II 109th CONGRESS 1st Session S. 1001 IN THE SENATE OF THE UNITED STATES May 11, 2005 Mr. Wyden introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To establish hospice demonstration projects and a hospice grant program for beneficiaries under the medicare program under title XVIII of the Social Security Act, and for other purposes.
1.
Short title
This Act may be cited as the Medicare Hospice Demonstration Act of 2005.
2.
Findings
Congress makes the following findings: (1)Each year more than 1/3 of the people who die suffer from a chronic illness. (2)Approximately 1/3 of Americans are unsure about whom to contact to get the best care during life’s last stages. (3)Americans want a team of professionals to care for the patient at the end of life. (4)Americans want emotional and spiritual support for the patient and family. (5)Ninety percent of Americans do not realize that hospice care is a benefit provided under the medicare program under title XVIII of the Social Security Act. (6)Data of the Centers for Medicare & Medicaid Services show that beneficiaries were enrolled in hospice for an average of less than 7 weeks in 1998, far less than the full 6-month benefit under the medicare program. (7)According to the most recent data available, although more medicare beneficiaries are enrolled in hospice, the medicare length of stay has declined. (8)Use of hospice among medicare beneficiaries has been decreasing, from a high of 59 days in 1995 to less than 48 days in 1998.
3.
Hospice demonstration projects and Hospice Education Grants
(a)
Definitions
In this section: (1)
Demonstration project
The term demonstration project means a demonstration project established by the Secretary under subsection (b)(1). (2)
Hospice care
The term hospice care means the items and services described in subparagraphs (A) through (I) of section 1861(dd)(1) of the Social Security Act (42 U.S.C. 1395x(dd)(1)) that are provided to a seriously ill medicare beneficiary under a demonstration project by a hospice program (or by others under an arrangement with such a program) under a written plan for providing such care to such beneficiary established and periodically reviewed by the beneficiary’s attending physician, by the medical director of the program, and by the interdisciplinary group described in section 1861(dd)(2)(B) of such Act (42 U.S.C. 1395x(dd)(2)(B)). (3)
Hospice program
The term hospice program has the meaning given that term in section 1861(dd)(2) of the Social Security Act (42 U.S.C. 1395x(dd)(2)). (4)
Medicare beneficiary
The term medicare beneficiary means any individual who is entitled to benefits under part A or enrolled under part B of the medicare program. (5)
Medicare program
The term medicare program means the health benefits program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). (6)
Secretary
The term Secretary means the Secretary of Health and Human Services. (7)
Seriously ill
The term seriously ill has the meaning given such term by the Secretary (in consultation with hospice programs and academic experts in end-of-life care), except that the Secretary may not limit such term to individuals who are terminally ill (as defined in section 1861(dd)(3)(A) of the Social Security Act (42 U.S.C. 1395x(dd)(3)(A))). (b)
Hospice demonstration projects
(1)
Establishment
The Secretary shall establish demonstration projects in accordance with the provisions of this subsection to increase the utility of the hospice care for seriously ill medicare beneficiaries. (2)
Participation
(A)
Hospice programs
Except as provided in paragraph (4)(A), only a hospice program with an agreement under section 1866 of the Social Security Act (42 U.S.C. 1395cc), a consortium of such hospice programs, or a State hospice association may participate in the demonstration program. (B)
Seriously ill medicare beneficiaries
The Secretary shall permit any seriously ill medicare beneficiary residing in the service area of a hospice program participating in a demonstration project to participate in such project on a voluntary basis. (3)
Services under demonstration projects
The provisions of section 1814(i) of the Social Security Act (42 U.S.C. 1395f(i)) shall apply to the payment for hospice care provided under the demonstration projects, except that— (A)notwithstanding section 1862(a)(1)(C) of such Act (42 U.S.C. 1395y(a)(1)(C)), the Secretary shall provide for reimbursement for items and services provided under the supportive and comfort care benefit established under paragraph (3); (B)any licensed nurse practitioner or physician assistant may admit a seriously ill medicare beneficiary as the primary care provider when necessary and within the scope of practice of such practitioner or assistant under State law; (C)if an underserved community included in a demonstration project does not have a qualified social worker, any professional (other than a social worker) who has the necessary knowledge, skills, and ability to provide medical social services may provide such services; (D)the Secretary shall waive any requirement that nursing facilities used for respite care have skilled nurses on the premises 24 hours per day; (E)the Secretary shall permit respite care to be provided to the seriously ill medicare beneficiary at home; and (F)the Secretary shall waive reimbursement regulations to provide— (i)reimbursement for consultations and preadmission informational visits, even if the seriously ill medicare beneficiary does not elect hospice care at that time; (ii)except with respect to the supportive and comfort care benefit under paragraph (3), a minimum payment for hospice care provided under the demonstration projects based on the provision of hospice care to a seriously ill medicare beneficiary for a period of 14 days, that— (I)the Secretary shall pay to any hospice program participating in a demonstration project and providing such care (regardless of the length of stay of the seriously ill medicare beneficiary); and (II)may not be less than the amount of payment that would have been made for hospice care if payment had been made at the daily rate of payment for such care under section 1814(i) of the Social Security Act (42 U.S.C. 1395f(i)); (iii)an increase in the reimbursement rates for hospice care to offset— (I)changes in hospice care and oversight under the demonstration projects; (II)the higher costs of providing hospice care in rural areas due to lack of economies of scale or large geographic areas; and (III)the higher costs of providing hospice care in urban underserved areas due to unique costs specifically associated with people living in those areas, including providing security; (iv)direct payment of any nurse practitioner or physician assistant practicing within the scope of State law in relation to hospice care provided by such practitioner or assistant; and (v)a per diem rate of payment for in-home care under subparagraph (E) that reflects the range of care needs of the seriously ill medicare beneficiary and that— (I)in the case of a seriously ill medicare beneficiary that needs routine care, is not less than 150 percent, and not more than 200 percent, of the routine home care rate for hospice care; and (II)in the case of a seriously ill medicare beneficiary that needs acute care, is equal to the continuous home care day rate for hospice care. (4)
Supportive and comfort care benefit
(A)
In general
For purposes of the demonstration projects, the Secretary shall establish a supportive and comfort care benefit for any eligible seriously ill medicare beneficiary (as defined in subparagraph (C)). (B)
Participation
Any individual or entity with an agreement under section 1866 of the Social Security Act (42 U.S.C. 1395cc) may furnish items or services covered under the supportive and comfort care benefit. (C)
Benefit
Under the supportive and comfort care benefit, any eligible seriously ill medicare beneficiary may— (i)continue to receive benefits for disease and symptom modifying treatment under the medicare program (and the Secretary may not require or prohibit any specific treatment or decision); (ii)receive case management and hospice care through a hospice program participating in a demonstration project (for which payment shall be made under paragraph (2)(F)(ii)); and (iii)receive information and education in order to better understand the utility of hospice care. (D)
Payment
The Secretary shall establish procedures under which the Secretary pays for items and services furnished to seriously ill medicare beneficiaries under the supportive and comfort care benefit on a fee-for-service basis. (E)
Eligible seriously ill medicare beneficiary defined
(i)
In general
In this paragraph, the term eligible seriously ill medicare beneficiary means any seriously ill medicare beneficiary that meets the criteria approved by the Secretary under clause (ii). (ii)
Approval of criteria
(I)
In general
With respect to each demonstration project, the Secretary shall approve criteria for determining whether a seriously ill medicare beneficiary is eligible for hospice care under a demonstration project that has been developed by hospice programs in consultation with researchers in end-of-life care and the broader medical community. (II)
Data comparability
The Secretary may only approve criteria that ensures that each demonstration project yields comparable data with respect to eligible seriously ill medicare beneficiaries on— (aa)the utilization of services by such beneficiaries; (bb)the cost of providing services to such beneficiaries, including any costs associated with providing services before an individual is terminally ill (as defined in section 1861(dd)(3)(A) of the Social Security Act (42 U.S.C. 1395x(dd)(3)(A))); and (cc)the effect of the demonstration project on the quality of care of such beneficiaries. (III)
Limitation
The Secretary may not approve criteria if the purpose of such criteria is to segment services or to provide a benefit for the chronically ill. (5)
Conduct of demonstration projects
(A)
Sites
The Secretary shall conduct demonstration projects in at least 3, but not more than 6, sites (which may be statewide). (B)
Selection of sites
(i)
In general
Except as provided in clause (ii), the Secretary shall select demonstration sites on the basis of proposals submitted under subparagraph (C) that are located in geographic areas that— (I)include both urban and rural hospice programs; and (II)are geographically diverse and readily accessible to a significant number of seriously ill medicare beneficiaries. (ii)
Exceptions
(I)
Underserved urban areas
If a geographic area does not have any rural hospice program available to participate in a demonstration project, such area may substitute an underserved urban area, but the Secretary shall give priority to those proposals that include a rural hospice program. (II)
Specific site
The Secretary shall select as a demonstration site the State in which (according to the Hospital Referral Region of Residence, 1994–1995, as listed in the Dartmouth Atlas of Health Care 1998) the largest metropolitan area of the State had the lowest percentage of medicare beneficiary deaths in a hospital when compared to the largest metropolitan area of each other State, and the percentage of enrollees who experienced intensive care during the last 6 months of life was 21.5 percent. (C)
Proposals
(i)
In general
The Secretary shall accept proposals by any State hospice association, hospice program, or consortium of hospice programs at such time, in such manner, and in such form as the Secretary may reasonably require. (ii)
Research designs
The Secretary shall permit research designs that use time series, sequential implementation of the intervention, randomization by wait list, and other designs that allow the strongest possible implementation of the demonstration projects, while still allowing strong evaluation about the merits of the demonstration projects. (D)
Facilitation of evaluation
The Secretary shall design the program to facilitate the evaluation conducted under paragraph (7). (6)
Duration
The Secretary shall complete the demonstration projects within a period of 61/2 years that includes a period of 18 months during which the Secretary shall complete the evaluation under paragraph (7). (7)
Evaluation
During the 18-month period following the first 5 years of the demonstration projects, the Secretary shall complete an evaluation of the demonstration projects in order to determine— (A)the short-term and long-term costs and benefits of changing hospice care provided under the medicare program to include the items, services, and reimbursement options provided under the demonstration projects; (B)whether any increase in payments for the hospice care provided under the medicare program are offset by savings in other parts of the medicare program; (C)the projected cost of implementing the demonstration projects on a national basis; and (D)in consultation with hospice organizations and hospice programs (including organizations and providers that represent rural areas), whether a payment system based on diagnosis-related groups is useful for administering the hospice care provided under the medicare program. (8)
Reports to congress
(A)
Preliminary report
Not later than 3 years after the date of enactment of this Act, the Secretary shall submit to the Committee on Ways and Means of the House of Representatives and to the Committee on Finance of the Senate a preliminary report on the progress made in the demonstration projects. (B)
Interim report
Not later than 30 months after the implementation of the demonstration projects, the Secretary, in consultation with participants in the projects, shall submit to the committees described in subparagraph (A) an interim report on the demonstration projects. (C)
Final report
Not later than the date on which the demonstration projects end, the Secretary shall submit a final report to the committees described in subparagraph (A) on the demonstration projects that includes the results of the evaluation conducted under paragraph (7) and recommendations for appropriate legislative changes. (9)
Waiver of medicare requirements
The Secretary shall waive compliance with such requirements of the medicare program to the extent and for the period the Secretary finds necessary to conduct the demonstration projects. (10)
Special rules for payment of medicare advantage organizations
The Secretary shall establish procedures under which the Secretary provides for an appropriate adjustment in the monthly payments made under section 1853 of the Social Security Act (42 U.S.C. 1395w–23) to any Medicare Advantage organization offering a Medicare Advantage plan to reflect the participation of each seriously ill medicare beneficiary enrolled in such plan in a demonstration project. (c)
Hospice Education Grant program
(1)
In general
The Secretary shall establish a Hospice Education Grant program under which the Secretary awards education grants to entities participating in the demonstration projects for the purpose of providing information about— (A)the hospice care under the medicare program; and (B)the benefits available to medicare beneficiaries under the demonstration projects. (2)
Use of funds
Grants awarded under paragraph (1) shall be used— (A)to provide— (i)individual or group education to medicare beneficiaries and the families of such beneficiaries; and (ii)individual or group education of the medical and mental health community caring for medicare beneficiaries; and (B)to test strategies to improve the general public knowledge about hospice care under the medicare program and the benefits available to medicare beneficiaries under the demonstration projects. (d)
Funding
(1)
Hospice demonstration projects
(A)
In general
Except as provided in subparagraph (B), the Secretary shall provide for the transfer from the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act (42 U.S.C. 1395i) such sums as may be necessary to carry out this section. (B)
Supportive and comfort care benefit
The Secretary shall provide for the transfer from the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary Medical Insurance Trust Fund established under section 1841 of such Act (42 U.S.C. 1395t), in such proportion as the Secretary determines is appropriate, such sums as may be necessary to provide for payment of the costs attributable to the supportive and comfort care benefit. (2)
Hospice Education Grants
The Secretary shall expend such sums as may be necessary for the purposes of carrying out the Hospice Education Grant program established under subsection (c)(1) from the Research and Demonstration Budget of the Centers for Medicare & Medicaid Services.