[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2911 Introduced in House (IH)]
111th CONGRESS
1st Session
H. R. 2911
To improve end-of-life care.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
June 17, 2009
Mr. Blumenauer (for himself, Ms. Baldwin, Mr. Levin, and Mr. Pascrell)
introduced the following bill; which was referred to the Committee on
Energy and Commerce, and in addition to the Committees on Ways and
Means and the Judiciary, 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 improve end-of-life care.
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 ``Advance Planning
and Compassionate Care Act of 2009''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Definitions.
TITLE I--ADVANCE CARE PLANNING
Subtitle A--Consumer and Provider Education
Part I--Consumer Education
subpart a--national initiatives
Sec. 101. Advance care planning telephone hotline.
Sec. 102. Advance care planning information clearinghouses.
Sec. 103. Advance care planning toolkit.
Sec. 104. National public education campaign.
Sec. 105. Update of Medicare and Social Security handbooks.
Sec. 106. Authorization of appropriations.
subpart b--state and local initiatives
Sec. 111. Financial assistance for advance care planning.
Sec. 112. Grants for programs for orders regarding life sustaining
treatment.
Part II--Provider Education
Sec. 121. Public provider advance care planning website.
Sec. 122. Continuing education for physicians and nurses.
Subtitle B--Portability of Advance Directives; Health Information
Technology
Sec. 131. Portability of advance directives.
Sec. 132. State advance directive registries; driver's license advance
directive notation.
Sec. 133. GAO study and report on establishment of national advance
directive registry.
Subtitle C--National Uniform Policy on Advance Care Planning
Sec. 141. Study and report by the Secretary regarding the establishment
and implementation of a national uniform
policy on advance directives.
TITLE II--COMPASSIONATE CARE
Subtitle A--Workforce Development
Part I--Education and Training
Sec. 201. National Geriatric and Palliative Care Services Corps.
Sec. 202. Exemption of palliative medicine fellowship training from
Medicare graduate medical education caps.
Sec. 203. Medical school curricula.
Subtitle B--Coverage Under Medicare, Medicaid, and CHIP
Part I--Coverage of Advance Care Planning
Sec. 211. Medicare, Medicaid, and CHIP coverage.
Part II--Hospice
Sec. 221. Adoption of MedPAC hospice payment methodology
recommendations.
Sec. 222. Removing hospice inpatient days in setting per diem rates for
critical access hospitals.
Sec. 223. Hospice payments for dual eligible individuals residing in
long-term care facilities.
Sec. 224. Delineation of respective care responsibilities of hospice
programs and long-term care facilities.
Sec. 225. Adoption of MedPAC hospice program eligibility certification
and recertification recommendations.
Sec. 226. Concurrent care for children.
Sec. 227. Making hospice a required benefit under Medicaid and CHIP.
Sec. 228. Medicare Hospice payment model demonstration projects.
Sec. 229. MedPAC studies and reports.
Sec. 230. HHS Evaluations.
Subtitle C--Quality Improvement
Sec. 241. Patient satisfaction surveys.
Sec. 242. Development of core end-of-life care quality measures across
each relevant provider setting.
Sec. 243. Accreditation of hospital-based palliative care programs.
Sec. 244. Survey and data requirements for all Medicare participating
hospice programs.
Subtitle D--Additional Reports, Research, and Evaluations
Sec. 251. National Center on Palliative and End-of-Life Care.
Sec. 252. National Mortality Followback Survey.
Sec. 253. Demonstration projects for use of telemedicine services in
advance care planning.
Sec. 254. Inspector General investigation of fraud and abuse.
Sec. 255. GAO study and report on provider adherence to advance
directives.
SEC. 2. DEFINITIONS.
In this Act:
(1) Advance care planning.--The term ``advance care
planning'' means the process of--
(A) determining an individual's priorities, values
and goals for care in the future when the individual is
no longer able to express his or her wishes;
(B) engaging family members, health care proxies,
and health care providers in an ongoing dialogue
about--
(i) the individual's wishes for care;
(ii) what the future may hold for people
with serious illnesses or injuries;
(iii) how individuals, their health care
proxies, and family members want their beliefs
and preferences to guide care decisions; and
(iv) the steps that individuals and family
members can take regarding, and the resources
available to help with, finances, family
matters, spiritual questions, and other issues
that impact seriously ill or dying patients and
their families; and
(C) executing and updating advance directives and
appointing a health care proxy.
(2) Advance directive.--The term ``advance directive''
means a living will, medical directive, health care power of
attorney, durable power of attorney, or other written statement
by a competent individual that is recognized under State law
and indicates the individual's wishes regarding medical
treatment in the event of future incompetence. Such term
includes an advance health care directive and a health care
directive recognized under State law.
(3) CHIP.--The term ``CHIP'' means the program established
under title XXI of the Social Security Act (42 U.S.C. 1397aa et
seq.).
(4) End-of-life-care.--The term ``end-of-life care'' means
all aspects of care of a patient with a potentially fatal
condition, and includes care that is focused on specific
preparations for an impending death.
(5) Health care power of attorney.--The term ``health care
power of attorney'' means a legal document that identifies a
health care proxy or decision maker for a patient who has the
authority to act on the patient's behalf when the patient is
unable to communicate his or her wishes for medical care on
matters that the patient specifies when he or she is competent.
Such term includes a durable power of attorney that relates to
medical care.
(6) Living will.--The term ``living will'' means a legal
document--
(A) used to specify the type of medical care
(including any type of medical treatment, including
life-sustaining procedures if that person becomes
permanently unconscious or is otherwise dying) that an
individual wants provided or withheld in the event the
individual cannot speak for himself or herself and
cannot express his or her wishes; and
(B) that requires a physician to honor the
provisions of upon receipt or to transfer the care of
the individual covered by the document to another
physician that will honor such provisions.
(7) Medicaid.--The term ``Medicaid'' means the program
established under title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
(8) Medicare.--The term ``Medicare'' means the program
established under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.).
(9) Orders for life-sustaining treatment.--The term
``orders for life-sustaining treatment'' means a process for
focusing a patients' values, goals, and preferences on current
medical circumstances and to translate such into visible and
portable medical orders applicable across care settings,
including home, long-term care, emergency medical services, and
hospitals.
(10) Palliative care.--The term ``palliative care'' means
interdisciplinary care for individuals with a life-threatening
illness or injury relating to pain and symptom management and
psychological, social, and spiritual needs and that seeks to
improve the quality of life for the individual and the
individual's family.
(11) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
TITLE I--ADVANCE CARE PLANNING
Subtitle A--Consumer and Provider Education
PART I--CONSUMER EDUCATION
Subpart A--National Initiatives
SEC. 101. ADVANCE CARE PLANNING TELEPHONE HOTLINE.
(a) In General.--Not later than January 1, 2011, the Secretary,
acting through the Director of the Centers for Disease Control and
Prevention, shall establish and operate directly, or by grant,
contract, or interagency agreement, a 24-hour toll-free telephone
hotline to provide consumer information regarding advance care
planning, including--
(1) an explanation of advanced care planning and its
importance;
(2) issues to be considered when developing an individual's
advance care plan;
(3) how to establish an advance directive;
(4) procedures to help ensure that an individual's
directives for end-of-life care are followed;
(5) Federal and State-specific resources for assistance
with advance care planning; and
(6) hospice and palliative care (including their respective
purposes and services).
(b) Establishment.--In carrying out the requirements under
subsection (a), the Director of the Centers for Disease Control and
Prevention may designate an existing 24-hour toll-free telephone
hotline or, if no such service is available or appropriate, establish a
new 24-hour toll-free telephone hotline.
SEC. 102. ADVANCE CARE PLANNING INFORMATION CLEARINGHOUSES.
(a) Expansion of National Clearinghouse for Long-Term Care
Information.--
(1) Development.--Not later than January 1, 2010, the
Secretary shall develop an online clearinghouse to provide
comprehensive information regarding advance care planning.
(2) Maintenance.--The advance care planning clearinghouse,
which shall be clearly identifiable and available on the
homepage of the Department of Health and Human Service's
National Clearinghouse for Long-Term Care Information website,
shall be maintained and publicized by the Secretary on an
ongoing basis.
(3) Content.--The advance care planning clearinghouse shall
include--
(A) any relevant content contained in the national
public education campaign required under section 104;
(B) content addressing--
(i) an explanation of advanced care
planning and its importance;
(ii) issues to be considered when
developing an individual's advance care plan;
(iii) how to establish an advance
directive;
(iv) procedures to help ensure that an
individual's directives for end-of-life care
are followed; and
(v) hospice and palliative care (including
their respective purposes and services);
(C) available Federal and State-specific resources
for assistance with advance care planning, including--
(i) contact information for any State
public health departments that are responsible
for issues regarding end-of-life care;
(ii) contact information for relevant legal
service organizations, including those funded
under the Older Americans Act of 1965 (42
U.S.C. 3001 et seq.); and
(iii) advance directive forms for each
State; and
(D) any additional information, as determined by
the Secretary.
(b) Establishment of Pediatric Advance Care Planning
Clearinghouse.--
(1) Development.--Not later than January 1, 2011, the
Secretary, in consultation with the Assistant Secretary for
Children and Families of the Department of Health and Human
Services, shall develop an online clearinghouse to provide
comprehensive information regarding pediatric advance care
planning.
(2) Maintenance.--The pediatric advance care planning
clearinghouse, which shall be clearly identifiable on the
homepage of the Administration for Children and Families
website, shall be maintained and publicized by the Secretary on
an ongoing basis.
(3) Content.--The pediatric advance care planning
clearinghouse shall provide advance care planning information
specific to children with life-threatening illnesses or
injuries and their families.
SEC. 103. ADVANCE CARE PLANNING TOOLKIT.
(a) Development.--Not later than July 1, 2010, the Secretary, in
consultation with the Director of the Centers for Disease Control and
Prevention, shall develop an online advance care planning toolkit.
(b) Maintenance.--The advance care planning toolkit, which shall be
available in English, Spanish, and any other languages that the
Secretary deems appropriate, shall be maintained and publicized by the
Secretary on an ongoing basis and made available on the following
websites:
(1) The Centers for Disease Control and Prevention.
(2) The Department of Health and Human Service's National
Clearinghouse for Long-Term Care Information.
(3) The Administration for Children and Families.
(c) Content.--The advance care planning toolkit shall include
content addressing--
(1) common issues and questions regarding advance care
planning, including individuals and resources to contact for
further inquiries;
(2) advance directives and their uses, including living
wills and durable powers of attorney;
(3) the roles and responsibilities of a health care proxy;
(4) Federal and State-specific resources to assist
individuals and their families with advance care planning,
including--
(A) the advance care planning toll-free telephone
hotline established under section 101;
(B) the advance care planning clearinghouses
established under section 102;
(C) the advance care planning toolkit established
under this section;
(D) available State legal service organizations to
assist individuals with advance care planning,
including those organizations that receive funding
pursuant to the Older Americans Act of 1965 (42 U.S.C.
3001 et seq.); and
(E) website links or addresses for State-specific
advance directive forms; and
(5) any additional information, as determined by the
Secretary.
SEC. 104. NATIONAL PUBLIC EDUCATION CAMPAIGN.
(a) National Public Education Campaign.--
(1) In general.--Not later than January 1, 2011, the
Secretary, acting through the Director of the Centers for
Disease Control and Prevention, shall, directly or through
grants, contracts, or interagency agreements, develop and
implement a national campaign to inform the public of the
importance of advance care planning and of an individual's
right to direct and participate in their health care decisions.
(2) Content of educational campaign.--The national public
education campaign established under paragraph (1) shall--
(A) employ the use of various media, including
regularly televised public service announcements;
(B) provide culturally and linguistically
appropriate information;
(C) be conducted continuously over a period of not
less than 5 years;
(D) identify and promote the advance care planning
information available on the Department of Health and
Human Service's National Clearinghouse for Long-Term
Care Information website and Administration for
Children and Families website, as well as any other
relevant Federal or State-specific advance care
planning resources;
(E) raise public awareness of the consequences that
may result if an individual is no longer able to
express or communicate their health care decisions;
(F) address the importance of individuals speaking
to family members, health care proxies, and health care
providers as part of an ongoing dialogue regarding
their health care choices;
(G) address the need for individuals to obtain
readily available legal documents that express their
health care decisions through advance directives
(including living wills, comfort care orders, and
durable powers of attorney for health care);
(H) raise public awareness regarding the
availability of hospice and palliative care; and
(I) encourage individuals to speak with their
physicians about their options and intentions for end-
of-life care.
(3) Evaluation.--
(A) In general.--Not later than July 1, 2013, the
Secretary, acting through the Director of the Centers
for Disease Control and Prevention, shall conduct a
nationwide survey to evaluate whether the national
campaign conducted under this subsection has achieved
its goal of changing public awareness, attitudes, and
behaviors regarding advance care planning.
(B) Baseline survey.--In order to evaluate the
effectiveness of the national campaign, the Secretary
shall conduct a baseline survey prior to implementation
of the campaign.
(C) Reporting requirement.--Not later than December
31, 2013, the Secretary shall report the findings of
such survey, as well as any recommendations that the
Secretary determines appropriate regarding the need for
continuation or legislative or administrative changes
to facilitate changing public awareness, attitudes, and
behaviors regarding advance care planning, to the
appropriate committees of the Congress.
(b) Repeal.--Section 4751(d) of the Omnibus Budget Reconciliation
Act of 1990 (42 U.S.C. 1396a note; Public Law 101-508) is repealed.
SEC. 105. UPDATE OF MEDICARE AND SOCIAL SECURITY HANDBOOKS.
(a) Medicare & You Handbook.--
(1) In general.--Not later than 60 days after the date of
enactment of this Act, the Secretary shall update the online
version of the ``Planning Ahead'' section of the Medicare & You
Handbook to include--
(A) an explanation of advance care planning and
advance directives, including--
(i) living wills;
(ii) health care proxies; and
(iii) after-death directives;
(B) Federal and State-specific resources to assist
individuals and their families with advance care
planning, including--
(i) the advance care planning toll-free
telephone hotline established under section
101;
(ii) the advance care planning
clearinghouses established under section 102;
(iii) the advance care planning toolkit
established under section 103;
(iv) available State legal service
organizations to assist individuals with
advance care planning, including those
organizations that receive funding pursuant to
the Older Americans Act of 1965 (42 U.S.C. 3001
et seq.); and
(v) website links or addresses for State-
specific advance directive forms; and
(C) any additional information, as determined by
the Secretary.
(2) Update of paper and subsequent versions.--The Secretary
shall include the information described in paragraph (1) in all
paper and electronic versions of the Medicare & You Handbook
that are published on or after the date that is 60 days after
the date of enactment of this Act.
(b) Social Security Handbook.--The Commissioner of Social Security
shall--
(1) not later than 60 days after the date of enactment of
this Act, update the online version of the Social Security
Handbook for beneficiaries to include the information described
in subsection (a)(1); and
(2) include such information in all paper and online
versions of such handbook that are published on or after the
date that is 60 days after the date of enactment of this Act.
SEC. 106. AUTHORIZATION OF APPROPRIATIONS.
There is authorized to be appropriated for the period of fiscal
years 2010 through 2014--
(1) $195,000,000 to the Secretary to carry out sections
101, 102, 103, 104 and 105(a); and
(2) $5,000,000 to the Commissioner of Social Security to
carry out section 105(b).
Subpart B--State and Local Initiatives
SEC. 111. FINANCIAL ASSISTANCE FOR ADVANCE CARE PLANNING.
(a) Legal Assistance for Advance Care Planning.--
(1) Definition of recipient.--Section 1002(6) of the Legal
Services Corporation Act (42 U.S.C. 2996a(6)) is amended by
striking ``clause (A) of'' and inserting ``subparagraph (A) or
(B) of''.
(2) Advance care planning.--Section 1006 of the Legal
Services Corporation Act (42 U.S.C. 2996e) is amended--
(A) in subsection (a)(1)--
(i) by striking ``title, and (B) to make''
and inserting the following: ``title;
``(C) to make''; and
(ii) by inserting after subparagraph (A)
the following:
``(B) to provide financial assistance, and make grants and
contracts, as described in subparagraph (A), on a competitive
basis for the purpose of providing legal assistance in the form
of advance care planning (as defined in section 3 of the
Advance Planning and Compassionate Care Act of 2009, and
including providing information about State-specific advance
directives, as defined in that section) for eligible clients
under this title, including providing such planning to the
family members of eligible clients and persons with power of
attorney to make health care decisions for the clients; and'';
and
(B) in subsection (b), by adding at the end the
following:
``(2) Advance care planning provided in accordance with subsection
(a)(1)(B) shall not be construed to violate the Assisted Suicide
Funding Restriction Act of 1997 (42 U.S.C. 14401 et seq.).''.
(3) Reports.--Section 1008(a) of the Legal Services
Corporation Act (42 U.S.C. 2996g(a)) is amended by adding at
the end the following: ``The Corporation shall require such a
report, on an annual basis, from each grantee, contractor, or
other recipient of financial assistance under section
1006(a)(1)(B).''.
(4) Authorization of appropriations.--Section 1010 of the
Legal Services Corporation Act (42 U.S.C. 2996i) is amended--
(A) in subsection (a)--
(i) by striking ``(a)'' and inserting
``(a)(1)'';
(ii) in the last sentence, by striking
``Appropriations for that purpose'' and
inserting the following:
``(3) Appropriations for a purpose described in paragraph (1) or
(2)''; and
(iii) by inserting before paragraph (3) (as
designated by clause (ii)) the following:
``(2) There are authorized to be appropriated to carry out section
1006(a)(1)(B), $10,000,000 for each of fiscal years 2010, 2011, 2012,
2013, and 2014.''; and
(B) in subsection (d), by striking ``subsection
(a)'' and inserting ``subsection (a)(1)''.
(5) Effective date.--This subsection and the amendments
made by this subsection take effect July 1, 2010.
(b) State Health Insurance Assistance Programs.--
(1) In general.--The Secretary shall use amounts made
available under paragraph (3) to award grants to States for
State health insurance assistance programs receiving assistance
under section 4360 of the Omnibus Budget Reconciliation Act of
1990 to provide advance care planning services to Medicare
beneficiaries, personal representatives of such beneficiaries,
and the families of such beneficiaries. Such services shall
include information regarding State-specific advance directives
and ways to discuss individual care wishes with health care
providers.
(2) Requirements.--
(A) Award of grants.--In making grants under this
subsection for a fiscal year, the Secretary shall
satisfy the following requirements:
(i) Two-thirds of the total amount of funds
available under paragraph (3) for a fiscal year
shall be allocated among those States approved
for a grant under this section that have
adopted the Uniform Health-Care Decisions Act
drafted by the National Conference of
Commissioners on Uniform State Laws and
approved and recommended for enactment by all
States at the annual conference of such
commissioners in 1993.
(ii) One-third of the total amount of funds
available under paragraph (3) for a fiscal year
shall be allocated among those States approved
for a grant under this section that have
adopted a uniform form for orders regarding
life sustaining treatment as defined in section
1861(hhh)(5) of the Social Security Act (as
amended by section 211 of this Act) or a
comparable approach to advance care planning.
(B) Work plan; report.--As a condition of being
awarded a grant under this subsection, a State shall
submit the following to the Secretary:
(i) An approved plan for expending grant
funds.
(ii) For each fiscal year for which the
State is paid grant funds under this
subsection, an annual report regarding the use
of the funds, including the number of Medicare
beneficiaries served and their satisfaction
with the services provided.
(C) Limitation.--No State shall be paid funds from
a grant made under this subsection prior to July 1,
2010.
(3) Authorization of appropriations.--There is authorized
to be appropriated to the Secretary to the Centers for Medicare
& Medicaid Services Program Management Account, $12,000,000 for
each of fiscal years 2010 through 2014 for purposes of awarding
grants to States under paragraph (1).
(c) Medicaid Transformation Grants for Advance Care Planning.--
Section 1903(z) of the Social Security Act (42 U.S.C. 1396b(z)) is
amended--
(1) in paragraph (2), by adding at the end the following
new subparagraph:
``(G) Methods for improving the effectiveness and
efficiency of medical assistance provided under this
title by making available to individuals enrolled in
the State plan or under a waiver of such plan
information regarding advance care planning (as defined
in section 3 of the Advance Planning and Compassionate
Care Act of 2009), including at time of enrollment or
renewal of enrollment in the plan or waiver, through
providers, and through such other innovative means as
the State determines appropriate.'';
(2) in paragraph (3), by adding at the end the following
new subparagraph:
``(D) Work plan required for award of advance care
planning grants.--Payment to a State under this
subsection to adopt the innovative methods described in
paragraph (2)(G) is conditioned on the State submitting
to the Secretary an approved plan for expending the
funds awarded to the State under this subsection.'';
and
(3) in paragraph (4)--
(A) in subparagraph (A)--
(i) in clause (i), by striking ``and'' at
the end;
(ii) in clause (ii), by striking the period
at the end and inserting ``; and''; and
(iii) by inserting after clause (ii), the
following new clause:
``(iii) $20,000,000 for each of fiscal
years 2010 through 2014.''; and
(B) by striking subparagraph (B), and inserting the
following:
``(B) Allocation of funds.--The Secretary shall
specify a method for allocating the funds made
available under this subsection among States awarded a
grant for fiscal year 2010, 2011, 2012, 2013, or 2014.
Such method shall provide that--
``(i) 100 percent of such funds for each of
fiscal years 2010 through 2014 shall be awarded
to States that design programs to adopt the
innovative methods described in paragraph
(2)(G); and
``(ii) in no event shall a payment to a
State awarded a grant under this subsection for
fiscal year 2010 be made prior to July 1,
2010.''.
(d) Advance Care Planning Community Training Grants.--
(1) In general.--The Secretary shall use amounts made
available under paragraph (3) to award grants to area agencies
on aging (as defined in section 102 of the Older Americans Act
of 1965 (42 U.S.C. 3002)).
(2) Requirements.--
(A) Use of funds.--Funds awarded to an area agency
on aging under this subsection shall be used to provide
advance care planning education and training
opportunities for local aging service providers and
organizations.
(B) Work plan; report.--As a condition of being
awarded a grant under this subsection, an area agency
on aging shall submit the following to the Secretary:
(i) An approved plan for expending grant
funds.
(ii) For each fiscal year for which the
agency is paid grant funds under this
subsection, an annual report regarding the use
of the funds, including the number of Medicare
beneficiaries served and their satisfaction
with the services provided.
(C) Limitation.--No area agency on aging shall be
paid funds from a grant made under this subsection
prior to July 1, 2010.
(3) Authorization of appropriations.--There is authorized
to be appropriated to the Secretary to the Centers for Medicare
& Medicaid Services Program Management Account, $12,000,000 for
each of fiscal years 2010 through 2014 for purposes of awarding
grants to area agencies on aging under paragraph (1).
(e) Nonduplication of Activities.--The Secretary shall establish
procedures to ensure that funds made available under grants awarded
under this section or pursuant to amendments made by this section
supplement, not supplant, existing Federal funding, and that such funds
are not used to duplicate activities carried out under such grants or
under other federally funded programs.
SEC. 112. GRANTS FOR PROGRAMS FOR ORDERS REGARDING LIFE SUSTAINING
TREATMENT.
(a) In General.--The Secretary shall make grants to eligible
entities for the purpose of--
(1) establishing new programs for orders regarding life
sustaining treatment in States or localities;
(2) expanding or enhancing an existing program for orders
regarding life sustaining treatment in States or localities; or
(3) providing a clearinghouse of information on programs
for orders for life sustaining treatment and consultative
services for the development or enhancement of such programs.
(b) Authorized Activities.--Activities funded through a grant under
this section for an area may include--
(1) developing such a program for the area that includes
home care, hospice, long-term care, community and assisted
living residences, skilled nursing facilities, inpatient
rehabilitation facilities, hospitals, and emergency medical
services within the area;
(2) securing consultative services and advice from
institutions with experience in developing and managing such
programs; and
(3) expanding an existing program for orders regarding life
sustaining treatment to serve more patients or enhance the
quality of services, including educational services for
patients and patients' families or training of health care
professionals.
(c) Distribution of Funds.--In funding grants under this section,
the Secretary shall ensure that, of the funds appropriated to carry out
this section for each fiscal year--
(1) at least two-thirds are used for establishing or
developing new programs for orders regarding life sustaining
treatment; and
(2) one-third is used for expanding or enhancing existing
programs for orders regarding life sustaining treatment.
(d) Definitions.--In this section:
(1) The term ``eligible entity'' includes--
(A) an academic medical center, a medical school, a
State health department, a State medical association, a
multi-State taskforce, a hospital, or a health system
capable of administering a program for orders regarding
life sustaining treatment for a State or locality; or
(B) any other health care agency or entity as the
Secretary determines appropriate.
(2) The term ``order regarding life sustaining treatment''
has the meaning given such term in section 1861(hhh)(5) of the
Social Security Act, as added by section 211.
(3) The term ``program for orders regarding life sustaining
treatment'' means, with respect to an area, a program that
supports the active use of orders regarding life sustaining
treatment in the area.
(e) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated such sums as may be necessary
for each of the fiscal years 2009 through 2014.
PART II--PROVIDER EDUCATION
SEC. 121. PUBLIC PROVIDER ADVANCE CARE PLANNING WEBSITE.
(a) Development.--Not later than January 1, 2010, the Secretary,
acting through the Administrator of the Centers for Medicare & Medicaid
Services and the Director of the Agency for Healthcare Research and
Quality, shall establish a website for providers under Medicare,
Medicaid, the Children's Health Insurance Program, the Indian Health
Service (include contract providers) and other public health providers
on each individual's right to make decisions concerning medical care,
including the right to accept or refuse medical or surgical treatment,
and the existence of advance directives.
(b) Maintenance.--The website, shall be maintained and publicized
by the Secretary on an ongoing basis.
(c) Content.--The website shall include content, tools, and
resources necessary to do the following:
(1) Inform providers about the advance directive
requirements under the health care programs described in
subsection (a) and other State and Federal laws and regulations
related to advance care planning.
(2) Educate providers about advance care planning quality
improvement activities.
(3) Provide assistance to providers to--
(A) integrate advance directives into electronic
health records, including oral directives; and
(B) develop and disseminate advance care planning
informational materials for their patients.
(4) Inform providers about advance care planning continuing
education requirements and opportunities.
(5) Encourage providers to discuss advance care planning
with their patients of all ages.
(6) Assist providers' understanding of the continuum of
end-of-life care services and supports available to patients,
including palliative care and hospice.
(7) Inform providers of best practices for discussing end-
of-life care with dying patients and their loved ones.
SEC. 122. CONTINUING EDUCATION FOR PHYSICIANS AND NURSES.
(a) In General.--Not later than January 1, 2012, the Secretary,
acting through the Director of Health Resources and Services
Administration, shall develop, in consultation with health care
providers and State boards of medicine and nursing, a curriculum for
continuing education that States may adopt for physicians and nurses on
advance care planning and end-of-life care.
(b) Content.--
(1) In general.--The continuing education curriculum
developed under subsection (a) for physicians and nurses shall,
at a minimum, include--
(A) a description of the meaning and importance of
advance care planning;
(B) a description of advance directives, including
living wills and durable powers of attorney, and the
use of such directives;
(C) palliative care principles and approaches to
care; and
(D) the continuum of end-of-life services and
supports, including palliative care and hospice.
(2) Additional content for physicians.--The continuing
education curriculum for physicians developed under subsection
(a) shall include instruction on how to conduct advance care
planning with patients and their loved ones.
Subtitle B--Portability of Advance Directives; Health Information
Technology
SEC. 131. PORTABILITY OF ADVANCE DIRECTIVES.
(a) Medicare.--Section 1866(f) of the Social Security Act (42
U.S.C. 1395cc(f)) is amended--
(1) in paragraph (1)--
(A) in subparagraph (B), by inserting ``and if
presented by the individual, to include the content of
such advance directive in a prominent part of such
record'' before the semicolon at the end;
(B) in subparagraph (D), by striking ``and'' after
the semicolon at the end;
(C) in subparagraph (E), by striking the period at
the end and inserting ``; and''; and
(D) by inserting after subparagraph (E) the
following new subparagraph:
``(F) to provide each individual with the opportunity to
discuss issues relating to the information provided to that
individual pursuant to subparagraph (A) with an appropriately
trained professional.'';
(2) in paragraph (3), by striking ``a written'' and
inserting ``an''; and
(3) by adding at the end the following new paragraph:
``(5)(A) An advance directive validly executed outside of the State
in which such advance directive is presented by an adult individual to
a provider of services, a Medicare Advantage organization, or a prepaid
or eligible organization shall be given the same effect by that
provider or organization as an advance directive validly executed under
the law of the State in which it is presented would be given effect.
``(B)(i) The definition of an advanced directive shall also include
actual knowledge of instructions made while an individual was able to
express the wishes of such individual with regard to health care.
``(ii) For purposes of clause (i), the term `actual knowledge'
means the possession of information of an individual's wishes
communicated to the health care provider orally or in writing by the
individual, the individual's medical power of attorney representative,
the individual's health care surrogate, or other individuals resulting
in the health care provider's personal cognizance of these wishes.
Other forms of imputed knowledge are not actual knowledge.
``(C) The provisions of this paragraph shall preempt any State law
to the extent such law is inconsistent with such provisions. The
provisions of this paragraph shall not preempt any State law that
provides for greater portability, more deference to a patient's wishes,
or more latitude in determining a patient's wishes.''.
(b) Medicaid.--Section 1902(w) of the Social Security Act (42
U.S.C. 1396a(w)) is amended--
(1) in paragraph (1)--
(A) in subparagraph (B)--
(i) by striking ``in the individual's
medical record'' and inserting ``in a prominent
part of the individual's current medical
record''; and
(ii) by inserting ``and if presented by the
individual, to include the content of such
advance directive in a prominent part of such
record'' before the semicolon at the end;
(B) in subparagraph (D), by striking ``and'' after
the semicolon at the end;
(C) in subparagraph (E), by striking the period at
the end and inserting ``; and''; and
(D) by inserting after subparagraph (E) the
following new subparagraph:
``(F) to provide each individual with the opportunity to
discuss issues relating to the information provided to that
individual pursuant to subparagraph (A) with an appropriately
trained professional.'';
(2) in paragraph (4), by striking ``a written'' and
inserting ``an''; and
(3) by adding at the end the following paragraph:
``(6)(A) An advance directive validly executed outside of the State
in which such advance directive is presented by an adult individual to
a provider or organization shall be given the same effect by that
provider or organization as an advance directive validly executed under
the law of the State in which it is presented would be given effect.
``(B)(i) The definition of an advance directive shall also include
actual knowledge of instructions made while an individual was able to
express the wishes of such individual with regard to health care.
``(ii) For purposes of clause (i), the term `actual knowledge'
means the possession of information of an individual's wishes
communicated to the health care provider orally or in writing by the
individual, the individual's medical power of attorney representative,
the individual's health care surrogate, or other individuals resulting
in the health care provider's personal cognizance of these wishes.
Other forms of imputed knowledge are not actual knowledge.
``(C) The provisions of this paragraph shall preempt any State law
to the extent such law is inconsistent with such provisions. The
provisions of this paragraph shall not preempt any State law that
provides for greater portability, more deference to a patient's wishes,
or more latitude in determining a patient's wishes.''.
(c) CHIP.--Section 2107(e)(1) of the Social Security Act (42 U.S.C.
1397gg(e)(1)) is amended--
(1) by redesignating subparagraphs (E) through (L) as
subparagraphs (D) through (M), respectively; and
(2) by inserting after subparagraph (D) the following:
``(E) Section 1902(w) (relating to advance
directives).''.
(d) Study and Report Regarding Implementation.--
(1) Study.--The Secretary shall conduct a study regarding
the implementation of the amendments made by subsections (a)
and (b).
(2) Report.--Not later than 18 months after the date of
enactment of this Act, the Secretary shall submit to Congress a
report on the study conducted under paragraph (1), together
with recommendations for such legislation and administrative
actions as the Secretary considers appropriate.
(e) Effective Dates.--
(1) In general.--Subject to paragraph (2), the amendments
made by subsections (a), (b), and (c) shall apply to provider
agreements and contracts entered into, renewed, or extended
under title XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.), and to State plans under title XIX of such Act (42
U.S.C. 1396 et seq.) and State child health plans under title
XXI of such Act (42 U.S.C. 1397aa et seq.), on or after such
date as the Secretary specifies, but in no case may such date
be later than 1 year after the date of enactment of this Act.
(2) Extension of effective date for state law amendment.--
In the case of a State plan under title XIX of the Social
Security Act or a State child health plan under title XXI of
such Act which the Secretary determines requires State
legislation in order for the plan to meet the additional
requirements imposed by the amendments made by subsections (b)
and (c), the State plan shall not be regarded as failing to
comply with the requirements of such title solely on the basis
of its failure to meet these additional requirements before the
first day of the first calendar quarter beginning after the
close of the first regular session of the State legislature
that begins after the date of enactment of this Act. For
purposes of the previous sentence, in the case of a State that
has a 2-year legislative session, each year of the session is
considered to be a separate regular session of the State
legislature.
SEC. 132. STATE ADVANCE DIRECTIVE REGISTRIES; DRIVER'S LICENSE ADVANCE
DIRECTIVE NOTATION.
Part P of title III of the Public Health Service Act (42 U.S.C.
280g) is amended--
(1) by redesignating section 399R (as inserted by section 2
of Public Law 110-373) as section 399S;
(2) by redesignating section 399R (as inserted by section 3
of Public Law 110-374) as section 399T; and
(3) by adding at the end the following:
``SEC. 399U. STATE ADVANCE DIRECTIVE REGISTRIES.
``(a) State Advance Directive Registry.--In this section, the term
`State advance directive registry' means a secure, electronic database
that--
``(1) is available free of charge to residents of a State;
and
``(2) stores advance directive documents and makes such
documents accessible to medical service providers in accordance
with Federal and State privacy laws.
``(b) Grant Program.--Beginning on July 1, 2010, the Secretary,
acting through the Director of the Centers for Disease Control and
Prevention, shall award grants on a competitive basis to eligible
entities to establish and operate, directly or indirectly (by
competitive grant or competitive contract), State advance directive
registries.
``(c) Eligible Entities.--
``(1) In general.--To be eligible to receive a grant under
this section, an entity shall--
``(A) be a State department of health; and
``(B) submit to the Director an application at such
time, in such manner, and containing--
``(i) a plan for the establishment and
operation of a State advance directive
registry; and
``(ii) such other information as the
Director may require.
``(2) No requirement of notation mechanism.--The Secretary
shall not require that an entity establish and operate a
driver's license advance directive notation mechanism for State
residents under section 399V to be eligible to receive a grant
under this section.
``(d) Annual Report.--For each year for which an entity receives an
award under this section, such entity shall submit an annual report to
the Director on the use of the funds received pursuant to such award,
including the number of State residents served through the registry.
``(e) Authorization.--There is authorized to be appropriated to
carry out this section $20,000,000 for fiscal year 2010 and each fiscal
year thereafter.
``SEC. 399V. DRIVER'S LICENSE ADVANCE DIRECTIVE NOTATION.
``(a) In General.--Beginning July 1, 2010, the Secretary, acting
through the Director of the Centers for Disease Control and Prevention,
shall award grants on a competitive basis to States to establish and
operate a mechanism for a State resident with a driver's license to
include a notice of the existence of an advance directive for such
resident on such license.
``(b) Eligibility.--To be eligible to receive a grant under this
section, a State shall--
``(1) establish and operate a State advance directive
registry under section 399U; and
``(2) submit to the Director an application at such time,
in such manner, and containing--
``(A) a plan that includes a description of how the
State will--
``(i) disseminate information about advance
directives at the time of driver's license
application or renewal;
``(ii) enable each State resident with a
driver's license to include a notice of the
existence of an advance directive for such
resident on such license in a manner consistent
with the notice on such a license indicating a
driver's intent to be an organ donor; and
``(iii) coordinate with the State
department of health to ensure that, if a State
resident has an advance directive notice on his
or her driver's license, the existence of such
advance directive is included in the State
registry established under section 399U; and
``(B) any other information as the Director may
require.
``(c) Annual Report.--For each year for which a State receives an
award under this section, such State shall submit an annual report to
the Director on the use of the funds received pursuant to such award,
including the number of State residents served through the mechanism.
``(d) Authorization.--There is authorized to be appropriated to
carry out this section $50,000,000 for fiscal year 2010 and each fiscal
year thereafter.''.
SEC. 133. GAO STUDY AND REPORT ON ESTABLISHMENT OF NATIONAL ADVANCE
DIRECTIVE REGISTRY.
(a) Study.--The Comptroller General of the United States shall
conduct a study on the feasibility of a national registry for advance
directives, taking into consideration the constraints created by the
privacy provisions enacted as a result of the Health Insurance
Portability and Accountability Act of 1996 (Public Law 104-191).
(b) Report.--Not later than 18 months after the date of enactment
of this Act, the Comptroller General of the United States shall submit
to Congress a report on the study conducted under subsection (a)
together with recommendations for such legislation and administrative
action as the Comptroller General of the United States determines to be
appropriate.
Subtitle C--National Uniform Policy on Advance Care Planning
SEC. 141. STUDY AND REPORT BY THE SECRETARY REGARDING THE ESTABLISHMENT
AND IMPLEMENTATION OF A NATIONAL UNIFORM POLICY ON
ADVANCE DIRECTIVES.
(a) Study.--
(1) In general.--The Secretary, acting through the Office
of the Assistant Secretary for Planning and Evaluation, shall
conduct a thorough study of all matters relating to the
establishment and implementation of a national uniform policy
on advance directives for individuals receiving items and
services under titles XVIII, XIX, or XXI of the Social Security
Act (42 U.S.C. 1395 et seq.; 1396 et seq.; 1397aa et seq.).
(2) Matters studied.--The matters studied by the Secretary
under paragraph (1) shall include issues concerning--
(A) family satisfaction that a patient's wishes, as
stated in the patient's advance directive, were carried
out;
(B) the portability of advance directives,
including cases involving the transfer of an individual
from one health care setting to another;
(C) immunity from civil liability and criminal
responsibility for health care providers that follow
the instructions in an individual's advance directive
that was validly executed in, and consistent with the
laws of, the State in which it was executed;
(D) conditions under which an advance directive is
operative;
(E) revocation of an advance directive by an
individual;
(F) the criteria used by States for determining
that an individual has a terminal condition;
(G) surrogate decisionmaking regarding end-of-life
care;
(H) the provision of adequate palliative care (as
defined in paragraph (3)), including pain management;
(I) adequate and timely referrals to hospice care
programs; and
(J) the end-of-life care needs of children and
their families.
(3) Palliative care.--For purposes of paragraph (2)(H), the
term ``palliative care'' means interdisciplinary care for
individuals with a life-threatening illness or injury relating
to pain and symptom management and psychological, social, and
spiritual needs and that seeks to improve the quality of life
for the individual and the individual's family.
(b) Report to Congress.--Not later than 18 months after the date of
enactment of this Act, the Secretary shall submit to Congress a report
on the study conducted under subsection (a), together with
recommendations for such legislation and administrative actions as the
Secretary considers appropriate.
(c) Consultation.--In conducting the study and developing the
report under this section, the Secretary shall consult with the Uniform
Law Commissioners, and other interested parties.
TITLE II--COMPASSIONATE CARE
Subtitle A--Workforce Development
PART I--EDUCATION AND TRAINING
SEC. 201. NATIONAL GERIATRIC AND PALLIATIVE CARE SERVICES CORPS.
Section 331 of the Public Health Service Act (42 U.S.C. 254d) is
amended--
(1) by redesignating subsection (j) as subsection (k); and
(2) by inserting after subsection (i), the following:
``(j) National Geriatric and Palliative Care Services Corps.--
``(1) Establishment.--Not later than January 1, 2012, the
Secretary shall establish within the National Health Service
Corps a National Geriatric and Palliative Care Services Corps
(referred to in this subsection as the `Corps') which shall
consist of--
``(A) such officers of the Regular and Reserve
Corps of the Service as the Secretary may designate;
``(B) such civilian employees of the United States
as the Secretary may appoint; and
``(C) such other individuals who are not employees
of the United States.
``(2) Duties.--The Corps shall be utilized by the Secretary
to provide geriatric and palliative care services within health
professional shortage areas.
``(3) Application of provisions.--The loan-forgiveness,
scholarship, and direct financial incentives programs provided
for under this section shall apply to physicians, nurses, and
other health professionals (as identified by the Secretary)
with respect to the training necessary to enable such
individuals to become geriatric or palliative care specialists
and provide geriatric and palliative care services in health
professional shortage areas.
``(4) Report.--Not later than 6 months prior to the date on
which the Secretary establishes the Corps under paragraph (1),
the Secretary shall submit to Congress a report concerning the
organization of the Corps, the application process for
membership in the Corps, and the funding necessary for the
Corps (targeted by profession and by specialization).''.
SEC. 202. EXEMPTION OF PALLIATIVE MEDICINE FELLOWSHIP TRAINING FROM
MEDICARE GRADUATE MEDICAL EDUCATION CAPS.
(a) Direct Graduate Medical Education.--Section 1886(h)(4)(F) of
the Social Security Act (42 U.S.C. 1395ww(h)(4)(F)) is amended--
(1) in clause (i), by inserting ``clause (iii) and'' after
``subject to''; and
(2) by adding at the end the following new clause:
``(iii) Increase allowed for palliative
medicine fellowship training.--For cost
reporting periods beginning on or after January
1, 2011, in applying clause (i), there shall
not be taken into account full-time equivalent
residents in the field of allopathic or
osteopathic medicine who are in palliative
medicine fellowship training that is approved
by the Accreditation Council for Graduate
Medical Education.''.
(b) Indirect Medical Education.--Section 1886(d)(5)(B) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at
the end the following new clause:
``(x) Clause (iii) of subsection (h)(4)(F) shall apply to
clause (v) in the same manner and for the same period as such
clause (iii) applies to clause (i) of such subsection.''.
SEC. 203. MEDICAL SCHOOL CURRICULA.
(a) In General.--The Secretary, in consultation with the
Association of American Medical Colleges, shall establish guidelines
for the imposition by medical schools of a minimum amount of end-of-
life training as a requirement for obtaining a Doctor of Medicine
degree in the field of allopathic or osteopathic medicine.
(b) Training.--Under the guidelines established under subsection
(a), minimum training shall include--
(1) training in how to discuss and help patients and their
loved ones with advance care planning;
(2) with respect to students and trainees who will work
with children, specialized pediatric training;
(3) training in the continuum of end-of-life services and
supports, including palliative care and hospice;
(4) training in how to discuss end-of-life care with dying
patients and their loved ones; and
(5) medical and legal issues training.
(c) Distribution.--Not later than January 1, 2011, the Secretary
shall disseminate the guidelines established under subsection (a) to
medical schools.
(d) Compliance.--Effective beginning not later than July 1, 2012, a
medical school that is receiving Federal assistance shall be required
to implement the guidelines established under subsection (a). A medical
school that the Secretary determines is not implementing such
guidelines shall not be eligible for Federal assistance.
Subtitle B--Coverage Under Medicare, Medicaid, and CHIP
PART I--COVERAGE OF ADVANCE CARE PLANNING
SEC. 211. MEDICARE, MEDICAID, AND CHIP COVERAGE.
(a) Medicare.--
(1) In general.--Section 1861 of the Social Security Act
(42 U.S.C. 1395x) is amended--
(A) in subsection (s)(2)--
(i) by striking ``and'' at the end of
subparagraph (DD);
(ii) by adding ``and'' at the end of
subparagraph (EE); and
(iii) by adding at the end the following
new subparagraph:
``(FF) advance care planning consultation (as
defined in subsection (hhh)(1));''; and
(B) by adding at the end the following new
subsection:
``Advance Care Planning Consultation
``(hhh)(1) Subject to paragraphs (3) and (4), the term `advance
care planning consultation' means a consultation between the individual
and a practitioner described in paragraph (2) regarding advance care
planning, if, subject to subparagraphs (A) and (B) of paragraph (3),
the individual involved has not had such a consultation within the last
5 years. Such consultation shall include the following:
``(A) An explanation by the practitioner of advance care
planning, including key questions and considerations, important
steps, and suggested people to talk to.
``(B) An explanation by the practitioner of advance
directives, including living wills and durable powers of
attorney, and their uses.
``(C) An explanation by the practitioner of the role and
responsibilities of a health care proxy.
``(D) The provision by the practitioner of a list of
national and State-specific resources to assist consumers and
their families with advance care planning, including the
national toll-free hotline, the advance care planning
clearinghouses, and State legal service organizations
(including those funded through the Older Americans Act).
``(E) An explanation by the practitioner of the continuum
of end-of-life services and supports available, including
palliative care and hospice, and benefits for such services and
supports that are available under this title.
``(F)(i) Subject to clause (ii), an explanation of orders
regarding life sustaining treatment or similar orders, which
shall include--
``(I) the reasons why the development of such an
order is beneficial to the individual and the
individual's family and the reasons why such an order
should be updated periodically as the health of the
individual changes;
``(II) the information needed for an individual or
legal surrogate to make informed decisions regarding
the completion of such an order; and
``(III) the identification of resources that an
individual may use to determine the requirements of the
State in which such individual resides so that the
treatment wishes of that individual will be carried out
if the individual is unable to communicate those
wishes, including requirements regarding the
designation of a surrogate decision maker (also known
as a health care proxy).
``(ii) The Secretary may limit the requirement for
explanations under clause (i) to consultations furnished in
States, localities, or other geographic areas in which orders
described in such clause have been widely adopted.
``(2) A practitioner described in this paragraph is--
``(A) a physician (as defined in subsection (r)(1)); and
``(B) a nurse practitioner or physician's assistant who has
the authority under State law to sign orders for life
sustaining treatments.
``(3)(A) An initial preventive physical examination under
subsection (ww), including any related discussion during such
examination, shall not be considered an advance care planning
consultation for purposes of applying the 5-year limitation under
paragraph (1).
``(B) An advance care planning consultation with respect to an
individual shall be conducted more frequently than provided under
paragraph (1) if there is a significant change in the health condition
of the individual, including diagnosis of a chronic, progressive, life-
limiting disease, a life-threatening or terminal diagnosis or life-
threatening injury, or upon admission to a skilled nursing facility, a
long-term care facility (as defined by the Secretary), or a hospice
program.
``(4) A consultation under this subsection may include the
formulation of an order regarding life sustaining treatment or a
similar order.
``(5)(A) For purposes of this section, the term `order regarding
life sustaining treatment' means, with respect to an individual, an
actionable medical order relating to the treatment of that individual
that--
``(i) is signed and dated by a physician (as defined in
subsection (r)(1)) or another health care professional (as
specified by the Secretary and who is acting within the scope
of the professional's authority under State law in signing such
an order) and is in a form that permits it to stay with the
patient and be followed by health care professionals and
providers across the continuum of care, including home care,
hospice, long-term care, community and assisted living
residences, skilled nursing facilities, inpatient
rehabilitation facilities, hospitals, and emergency medical
services;
``(ii) effectively communicates the individual's
preferences regarding life sustaining treatment, including an
indication of the treatment and care desired by the individual;
``(iii) is uniquely identifiable and standardized within a
given locality, region, or State (as identified by the
Secretary);
``(iv) is portable across care settings; and
``(v) may incorporate any advance directive (as defined in
section 1866(f)(3)) if executed by the individual.
``(B) The level of treatment indicated under subparagraph (A)(ii)
may range from an indication for full treatment to an indication to
limit some or all or specified interventions. Such indicated levels of
treatment may include indications respecting, among other items--
``(i) the intensity of medical intervention if the patient
is pulseless, apneic, or has serious cardiac or pulmonary
problems;
``(ii) the individual's desire regarding transfer to a
hospital or remaining at the current care setting;
``(iii) the use of antibiotics; and
``(iv) the use of artificially administered nutrition and
hydration.''.
(2) Payment.--Section 1848(j)(3) of the Social Security Act
(42 U.S.C. 1395w-4(j)(3)) is amended by inserting ``(2)(FF),''
after ``(2)(EE),''.
(3) Frequency limitation.--Section 1862(a) of the Social
Security Act (42 U.S.C. 1395y(a)(1)) is amended--
(A) in paragraph (1)--
(i) in subparagraph (N), by striking
``and'' at the end;
(ii) in subparagraph (O) by striking the
semicolon at the end and inserting ``, and'';
and
(iii) by adding at the end the following
new subparagraph:
``(P) in the case of advance care planning consultations
(as defined in section 1861(hhh)(1)), which are performed more
frequently than is covered under such section;''; and
(B) in paragraph (7), by striking ``or (K)'' and
inserting ``(K), or (P)''.
(4) Effective date.--The amendments made by this subsection
shall apply to consultations furnished on or after January 1,
2011.
(b) Medicaid.--
(1) Mandatory benefit.--Section 1902(a)(10)(A) of the
Social Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended in
the matter preceding clause (i) by striking ``and (21)'' and
inserting ``, (21), and (28)''.
(2) Medical assistance.--Section 1905 of such Act (42
U.S.C. 1396d) is amended--
(A) in subsection (a)--
(i) in paragraph (27), by striking ``and''
at the end;
(ii) by redesignating paragraph (28) as
paragraph (29); and
(iii) by inserting after paragraph (27) the
following new paragraph:
``(28) advance care planning consultations (as defined in
subsection (y));''; and
(B) by adding at the end the following:
``(y)(1) For purposes of subsection (a)(28), the term `advance care
planning consultation' means a consultation between the individual and
a practitioner described in paragraph (2) regarding advance care
planning, if, subject to paragraph (3), the individual involved has not
had such a consultation within the last 5 years. Such consultation
shall include the following:
``(A) An explanation by the practitioner of advance care
planning, including key questions and considerations, important
steps, and suggested people to talk to.
``(B) An explanation by the practitioner of advance
directives, including living wills and durable powers of
attorney, and their uses.
``(C) An explanation by the practitioner of the role and
responsibilities of a health care proxy.
``(D) The provision by the practitioner of a list of
national and State-specific resources to assist consumers and
their families with advance care planning, including the
national toll-free hotline, the advance care planning
clearinghouses, and State legal service organizations
(including those funded through the Older Americans Act).
``(E) An explanation by the practitioner of the continuum
of end-of-life services and supports available, including
palliative care and hospice, and benefits for such services and
supports that are available under this title.
``(F)(i) Subject to clause (ii), an explanation of orders
for life sustaining treatments or similar orders, which shall
include--
``(I) the reasons why the development of such an
order is beneficial to the individual and the
individual's family and the reasons why such an order
should be updated periodically as the health of the
individual changes;
``(II) the information needed for an individual or
legal surrogate to make informed decisions regarding
the completion of such an order; and
``(III) the identification of resources that an
individual may use to determine the requirements of the
State in which such individual resides so that the
treatment wishes of that individual will be carried out
if the individual is unable to communicate those
wishes, including requirements regarding the
designation of a surrogate decision maker (also known
as a health care proxy).
``(ii) The Secretary may limit the requirement for
explanations under clause (i) to consultations furnished in
States, localities, or other geographic areas in which orders
described in such clause have been widely adopted.
``(2) A practitioner described in this paragraph is--
``(A) a physician (as defined in section 1861(r)(1)); and
``(B) a nurse practitioner or physician's assistant who has
the authority under State law to sign orders for life
sustaining treatments.
``(3) An advance care planning consultation with respect to an
individual shall be conducted more frequently than provided under
paragraph (1) if there is a significant change in the health condition
of the individual including diagnosis of a chronic, progressive, life-
limiting disease, a life-threatening or terminal diagnosis or life-
threatening injury, or upon admission to a nursing facility, a long-
term care facility (as defined by the Secretary), or a hospice program.
``(4) A consultation under this subsection may include the
formulation of an order regarding life sustaining treatment or a
similar order.
``(5) For purposes of this subsection, the term `orders regarding
life sustaining treatment' has the meaning given that term in section
1861(hhh)(5).''.
(c) CHIP.--
(1) Child health assistance.--Section 2110(a) of the Social
Security Act (42 U.S.C. 1397jj) is amended--
(A) by redesignating paragraph (28) as paragraph
(29); and
(B) by inserting after paragraph (27), the
following:
``(28) Advance care planning consultations (as defined in
section 1905(y)).''.
(2) Mandatory coverage.--
(A) In general.--Section 2103 of such Act (42
U.S.C. 1397cc), is amended--
(i) in subsection (a), in the matter
preceding paragraph (1), by striking ``and
(7)'' and inserting ``(7), and (9)''; and
(ii) in subsection (c), by adding at the
end the following:
``(9) End-of-life care.--The child health assistance
provided to a targeted low-income child shall include coverage
of advance care planning consultations (as defined in section
1905(y) and at the same payment rate as the rate that would
apply to such a consultation under the State plan under title
XIX).''.
(B) Conforming amendment.--Section 2102(a)(7)(B) of
such Act (42 U.S.C. 1397bb(a)(7)(B)) is amended by
striking ``section 2103(c)(5)'' and inserting
``paragraphs (5) and (9) of section 2103(c)''.
(d) Definition of Advance Directive Under Medicare, Medicaid, and
CHIP.--
(1) Medicare.--Section 1866(f)(3) of the Social Security
Act (42 U.S.C. 1395cc(f)(3)) is amended by striking ``means''
and all that follows through the period and inserting ``means a
living will, medical directive, health care power of attorney,
durable power of attorney, or other written statement by a
competent individual that is recognized under State law and
indicates the individual's wishes regarding medical treatment
in the event of future incompetence. Such term includes an
advance health care directive and a health care directive
recognized under State law.''.
(2) Medicaid and chip.--Section 1902(w)(4) of such Act (42
U.S.C. 1396a(w)(4)) is amended by striking ``means'' and all
that follows through the period and inserting ``means a living
will, medical directive, health care power of attorney, durable
power of attorney, or other written statement by a competent
individual that is recognized under State law and indicates the
individual's wishes regarding medical treatment in the event of
future incompetence. Such term includes an advance health care
directive and a health care directive recognized under State
law.''.
(e) Effective Date.--The amendments made by this section take
effect January 1, 2010.
PART II--HOSPICE
SEC. 221. ADOPTION OF MEDPAC HOSPICE PAYMENT METHODOLOGY
RECOMMENDATIONS.
Section 1814(i) of the Social Security Act (42 U.S.C. 1395f(i)) is
amended by adding at the end the following new paragraph:
``(6)(A) The Secretary shall conduct an evaluation of the
recommendations of the Medicare Payment Commission for
reforming the hospice care benefit under this title that are
contained in chapter 6 of the Commission's report entitled
`Report to Congress: Medicare Payment Policy (March 2009)',
including the impact that such recommendations if implemented
would have on access to care and the quality of care. In
conducting such evaluation, the Secretary shall take into
account data collected in accordance with section 263(b) of the
Advance Planning and Compassionate Care Act of 2009.
``(B) Based on the results of the examination conducted
under subparagraph (A), the Secretary shall make appropriate
refinements to the recommendations described in subparagraph
(A). Such refinements shall take into account--
``(i) the impact on patient populations with longer
that average lengths of stay;
``(ii) the impact on populations with shorter that
average lengths of stay; and
``(iii) the utilization patterns of hospice
providers in underserved areas, including rural
hospices.
``(C) Not later than January 1, 2013, the Secretary shall
submit to Congress a report that contains a detailed
description of--
``(i) the refinements determined appropriate by the
Secretary under subparagraph (B);
``(ii) the revisions that the Secretary will
implement through regulation under this title pursuant
to subparagraph (D); and
``(iii) the revisions that the Secretary determines
require additional legislative action by Congress.
``(D)(i) The Secretary shall implement the recommendations
described in subparagraph (A), as refined under subparagraph
(B).
``(ii) Subject to clause (iii), the implementation of such
recommendations shall apply to hospice care furnished on or
after January 1, 2014.
``(iii) The Secretary shall establish an appropriate
transition to the implementation of such recommendations.
``(E) For purposes of carrying out the provisions of this
paragraph, the Secretary shall provide for the transfer, from
the Federal Hospital Insurance Trust Fund under section 1817,
of such sums as may be necessary to the Centers for Medicare &
Medicaid Services Program Management Account.''.
SEC. 222. REMOVING HOSPICE INPATIENT DAYS IN SETTING PER DIEM RATES FOR
CRITICAL ACCESS HOSPITALS.
Section 1814(l) of the Social Security Act (42 U.S.C. 1395f(l)), as
amended by section 4102(b)(2) of the HITECH Act (Public Law 111-5), is
amended by adding at the end the following new paragraph:
``(6) For cost reporting periods beginning on or after
January 1, 2011, the Secretary shall remove Medicare-certified
hospice inpatient days from the calculation of per diem rates
for inpatient critical access hospital services.''.
SEC. 223. HOSPICE PAYMENTS FOR DUAL ELIGIBLE INDIVIDUALS RESIDING IN
LONG-TERM CARE FACILITIES.
(a) In General.--Section 1888 of the Social Security Act (42 U.S.C.
1395yy) is amended by adding at the end the following new subsection:
``(f) Payments for Dual Eligible Individuals Residing in Long-Term
Care Facilities.--For cost reporting periods beginning on or after
January 1, 2011, the Secretary, acting through the Administrator of the
Centers for Medicare & Medicaid Services, shall establish procedures
under which payments for room and board under the State Medicaid plan
with respect to an applicable individual are made directly to the long-
term care facility (as defined by the Secretary for purposes of title
XIX) the individual is a resident of. For purposes of the preceding
sentence, the term `applicable individual' means an individual who is
entitled to or enrolled for benefits under part A or enrolled for
benefits under part B and is eligible for medical assistance for
hospice care under a State plan under title XIX.''.
(b) State Plan Requirement.--
(1) In general.--Section 1902(a) of the Social Security Act
(42 U.S.C. 1396a(a)) is amended--
(A) in paragraph (72), by striking ``and'' at the
end;
(B) in paragraph (73), by striking the period at
the end and inserting ``; and''; and
(C) by inserting after paragraph (73) the following
new paragraph:
``(74) provide that the State will make payments for room
and board with respect to applicable individuals in accordance
with section 1888(f).''.
(2) Effective date.--
(A) In general.--Except as provided in subparagraph
(B), the amendments made by paragraph (1) take effect
on January 1, 2011.
(B) Extension of effective date for state law
amendment.--In the case of a State plan under title XIX
of the Social Security Act (42 U.S.C. 1396 et seq.)
which the Secretary determines requires State
legislation in order for the plan to meet the
additional requirements imposed by the amendments made
by paragraph (1), the State plan shall not be regarded
as failing to comply with the requirements of such
title solely on the basis of its failure to meet these
additional requirements before the first day of the
first calendar quarter beginning after the close of the
first regular session of the State legislature that
begins after the date of enactment of this Act. For
purposes of the previous sentence, in the case of a
State that has a 2-year legislative session, each year
of the session is considered to be a separate regular
session of the State legislature.
SEC. 224. DELINEATION OF RESPECTIVE CARE RESPONSIBILITIES OF HOSPICE
PROGRAMS AND LONG-TERM CARE FACILITIES.
Section 1888 of the Social Security Act (42 U.S.C. 1395yy), as
amended by section 223(a), is amended by adding at the end the
following new subsection:
``(g) Delineation of Respective Care Responsibilities of Hospice
Programs and Long-Term Care Facilities.--Not later than July 1, 2011,
the Secretary, acting through the Administrator of the Centers for
Medicare & Medicaid Services, shall delineate and enforce the
respective care responsibilities of hospice programs and long-term care
facilities (as defined by the Secretary for purposes of title XIX) with
respect to individuals residing in such facilities who are furnished
hospice care.''.
SEC. 225. ADOPTION OF MEDPAC HOSPICE PROGRAM ELIGIBILITY CERTIFICATION
AND RECERTIFICATION RECOMMENDATIONS.
In accordance with the recommendations of the Medicare Payment
Advisory Commission contained in the March 2009 report entitled
``Report to Congress: Medicare Payment Policy'', section 1814(a)(7) of
the Social Security Act (42 U.S.C. 1395f(a)(7)) is amended--
(1) in subparagraph (B), by striking ``and'' at the end;
and
(2) by adding at the end the following new subparagraph:
``(D) on or after January 1, 2011--
``(i) a hospice physician or advance
practice nurse visits the individual to
determine continued eligibility of the
individual for hospice care prior to the 180th
day recertification and each subsequent
recertification under subparagraph (A)(ii) and
attests that such visit took place (in
accordance with procedures established by the
Secretary, in consultation with the
Administrator of the Centers for Medicare &
Medicaid Services); and
``(ii) any certification or recertification
under subparagraph (A) includes a brief
narrative describing the clinical basis for the
individual's prognosis (in accordance with
procedures established by the Secretary, in
consultation with the Administrator of the
Centers for Medicare & Medicaid Services);
and''.
SEC. 226. CONCURRENT CARE FOR CHILDREN.
(a) Permitting Medicare Hospice Beneficiaries 18 Years of Age or
Younger To Receive Curative Care.--
(1) In general.--Section 1812 of the Social Security Act
(42 U.S.C. 1395d) is amended--
(A) in subsection (a)(4), by inserting ``(subject
to the second sentence of subsection (d)(2)(A))'' after
``in lieu of certain other benefits''; and
(B) in subsection (d)--
(i) in paragraph (1), by inserting `` ,
subject to the second sentence of paragraph
(2)(A),'' after ``instead''; and
(ii) in paragraph (2)(A), by adding at the
end the following new sentence: ``Clause
(ii)(I) shall not apply to an individual who is
18 years of age or younger.''
(2) Conforming amendment.--Section 1862(a)(1)(C) of the
Social Security Act (42 U.S.C. 1395y(a)(1)(C)) is amended
inserting ``subject to the second sentence of section
1812(d)(2)(A),'' after ``hospice care,''.
(b) Application to Medicaid and CHIP.--
(1) Medicaid.--Section 1905(o)(1)(A) of the Social Security
Act (42 U.S.C. 1395d(o)(1)(A)) is amended by inserting
``(subject, in the case of an individual who is a child, to the
second sentence of such section)'' after ``section
1812(d)(2)(A)''.
(2) CHIP.--Section 2110(a)(23) of the Social Security Act
(42 U.S.C. 1397jj(a)(23)) is amended by inserting
``(concurrent, in the case of an individual who is a child,
with care related to the treatment of the individual's
condition with respect to which a diagnosis of terminal illness
has been made)'' after ``hospice care''.
(c) Effective Date.--The amendments made by this section shall
apply to items and services furnished on or after January 1, 2011.
SEC. 227. MAKING HOSPICE A REQUIRED BENEFIT UNDER MEDICAID AND CHIP.
(a) Mandatory Benefit.--
(1) Medicaid.--
(A) In general.--Section 1902(a)(10)(A) of the
Social Security Act (42 U.S.C. 1396a(a)(10)(A)), as
amended by section 211(b)(1), is amended in the matter
preceding clause (i) by inserting ``(18),'' after
``(17),''.
(B) Conforming amendment.--Section 1902(a)(10)(C)
of such Act (42 U.S.C. 1396a(a)(10)(C)) is amended--
(i) in clause (iii)--
(I) in subclause (I), by inserting
``and hospice care'' after ``ambulatory
services''; and
(II) in subclause (II), by
inserting ``and hospice care'' after
``delivery services''; and
(ii) in clause (iv), by inserting ``and
(18)'' after ``(17)''.
(2) CHIP.--Section 2103(c)(9) of such Act (42 U.S.C.
1397cc(c)(9)), as added by section 211(c)(2)(A), is amended by
inserting ``and hospice care'' before the period.
(b) Effective Date.--The amendments made subsection (a) take effect
on January 1, 2011.
SEC. 228. MEDICARE HOSPICE PAYMENT MODEL DEMONSTRATION PROJECTS.
(a) Establishment.--Not later than July 1, 2012, the Secretary,
acting through the Administrator of the Centers for Medicare & Medicaid
Services and the Director of the Agency for Healthcare Research and
Quality, shall conduct demonstration projects to examine ways to
improve how the Medicare hospice care benefit predicts disease
trajectory. Projects shall include the following models:
(1) Models that better and more appropriately care for, and
transition as needed, patients in their last years of life who
need palliative care, but do not qualify for hospice care under
the Medicare hospice eligibility criteria.
(2) Models that better and more appropriately care for
long-term patients who are not recertified in hospice but still
need palliative care.
(3) Any other models determined appropriate by the
Secretary.
(b) Waiver Authority.--The Secretary may waive compliance of such
requirements of titles XI and XVIII of the Social Security Act as the
Secretary determines necessary to conduct the demonstration projects
under this section.
(c) Reports.--The Secretary shall submit to Congress periodic
reports on the demonstration projects conducted under this section.
SEC. 229. MEDPAC STUDIES AND REPORTS.
(a) Study and Report Regarding an Alternative Payment Methodology
for Hospice Care Under the Medicare Program.--
(1) Study.--The Medicare Payment Advisory Commission (in
this section referred to as the ``Commission'') shall conduct a
study on the establishment of a reimbursement system for
hospice care furnished under the Medicare program that is based
on diagnoses. In conducting such study, the Commission shall
use data collected under new provider data requirements. Such
study shall include an analysis of the following:
(A) Whether such a reimbursement system better
meets patient needs and better corresponds with
provider resource expenditures than the current system.
(B) Whether such a reimbursement system improves
quality, including facilitating standardization of care
toward best practices and diagnoses-specific clinical
pathways in hospice.
(C) Whether such a reimbursement system could
address concerns about the blanket 6-month terminal
prognosis requirement in hospice.
(D) Whether such a reimbursement system is more
cost effective than the current system.
(E) Any other areas determined appropriate by the
Commission.
(2) Report.--Not later than June 15, 2013, the Commission
shall submit to Congress a report on the study conducted under
subsection (a) together with recommendations for such
legislation and administrative action as the Commission
determines appropriate.
(b) Study and Report Regarding Rural Hospice Transportation Costs
Under the Medicare Program.--
(1) Study.--The Commission shall conduct a study on rural
Medicare hospice transportation mileage to determine potential
Medicare reimbursement changes to account for potential higher
costs.
(2) Report.--Not later than June 15, 2013, the Commission
shall submit to Congress a report on the study conducted under
subsection (a) together with recommendations for such
legislation and administrative action as the Commission
determines appropriate.
(c) Evaluation of Reimbursement Disincentives To Elect Medicare
Hospice Within the Medicare Skilled Nursing Facility Benefit.--
(1) Study.--The Commission shall conduct a study to
determine potential Medicare reimbursement changes to remove
Medicare reimbursement disincentives for patients in a skilled
nursing facility who want to elect hospice.
(2) Report.--Not later than June 15, 2013, the Commission
shall submit to Congress a report on the study conducted under
subsection (a) together with recommendations for such
legislation and administrative action as the Commission
determines appropriate.
SEC. 230. HHS EVALUATIONS.
(a) Evaluation of Access to Hospice and Hospital-Based Palliative
Care.--
(1) Evaluation.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration, shall conduct an evaluation of geographic areas
and populations underserved by hospice and hospital-based
palliative care to identify potential barriers to access.
(2) Report.--Not later than December 31, 2012, the
Secretary shall report to Congress, on the evaluation conducted
under subsection (a) together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate to address barriers to access to hospice
and hospital-based palliative care.
(b) Evaluation of Awareness and Use of Hospice Respite Care Under
Medicare, Medicaid, and CHIP.--
(1) Evaluation.--The Secretary, acting through the Director
of the Centers for Medicare & Medicaid Services, shall evaluate
the awareness and use of hospice respite care by informal
caregivers of beneficiaries under Medicare, Medicaid, and CHIP.
(2) Report.--Not later than December 31, 2010, the
Secretary shall report to Congress, on the evaluation conducted
under subsection (a) together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate to increase awareness or use of hospice
respite care under Medicare, Medicaid, and CHIP.
Subtitle C--Quality Improvement
SEC. 241. PATIENT SATISFACTION SURVEYS.
Not later than January 1, 2012, the Secretary, acting through the
Administrator of the Centers for Medicare & Medicaid Services, shall
establish a mechanism for--
(1) collecting information from patients (or their health
care proxies or families members in the event patients are
unable to speak for themselves) in relevant provider settings
regarding their care at the end of life; and
(2) incorporating such information in a timely manner into
mechanisms used by the Administrator to provide quality of care
information to consumers, including the Hospital Compare and
Nursing Home Compare websites maintained by the Administrator.
SEC. 242. DEVELOPMENT OF CORE END-OF-LIFE CARE QUALITY MEASURES ACROSS
EACH RELEVANT PROVIDER SETTING.
(a) In General.--The Secretary, acting through the Administrator of
the Agency for Healthcare Research and Quality (in this section
referred to as the ``Administrator'') and in consultation with the
Director of the National Institutes of Health, shall require specific
end-of-life quality measures for each relevant provider setting, as
identified by the Administrator, in accordance with the requirements of
subsection (b).
(b) Requirements.--For purposes of subsection (a), the requirements
specified in this subsection are the following:
(1) Selection of the specific measure or measures for an
identified provider setting shall be--
(A) based on an assessment of what is likely to
have the greatest positive impact on quality of end-of-
life care in that setting; and
(B) made in consultation with affected providers
and public and private organizations, that have
developed such measures.
(2) The measures may be structure-oriented, process-
oriented, or outcome-oriented, as determined appropriate by the
Administrator.
(3) The Administrator shall ensure that reporting
requirements related to such measures are imposed consistent
with other applicable laws and regulations, and in a manner
that takes into account existing measures, the needs of patient
populations, and the specific services provided.
(4) Not later than--
(A) April 1, 2011, the Secretary shall disseminate
the reporting requirements to all affected providers;
and
(B) April 1, 2012, initial reporting relating to
the measures shall begin.
SEC. 243. ACCREDITATION OF HOSPITAL-BASED PALLIATIVE CARE PROGRAMS.
(a) In General.--The Secretary, acting through the Director of the
Agency for Healthcare Research and Quality, shall designate a public or
private agency, entity, or organization to develop requirements,
standards, and procedures for accreditation of hospital-based
palliative care programs.
(b) Reporting.--Not later than January 1, 2012, the Secretary shall
prepare and submit a report to Congress on the proposed accreditation
process for hospital-based palliative care programs.
(c) Accreditation.--Not later than July 1, 2012, the Secretary
shall--
(1) establish and promulgate standards and procedures for
accreditation of hospital-based palliative care programs; and
(2) designate an agency, entity, or organization that shall
be responsible for certifying such programs in accordance with
the standards established under paragraph (1).
(d) Definitions.--For the purposes of this section:
(1) The term ``hospital-based palliative care program''
means a hospital-based program that is comprised of an
interdisciplinary team that specializes in providing palliative
care services and consultations in a variety of health care
settings, including hospitals, nursing homes, and home and
community-based services.
(2) The term ``interdisciplinary team'' means a group of
health care professionals (consisting of, at a minimum, a
doctor, a nurse, and a social worker) that have received
specialized training in palliative care.
SEC. 244. SURVEY AND DATA REQUIREMENTS FOR ALL MEDICARE PARTICIPATING
HOSPICE PROGRAMS.
(a) Hospice Surveys.--Section 1861(dd) of the Social Security Act
(42 U.S.C. 1395x(dd)) is amended by adding at the end the following new
paragraph:
``(6) In accordance with the recommendations of the Medicare
Payment Advisory Commission contained in the March 2009 report entitled
`Report to Congress: Medicare Payment Policy', the Secretary shall
establish, effective July 1, 2010, the following survey requirements
for hospice programs:
``(A) Any hospice program seeking initial certification
under this title on or after that date shall be subject to an
initial survey by an appropriate State or local agency, or an
approved accreditation agency, not later than 6 months after
the program first seeks such certification.
``(B) All hospice programs certified for participation
under this title shall be subject to a standard survey by an
appropriate State or local agency, or an approved accreditation
agency, at least every 3 years after initially being so
certified.''.
(b) Required Hospice Resource Inputs Data.--Section 1861(dd) of the
Social Security Act (42 U.S.C. 1395x(dd)), as amended by subsection
(a), is amended--
(1) in paragraph (3)--
(A) in subparagraph (F), by striking ``and'' at the
end;
(B) by redesignating subparagraph (G) as
subparagraph (H); and
(C) by inserting after subparagraph (F) the
following new subparagraph:
``(G) to comply with the reporting requirements under
paragraph (7); and''; and
(2) by adding at the end the following new paragraph:
``(7)(A) In accordance with the recommendations of the
Medicare Payment Advisory Commission for additional data (as
contained in the March 2009 report entitled `Report to
Congress: Medicare Payment Policy'), beginning January 1, 2011,
a hospice program shall report to the Secretary, in such form
and manner, and at such intervals, as the Secretary shall
require, the following data with respect to each patient visit:
``(i) Visit type (such as admission, routine,
emergency, education for family, other).
``(ii) Visit length.
``(iii) Professional or paraprofessional
disciplines involved in the visit, including nurse,
social worker, home health aide, physician, nurse
practitioner, chaplain or spiritual counselor,
counselor, dietician, physical therapist, occupational
therapist, speech language pathologist, music or art
therapist, and including bereavement and support
services provided to a family after a patient's death.
``(iv) Drugs and other therapeutic interventions
provided.
``(v) Home medical equipment and other medical
supplies provided.
``(B) In collecting the data required under subparagraph
(A), the Secretary shall ensure that the data are reported in a
manner that allows for summarized cross-tabulations of the data
by patients' terminal diagnoses, lengths of stay, age, sex, and
race.''.
Subtitle D--Additional Reports, Research, and Evaluations
SEC. 251. NATIONAL CENTER ON PALLIATIVE AND END-OF-LIFE CARE.
Part E of title IV of the Public Health Service Act (42 U.S.C. 287
et seq.) is amended by adding at the end the following:
``Subpart 7--National Center on Palliative and End-of-Life Care
``SEC. 485J. NATIONAL CENTER ON PALLIATIVE AND END-OF-LIFE CARE.
``(a) Establishment.--Not later than July 1, 2011, there shall be
established within the National Institutes of Health, a National Center
on Palliative and End-of-Life Care (referred to in this section as the
`Center').
``(b) Purpose.--The general purpose of the Center is to conduct and
support research relating to palliative and end-of-life care
interventions and approaches.
``(c) Activities.--The Center shall--
``(1) develop and continuously update a research agenda
with the goal of--
``(A) providing a better biomedical understanding
of the end of life; and
``(B) improving the quality of care and life at the
end of life; and
``(2) provide funding for peer-review-selected extra- and
intra-mural research that includes the evaluation of existing,
and the development of new, palliative and end-of-life care
interventions and approaches.''.
SEC. 252. NATIONAL MORTALITY FOLLOWBACK SURVEY.
(a) In General.--Not later than December 31, 2010, and annually
thereafter, the Secretary, acting through the Director of the Centers
for Disease Control and Prevention, shall renew and conduct the
National Mortality Followback Survey (referred to in this section as
the ``Survey'') to collect data on end-of-life care.
(b) Purpose.--The purpose of the Survey shall be to gain a better
understanding of current end-of-life care in the United States.
(c) Questions.--
(1) In general.--In conducting the Survey, the Director of
the Centers for Disease Control and Prevention shall, at a
minimum, include the following questions with respect to the
loved one of a respondent:
(A) Did he or she have an advance directive, and if
so, when it was completed.
(B) Did he or she have an order for life-sustaining
treatment, and if so, when was it completed.
(C) Did he or she have a durable power of attorney,
and if so, when it was completed.
(D) Had he or she discussed his or her wishes with
loved ones, and if so, when.
(E) Had he or she discussed his or her wishes with
his or her physician, and if so, when.
(F) In the opinion of the respondent, was he or she
satisfied with the care he or she received in the last
year of life and in the last week of life.
(G) Was he or she cared for by hospice, and if so,
when.
(H) Was he or she cared for by palliative care
specialists, and if so, when.
(I) Did he or she receive effective pain management
(if needed).
(J) What was the experience of the main caregiver
(including if such caregiver was the respondent), and
whether he or she received sufficient support in this
role.
(2) Additional questions.--Additional questions to be asked
during the Survey shall be determined by the Director of the
Centers for Disease Control and Prevention on an ongoing basis
with input from relevant research entities.
SEC. 253. DEMONSTRATION PROJECTS FOR USE OF TELEMEDICINE SERVICES IN
ADVANCE CARE PLANNING.
(a) In General.--Not later than July 1, 2013, the Secretary shall
establish a demonstration program to reimburse eligible entities for
costs associated with the use of telemedicine services (including
equipment and connection costs) to provide advance care planning
consultations with geographically distant physicians and their
patients.
(b) Duration.--The demonstration project under this section shall
be conducted for at least a 3-year period.
(c) Definitions.--For purposes of this section:
(1) The term ``eligible entity'' means a physician or an
advance practice nurse who provides services pursuant to a
hospital-based palliative care program (as defined in section
262(d)(1)).
(2) The term ``geographically distant'' has the meaning
given that term by the Secretary for purposes of conducting the
demonstration program established under this section.
(3) The term ``telemedicine services'' means a service or
consultation provided via telecommunication equipment that
allows an eligible entity to exchange or discuss medical
information with a patient or a health care professional at a
separate location through real-time videoconferencing, or a
similar format, for the purpose of providing health care
diagnosis and treatment.
(d) Funding.--There are authorized to be appropriated to the
Secretary such sums as may be necessary to carry out this section.
SEC. 254. INSPECTOR GENERAL INVESTIGATION OF FRAUD AND ABUSE.
In accordance with the recommendations of the Medicare Payment
Advisory Commission for additional data (as contained in the March 2009
report entitled ``Report to Congress: Medicare Payment Policy''), the
Secretary shall direct the Office of the Inspector General of the
Department of Health and Human Services to investigate, not later than
January 1, 2012, the following with respect to hospice benefit under
Medicare, Medicaid, and CHIP:
(1) The prevalence of financial relationships between
hospices and long-term care facilities, such as nursing
facilities and assisted living facilities, that may represent a
conflict of interest and influence admissions to hospice.
(2) Differences in patterns of nursing home referrals to
hospice.
(3) The appropriateness of enrollment practices for
hospices with unusual utilization patterns (such as high
frequency of very long stays, very short stays, or enrollment
of patients discharged from other hospices).
(4) The appropriateness of hospice marketing materials and
other admissions practices and potential correlations between
length of stay and deficiencies in marketing or admissions
practices.
SEC. 255. GAO STUDY AND REPORT ON PROVIDER ADHERENCE TO ADVANCE
DIRECTIVES.
Not later than January 1, 2012, the Comptroller General of the
United States shall conduct a study of the extent to which providers
comply with advance directives under the Medicare and Medicaid programs
and shall submit a report to Congress on the results of such study,
together with such recommendations for administrative or legislative
changes as the Comptroller General determines appropriate.
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