating barriers to hospice care.

“You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die.”— Dame Cicely Saunders, nurse, physician and writer, and founder of hospice movement (1918 – 2005). (6).


1) Buppert, C. (2006). Three things no NP may do. The Journal for Nurse Practitioners, pp. 149-151.

2) American Association of Nurse Practitioners (2012). Retrieved from

3) American Nurses Association. Retrieved from

4) Longest, B. B. Jr. (2010). Health policymaking in the Unites States (5th ed.). Chicago, IL: Health Administration Press.

5) Lynch, S. (2012). Hospice and palliative care access issues in rural areas. American Journal of Hospice and Palliative Medicine, 30(2).

6) Life Before Death. Retrieved from


Week 1. Nurse practitioner scope of practice: Certification of terminal illness


This blog will discuss the topic of terminal illness certification. In my daily practice as a hospice nurse practitioner (NP), I am given the title of Following/Attending of the only inpatient hospice palliative care unit (PCU) in the United States that specializes in caring for persons with dementia.

All hospice teams function as an interdisciplinary team (certified nursing assistant, nurse, social worker, chaplain, NP, physician, volunteer) and our PCU values each member equally. However, as the primary clinician, I am responsible for managing complex patients with varying types of dementia. My everyday obligations involve clinical decision making; communicating with families regarding end-of-life care decisions, goal setting & prognosis; prescribing; and signing death certifications. However, I am not allowed to make the determination for hospice eligibility (prognosis of 6 months or less if the disease runs its natural course) or receive the title of Medical Director.

Current Legislation

“A nurse practitioner may not certify the patient’s terminal illness even if they will be serving as the patient’s attending physician.” (CMS, CR 2750, 2003) (1)

Section §1814(a)(7) of the Social Security Act states that only a physician (medical doctor or osteopathic doctor) can certify terminal illness (and thereby facilitate admission to hospice services). (1)

Problem Identification and Significance

Current policy restricts NP scope of practice and presents a barrier to NPs in all practice environments who identify patients that qualify for hospice yet must find a physician to state terminal status.

Changing current legislation to allow nurse practitioners to sign terminal certifications and admit patients to hospice has the potential to increase patient access to hospice care (particularly in rural areas), decrease costs (reducing physician time signing terminal certifications), facilitate continuity of care, and allow nurse practitioners to function at a full scope of practice.

Further, The Future of Nursing Institute of Medicine Report (2010) recommends removing scope of practice barriers to advance practice nurses and includes a statement to congress to “amend the Medicare program to authorize advanced practice registered nurses to perform admission assessments, as well as certification of patients for home health care services and for admission to hospice and skilled nursing facilities.” (2)

Looking Ahead

I look forward to exploring this topic with you and reading your varied perspectives, experiences, and ideas.


1)    Retrieved from

2) Retrieved from