AARP Public Policy Institute INSIGHT on the Issues Removing Barriers to Advanced Practice Registered Nurse Care: Home Health and Hospice Services Andrea Brassard AARP Public Policy Institute The landmark 2011 Institute of Medicine report, The Future of Nursing, Leading Change, Advancing Health, recommends that advanced practice registered nurses (APRNs) be allowed to certify patients for Medicare payment of home health and hospice services. 1 However, Medicare laws and regulations prohibit APRNs from conducting certification for these services. This report shows how removing this barrier would benefit consumers, physicians, and the health care system. Advanced practice registered nurses help with bathing or meals, from a home (APRNs) provide high-quality primary health aide. About 10 percent of care on a daily basis in communities Medicare beneficiaries use home health across the nation, 2 particularly in rural services each year, 5 allowing them to and underserved areas. 3 APRNs also receive nursing care and other health play a vital role in providing care services at home as an alternative to coordination for people with multiple extended hospital stays or nursing home diseases and chronic conditions. Their care. advanced education and training equips APRNs with the knowledge and Physicians are the gatekeepers of the experience to refer patients for home Medicare home health benefit, but health and hospice services. Despite this, nursing is the fundamental home health Medicare rules and regulations do not service. 6 In order for a Medicare allow ARPNs to sign certification beneficiary to receive home health documents to allow consumers to services, a physician must certify that the receive these needed services. patient is homebound and requires skilled services, such as nursing care or physical therapy. What are Home Health and Hospice Services? Who are Advanced Practice Home health and hospice services are Registered Nurses? Medicare benefits provided to Advanced Practice Registered Nurses (APRNs): beneficiaries in their homes, including wound care, physical and occupational  Are registered nurses (RNs) with master’s, post-master’s, or doctoral degrees. therapy, patient and caregiver education, and monitoring serious illness and  Pass national certification exams. unstable health status. These Medicare  Teach and counsel patients to understand their health problems and what they can services were designed to be short-term, do to get better. post-hospitalization health care services. 4 A Medicare beneficiary who  Coordinate care and advocate for patients in the complex health system. requires the skilled services of a registered nurse or therapist may also  Refer patients to physicians and other health care providers. receive personal care services, such as Removing Barriers to Advanced Practice Registered Nurse Care: Home Health and Hospice Services Types of Advanced Practice Registered Nurses How many Who are they? in U.S.? What do they do? Nurse Practitioners (NP) 158,348 Take health histories and provide complete physical exams; diagnose and treat acute and chronic illnesses; provide immunizations; prescribe and manage medications and other therapies; order and interpret lab tests and x-rays; provide health teaching and supportive counseling. Clinical Nurse 59,242* Provide advanced nursing care in hospitals and other clinical Specialists (CNS) sites; provide acute and chronic care management; develop quality improvement programs; serve as mentors, educators, researchers, and consultants. Certified Registered 34,821 Administer anesthesia and related care before and after surgical, Nurse Anesthetists therapeutic, diagnostic, and obstetrical procedures, as well as (CRNA) pain management. Settings include operating rooms, outpatient surgical centers, and dental offices. CRNAs deliver more than 65% of all anesthetics to patients in the U.S. Certified Nurse- 18,492 Provide primary care to women, including gynecological exams, Midwives (CNM) family planning advice, prenatal care, management of low risk labor and delivery, and neonatal care. Practice settings include hospitals, birthing centers, community clinics and patient homes. Sources: AARP Public Policy Institute, Center to Champion Nursing in America, Preparation and Roles of Nursing Care Providers in America. Washington, DC, 2009. U.S. Department of Health and Human Services, Health Resources and Services Administration, The Registered Nurse Population: Initial Findings from the 2008 National Sample Survey of Registered Nurses. Washington, DC, 2010. (*APRNs are identified by their responses to the National Sample Survey and may not reflect the true population of clinical nurse specialists.) Hospice services are provided by a team to die at home, 10 according to the latest of health care professionals and support Medicare information available, only staff to terminally ill patients and their about 42 percent of Medicare families in their home or in an inpatient beneficiaries who died in 2009 used facility. 7 The Medicare hospice benefit hospice services, up from about includes nursing care, pain medication, 23 percent in 2000. 11 and personal care services for terminally ill patients, as well as counseling and Medicare Rules for Home Health support for their family caregivers. 8 and Hospice Services May Pose Unlike Medicare home health services, Barriers to Care there is no requirement that the hospice beneficiary be homebound. Both Medicare Medicare laws and regulations regarding home health and hospice services are the role of APRNs are inconsistent. For provided to beneficiaries without the need example, Medicare specifies that only a to pay any deductibles or copayments. physician (not an APRN or physician assistant) may order home health Medicare requires that a physician services. 12,13,14 Medicare regulations certify that a hospice patient’s life also specifically exclude nurse expectancy is six months or less. This practitioners (NPs) from being allowed requirement assumes that there is a to certify patients for hospice. 15 reasonable probability—not certainty— of the hospice beneficiary’s prognosis. 9 However, since 2003, NPs have been authorized to act as “attending physicians” Although several studies have found that for hospice patients. 16 Medicare hospice the vast majority of people would prefer regulations define an attending physician 2 Removing Barriers to Advanced Practice Registered Nurse Care: Home Health and Hospice Services as a “doctor of medicine or osteopathy or a The requirement for a face-to-face nurse practitioner [who] is identified by the encounter was designed to combat fraud by individual, at the time he or she elects to ensuring that physicians and other health receive hospice care, as having the most care providers have met the patients in significant role in the determination and person and determined that they are indeed delivery of the individual’s medical eligible for Medicare home health or care.” 17 hospice benefits. 21 Furthermore, although Medicare does not Although only physicians may certify allow NPs or other APRNs to certify patients for home health and hospice patients for hospice or home health services, services, the face-to-face encounter may be since 1995, APRNs have been authorized to performed by NPs, clinical nurse specialists, certify patients for post-hospitalization and physician assistants (PAs), in addition to extended care services in skilled nursing physicians. These nonphysician providers facilities. Medicare accepts APRN are required to document the clinical signatures on certification or recertification findings of the encounter and communicate forms to enable beneficiaries to receive those findings to the certifying physician. postacute care and rehabilitation for The certifying physician then writes a complex medical conditions such as joint narrative based on those clinical findings replacement, stroke, and heart failure. 18 that supports the patient’s homebound status and need for skilled services. Medicare APRNs Play a Significant Role provides an example of a physician narrative Preventing Medicare Fraud on its website: The Medicare Payment Advisory The patient is temporarily homebound Commission (MedPAC) has expressed secondary to status post total knee concern regarding fraudulent overuse of replacement and currently walker Medicare home health and hospice dependent with painful ambulation. PT services. 19 The Office of the Inspector [physical therapy] is needed to restore General found that home health agencies the ability to walk without support. received $432 million in overpayments Short-term skilled nursing is needed to for services that were not medically monitor for signs of decomposition or necessary. The Medicare beneficiaries adverse events from the new COPD who received these services were not [chronic obstructive pulmonary homebound, not in need of skilled disease] medical regimen. 22 nursing care, or not under the care of a For hospice services, only physicians or physician. The overpayment of NPs are authorized to perform the face-to- $432 million represents about 2.5 percent face encounter. Clinical nurse specialists of the total $17 billion in Medicare home and PAs are excluded. If a hospice NP health payments in 2008. 20 performs the face-to-face encounter, the To reduce Medicare payment fraud, as part NP must attest in writing the visit date and of the Patient Protection and Affordable “state that the clinical findings of that visit Care Act, Medicare now requires a face-to- were provided to the certifying physician, face encounter to certify eligibility for for use in determining whether the patient home health and hospice services. The [has]…a life expectancy of 6 months or face-to-face encounter may take place in a less, should the illness run its normal physician’s office, a hospital or other course.” 23 health care setting, or in the patient’s Having APRNs perform the face-to-face home. In rural areas, the encounter may be encounter and then requiring written conducted via telehealth technology. 3 Removing Barriers to Advanced Practice Registered Nurse Care: Home Health and Hospice Services documentation of the encounter by both services. 27 AARP is committed to the APRN and the certifying physician ensuring that consumers have access to often delays access to needed care and health care providers who are qualified, increases costs. educated, and certified to provide high- quality primary care, chronic care The Institute of Medicine management, and other services that Recommends that APRNs Be help them live a high-quality life, with Authorized to Certify Home Health dignity, in locations of their choice. 28 and Hospice Services For the vast majority of older The Institute of Medicine report The Americans, that location is home. 29 For Future of Nursing: Leading Change, homebound patients, the current Advancing Health recommends that requirement that a physician sign-off on APRNs be authorized to certify eligible APRN recommendations for home care patients for home health and hospice services may delay care and may result services. 24 Ordering home health services in hospitalizations that could have been is within the scope of practice of an NP, avoided. clinical nurse specialist, and certified Allowing APRNs to authorize home nurse midwife. 25 These APRNs have health and hospice services could advanced education and training and are increase access and reduce costs. At capable of determining if a Medicare present, if an NP sees a patient in a recipient is homebound and in need of medical office or on a house call—and skilled nursing or therapy services in the more NPs are going into independent home, as well as in a nursing home. house call practices (see “Manhattan NPs who work in hospice settings are House Calls” box)—and determines that educated and trained in the care of the patient needs home health or hospice terminally ill patients. Estimating services, the NP is required to ask a prognosis and predicting survival for a physician to sign the home health or patient with a terminal diagnosis is based hospice forms. Some physicians will on the natural history of the disease, the charge the NP a fee for signing patient’s functional status, signs and Medicare certification forms. Other symptoms, and laboratory and other physicians will not certify home health diagnostic tests. 26 NPs who function as or hospice services unless they have hospice “attending physicians” are well seen the patient. This means an extra informed about their patients’ medical visit to a physician’s office for a history and current status. These NPs are homebound patient—often by capable of determining if a patient has a ambulance. terminal illness with a life expectancy of Allowing APRNs to authorize home six months or less. health and hospice services could reduce delays in care for vulnerable, homebound The Benefits of Allowing APRNs patients (see “Mobile Medicine” box). to Authorize Home Health and APRNs are willing to provide services in Hospice Services areas where access to physicians is limited, including underserved urban and Consumers will benefit from more remote rural areas. More than two-thirds direct access to home health and hospice of NPs practice in primary care settings, services. Since 2010, AARP has and 18 percent practice in remote rural or supported proposed legislation to allow frontier settings. 30 APRNs to certify home health 4 Removing Barriers to Advanced Practice Registered Nurse Care: Home Health and Hospice Services Physicians will benefit when APRNs can health and hospice services would certify home health and hospice services. eliminate the need for NP practices to put their collaborating physician’s name on Allowing APRNs to sign certification home health or hospice orders, lab forms would reduce the paperwork piles requests, or patient summaries. Valuable in medical offices throughout the country. medical staff office time would no longer In a public meeting held on January 15, be used notifying physicians about home 2010, MedPAC discussed the face-to- health or hospice orders or test results of face encounter as a way to reduce home homebound patients they have never seen health service overuse and to prevent nor ever will see (see “Advanced Geriatric Medicare fraud. MedPAC commissioner Education & Consulting LLC” box). William Scanlon recommended that NPs not only perform the face-to-face Allowing APRNs to certify home health encounter but also be able to certify services could result in $129.2 million to patients for home health services. Dr. $309.5 million cost savings for Medicare Scanlon advised that NPs were capable of in the next 10 years. 35 Cost savings in making certification decisions and that this report are based on the 15 percent this would increase efficiency and “take a reduction in Medicare payment when a burden off physicians.” 31 service is billed by a nonphysician provider. Cost estimates for allowing Allowing the APRN who performs the APRNs to certify hospice services have face-to-face encounter that is used to not been determined, but because the determine eligibility for home health and numbers of NPs who practice as hospice hospice services to also write and sign the attending physicians are very small, required narrative would eliminate a accounting for just 4 percent of Part B tedious, unnecessary task for physicians. Medicare Hospice services in 2006, 36 Since about half of all office-based minor cost reductions could result. physicians work with an APRN or PA, 32 removing the requirement for physician Indirect costs of this barrier to APRN sign-off would be a welcome reduction in practice and care include visits to physician workload. Medicare recently physicians, often by ambulance, by acknowledged the administrative burden homebound beneficiaries for the sole associated with physician documentation of purpose of getting certifications signed, APRN or PA performed face-to-face as well as unnecessary emergency encounters by proposing a special payment department visits or hospitalizations due code of $15 for this administrative task. 33 to delays in home health or hospice services because of unsigned The health care system will benefit certification forms. These indirect costs when APRNs can certify home health have not been calculated, but allowing and hospice services. APRNs to certify home health and hospice services could surely reduce Home health and hospice providers could overall costs to the health care system. gain efficiencies if APRNs could certify home health and hospice services. Locating and obtaining documentation Conclusion from physicians for home care and hospice certification is cumbersome and Removing barriers to APRN care in home expensive for home health agencies. 34 health and hospice services will benefit consumers, nurses, physicians, and the NP and physician practices would also health care system. Removing these benefit. Allowing APRNs to certify home barriers, which will require legislative action, would increase access to care for 5 Removing Barriers to Advanced Practice Registered Nurse Care: Home Health and Hospice Services vulnerable patients and their family services. Allowing APRNs to certify home caregivers. Continuity of care would health and hospice services can potentially improve if the NPs who provide house calls decrease costs, expedite treatment by or other primary care services could be the eliminating the need for physician sign-off, providers of record for their patients’ and allow patient-centered health care Medicare home health and hospice teams to practice more efficiently. Manhattan House Calls, LLC “For many seniors, accessing medical care can be both financially and physically demanding. By performing medical house calls, we strive to alleviate this burden.” — DENIS F. TARRANT, NP Nurse practitioner Denis Tarrant submits more than 300 certifications for home health services each year, and not one of these patients has seen a physician. Denis’s homebound patients are able to receive home health services under Medicare because his physician collaborator is willing to sign the certification documents. For this Medicare requirement, Denis pays the physician collaborator $15,000 annually. Denis is an associate member of the American Academy of Home Care Physicians and says that often physician members post on the academy’s listserv their support for the passage of federal legislation to allow APRNs to certify home health services. Effective January 1, 2011, as part of the Affordable Care Act, Medicare requires a face-to- face encounter by the certifying physician or a nonphysician provider (nurse practitioner, clinical nurse specialist, certified nurse midwife, or physician assistant). For Denis, this requirement means one more document that he fills out and submits to his collaborating physician for signature. Denis says that by allowing nurse practitioners to see the patient and having the physician sign off on the nurse practitioner’s statement, Medicare is acknowledging that physicians do not have the time or capacity to see every patient who needs home health care. It would be in the patient’s best interest that the provider who makes the house call be the provider who certifies the need for home health services and communicates those needs to the Medicare-certified home health agency. 6 Removing Barriers to Advanced Practice Registered Nurse Care: Home Health and Hospice Services Mobile Medicine Biking nurse makes house calls in Bellingham, Washington. http://www.bellinghamherald.com/2010/10/15/1671247/bellingham-nurse-practitioner.html. Jody Hoppis, an adult nurse practitioner, owns a house calls practice in Bellingham, Washington. She travels by bicycle to her clients’ homes and workplaces, transporting medical supplies behind her. As an independent nurse practitioner in Washington State, Jody can practice to the full extent of her education and training, including prescribing medications and physical therapy, ordering and interpreting diagnostic tests, and referring patients to specialists. The largest barrier to this APRN practice is the Medicare requirement for physician certification of home health services. Jody had to find a physician willing to countersign home health orders and set up a contract. Since the physician’s office is located two hours away, Jody spends time and resources faxing authorizations back and forth between her practice, the physician, and home health agencies. This barrier has already had a detrimental effect on one of Jody’s homebound patients. This patient had not been out of bed for four years and welcomed Jody’s visit. On the initial visit, Jody diagnosed a wound and recommended visiting nurse services. It took more than a week for Jody to obtain authorization for wound care for this patient and for the home health agency to accept the orders. The delay in care resulted in a significantly larger wound and delayed the patient’s treatment and recovery. 7 Removing Barriers to Advanced Practice Registered Nurse Care: Home Health and Hospice Services Advanced Geriatric Education & Consulting, LLC Phyllis Atkinson has been a registered nurse for 32 years and a geriatric nurse practitioner (GNP) for 18 of those years. For the past three years, she and her business partner Kathy Ferriell have made house calls to frail older adults through Advanced Geriatric Education & Consulting, LLC (AGE). Their clients, like most older adults, want to stay in their own homes as long as possible. The Medicare rule that does not permit GNPs to order home health and hospice services is a daily problem, causing delays in care and unnecessary emergency department visits and hospitalizations. Home health agencies have interpreted the outdated Medicare rule to mean that they cannot accept any telephone orders from NPs. Fortunately, the AGE house calls practice collaborates with the geriatric department of Wright State Physicians, which will sign home care and hospice orders for Phyllis and Kathy’s patients. Unfortunately, this arrangement creates confusion and delays care. Since the home health agency will not accept orders from NPs, lab tests and other diagnostic tests must be written with the collaborating physician’s name on the lab slip. Results are then faxed to the large academic physician practice, not the house calls practice. Administrative staff at the Wright State geriatric practice waste time notifying physicians about lab results on patients they have not seen and are not they following, NPs spend time trying to track results, and both NPs and physicians spend unnecessary time away from their patients. The Wright State Physicians who practice in the department of geriatrics are happy to collaborate with the AGE house calls practice but would be much happier if they were not required to sign Medicare forms or receive lab results on patients not under their care. Home health and hospice nurses would prefer to communicate directly with the patients’ primary care provider—in this case, the NP who sees the patients in their homes. Patients would prefer to stay in their homes and be able to receive complete, comprehensive care from primary care providers who know them best. 8 Removing Barriers to Advanced Practice Registered Nurse Care: Home Health and Hospice Services Endnotes 1 Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health (Washington, DC: The National Academies Press, 2011). 2 AARP Public Policy Institute, Removing Barriers to Advanced Practice Registered Nurse Care: Hospital Privileges, Insight on the Issues (Washington, DC: AARP, September 2011). 3 Center to Champion Nursing in America, “Improving Access to Primary Care: The Growing Role of Advanced Practice Registered Nurses,” http://bit.ly/APRNs-primary-care, accessed April 26, 2012. 4 Robert H. Binstock and Leighton E. Cluff, eds., Home Care Advances: Essential Research and Policy Issues (New York, NY: Springer, 2000). 5 Medicare Payment Advisory Commission, Report to the Congress: Medicare payment policy, Chapter 8, Home Health Services (Washington, DC: MedPAC, 2012), http://www.medpac.gov/chapters/Mar12_Ch08.pdf. 6 Eli Ginzberg, Warren L. Balinsky, and Miriam Ostow, Home Health Care (Totowa, NJ: Rowman & Allenheld, 1984). 7 Centers for Medicare & Medicaid Services, “Medicare Hospice Benefits,” http://www.medicare.gov/Publications/Pubs/pdf/02154.pdf, accessed April 26, 2012. 8 Ibid. 9 American Academy of Home Care Physicians, “Making Home Care Work in a Medical Practice,” (Edgewood, MD: American Academy of Home Care Physicians, April 2012). 10 Ibid. 11 Medicare Payment Advisory Commission, Report to the Congress: Medicare payment policy, Chapter 11 Hospice Services (Washington, DC: MedPAC, 2012), http://www.medpac.gov/chapters/Mar12_Ch11.pdf. 12 Conditions for Medicare Payment 42 C.F. R. § 424.22 (2011), http://ecfr.gpoaccess.gov/cgi/t/text/text- idx?c=ecfr&sid=c7de1c82785554aa9f7f6476345fd03d&rgn=div8&view=text&node=42:3.0.1.1.11.2.6.8 &idno=42. 13 42 U.S.C. § 1395x(m)8, http://www.ssa.gov/OP_Home/ssact/title18/1861.htm. 14 42 U.S.C. § 1395f, www.ssa.gov/OP_Home/ssact/title18/1814.htm. 15 Hospice Conditions of Participation, 42 C.F.R. § 418 (2008), http://www.gpo.gov/fdsys/pkg/FR-2008- 06-05/pdf/08-1305.pdf. 16 Medicare Claims Processing Manual Transmittal, September 24, 2004, http://www.cms.gov/Regulations- and-Guidance/Guidance/Transmittals/downloads//R304CP.pdf. 17 Medicare Benefit Policy Manual, June 15, 2004, http://www.cms.gov/Regulations-and-Guidance/ Guidance/Transmittals/downloads//R15BP.pdf. 18 Medicare Program: Allowing Certifications and Recertifications by Nurse Practitioners and Clinical Nurse Specialists for Certain Services, 42 C.F.R. § 424.20(e) (2) (1995), http://www.gpo.gov/fdsys/pkg/FR-1995-07-26/pdf/95-18282.pdf. 19 Medicare Payment Advisory Commission. Report to the Congress: Medicare payment policy, Chapter 8, Home Health Services. 20 Department of Health and Human Services, Office of Inspector General, “Documentation of Coverage Requirements for Medicare Home Health Claims” (March 2012), http://oig.hhs.gov/oei/reports/oei-01-08- 00390.pdf. 21 Center for Medicare Advocacy, Inc., “Home Health Face-to-Face Physician/Practitioner Requirement Challenges,” http://www.medicareadvocacy.org/2012/04/12/home-health-face-to-face-physician practitioner-requirement-challenges. 22 Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services. Medicare Home Health Face-to-Face Requirement (Baltimore, MD: CMS, 2011), https://www.cms.gov/ HomeHealthPPS/Downloads/face-to-face-requirement-powerpoint.pdf. 9 Removing Barriers to Advanced Practice Registered Nurse Care: Home Health and Hospice Services 23 Centers for Medicare & Medicaid Services, Department of Health and Human Services. Medicare Home Health Face-to-Face Guidance (Baltimore, MD: CMS, 2011), https://www.cms.gov/Hospice/Downloads/ HospiceFace-to-FaceGuidance.pdf. 24 Institute of Medicine, The Future of Nursing. 25 Carolyn Buppert, “Why Can’t Advanced Practice Nurses Order Home Health Services?” http://www.medscape.com/viewarticle/748243, accessed April 13, 2012. INSIGHT on the Issues 26 National Hospice Organization, Important Questions for Hospice in the Next Century, Appendix C. Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases (Arlington, VA: National Hospice Organization, 1996), http://aspe.hhs.gov/daltcp/reports/impquesa.pdf. 27 http://www.aarp.org/politics-society/advocacy/info-05-2010/eye_on_nursing.html. 28 AARP Letter to Representative Schwartz (2011), http://assets.aarp.org/www.aarp.org_/cs/health/ ltrrepresentativeschwartz.6_22_11.docx.pdf. 29 David Crary, “Aging in Place: a Little Help Can Go a Long Way” (November 21, 2011), http://www.aarp.org/home-garden/livable-communities/news-10-2011/us-fea--aging-america-aging-in- place.html. 30 American Academy of Nurse Practitioners, “Nurse Practitioner Facts,” http://www.aanp.org/NR/rdonlyres/ 90C86114-C17C-407B-8056-D47956C9DB0F/0/AANPNPFactsLogo1111.pdf. 31 Medicare Payment Advisory Commission, Public Meeting Transcript, January 14–15, 2010, http://www.medpac.gov/transcripts/0114-0115MedPAC.final.pdf. 32 Melissa Park, Donald Cherry, and Sandra L. Decker, “Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants in Physician Offices,” National Center for Health Statistics (NCHS) Data Brief, No. 69 (August 2011), http://www.cdc.gov/nchs/data/databriefs/db69.pdf. 33 Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services, Medicare Program; Revision to Payment Policies Under the Physician Fee Schedule, DME Face-to-Face Encounters, Elimination of the Requirement for Termination of Non-Random Prepayment Complex Medical Review and Other Revisions to Part B for CY 2013. https://www.federalregister.gov/articles/2012/07/30/2012- 16814/revisions-to-payment-policies-under-physician-fee-schedule-dme-face-to-face-encounters-etc- medicare. 34 Dobson DaVanzo and Associates, Memorandum: Impact of Proposed Legislation S. 2814/H.R. 4993 on Medicare Expenditures, November 5, 2010, http://vnaa.org/vnaa/g/?h=html/Advocacy_nurse_ Insight on the Issues 66, July, 2012 practicioners.html. 35 Ibid. AARP Public Policy Institute, 36 The Lewin Group, “Cost Estimates for the Coverage 601 E Street, NW, Washington, DC 20049 of Physician Assistant Services for Medicare www.aarp.org/ppi. Beneficiaries” (May 7, 2009). http://www.aapa.org/ 202-434-3844, ppi@aarp.org uploadedFiles/content/The_PA_Profession/Federal_ © 2012, AARP. and_State_Affairs/Resource_Items/LEWIN%20Final %20Rept%20%205%2009.pdf. Reprinting with permission only. 10