[Congressional Record Volume 143, Number 61 (Monday, May 12, 1997)]
[Senate]
[Pages S4320-S4321]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BREAUX (for himself, Mr. Mack, Mr. Graham, and Mr. 
        Dorgan):
  S. 734. A bill to amend title XVIII of the Social Security Act to 
make certain changes to hospice care under the Medicare Program; to the 
Committee on Finance.


            THE MEDICARE HOSPICE BENEFIT AMENDMENTS OF 1997

 Mr. BREAUX. Mr. President, I introduce legislation to make 
technical changes to the Medicare hospice benefit which will ensure 
that high-quality hospice services will be available to all terminally 
ill Medicare beneficiaries. This legislation is identical to H.R. 521, 
introduced by Representative Cardin.
  Hospices care for and comfort terminally ill patients at home or in 
home-like settings. There are 2,800 hospice programs in all 50 States 
and in 1995 they cared for more than 390,000 patients. One out of every 
three people who died from cancer or AIDS were cared for by hospice.
  Services provided under the Medicare hospice benefit include 
physician services, nursing care, drugs for symptom management, pain 
relief, short term inpatient and respite care, and counseling both for 
the terminally ill and their families. But terminally ill patients who 
elect hospice care opt out of most other Medicare services related to 
their terminal illness.
  Hospice services permit terminally ill people to die with dignity, 
usually in the comforting surroundings of their own homes with their 
loved ones nearby. Hospice is also a cost-effective form of care. At a 
time when Medicare is pushing to enroll more beneficiaries in managed 
care plans, hospice is already managed. Hospices provide patients with 
whatever palliative services are needed to manage their terminal 
illness, and they are reimbursed a standard per diem rate, based on the 
intensity of care needed and the location of the provision of care.
  With 28 percent of all Medicare costs now going toward the care of 
people in their last year of life, and almost 50 percent of those costs 
spent during the last 2 months of life, cost-effective alternatives are 
needed. Studies show hospices reduce Medicare spending. A 1995 Lewin 
study showed that for every dollar Medicare spent on hospice, it saved 
$1.52 in Medicare part A and part B expenditures. Similarly, a 1989 
study commissioned by the Health Care Financing Administration showed 
savings of $1.26 for every Medicare dollar spent on hospice.
  Since 1982, when the hospice benefit was added to the Medicare 
statute, more and more Americans have chosen to spend their final 
months of life in this humane and cost-effective setting. Yet in recent 
years, it has become clear that certain technical changes are needed in 
the Medicare hospice benefit to protect beneficiaries and ensure that a 
full range of cost-effective hospice services continue to be available. 
The bill I am introducing today makes these necessary technical 
changes.

  First, the Medicare Hospice Benefits Amendments of 1997 restructure 
the hospice benefit periods. The basic eligibility criteria do not 
change. Under this bill, as in current law, a person is eligible for 
the Medicare hospice benefit only if two physicians have certified that 
the patient is terminally ill with a life expectancy of six months or 
less. Patients who elect to receive hospice benefits give up most other 
Medicare benefits unless and until they withdraw from the hospice 
program.
  While this bill does not change hospice eligibility criteria, it does 
change how the benefit periods are structured. Currently, the Medicare 
benefit consists of four benefit periods. At the end of each of the 
first three periods, the patient must be recertified as being 
terminally ill. The fourth benefit period is of unlimited duration. 
However, a patient who withdraws from hospice during the fourth hospice 
period forfeits his ability to elect hospice services in the future. 
Thus, patients who go into remission, and are thus no longer eligible 
for hospice because their life expectancy exceeds 6 months, cannot 
return to hospice when their condition worsens.
  This bill restructures the hospice benefit periods to eliminate the 
existing open-ended fourth benefit period and to provide that after the 
first two 90-day periods, patients are reevaluated every 60 days to 
ensure they still qualify for hospice services. This restructuring 
ensures that those receiving Medicare benefits are able to receive 
hospice services at the time they need them and can be discharged from 
hospice care with no penalty if their prognosis changes.
  Second, the bill clarifies that ambulance services, diagnostic tests, 
radiation, and chemotherapy are covered under the hospice benefit when 
they are included in the patient's plan of care. No separate payment 
will be made for these services, but hospices will have to provide them 
when they are found to be necessary as a palliative measure. This 
change conforms the statute to current Medicare regulatory policy and 
does not cost Medicare any additional money because payments are 
covered by the current per-diem payments.
  Third, the bill also permits hospices to have independent contractor 
relationships with physicians. Under current law, hospices must 
directly employ their medical directors and other staff physicians. 
This creates a legal problem in some States which prohibit the 
corporate practice of medicine, and the requirement has made it 
increasingly difficult to recruit part-time hospice physicians.
  Fourth, the bill creates a mechanism to allow waiver of certain 
staffing requirements for rural hospices, which often have difficulty 
becoming Medicare-certified because of shortages of certain health 
professionals. Currently, about 80 percent of hospices are Medicare-
certified or pending certification.
  Finally, this bill provides some administrative flexibility regarding 
certification of terminal illness. Currently, the statute requires that 
paperwork documenting 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. It gives the Health Care Financing Administration the 
discretion, as it currently has with home health certifications, to 
require hospice certifications to be on file before a Medicare claim is 
submitted.
  The Medicare Hospice Benefit Amendments of 1997 are noncontroversial 
and should not affect Medicare spending, but they will make important 
and necessary changes to the Medicare hospice benefit, to enable 
hospices to provide high-quality, cost-effective care to the terminally 
ill, and to protect beneficiaries who depend on these services.
  I urge my colleagues to support this bill, and I ask unanimous 
consent that the full text of the bill be printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                 S. 734

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Medicare Hospice Benefit 
     Amendments of 1997''.

     SEC. 2. HOSPICE CARE BENEFIT PERIODS.

       (a) Restructuring of Benefit Period.--Section 1812 of the 
     Social Security Act (42 U.S.C. 1395d) is amended in 
     subsections (a)(4) and (d)(1), by striking ``, a subsequent 
     period of 30 days, and a subsequent extension period'' and 
     inserting ``and an unlimited number of subsequent periods of 
     60 days each''.
       (b) Conforming Amendments.--
       (1) Section 1812 of the Social Security Act (42 U.S.C. 
     1395d) is amended in subsection (d)(2)(B) by striking ``90- 
     or 30-day period or a subsequent extension period'' and 
     inserting ``90-day period or a subsequent 60-day period''.
       (2) Section 1814(a)(7)(A) of the Social Security Act (42 
     U.S.C. 1395f(a)(7)(A)) is amended--
       (A) in clause (i), by inserting ``and'' at the end;
       (B) in clause (ii)--
       (i) by striking ``30-day'' and inserting ``60-day''; and

[[Page S4321]]

       (ii) by striking ``, and'' at the end and inserting a 
     period; and
       (C) by striking clause (iii).

     SEC. 3. OTHER ITEMS AND SERVICES INCLUDED IN HOSPICE CARE.

       Section 1861(dd)(1) of the Social Security Act (42 U.S.C. 
     1395x(dd)(1)) is amended--
       (1) in subparagraph (G), by striking ``and'' at the end;
       (2) in subparagraph (H), by striking the period at the end 
     and inserting ``, and''; and
       (3) by inserting after subparagraph (H) the following:
       ``(I) any other item or service which is specified in the 
     plan and for which payment may otherwise be made under this 
     title.''.

     SEC. 4. CONTRACTING WITH INDEPENDENT PHYSICIANS OR PHYSICIAN 
                   GROUPS FOR HOSPICE CARE SERVICES PERMITTED.

       Section 1861(dd)(2) of the Social Security Act (42 U.S.C. 
     1395x(dd)(2)) is amended--
       (1) in subparagraph (A)(ii)(I), by striking ``(F),''; and
       (2) in subparagraph (B)(i), by inserting ``or under 
     contract with'' after ``employed by''.

     SEC. 5. WAIVER OF CERTAIN STAFFING REQUIREMENTS FOR HOSPICE 
                   CARE PROGRAMS IN NONURBANIZED AREAS.

       Section 1861(dd)(5) of the Social Security Act (42 U.S.C. 
     1395x(dd)(5)) is amended--
       (1) in subparagraph (B), by inserting ``or (C)'' after 
     ``subparagraph (A)'' each place it appears; and
       (2) by adding at the end the following:
       ``(C) The Secretary may waive the requirements of clauses 
     (i) and (ii) of paragraph (2)(A) for an agency or 
     organization with respect to the services described in 
     paragraph (1)(B) and, with respect to dietary counseling, 
     paragraph (1)(H), if such agency or organization--
       ``(i) is located in an area which is not an urbanized area 
     (as defined by the Bureau of Census); and
       ``(ii) demonstrates to the satisfaction of the Secretary 
     that the agency or organization has been unable, despite 
     diligent efforts, to recruit appropriate personnel.''.

     SEC. 6. LIMITATION ON LIABILITY OF BENEFICIARIES AND 
                   PROVIDERS FOR CERTAIN HOSPICE COVERAGE DENIALS.

       Section 1879(g) of the Social Security Act (42 U.S.C. 
     1395pp(g)) is amended--
       (1) by redesignating paragraphs (1) and (2) as 
     subparagraphs (A) and (B), respectively, and moving those 
     subparagraphs 2 ems to the right;
       (2) by striking ``is,'' and inserting ``is--'';
       (3) by making the remaining text of subsection (g) (as 
     amended) that follows ``is--'' a new paragraph (1) and 
     indenting that paragraph 2 ems to the right;
       (4) by striking the period at the end and inserting ``; 
     and''; and
       (5) by adding at the end the following:
       ``(2) with respect to the provision of hospice care to an 
     individual, a determination that the individual is not 
     terminally ill.''.

     SEC. 7. EXTENDING THE PERIOD FOR PHYSICIAN CERTIFICATION OF 
                   AN INDIVIDUAL'S TERMINAL ILLNESS.

       Section 1814(a)(7)(A)(i)(II) of the Social Security Act (42 
     U.S.C. 1395f(a)(7)(A)(i)(II)) is amended by striking ``, not 
     later than 2 days after hospice care is initiated (or, if 
     each certify verbally not later than 2 days after hospice 
     care is initiated, not later than 8 days after such care is 
     initiated),'' and inserting ``at the beginning of the 
     period''.

     SEC. 8. EFFECTIVE DATE.

       The amendments made by this Act apply to benefits provided 
     on or after the date of enactment of this Act, regardless of 
     whether or not an individual has made an election under 
     section 1812(d) of the Social Security Act (42 U.S.C. 
     1395d(d)) before that date.
                                 ______