[Congressional Record Volume 146, Number 106 (Tuesday, September 12, 2000)]
[Senate]
[Pages S8413-S8415]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. WYDEN:
  S. 3026. A bill to establish a hospice demonstration and grant 
program for beneficiaries under the Medicare Program under title XVIII 
of the Social Security Act, and for other purposes; to the Committee on 
Finance.


                hospice demonstration and grant program

  Mr. WYDEN. Mr. President, today, I am introducing groundbreaking 
legislation to make a difference in the way in which dying patients and 
their families can access hospice care. Ninety percent of Americans do 
not realize that there is a hospice benefit provided under the Medicare 
program. Over time, the length of stay in a hospice is decreasing so 
that patients do not get the full benefit of services that could make 
them more comfortable at a crucial time in their lives.
  The issues related to how we die are too important to permit the 
Medicare Hospice benefit to remain fixed in time. Now is the time to 
begin to test new ways to design the benefit so that the benefit can 
remain truly patient-centered at one of the most crucial times in 
patients' and their families' lives.
  Just as we push our health care system for medical breakthroughs that 
will allow more of us to live healthier and longer, we need to drive 
our health care system to create accessible, positive care for those 
facing the end of life.
  My legislation, the Hospice Improvement Act of 2000, would require 
the Secretary to establish a demonstration program to increase access 
and use of hospice care for patients at the end-of-life, and to 
increase the knowledge of hospice among the medical, mental health and 
patient communities. My legislation stresses the following:
  Supportive and Comfort Care: To assist families and patients in 
getting the benefit of hospice care, the Demonstration program will 
allow for a new supportive and comfort care benefit. This benefit, 
elected at the option of the patient, will not require the terminally 
ill to elect hospice care instead of other medical treatment, but will 
permit a patient to have supportive and comfort care in place while the 
patient still seeks ``curative treatment.'' This will permit patients 
and families to learn about hospice without forcing them to make a 
choice between hospice and other care. Case management would be 
provided through a hospice provider reimbursed on a fee-for-service 
basis.
  Severity Index Instead of a Six-Month Prognosis: To determine whether 
or not a patient is eligible for the supportive and comfort care 
option, a severity index will be used instead of the current hospice 
requirement of a 6 month prognosis. This will permit patients to have 
access to support services, as needed, instead of relying on an often 
inaccurate time-related prognosis.
  Increase Rural Hospice Access: Permit nurse practitioners and 
physician assistants to admit patients to hospice if this is within 
their authority under state practice law. In communities without a 
qualified social worker, other professionals with skills, knowledge and 
ability may provide medical social services such as counseling on the 
effects of illness on the family.
  Respite Care: Nursing facilities used for respite care would not be 
required to have skilled nurses on the premises 24 hours a day (because 
hospice will be caring for the patient) or respite could be provided in 
the patient's home.
  Payment Issues: Permit reimbursement for consultations, preadmission 
informational visits, even if the patient does not elect hospice/
supportive care and provide minimum payment for Medicare hospice 
services provided under the demonstration program based on the 
provision of services for a period of 14 days, regardless of length of 
stay.
  In addition, the demonstration project could address other payment 
issues such as offsetting changes in services and oversight and the 
increased cost of providing services in rural areas and creating a per 
diem rate of payment for respite care that reflects the range of care 
needs.
  In addition to the Demonstration program, the Secretary would be 
required to establish an education grant program for the purpose of 
providing information about the Medicare hospice benefit, and the 
benefits available under the demonstration program. Education grants 
could be used to provide individual or group education to patients and 
their families and to the medical and mental health community, and to 
test messages to improve public

[[Page S8414]]

knowledge about the Medicare hospice benefit.
  Let me conclude by saying that in the time left for this Congress, we 
have a unique opportunity to truly begin to improve care for the dying. 
There are fewer who are more vulnerable than someone who is dying and 
having to cope with the physical breakdown of their body and the 
emotional turmoil that imminent death brings to a family. This 
legislation provides us an opportunity to begin to remove the barriers 
to care for those who facing death.
  Mr. President, 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. 3026

       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 ``Hospice Improvement Program 
     Act of 2000''.

     SEC. 2. FINDINGS.

       Congress makes the following findings:
       (1) Each year more than \1/3\ of the people who die suffer 
     from a chronic illness.
       (2) Approximately \1/3\ of Americans are unsure about whom 
     to contact to get the best care during life's last stages.
       (3) Americans want a team of professionals to care for the 
     patient at the end of life.
       (4) Americans want emotional and spiritual support for the 
     patient and family.
       (5) Ninety percent of Americans do not realize that hospice 
     care is a benefit provided under the medicare program under 
     title XVIII of the Social Security Act (42 U.S.C. 1395 et 
     seq.).
       (6) Health Care Financing Administration data show that 
     beneficiaries were enrolled in hospice for an average of less 
     than 7 weeks in 1998, far less than the full 6-month benefit 
     under the medicare program.
       (7) According to the most recent data available, although 
     the average hospice enrollment is longer, half of the 
     enrollees live only 30 days after admission and almost 20 
     percent die within 1 week of enrollment.
       (8) Use of hospice among medicare beneficiaries has been 
     decreasing, from a high of 59 days in 1995 to less than 48 
     days in 1998.

     SEC. 3. HOSPICE DEMONSTRATION PROGRAM AND HOSPICE EDUCATION 
                   GRANTS.

       (a) Definitions.--In this section:
       (1) Demonstration program.--The term ``demonstration 
     program'' means the Hospice Demonstration Program established 
     by the Secretary under subsection (b)(1).
       (2) Medicare beneficiary.--The term ``medicare 
     beneficiary'' means any individual who is entitled to 
     benefits under part A or enrolled under part B of the 
     medicare program, including any individual enrolled in a 
     Medicare+Choice plan offered by a Medicare+Choice 
     organization under part C of such program.
       (3) Medicare hospice services.--The term ``medicare hospice 
     services'' means the items and services for which payment may 
     be made under section 1814(i) of the Social Security Act (42 
     U.S.C. 1395f(i)).
       (4) Medicare program.--The term ``medicare program'' means 
     the health benefits program under title XVIII of the Social 
     Security Act (42 U.S.C. 1395 et seq.).
       (5) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services, acting through the 
     Administrator of the Health Care Financing Administration.
       (b) Hospice Demonstration Program.--
       (1) Establishment.--The Secretary shall establish a Hospice 
     Demonstration Program in accordance with the provisions of 
     this subsection to increase the utility of the medicare 
     hospice services for medicare beneficiaries.
       (2) Services under demonstration program.--The provisions 
     of section 1814(i) of the Social Security Act (42 U.S.C. 
     1395f(i)) shall apply to the payment for items and services 
     provided under the demonstration program, except that--
       (A) notwithstanding section 1862(a)(1)(C) of such Act (42 
     U.S.C. 1395y(a)(1)(C)), the Secretary shall provide for 
     reimbursement for items and services provided under the 
     supportive and comfort care benefit established under 
     paragraph (3);
       (B) any licensed nurse practitioner or physician assistant 
     may certify a medicare beneficiary as the primary care 
     provider when necessary and within the scope of practice of 
     such practitioner or assistant under State law;
       (C) if a community does not have a qualified social worker, 
     any professional who has the necessary knowledge, skills, and 
     ability (other than social workers) to provide medical social 
     services shall provide such services;
       (D) the Secretary shall waive any requirement that nursing 
     facilities used for respite care have skilled nurses on the 
     premises 24 hours per day;
       (E) the Secretary shall permit respite care to be provided 
     to the medicare beneficiary at home; and
       (F) the Secretary shall waive reimbursement regulations to 
     provide--
       (i) reimbursement for consultations and preadmission 
     informational visits, even if the medicare beneficiary does 
     not choose hospice care (including the supportive and comfort 
     care benefit under paragraph (3)) at that time;
       (ii) a minimum payment for medicare hospice services 
     provided under the demonstration program based on the 
     provision of medicare hospice services to a medicare 
     beneficiary for a period of 14 days, that the Secretary shall 
     pay to any hospice provider participating in the 
     demonstration program and providing such services (regardless 
     of the length of stay of the medicare beneficiary);
       (iii) an increase in the reimbursement rates for hospice 
     services to offset--

       (I) changes in medicare hospice services and oversight 
     under the demonstration program;
       (II) the higher costs of providing medicare hospice 
     services in rural areas due to lack of economies of scale or 
     large geographic areas; and
       (III) the higher costs of providing medicare hospice 
     services in urban underserved areas due to unique costs 
     specifically associated with people living in those areas, 
     including providing security;

       (iv) direct payment of any nurse practitioner or physician 
     assistant practicing within the scope of State law in 
     relation to medicare hospice services provided by such 
     practitioner or assistant; and
       (v) a per diem rate of payment for in-home care under 
     subparagraph (E) that reflects the range of care needs of the 
     medicare beneficiary and that--

       (I) in the case of a medicare beneficiary that needs 
     routine care, is not less than 150 percent, and not more than 
     200 percent, of the routine home care rate for medicare 
     hospice services; and

       (II) in the case of a medicare beneficiary that needs acute 
     care, is equal to the continuous home care day rate for 
     medicare hospice services.
       (3) Supportive and comfort care benefit.--
       (A) In general.--For purposes of the demonstration program, 
     the Secretary shall establish a supportive and comfort care 
     benefit for any eligible medicare beneficiary (as defined in 
     subparagraph (C)).
       (B) Benefit.--Under the supportive and comfort care benefit 
     established under subparagraph (A), any eligible medicare 
     beneficiary may--
       (i) continue to receive benefits for disease and symptom 
     modifying treatment under the medicare program (and the 
     Secretary may not require or prohibit any specific treatment 
     or decision);
       (ii) receive case management and medicare hospice services 
     through a hospice provider, which the Secretary shall 
     reimburse on a fee-for-service basis; and
       (iii) receive information and experience in order to better 
     understand the utility of medicare hospice services.
       (C) Eligible medicare beneficiary defined.--
       (i) In general.--In this paragraph, the term ``eligible 
     medicare beneficiary'' means any medicare beneficiary with a 
     serious illness that has been documented by a physician to be 
     at a level of severity determined by the Secretary to meet 
     the criteria developed under clause (ii).
       (ii) Development of criteria.--

       (I) In general.--The Secretary, in consultation with 
     hospice providers and experts in end-of-life care, shall 
     develop criteria for determining the level of severity of an 
     established serious illness taking into account the factors 
     described in subclause (II).
       (II) Factors.--The factors described in this clause include 
     the level of function of the medicare beneficiary, any 
     coexisting illnesses of the beneficiary, and the severity of 
     any chronic condition that will lead to the death of the 
     beneficiary.
       (III) Prognosis not a basis for criteria.--The Secretary 
     may not base the criteria developed under this subparagraph 
     on the prognosis of a medicare beneficiary.

       (4) Conduct of program.--Under the demonstration program, 
     the Secretary shall--
       (A) accept proposals submitted by any State hospice 
     association;
       (B)(i) except as provided in clause (ii), conduct the 
     program in at least 3, but not more than 6, geographic areas 
     (which may be statewide) that include both urban and rural 
     hospice providers; and
       (ii) if a geographic area does not have any rural hospice 
     provider available to participate in the demonstration 
     program, such area may substitute an underserved urban area, 
     but the Secretary shall give priority to those proposals that 
     include a rural hospice provider;
       (C)(i) except for the geographic area designated under 
     clause (ii), select such geographic areas so that such areas 
     are geographically diverse and readily accessible to a 
     significant number of medicare beneficiaries; and
       (ii) designate as such an area 1 State in which the largest 
     metropolitan area of such State had the lowest percentage of 
     medicare beneficiary deaths in a hospital compared to the 
     largest metropolitan area of each other State according to 
     the Hospital Referral Region of Residence, 1994-1995, as 
     listed in the Dartmouth Atlas of Health Care 1998;
       (D) provide for the participation of medicare beneficiaries 
     in such program on a voluntary basis;
       (E) permit research designs that use time series, 
     sequential implementation of the intervention, randomization 
     by wait list, and

[[Page S8415]]

     other designs that allow the strongest possible 
     implementation of the demonstration program, while still 
     allowing strong evaluation about the merits of the 
     demonstration program; and
       (F) design the program to facilitate the evaluation 
     conducted under paragraph (6).
       (5) Duration.--The Secretary shall complete the 
     demonstration program within a period of 6\1/2\ years that 
     includes a period of 18 months during which the Secretary 
     shall complete the evaluation under paragraph (6).
       (6) Evaluation.--During the 18-month period following the 
     first 5 years of the demonstration program, the Secretary 
     shall complete an evaluation of the demonstration program in 
     order to determine--
       (A) the short-term and long-term costs and benefits of 
     changing medicare hospice services to include the items, 
     services, and reimbursement options provided under the 
     demonstration program;
       (B) whether increases in payments for the medicare hospice 
     benefit are offset by savings in other parts of the medicare 
     program;
       (C) the projected cost of implementing the demonstration 
     program on a national basis; and
       (D) in consultation with hospice organizations and hospice 
     providers (including organizations and providers that 
     represent rural areas), whether a payment system based on 
     diagnosis-related groups is useful for administering the 
     medicare hospice benefit.
       (7) Reports to congress.--
       (A) Preliminary report.--Not later than 3 years after the 
     date of enactment of this Act, the Secretary shall submit a 
     preliminary report to the Committee on Ways and Means of the 
     House of Representatives and to the Committee on Finance of 
     the Senate on the progress made in the demonstration program.
       (B) Interim report.--Not later than 30 months after the 
     implementation of the demonstration program, the Secretary, 
     in consultation with participants in the program, shall 
     submit an interim report on the demonstration program to the 
     committees described in subparagraph (A).
       (C) Final report.--Not later than the date on which the 
     demonstration program ends, the Secretary shall submit a 
     final report to the committees described in subparagraph (A) 
     on the demonstration program that includes the results of the 
     evaluation conducted under paragraph (6) and recommendations 
     for appropriate legislative changes.
       (8) Waiver of medicare requirements.--The Secretary shall 
     waive compliance with such requirements of the medicare 
     program to the extent and for the period the Secretary finds 
     necessary for the conduct of the demonstration program.
       (9) Special rules for payment of medicare+choice 
     organizations.--The Secretary shall establish procedures 
     under which the Secretary provides for an appropriate 
     adjustment in the monthly payments made under section 1853 of 
     the Social Security Act (42 U.S.C. 1395w-23) to any 
     Medicare+Choice organization offering a Medicare+Choice plan 
     in which a medicare beneficiary that participates in the 
     demonstration program is enrolled to reflect such 
     participation.
       (c) Hospice Education Grants.--
       (1) In general.--The Secretary shall establish a Hospice 
     Education Grant program under which the Secretary awards 
     education grants to entities participating in the 
     demonstration program for the purpose of providing 
     information about--
       (A) the medicare hospice benefit; and
       (B) the benefits available to medicare beneficiaries under 
     the demonstration program.
       (2) Use of funds.--Grants awarded pursuant to paragraph (1) 
     shall be used--
       (A) to provide--
       (i) individual or group education to medicare beneficiaries 
     and their families; and
       (ii) individual or group education of the medical and 
     mental health community caring for medicare beneficiaries; 
     and
       (B) to test strategies to improve the general public 
     knowledge about the medicare hospice benefit and the benefits 
     available to medicare beneficiaries under the demonstration 
     program.
       (d) Funding.--
       (1) Hospice demonstration program.--
       (A) In general.--Except as provided in subparagraph (B), 
     expenditures made for the demonstration program shall be in 
     lieu of the funds that would have been provided to 
     participating hospices under section 1814(i) of the Social 
     Security Act (42 U.S.C. 1395f(i)).
       (B) Supportive and comfort care benefit.--The Secretary 
     shall pay any expenses for the supportive and comfort care 
     benefit established under subsection (a)(3) from the Federal 
     Hospital Insurance Trust Fund established under section 1817 
     of the Social Security Act (42 U.S.C. 1395i) and the Federal 
     Supplementary Medical Insurance Trust Fund established under 
     section 1841 of such Act (42 U.S.C. 1395t), in such 
     proportion as the Secretary determines is appropriate.
       (2) Hospice education grants.--The Secretary is authorized 
     to expend such sums as may be necessary for the purposes of 
     carrying out the Hospice Education Grant program established 
     under subsection (c)(1) from the Research and Demonstration 
     Budget of the Health Care Financing Administration.
                                 ______