Palliative Care Certification

ATIP Palliative Care Exemption – Working Description

Andrea Anderson, Executive Director ATIP
In the 2016 CDC Guidelines for the Treatment of Chronic Pain, the CDC included a specific exemption to arbitrary dose limits through a Palliative Care Exemption. Other exemptions included active and post-cancer care, end-of-life pain management, and hospice care.
However, the CDC did not provide an accurate or reliable definition of how “Palliative Care,” could function as an Exemption, and thus, it is undefined and unused. Practitioners do not have a clear definition under which to implement a legitimate Palliative Care Exemption for qualified patients, and thus it languishes, and neither providers nor pharmacists nor patients are receiving the protections it offers.  Palliative Care Exemption is a critical exemption, as it would give providers the ability to certify and treat patients with the individualized, specific authority their training and licensing grants, allowing them to properly treat and manage their patients with long-term, chronic, intractable pain syndromes. 
Since this very important exemption has not been implemented in any meaningful way, and is often blurred with hospice care, it has not provided the CDC’s intended benefit to patients or providers. ATIP has developed a working model of the Palliative Care Exemption to provide a legal and prudent way for providers to care for the over 5 million patients in the United States who suffer from over 200 illnesses or injuries that have incurable pain as a symptom. 
On the subject of Palliative Care, first it is important to define the terms and help us understand it.  There are many definitions of palliative care, several developed by different government agencies. Here are a few:

“Palliative care is a specialized medical care for people with serious illnesses. This type of care is focused on providing relief from the symptoms and stress of a serious illness or injury…the goal is to improve quality of life for both the patient and family. It is appropriate at any age and any stage, and can be provided along with curative therapies.”

“Since there are no time limits on when you can receive palliative care, it is able to fill the gap for patients who want and need comfort at any stage of their disease, whether terminal or chronic.” (Hospice versus palliative care, from Educational Broadcasting  Corporation/Public Affairs Television)
“Palliative care is defined in a manner consistent with that of the Institute of Medicine as care that provides relief from pain and other symptoms, supports quality-of-life, and is focused on patients with serious advanced illnesses (or injuries-added). Palliative care can begin early in the course of treatment for any serious illness that requires excellent management of pain or other distressing symptoms. This is separate from cancer patients and end-of-life care.” (CDC Guidelines for Prescribing Opioids for Chronic Pain, 2016.)
“Palliative Care is a free-standing method of patient care. Palliative care is an approach that improves the quality of life of patients due to the prevention and relief of suffering and treatment of pain or other problems, physical, psychosocial, and spiritual. These guidelines are not intended only for cancer patients or end of life patients. They are for all patients with serious chronic illness, especially where other therapies have failed.“ (World Health Organization.)
For the sake of the ATIP Palliative Care Exemption, intractable pain is considered an illness in and of itself.
“Intractable Pain has numerous, severe complications which shorten lifespan and incapacitate the patient unless bold measures are taken to control intractable pain. Some common causes of Intractable Pain are spine degeneration, neuropathies of any sort such as Reflex Sympathetic Dystrophy (RSD)or Complex Regional Pain Syndrome (CRPS), Fibromyalgia, Adhesions, Pelvic Neuropathies, Interstitial Cystitis, Chronic Migraine, joint degeneration in any joint, or Systemic Lupus Erythematosus…” (Forest Tennant, MD The Intractable Pain Patient’s Handbook for Survival
ATIP has developed a Palliative Care Exemption certificate. If adopted, either by state medical boards or state and federal legislation, this Palliative Care Exemption certificate would allow providers the discretion to treat patients requiring long-term pain management without arbitrary dosage limits or restrictions on medical or pharmaceutical therapies. Ideally, it would provide a framework for medical care that would grant protections for providers, pharmacists, and patients, and protect against unwarranted disciplinary actions by regulatory agencies.
ATIP’S intention is to thoroughly define the Palliative Care Exemption and oversee it’s adoption and use as the CDC intended. In addition, the ATIP Palliative Care Exemption does not disrupt any anti-addiction initiatives or policies.
Key Provisions:
1.  Much like a handicapped placard, the Palliative Care Exemption could either be a temporary or permanent designation, depending upon the patient’s diagnosis, and a treatment plan would be developed and documented. Recertification could occur every year, or at the provider’s discretion. 
2. A copy of the signed palliative Care Exemption certificate, along with the patient’s diagnosis, treatment plan, and schedule for recertification, would be be entered into the patient’s permanent EHR.
3. Another copy of the Palliative Care Exemption certificate would be given to the exclusive pharmacy as determined by the patient and Provider. This would ensure continuity of care between all members of the patient’s medical team and prevent disruptions in medication management.
4. The Palliative Care Exemption certification would allow pharmacists and dispensers to be aware of the patient’s legal exemption for treatment under the Palliative Care Exemption, and thus release them from any liability from dispensing medications in prescribed amounts that may supersede other existing guidelines.
5.  The Palliative Care Exemption could assign disciplinary action to pharmacists who arbitrarily refuse to fill a legitimate prescription if covered under this Palliative Care  exemption.
6. Ideally, a new ICD-10 code would be generated to compensate providers with a higher reimbursement than that of a standard office visit. Providers who prescribe opioids are often required to obtain additional CME‘s and are also tasked with a significant amount of administrative work.  As these additional requirements are quite  burdensome, additional reimbursement would provide an incentive to treat patients requiring long-term chronic pain treatment, and would more adequately reimburse providers who care for patients with intractable pain syndromes.
7. Palliative care would be recognized as distinct and separate from hospice care, and would not be subject to the rules of hospice treatment, such as imminent mortality or forsaking curative therapies. Patients treated under the Palliative Care Exemption would be treated on an outpatient basis, actively pursue curative therapies, and be supported in their goals to achieve the highest quality of life possible.
We hope to build alliances with all Palliative Care providers and associations, and draft legislation and policies to ensure adequate treatment of chronic, intractable pain.  Our hope is that patients, once certified as exempt by the Palliative Care Exemption, will avoid disruption or abandonment; protect providers, pharmacists, and insurers, and allow providers – whose training and discretion directs the prudent use of opioids, anti-seizure, anti-depressants, and other pain management medications to provide dignity and patient-oriented care without fear of reprisal. 
We welcome input to help craft the language of this exemption, and we welcome partnerships in implementing the CDC Palliative Care Exemption in a truly meaningful way.

Palliative Care Certificate – Word Format
Palliative Care Certificate – PDF Format