[Congressional Record Volume 143, Number 12 (Tuesday, February 4, 1997)]
[Extensions of Remarks]
[Pages E133-E134]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




    INTRODUCTION OF THE MEDICARE HOSPICE BENEFIT AMENDMENTS OF 1997

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                        HON. BENJAMIN L. CARDIN

                              of maryland

                    in the house of representatives

                       Tuesday, February 4, 1997

  Mr. CARDIN. Mr. Speaker, I rise today with my colleague, Rob Portman, 
and more than 50 additional colleagues to introduce the Medicare 
Hospice Benefit Amendments of 1997. This legislation will make 
technical changes and clarifications to improve the Medicare hospice 
benefit. This is a noncontroversial bill that has true bipartisan 
support and should be included as part of Medicare reform this year.
  Hospice care is a vital Medicare benefit. It is a coordinated program 
of palliative medicine and supportive services provided mainly in the 
home but also in home-like settings that provides for physical, 
psychological, social, and spiritual care for dying persons and their 
families. Services are provided by a medically directed, 
interdisciplinary team of professionals and volunteers. Hospice 
recognizes dying as part of the normal process of living and focuses on 
maintaining the quality of remaining life. Hospice affirms life and 
neither hastens nor postpones death.
  The concept of hospice care emerged in this country in response to 
the unmet needs of dying patients and their families for whom 
traditional medical care was no longer effective, appropriate, or 
desired. Hospice has become an effective alternative to there being 
``nothing else to do.'' The Nation's hospice programs currently provide 
compassionate care to more than 390,000 patients and families each 
year. In 1994, one out of every three people who died from cancer or 
AIDS were cared for by hospice. Terminally ill Medicare patients who 
elect hospice opt out of most other Medicare services related to their 
terminal illness and instead receive all of their care through the 
hospice program.
  Hospice is not only a compassionate and appropriate form of care for 
terminally ill individuals, it is also cost effective. A 1994 Lewin 
study comparing the relative cost of hospice care to conventional care 
for Medicare beneficiaries with cancer, found that for every dollar 
Medicare spent on hospice patients, it saved $1.52 in Medicare part A 
and B expenditures. Based on these findings, the growth and greater 
utilization of hospice care should be viewed in a positive light and 
should be encouraged.
  The Medicare hospice benefit was adopted by Congress 1982. Since 
then, more and

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more Americans have chosen to receive humane and cost-effective hospice 
care. In recent years, it has become clear that certain technical 
changes are necessary in the Medicare hospice benefit not only to 
protect beneficiaries but to ensure that high quality and cost-
effective hospice services continue to be available.
  The Medicare Hospice Benefit Amendments of 1997, will make six 
technical changes to the Medicare hospice benefit.
  First, the bill restructures the hospice benefit periods. Under 
current law, the patient's attending physician and the hospice medical 
director must certify that the patient electing hospice care in lieu of 
other Medicare services is terminally ill--defined as having a 
prognosis of 6 months or less to live if the illness runs its normal 
course. There are four benefit periods, with recertifications of 
terminal illness by the hospice physician at the beginning of each. The 
first two periods last 90 days, the third is 30 days, and the fourth is 
of unlimited duration.
  If a beneficiary revokes a hospice election during a benefit period, 
the remaining days in that period are forfeited. This existing 
structure is especially troubling for patients who withdraw from 
hospice during the fourth hospice period because they then forfeit 
their ability to elect hospice services in the future. Thus, a patient 
who goes into remission and is no longer eligible for hospice because 
his or her life expectancy exceeds 6 months, is not able to return to 
hospice when his or her condition worsens. Our bill would correct this 
problem by restructuring the benefit periods so that there would be two 
90-day periods, followed by an unlimited number of 60-day periods. This 
would also result in more frequent reevaluation of patients who outlive 
their original prognosis.
  Second, our bill clarifies that additional Medicare services are 
available--in addition to those specifically required by the hospice 
rules--when these services are a necessary component of the plan of 
care. This amendment is consistent with current HCFA policy. The 
existing statute is ambiguous because the beneficiary must waive 
coverage under part B for most services when they are related to the 
terminal illness, but some items are not clearly listed as part of the 
hospice benefit. For example, diagnostic tests and radiation therapy 
are not listed in the definition of hospice care, but occasionally the 
hospice team may agree with the attending physician that these services 
are necessary to manage the patient's terminal illness. Our bill would 
ensure that the hospice would be able to provide the appropriate care 
and that beneficiaries would not be liable for the costs of that care.
  Third, our bill amends the core services requirement to allow 
hospices to contract for physician services with independent contractor 
physicians or physician groups. HCFA has interpreted the existing 
statute as requiring a W-2 employer/employee relationship between the 
hospice and its medical director and other staff physicians. This 
raises corporate practice of medicine problems in some States, and it 
is increasingly difficult for hospices to recruit part-time physician 
employees as the trend toward physician groups continues.
  Fourth, the bill allows waivers of certain staffing requirements for 
rural hospices to be granted. Some hospices in rural areas have 
difficulty becoming Medicare-certified because of shortages of certain 
professionals. Currently, approximately 80 percent of hospices are 
Medicare-certified or pending certification.
  Fifth, our bill amends the so-called waiver of liability provisions 
to protect the beneficiary if a hospice claim is denied by Medicare 
because the terminal illness eligibility requirement allegedly was not 
met. While this bill does not reinstate the waiver of liability 
presumption under which providers with low error rates were paid before 
1996, waiver of liability for hospice reasonable and necessary denials 
is still available on a case-by-case basis. This means that the hospice 
may appeal the denials and the beneficiary is not liable for payment. 
The same process and protection are needed for denials based on 6-month 
prognosis issues.
  Last, our legislation allows HCFA to set documentation requirements 
for physician certifications. Currently, the statute requires that 
paperwork documenting the physician certification of a patient's 
terminal illness be completed within a certain number of days of the 
patient's admission to hospice. This bill will eliminate the strict 
statutory requirements and give HCFA the discretion, as it currently 
has with home health certifications, to require hospice certifications 
to be on file before a Medicare claim is submitted.
  In summary, the Medicare Hospice Benefit Amendments of 1997 is very 
similar to the bill we introduced last year. The major difference is 
that we dropped a provision in the 1996 legislation to extend the 
presumption of the waiver of liability that CBO scored with a budget 
impact. Therefore, our new bill should be revenue neutral. This 
Medicare Hospice Benefit Amendments of 1997 is noncontroversial and is 
needed to ensure that we have a smoothly operating Medicare hospice 
benefit for our Nation's seniors. I look forward to working with my 
colleagues to enact this legislation in this Congress.

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