[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2188 Introduced in House (IH)]







106th CONGRESS
  1st Session
                                H. R. 2188

To amend the Public Health Service Act to provide for a public response 
      to the public health crisis of pain, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             June 14, 1999

   Ms. Hooley of Oregon (for herself, Mr. Greenwood, Mr. Levin, Mrs. 
 Johnson of Connecticut, and Mrs. Maloney of New York) introduced the 
following bill; which was referred to the Committee on Commerce, and in 
    addition to the Committee on Ways and Means, for a period to be 
subsequently determined by the Speaker, in each case for consideration 
  of such provisions as fall within the jurisdiction of the committee 
                               concerned

_______________________________________________________________________

                                 A BILL


 
To amend the Public Health Service Act to provide for a public response 
      to the public health crisis of pain, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Conquering Pain 
Act of 1999''.
    (b) Table of Contents.--The table of contents for this Act is as 
follows:

Sec. 1. Short title.
Sec. 2. Findings.
Sec. 3. Definitions.
    TITLE I--EMERGENCY RESPONSE TO THE PUBLIC HEALTH CRISIS OF PAIN

Sec. 101. Guidelines for the treatment of pain.
Sec. 102. Patient expectations to have pain and symptom management.
Sec. 103. Quality improvement projects.
Sec. 104. Pain coverage quality evaluation and information.
Sec. 105. Surgeon General's report.
                TITLE II--DEVELOPING COMMUNITY RESOURCES

Sec. 201. Family support networks in pain and symptom management.
                   TITLE III--REIMBURSEMENT BARRIERS

Sec. 301. Reimbursement barriers report.
Sec. 302. Insurance coverage of pain and symptom management.
   TITLE IV--IMPROVING FEDERAL COORDINATION OF POLICY, RESEARCH, AND 
                              INFORMATION

Sec. 401. Advisory Committee on Pain and Symptom Management.
Sec. 402. Institutes of Medicine report on controlled substance 
                            regulation and the use of pain medications.
Sec. 403. Conference on pain research and care.
                    TITLE V--DEMONSTRATION PROJECTS

Sec. 501. Provider performance standards for improvement in pain and 
                            symptom management.

SEC. 2. FINDINGS.

    Congress finds that--
            (1) pain is often left untreated or under-treated 
        especially among older patients, African Americans, and 
        children;
            (2) chronic pain is a public health problem affecting at 
        least 50,000,000 Americans through some form of persisting or 
        recurring symptom;
            (3) 40 to 50 percent of patients experience moderate to 
        severe pain at least half the time in their last days of life;
            (4) 70 to 80 percent of cancer patients experience 
        significant pain during their illness;
            (5) despite the best intentions of physicians, nurses, 
        pharmacists, and other health care professionals, pain is often 
        under-treated because of the inadequate training of physicians 
        in pain management;
            (6) despite the best intentions of physicians, nurses, 
        pharmacists, and other health care professionals, pain and 
        symptom management is often suboptimal because the health care 
        system has focused on cure of disease rather than the 
        management of a patient's pain and other symptoms;
            (7) the technology and scientific basis to adequately 
        manage most pain is known;
            (8) pain should be considered the fifth vital sign; and
            (9) coordination of Federal efforts is needed to improve 
        access to high quality effective pain and symptom management in 
        order to assure the needs of chronic pain patients and those 
        who are terminally ill are met.

SEC. 3. DEFINITIONS.

    In this Act:
            (1) Chronic pain.--The term ``chronic pain'' means a pain 
        state that is persistent and in which the cause of the pain 
        cannot be removed or otherwise treated. Such term includes pain 
        that may be associated with long-term incurable or intractable 
        medical conditions or disease.
            (2) Drug therapy management services.--The term ``drug 
        therapy management services'' means consultations with a 
        physician concerning a patient which results in the physician--
                    (A) changing the drug regimen of the patient to 
                avoid an adverse drug interaction with another drug or 
                disease state;
                    (B) changing an inappropriate drug dosage or dosage 
                form with respect to the patient;
                    (C) discontinuing an unnecessary or harmful 
                medication with respect to the patient;
                    (D) initiating drug therapy for a medical condition 
                of the patient; or
                    (E) consulting with the patient or a caregiver in a 
                manner that results in a significant improvement in 
                drug regimen compliance.
        Such term includes services provided by a physician, 
        pharmacist, or other health care professional who is legally 
        authorized to furnish such services under the law of the State 
        in which such services are furnished.
            (3) End of life care.--The term ``end of life care'' means 
        a range of services, including hospice care, provided to a 
        patient, in the final stages of his or her life, who is 
        suffering from 1 or more conditions for which treatment toward 
        a cure or reasonable improvement is not possible, and whose 
        focus of care is palliative rather than curative.
            (4) Family support network.--The term ``family support 
        network'' means an association of 2 or more individuals or 
        entities in a collaborative effort to develop multi-
        disciplinary integrated patient care approaches that involve 
        medical staff and ancillary services to provide support to 
        chronic pain patients and patients at the end of life and their 
        caregivers across a broad range of settings in which pain 
        management might be delivered.
            (5) Hospice.--The term ``hospice care'' has the meaning 
        given such term in section 1861(dd)(1) of the Social Security 
        Act (42 U.S.C. 1395x(dd)(1)).
            (6) Pain and symptom management.--The term ``pain and 
        symptom management'' means services provided to relieve 
        physical or psychological pain or suffering, including any 1 or 
        more of the following physical complaints--
                    (A) weakness and fatigue;
                    (B) shortness of breath;
                    (C) nausea and vomiting;
                    (D) diminished appetite;
                    (E) wasting of muscle mass;
                    (F) difficulty in swallowing;
                    (G) bowel problems;
                    (H) dry mouth;
                    (I) failure of lymph drainage resulting in tissue 
                swelling;
                    (J) confusion;
                    (K) dementia;
                    (L) anxiety; and
                    (M) depression.
            (7) Palliative care.--The term ``palliative care'' means 
        the total care of patients whose disease is not responsive to 
        curative treatment, the goal of which is to provide the best 
        quality of life for such patients and their families. Such 
        care--
                    (A) may include the control of pain and of other 
                symptoms, including psychological, social and spiritual 
                problems;
                    (B) affirms life and regards dying as a normal 
                process;
                    (C) provides relief from pain and other distressing 
                symptoms;
                    (D) integrates the psychological and spiritual 
                aspects of patient care;
                    (E) offers a support system to help patients live 
                as actively as possible until death; and
                    (F) offers a support system to help the family cope 
                during the patient's illness and in their own 
                bereavement.
            (8) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.

    TITLE I--EMERGENCY RESPONSE TO THE PUBLIC HEALTH CRISIS OF PAIN

SEC. 101. GUIDELINES FOR THE TREATMENT OF PAIN.

    (a) Development of Website.--Not later than 2 months after the date 
of enactment of this Act, the Secretary, acting through the Agency for 
Health Care Policy Research, shall develop and maintain an Internet 
website to provide information to individuals, health care 
practitioners, and health facilities concerning evidence-based practice 
guidelines developed for the treatment of pain.
    (b) Requirements.--The website established under subsection (a) 
shall--
            (1) be designed to be quickly referenced by health care 
        practitioners; and
            (2) provide for the updating of guidelines as scientific 
        data warrants.
    (c) Provider Access to Guidelines.--
            (1) In general.--In establishing the website under 
        subsection (a), the Secretary shall ensure that health care 
        facilities have made the website known to health care 
        practitioners and that the website is easily available to all 
        health care personnel providing care or services at a health 
        care facility.
            (2) Use of certain equipment.--In making the information 
        described in paragraph (1) available to health care personnel, 
        the facility involved shall ensure that such personnel have 
        access to the website through the computer equipment of the 
        facility and shall carry out efforts to inform personnel at the 
        facility of the location of such equipment.
            (3) Rural areas.--
                    (A) In general.--A health care facility, 
                particularly a facility located in a rural or 
                underserved area, without access to the Internet shall 
                provide an alternative means of providing practice 
                guideline information to health care personnel.
                    (B) Alternative means.--The Secretary shall 
                determine appropriate alternative means by which a 
                health care facility may make available practice 
                guideline information on a 24-hour basis, 7 days a week 
                if the facility does not have Internet access. The 
                criteria for adopting such alternative means should be 
                clear in permitting facilities to develop alternative 
                means without placing a significant financial burden on 
                the facility and in permitting flexibility for 
                facilities to develop alternative means of making 
                guidelines available. Such criteria shall be published 
                in the Federal Register.

SEC. 102. PATIENT EXPECTATIONS TO HAVE PAIN AND SYMPTOM MANAGEMENT.

    (a) In General.--The administrator of each of the programs 
described in subsection (b) shall ensure that, as part of any 
informational materials provided to individuals under such programs, 
such materials shall include information, where relevant, to inform 
such individuals that they should expect to have their pain managed, an 
addition to other symptom management, when receiving benefits under 
such program.
    (b) Programs.--The programs described in this subsection shall 
include--
            (1) the medicare and medicaid programs under titles XIX and 
        XXI of the Social Security Act (42 U.S.C. 1935 et seq., 1936 et 
        seq.);
            (2) programs carried out through the Public Health Service;
            (3) programs carried out through the Indian Health Service;
            (4) programs carried out through health centers under 
        section 330 of the Public Health Service Act (42 U.S.C. 254b);
            (4) the Federal Employee Health Benefits Program under 
        title 5, United States Code;
            (5) the Civilian Health and Medical Program of the 
        Uniformed Services (CHAMPUS) as defined in section 1073(4) of 
        title 10, United States Code; and
            (6) other programs administered by the Secretary.

SEC. 103. QUALITY IMPROVEMENT EDUCATION PROJECTS.

    The Secretary shall provide funds for the implementation of special 
education projects, in as many States as is practicable, to be carried 
out by peer review organizations of the type described in section 1152 
of the Social Security Act (42 U.S.C. 1320c-1) to improve the quality 
of pain and symptom management. Such projects shall place an emphasis 
on improving pain and symptom management at the end of life, and may 
also include efforts to increase the quality of services delivered to 
chronic pain patients.

SEC. 105. PAIN COVERAGE QUALITY EVALUATION AND INFORMATION.

    (a) Medicare+Choice Plans.--
            (1) In general.--Section 1851(d)(4) of the Social Security 
        Act (42 U.S.C. 42 U.S.C. 1395w-21(d)(4)) is amended--
                    (A) in subparagraph (A), by adding at the end the 
                following:
                            ``(ix) The organization's coverage of pain 
                        and symptom management.''; and
                    (B) in subparagraph (D)--
                            (i) in clause (iii), by striking ``and'' at 
                        the end;
                            (ii) in clause (iv), by striking the period 
                        and inserting ``, and''; and
                            (iii) by adding at the end the following:
                            ``(v) not later than 2 years after the date 
                        of enactment of this clause, an evaluation 
                        (which may be made part of any other relevant 
                        report of quality evaluation that the plan is 
                        required to prepare) for the plan (updated 
                        annually) that indicates the performance of the 
                        plan with respect to access to, and quality of, 
                        pain and symptom management, including such 
                        management as part of end of life care.''.
            (2) Effective date.--The amendments made by paragraph (1) 
        apply to information provided with respect to annual, 
        coordinated election periods (as defined in section 
        1851(e)(3)(B) of the Social Security Act (42 U.S.C. 1395-
        21(e)(3)(B)) beginning after the date of enactment of this Act.
    (b) Inclusion of Pain Measurements in Federal Health Programs.--
            (1) In general.--Not later than 1 year after the date of 
        enactment of this Act, the Secretary shall make a determination 
        as to the manner in which to include measurements of pain and 
        symptom management in the programs under titles XVIII and XIX 
        of the Social Security Act (42 U.S.C. 1395 et seq. and 1396 et 
        seq.) and in other appropriate Federal program.
            (2) Development of measurements.--The determination 
        required under paragraph (1) shall be developed in consultation 
        with the Administrator of the Agency for Health Care Policy and 
        Research and the Director of the National Institutes of Health.

SEC. 106. SURGEON GENERAL'S REPORT.

    Not later than October 1, 2000, the Surgeon General shall prepare 
and submit to the appropriate committees of Congress and the public, a 
report concerning the state of pain and symptom management in the 
United States. The report shall include--
            (1) a description of the legal and regulatory barriers that 
        may exist at the Federal and State levels to providing adequate 
        pain and symptom management;
            (2) an evaluation of provider competency in providing pain 
        and symptom management;
            (3) an identification of vulnerable populations, including 
        children, advanced elderly, non-English speakers, and 
        minorities, who may be likely to be underserved or may face 
        barriers to access to pain management and recommendations to 
        improve access to pain management for these populations;
            (4) an identification of barriers that may exist in 
        providing pain and symptom management in health care settings, 
        including assisted living facilities;
            (5) and identification of patient and family attitudes that 
        may exist which pose barriers in accessing pain and symptom 
        management or in the proper use of pain medications;
            (6) an evaluation of medical school training and residency 
        training for pain and symptom management; and
            (7) a review of continuing medical education programs in 
        pain and symptom management.

                TITLE II--DEVELOPING COMMUNITY RESOURCES

SEC. 201. FAMILY SUPPORT NETWORKS IN PAIN AND SYMPTOM MANAGEMENT.

    (a) Establishment.--The Secretary, acting through the Public Health 
Service, shall award grants for the establishment of 6 National Family 
Support Networks in Pain and Symptom Management (in this section 
referred to as the ``Networks'') to serve as national models for 
improving the access and quality of pain and symptom management to 
chronic pain patients and those individuals in need of pain and symptom 
management at the end of life and to provide assistance to family 
members and caregivers.
    (b) Eligibility and Distribution.--
            (1) Eligibility.--To be eligible to receive a grant under 
        subsection (a), an entity shall--
                    (A) be an academic facility or other entity that 
                has demonstrated an effective approach to training 
                health care providers concerning pain and symptom 
                management and palliative care services; and
                    (B) prepare and submit to the Secretary an 
                application (to be peer reviewed by a committee 
                established by the Secretary), at such time, in such 
                manner, and containing such information as the 
                Secretary may require.
            (2) Distribution.--In providing for the establishment of 
        Networks under subsection (a), the Secretary shall ensure 
        that--
                    (A) the geographic distribution of such Networks 
                reflects a balance between rural and urban needs; and
                    (B) at least 3 Networks are established at academic 
                facilities.
    (c) Activities of Networks.--A Network that is established under 
this section shall--
            (1) provide for an integrated interdisciplinary approach to 
        the delivery of pain and symptom management;
            (2) provide community leadership in establishing and 
        expanding public access to appropriate pain care, including 
        pain care at the end of life;
            (3) provide assistance through caregiver and bereavement 
        supportive services;
            (4) develop a research agenda to promote effective pain and 
        symptom management for the broad spectrum of patients in need 
        of access to such care that can be implemented by the Network;
            (5) provide for coordination and linkages between clinical 
        services in academic centers and surrounding communities to 
        assist in the widespread dissemination of provider and patient 
        information concerning how to access options for pain 
        management;
            (6) establish telemedicine links to provide education and 
        for the delivery of services in pain and symptom management; 
        and
            (7) develop effective means of providing assistance to 
        providers and families for the management of a patient's pain 
        24 hours a day, 7 days a week.
    (d) Provider Pain and Symptom Management Communications Projects.--
            (1) In general.--Each Network shall establish a process to 
        provide health care personnel with information 24 hours a day, 
        7 days a week, concerning pain and symptom management. Such 
        process shall be designed to test the effectiveness of specific 
        forms of communications with health care personnel so that such 
        personnel may obtain information to ensure that all appropriate 
        patients are provided with pain and symptom management.
            (2) Termination.--The requirement of paragraph (1) shall 
        terminate with respect to a Network on the day that is 2 years 
        after the date on which the Network has established the 
        communications method.
            (3) Evaluation.--Not later than 60 days after the 
        expiration of the 2-year period referred to in paragraph (2), a 
        Network shall conduct an evaluation and prepare and submit to 
        the Secretary a report concerning the costs of operation and 
        whether the form of communication can be shown to have had a 
        positive impact on the care of patients in chronic pain or on 
        patients with pain at the end of life.
            (4) Rule of construction.--Nothing in this subsection shall 
        be construed as limiting a Network from developing other ways 
        in which to provide support to families and providers, 24 hours 
        a day, 7 days a week.
    (e) Authorization of Appropriations.--There is authorized to be 
appropriated to carry out this section, $18,000,000 for fiscal years 
2000 through 2002.

                   TITLE III--REIMBURSEMENT BARRIERS

SEC. 301. REIMBURSEMENT BARRIERS REPORT.

    The Medicare Payment Advisory Commission (MedPac) established under 
section 1805 of the Social Security Act (42 U.S.C. 1396b-6) shall 
conduct a study, and prepare and submit to the appropriate committees 
of Congress a report, concerning--
            (1) the manner in which medicare policies may pose barriers 
        in providing pain and symptom management and palliative care 
        services in different settings, including a focus on payment 
        for nursing home and home health services;
            (2) the identification of any financial barriers that may 
        exist within the medicare and medicaid programs under titles 
        XVIII and XIX of the Social Security Act (42 U.S.C. 1395 et 
        seq., 1396 et seq.) that interfere with continuity of care and 
        interdisciplinary care or supportive care for the broad range 
        of chronic pain patients and for those who are terminally ill, 
        and include the recommendations of the Commission on ways to 
        eliminate those barriers that the Commission may identify;
            (3) the reimbursement barriers that exist, if any, in 
        providing pain and symptom management through hospice care, 
        particularly in rural areas, and if barriers exist, 
        recommendations concerning adjustments that would assist in 
        assuring patient access to pain and symptom management through 
        hospice care in rural areas;
            (4) whether the medicare reimbursement system provides 
        incentives to providers to delay informing terminally ill 
        patients of the availability of hospice and palliative care; 
        and
            (5) the impact of providing payments for drug therapy 
        management services in pain and symptom management and 
        palliative care services.

SEC. 302. INSURANCE COVERAGE OF PAIN AND SYMPTOM MANAGEMENT.

    (a) In General.--The General Accounting Office shall conduct a 
survey of public and private health insurance providers, including 
managed care entities, to determine whether the reimbursement policies 
of such insurers inhibit the access of chronic pain patients to pain 
and symptom management and pain and symptom management for those in 
need of end-of-life care. The survey shall include a review of 
formularies for pain medication and the effect of such formularies on 
pain and symptom management.
    (b) Report.--Not later than 1 year after the date of enactment of 
this Act, the General Accounting Office shall prepare and submit to the 
appropriate committees of Congress a report concerning the survey 
conducted under subsection (a).

   TITLE IV--IMPROVING FEDERAL COORDINATION OF POLICY, RESEARCH, AND 
                              INFORMATION

SEC. 401. ADVISORY COMMITTEE ON PAIN AND SYMPTOM MANAGEMENT.

    (a) Establishment.--The Secretary shall establish an advisory 
committee, to be known as the Advisory Committee on Pain and Symptom 
Management, to make recommendations to the Secretary concerning a 
coordinated Federal agenda on pain and symptom management.
    (b) Membership.--The Advisory Committee established under 
subsection (a) shall be comprised of 11 individuals to be appointed by 
the Secretary, of which at least 1 member shall be a representative 
of--
            (1) physicians (medical doctors or doctors of osteopathy) 
        who treat chronic pain patients or the terminally ill;
            (2) nurses who treat chronic pain patients or the 
        terminally ill;
            (3) pharmacists who treat chronic pain patients or the 
        terminally ill;
            (4) hospice;
            (5) pain researchers;
            (6) patient advocates;
            (7) caregivers; and
            (8) health insurance issuers (as such term is defined in 
        section 2791(b) of the Public Health Service Act (42 U.S.C. 
        300gg-91(b))).
The members of the Committee shall designate 1 member to serve as the 
chairperson of the Committee.
    (c) Meetings.--The Advisory Committee shall meet at the call of the 
chairperson of the Committee.
    (d) Agenda.--The agenda of the Advisory Committee established under 
subsection (a) shall include--
            (1) the development of recommendations to create a 
        coordinated Federal agenda on pain and symptom management;
            (2) the development of proposals to ensure that pain is 
        considered as the fifth vital sign for all patients;
            (3) the identification of research needs in pain and 
        symptom management, including gaps in pain and symptom 
        management guidelines;
            (4) the identification and dissemination of pain and 
        symptom management practice guidelines, research information, 
        and best practices;
            (5) proposals for patient education concerning how to 
        access pain and symptom management across health care settings;
            (6) the manner in which to measure improvement in access to 
        pain and symptom management and improvement in the delivery of 
        care; and
            (7) the development of an ongoing mechanism to identify 
        barriers or potential barriers to pain and symptom management 
        created by Federal policies.
    (e) Recommendation.--Not later than 2 years after the date of 
enactment of this Act, the Advisory Committee established under 
subsection (a) shall prepare and submit to the Secretary 
recommendations concerning a prioritization of the need for a Federal 
agenda on pain, and ways in which to better coordinate the activities 
of entities within the Department of Health and Human Services, and 
other Federal entities charged with the responsibility for the delivery 
of health care services or research on pain, with respect to pain 
management.
    (f) Consultation.--In carrying out this section, the Advisory 
Committee shall consult with all Federal agencies that are responsible 
for providing health care services or access to health services to 
determine the best means to ensure that all Federal activities are 
coordinated with respect to research and access to pain and symptom 
management.
    (g) Administrative Support; Terms of Service; Other Provisions.--
The following shall apply with respect to the Advisory Committee:
            (1) The Committee shall receive necessary and appropriate 
        administrative support, including appropriate funding, from the 
        Department of Health and Human Services.
            (2) The Committee shall hold open meetings and meet not 
        less than 4 times per year.
            (3) Members of the Committee shall not receive additional 
        compensation for their service. Such members may receive 
        reimbursement for appropriate and additional expenses that are 
        incurred through service on the Committee which would not have 
        incurred had they not been a member of the Committee.
            (4) The requirements of appendix 2 of title 5, United 
        States Code.

SEC. 402. INSTITUTES OF MEDICINE REPORT ON CONTROLLED SUBSTANCE 
              REGULATION AND THE USE OF PAIN MEDICATIONS.

    (a) In General.--The Secretary, acting through a contract entered 
into with the Institute of Medicine, shall review findings that have 
been developed through research conducted concerning--
            (1) the effects of controlled substance regulation on 
        patient access to effective care;
            (2) factors, if any, that may contribute to the underuse of 
        pain medications, including opioids; and
            (3) the identification of State legal and regulatory 
        barriers, if any, that may impact patient access to medications 
        used for pain and symptom management.
    (b) Report.--Not later than 18 months after the date of enactment 
of this Act, the Secretary shall prepare and submit to the appropriate 
committees of Congress a report concerning the findings described in 
subsection (a).

SEC. 403. CONFERENCE ON PAIN RESEARCH AND CARE.

    Not later than December 31, 2003, the Secretary, acting through the 
National Institutes of Health, shall convene a national conference to 
discuss the translation of pain research into the delivery of health 
services to chronic pain patients and those needing end-of-life care. 
The Secretary shall use unobligated amounts appropriated for the 
Department of Health and Human Services to carry out this section.

                    TITLE V--DEMONSTRATION PROJECTS

SEC. 501. PROVIDER PERFORMANCE STANDARDS FOR IMPROVEMENT IN PAIN AND 
              SYMPTOM MANAGEMENT.

    (a) In General.--The Secretary, acting through the Public Health 
Service, shall award grants for the establishment of not less than 5 
demonstration projects to determine effective methods to measure 
improvement in the skills and knowledge of health care personnel in 
pain and symptom management as such skill and knowledge applies to 
providing services to chronic pain patients and those patients 
requiring pain and symptom management at the end of life.
    (b) Evaluation.--Projects established under subsection (a) shall be 
evaluated to determine patient and caregiver knowledge and attitudes 
toward pain and symptom management.
    (c) Application.--To be eligible to receive a grant under 
subsection (a), an entity shall prepare and submit to the Secretary an 
application at such time, in such manner and containing such 
information as the Secretary may require.
    (d) Termination.--A project established under subsection (a) shall 
terminate after the expiration of the 2-year period beginning on the 
date on which such project was established.
    (d) Authorization of Appropriations.--There is authorized to be 
appropriated such sums as may be necessary to carry out this section.
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