[Congressional Record Volume 151, Number 61 (Wednesday, May 11, 2005)]
[Senate]
[Pages S4939-S4946]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. WYDEN
  S. 1001. A bill to establish hospice demonstration projects and a 
hospice grant program for beneficiaries under the medicare program 
under title XVII

[[Page S4941]]

of the Social Security Act, and for other purposes; to the Committee on 
Finance.
  Mr. WYDEN. Mr. President, several weeks ago, I outlined what I 
believed this country needs to do in order to address the true issues 
related to how we care for those who are dying. Today, I am introducing 
3 bills to improve access to pain management, increase the number of 
providers trained to care for those with life-threatening illness, and 
improve the Medicare hospice benefit.
  Our medical system is geared towards curing patients, and gives short 
shrift to those we cannot cure. Modern advances in technology allow us 
to live longer, but that also means that many of us will live longer 
with chronic diseases including pain.
  The Conquering Pain Act will help those patients living and dying in 
pain, support their families and assist providers in getting 
information and guidance. This legislation will provide an opportunity 
for the country to develop and test different ways of providing pain 
management to patients 24 hours a day, seven days a week. It would 
create and fund regional networks to assist patients so they would not 
have to wait until normal business hours to get relief and help 
providers receive timely information and guidance as they treat 
difficult cases. This bill would create a website and require access to 
it in health care settings so families, patients and providers can have 
instant information. In addition, the bill requires several studies so 
we can better understand the other roadblocks for patients seeking pain 
management. These roadblocks include the lack of health insurance 
coverage for pain management and the interaction of the enforcement of 
laws concerning controlled substances and the delivery of appropriate 
pain management. I am pleased that my colleague from Oregon is 
cosponsoring the Conquering Pain Act.
  Another aspect of our health care system that needs strengthening, is 
in assuring that we have providers who know how to provide support and 
comfort care to the dying. The Palliative Care Training Act will 
increase the number of providers trained in palliative care. Palliative 
care is an approach that improves the quality of life of patients and 
their families facing the problems associated with life-threatening 
illness. It does so through the prevention and relief of suffering by 
early identification, assessment and treatment of pain and other 
problems. Palliative care affirms life and regards dying as a normal 
process. It neither hastens nor postpones death and is applicable early 
in the course of illness, in conjunction with other therapies that are 
intended to prolong life, such as chemotherapy or radiation therapy, 
and offers a support system to help patients live as actively as 
possible until death.
  My legislation provides grants to individuals with appointments as 
junior faculty at accredited medical schools so they will teach other 
providers palliative care. This is modeled after existing awards for 
the training of other specialties. When it comes down to it, assuring 
there is faculty in schools to teach this area of medicine, is an 
inexpensive way of strengthening the health care system in providing 
this needed care. I am pleased to note that when the National Hospice 
and Palliative Care Association recently testified before the Senate 
Health, Education and Labor Committee, they identified this legislation 
as addressing an important need.
  As we look at how to better care for those at the end of life, 
Medicare's hospice benefit bears examination. When the benefit was 
added to Medicare, it was hailed as a cost effective benefit that would 
assist many. In truth, few Americans know what hospice really is and 
the benefits it can provide. Too often seniors are advised of the 
benefits too late to get the full effect of the medical, social and 
spiritual support this benefit can provide. Part of the reason for this 
is Medicare requires the patient to choose between continuing to seek 
``curative'' care or hospice and palliative care. This means that 
literally the patient must choose between the hope of a cure and 
accepting that they are dying. Not many of us would want to give up 
seeking a cure or want to give up hope. However, that is what the 
Medicare program requires now. The Medicare Hospice Demonstration Act 
tests the idea that patients would not have to give up seeking 
``curative'' care, to get hospice. It is my belief that as people 
experience what hospice can do for them and for their families, they 
will find they can accept living the end of their lives with hospice 
and palliative care instead of seeking less effective care that will 
not cure them or enhance the quality of their life.
  It the U.S. Senate is going to examine end of life issues, we should 
not just look at legal issues. I believe these proposals are essential 
elements of the health care system that need to be supported and 
strengthened.
  I ask unanimous consent that the text of the bills be printed in the 
Record.
  There being no objection, the bills were ordered to be printed in the 
Record, as follows:

                                 S. 999

       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 ``Conquering 
     Pain Act of 2005''.
       (b) Table of Contents.--The table of contents for this Act 
     is as follows:

Sec. 1. Short title.
Sec. 2. Findings.
Sec. 3. Definitions.

    TITLE I--EMERGENCY RESPONSE TO THE PUBLIC HEALTH CRISIS OF PAIN

Sec. 101. Guidelines for the treatment of pain.
Sec. 102. Patient expectations to have pain and symptom management.
Sec. 103. Quality improvement projects.
Sec. 104. Pain coverage quality evaluation and information.
Sec. 105. Surgeon General's report.

                TITLE II--DEVELOPING COMMUNITY RESOURCES

Sec. 201. Family support networks in pain and symptom management.

                   TITLE III--REIMBURSEMENT BARRIERS

Sec. 301. Reimbursement barriers report.
Sec. 302. Insurance coverage of pain and symptom management.

   TITLE IV--IMPROVING FEDERAL COORDINATION OF POLICY, RESEARCH, AND 
                              INFORMATION

Sec. 401. Advisory Committee on Pain and Symptom Management.
Sec. 402. Institutes of Medicine report on controlled substance 
              regulation and the use of pain medications.
Sec. 403. Conference on pain research and care.

                    TITLE V--DEMONSTRATION PROJECTS

Sec. 501. Provider performance standards for improvement in pain and 
              symptom management.
Sec. 502. End of life care demonstration projects.

     SEC. 2. FINDINGS.

       Congress finds that--
       (1) pain is often left untreated or under-treated 
     especially among older patients, African Americans, Hispanics 
     and other minorities, and children;
       (2) chronic pain is a public health problem affecting at 
     least 50,000,000 Americans through some form of persisting or 
     recurring symptom;
       (3) 40 to 50 percent of patients experience moderate to 
     severe pain at least half the time in their last days of 
     life;
       (4) 70 to 80 percent of cancer patients experience 
     significant pain during their illness;
       (5) one in 7 nursing home residents experience persistent 
     pain that may diminish their quality of life;
       (6) despite the best intentions of physicians, nurses, 
     pharmacists, and other health care professionals, pain is 
     often under-treated because of the inadequate training of 
     clinicians in pain management;
       (7) despite the best intentions of physicians, nurses, 
     pharmacists, mental health professionals, and other health 
     care professionals, pain and symptom management is often 
     suboptimal because the health care system has focused on cure 
     of disease rather than the management of a patient's pain and 
     other symptoms;
       (8) the technology and scientific basis to adequately 
     manage most pain is known;
       (9) pain should be considered the fifth vital sign; and
       (10) coordination of Federal efforts is needed to improve 
     access to high quality effective pain and symptom management 
     in order to assure the needs of chronic pain patients and 
     those who are terminally ill are met.

     SEC. 3. DEFINITIONS.

       In this Act:
       (1) Chronic pain.--The term ``chronic pain'' means a pain 
     state that is persistent and in which the cause of the pain 
     cannot be removed or otherwise alleviated. Such term includes 
     pain that may be associated with long-term incurable or 
     intractable medical conditions or disease.
       (2) End of life care.--The term ``end of life care'' means 
     a range of services, including hospice care, provided to a 
     patient, in the final stages of his or her life, who is 
     suffering from 1 or more conditions for which treatment 
     toward a cure or reasonable improvement is not possible, and 
     whose focus of care is palliative rather than curative.

[[Page S4942]]

       (3) Family support network.--The term ``family support 
     network'' means an association of 2 or more individuals or 
     entities in a collaborative effort to develop multi-
     disciplinary integrated patient care approaches that involve 
     medical staff and ancillary services to provide support to 
     chronic pain patients and patients at the end of life and 
     their caregivers across a broad range of settings in which 
     pain management might be delivered.
       (4) Hospice.--The term ``hospice care'' has the meaning 
     given such term in section 1861(dd)(1) of the Social Security 
     Act (42 U.S.C. 1395x(dd)(1)).
       (5) Medication therapy management services.--The term 
     ``medication therapy management services'' means 
     consultations with a physician or other health care 
     professional (including a pharmacist) who is practicing 
     within the scope of the professional's license, concerning a 
     patient which results in--
       (A) a change in the drug regimen of the patient to avoid an 
     adverse drug interaction with another drug or disease state;
       (B) a change in inappropriate drug dosage or dosage form 
     with respect to the patient;
       (C) discontinuing an unnecessary or harmful medication with 
     respect to the patient;
       (D) an initiation of medication therapy for a medical 
     condition of the patient;
       (E) consultation with the patient or a caregiver in a 
     manner that results in a significant improvement in drug 
     regimen compliance; or
       (F) patient and caregiver understanding of the appropriate 
     use and adherence to medication therapy.
       (6) Pain and symptom management.--The term ``pain and 
     symptom management'' means services provided to relieve 
     physical or psychological pain or suffering, including any 1 
     or more of the following physical complaints--
       (A) weakness and fatigue;
       (B) shortness of breath;
       (C) nausea and vomiting;
       (D) diminished appetite;
       (E) wasting of muscle mass;
       (F) difficulty in swallowing;
       (G) bowel problems;
       (H) dry mouth;
       (I) failure of lymph drainage resulting in tissue swelling;
       (J) confusion;
       (K) dementia;
       (L) delirium;
       (M) anxiety;
       (N) depression; and
       (O) other related symptoms
       (7) Palliative care.--The term ``palliative care'' means 
     the total care of patients whose disease is not responsive to 
     curative treatment, the goal of which is to provide the best 
     quality of life for such patients and their families. Such 
     care--
       (A) may include the control of pain and of other symptoms, 
     including psychological, social and spiritual problems;
       (B) affirms life and regards dying as a normal process;
       (C) provides relief from pain and other distressing 
     symptoms;
       (D) integrates the psychological and spiritual aspects of 
     patient care;
       (E) offers a support system to help patients live as 
     actively as possible until death; and
       (F) offers a support system to help the family cope during 
     the patient's illness and in their own bereavement.
       (8) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.

    TITLE I--EMERGENCY RESPONSE TO THE PUBLIC HEALTH CRISIS OF PAIN

     SEC. 101. GUIDELINES FOR THE TREATMENT OF PAIN.

       (a) Development of Website.--Not later than 2 months after 
     the date of enactment of this Act, the Secretary, acting 
     through the Agency for Healthcare Research and Quality, shall 
     develop and maintain an Internet website to provide 
     information to individuals, health care practitioners, and 
     health facilities concerning evidence-based practice 
     guidelines developed for the treatment of physical and 
     psychological pain. Websites in existence on such date may be 
     used if such websites meet the requirements of this section.
       (b) Requirements.--The website established under subsection 
     (a) shall--
       (1) be designed to be quickly referenced by health care 
     practitioners; and
       (2) provide for the updating of guidelines as scientific 
     data warrants.
       (c) Provider Access to Guidelines.--
       (1) In general.--In establishing the website under 
     subsection (a), the Secretary shall ensure that health care 
     facilities have made the website known to health care 
     practitioners and that the website is easily available to all 
     health care personnel providing care or services at a health 
     care facility.
       (2) Use of certain equipment.--In making the information 
     described in paragraph (1) available to health care 
     personnel, the facility involved shall--
       (A) ensure that such personnel have access to the website 
     through the computer equipment of the facility;
       (B) carry out efforts to inform personnel at the facility 
     of the location of such equipment; and
       (C) ensure that patients, caregivers, and support groups 
     are provided with access to the website.
       (3) Rural areas.--
       (A) In general.--A health care facility, particularly a 
     facility located in a rural or underserved area, without 
     access to the Internet shall provide an alternative means of 
     providing practice guideline information to all health care 
     personnel.
       (B) Alternative means.--The Secretary shall determine 
     appropriate alternative means by which a health care facility 
     may make available practice guideline information on a 24-
     hour basis, 7 days a week if the facility does not have 
     Internet access. The criteria for adopting such alternative 
     means should be clear in permitting facilities to develop 
     alternative means without placing a significant financial 
     burden on the facility and in permitting flexibility for 
     facilities to develop alternative means of making guidelines 
     available. Such criteria shall be published in the Federal 
     Register.

     SEC. 102. PATIENT EXPECTATIONS TO HAVE PAIN AND SYMPTOM 
                   MANAGEMENT.

       (a) In General.--The administrator of each of the programs 
     described in subsection (b) shall ensure that, as part of any 
     informational materials provided to individuals under such 
     programs, such materials shall include information, where 
     relevant, to inform such individuals that they should expect 
     to have their pain assessed and should expect to be provided 
     with effective pain and symptom relief, when receiving 
     benefits under such program.
       (b) Programs.--The programs described in this subsection 
     shall include--
       (1) the medicare and medicaid programs under titles XIX and 
     XXI of the Social Security Act (42 U.S.C. 1935 et seq., 1936 
     et seq.);
       (2) programs carried out through the Public Health Service;
       (3) programs carried out through the Indian Health Service;
       (4) programs carried out through health centers under 
     section 330 of the Public Health Service Act (42 U.S.C. 
     254b);
       (5) the Federal Employee Health Benefits Program under 
     title 5, United States Code;
       (6) the Civilian Health and Medical Program of the 
     Uniformed Services (CHAMPUS) as defined in section 1073(4) of 
     title 10, United States Code; and
       (7) other programs administered by the Secretary.

     SEC. 103. QUALITY IMPROVEMENT EDUCATION PROJECTS.

       The Secretary shall provide funds for the implementation of 
     special education projects, in as many States as is 
     practicable, to be carried out by peer review organizations 
     of the type described in section 1152 of the Social Security 
     Act (42 U.S.C. 1320c-1) to improve the quality of pain and 
     symptom management. Such projects shall place an emphasis on 
     improving pain and symptom management at the end of life, and 
     may also include efforts to increase the quality of services 
     delivered to chronic pain patients and the chronically ill 
     for whom pain may be a significant symptom.

     SEC. 104. PAIN COVERAGE QUALITY EVALUATION AND INFORMATION.

       (a) In General.--Section 1851(d)(4) of the Social Security 
     Act (42 U.S.C. 42 U.S.C. 1395w-21(d)(4)) is amended--
       (1) in subparagraph (A), by adding at the end the 
     following:
       ``(ix) The organization's coverage of pain and symptom 
     management.''; and
       (2) in subparagraph (D)--
       (A) in clause (iii), by striking ``and'' at the end;
       (B) in clause (iv), by striking the period and inserting 
     ``, and''; and
       (C) by adding at the end the following:
       ``(v) not later than 2 years after the date of enactment of 
     this clause, an evaluation (which may be made part of any 
     other relevant report of quality evaluation that the plan is 
     required to prepare) for the plan (updated annually) that 
     indicates the performance of the plan with respect to access 
     to, and quality of, pain and symptom management, including 
     such management as part of end of life care. Data shall be 
     posted in a comparable manner for consumer use on 
     www.medicare.gov.''.
       (b) Effective Date.--The amendments made by paragraph (1) 
     apply to information provided with respect to annual, 
     coordinated election periods (as defined in section 
     1851(e)(3)(B) of the Social Security Act (42 U.S.C. 1395-
     21(e)(3)(B)) beginning after the date of enactment of this 
     Act.

     SEC. 105. SURGEON GENERAL'S REPORT.

       Not later than October 1, 2006, the Surgeon General shall 
     prepare and submit to the appropriate committees of Congress 
     and the public, a report concerning the state of pain and 
     symptom management in the United States. The report shall 
     include--
       (1) a description of the legal and regulatory barriers that 
     may exist at the Federal and State levels to providing 
     adequate pain and symptom management;
       (2) an evaluation of provider competency in providing pain 
     and symptom management;
       (3) an identification of vulnerable populations, including 
     children, advanced elderly, non-English speakers, and 
     minorities, who may be likely to be underserved or may face 
     barriers to access to pain management and recommendations to 
     improve access to pain management for these populations;
       (4) an identification of barriers that may exist in 
     providing pain and symptom management in health care 
     settings, including assisted living facilities;
       (5) an identification of patient and family attitudes that 
     may exist which pose barriers

[[Page S4943]]

     in accessing pain and symptom management or in the proper use 
     of pain medications;
       (6) an evaluation of medical, nursing, and pharmacy school 
     training and residency training for pain and symptom 
     management;
       (7) a review of continuing medical education programs in 
     pain and symptom management; and
       (8) a description of the use of and access to mental health 
     services for patients in pain and patients at the end of 
     life.

                TITLE II--DEVELOPING COMMUNITY RESOURCES

     SEC. 201. FAMILY SUPPORT NETWORKS IN PAIN AND SYMPTOM 
                   MANAGEMENT.

       (a) Establishment.--The Secretary, acting through the 
     Public Health Service, shall award grants for the 
     establishment of 6 National Family Support Networks in Pain 
     and Symptom Management (in this section referred to as the 
     ``Networks'') to serve as national models for improving the 
     access and quality of pain and symptom management to chronic 
     pain patients (including chronically ill patients for whom 
     pain is a significant symptom) and those individuals in need 
     of pain and symptom management at the end of life and to 
     provide assistance to family members and caregivers.
       (b) Eligibility and Distribution.--
       (1) Eligibility.--To be eligible to receive a grant under 
     subsection (a), an entity shall--
       (A) be an academic facility or other entity that has 
     demonstrated an effective approach to training health care 
     providers including mental health professionals concerning 
     pain and symptom management and palliative care services; and
       (B) prepare and submit to the Secretary an application (to 
     be peer reviewed by a committee established by the 
     Secretary), at such time, in such manner, and containing such 
     information as the Secretary may require.
       (2) Distribution.--In providing for the establishment of 
     Networks under subsection (a), the Secretary shall ensure 
     that--
       (A) the geographic distribution of such Networks reflects a 
     balance between rural and urban needs; and
       (B) at least 3 Networks are established at academic 
     facilities.
       (c) Activities of Networks.--A Network that is established 
     under this section--
       (1) shall provide for an integrated interdisciplinary 
     approach, that includes psychological and counseling 
     services, to the delivery of pain and symptom management;
       (2) shall provide community leadership in establishing and 
     expanding public access to appropriate pain care, including 
     pain care at the end of life;
       (3) shall provide assistance, through caregiver supportive 
     services, that include counseling and education services;
       (4) shall develop a research agenda to promote effective 
     pain and symptom management for the broad spectrum of 
     patients in need of access to such care that can be 
     implemented by the Network;
       (5) shall provide for coordination and linkages between 
     clinical services in academic centers and surrounding 
     communities to assist in the widespread dissemination of 
     provider and patient information concerning how to access 
     options for pain management;
       (6) shall establish telemedicine links to provide education 
     and for the delivery of services in pain and symptom 
     management;
       (7) shall develop effective means of providing assistance 
     to providers and families for the management of a patient's 
     pain 24 hours a day, 7 days a week; and
       (8) may include complimentary medicine provided in 
     conjunction with traditional medical services.
       (d) Provider Pain and Symptom Management Communications 
     Projects.--
       (1) In general.--Each Network shall establish a process to 
     provide health care personnel with information 24 hours a 
     day, 7 days a week, concerning pain and symptom management. 
     Such process shall be designed to test the effectiveness of 
     specific forms of communications with health care personnel 
     so that such personnel may obtain information to ensure that 
     all appropriate patients are provided with pain and symptom 
     management.
       (2) Termination.--The requirement of paragraph (1) shall 
     terminate with respect to a Network on the day that is 2 
     years after the date on which the Network has established the 
     communications method.
       (3) Evaluation.--Not later than 60 days after the 
     expiration of the 2-year period referred to in paragraph (2), 
     a Network shall conduct an evaluation and prepare and submit 
     to the Secretary a report concerning the costs of operation 
     and whether the form of communication can be shown to have 
     had a positive impact on the care of patients in chronic pain 
     or on patients with pain at the end of life.
       (4) Rule of construction.--Nothing in this subsection shall 
     be construed as limiting a Network from developing other ways 
     in which to provide support to families and providers, 24 
     hours a day, 7 days a week.
       (e) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section, $18,000,000 for 
     fiscal years 2005 through 2007.

                   TITLE III--REIMBURSEMENT BARRIERS

     SEC. 301. REIMBURSEMENT BARRIERS REPORT.

       The Medicare Payment Advisory Commission (MedPac) 
     established under section 1805 of the Social Security Act (42 
     U.S.C. 1396b-6) shall conduct a study, and prepare and submit 
     to the appropriate committees of Congress a report, 
     concerning--
       (1) the manner in which medicare policies may pose barriers 
     in providing pain and symptom management and palliative care 
     services in different settings, including a focus on payment 
     for nursing home and home health services;
       (2) the identification of any financial barriers that may 
     exist within the medicare and medicaid programs under titles 
     XVIII and XIX of the Social Security Act (42 U.S.C. 1395 et 
     seq., 1396 et seq.) that interfere with continuity of care 
     and interdisciplinary care or supportive care for the broad 
     range of chronic pain patients (including patients who are 
     chronically ill for whom pain is a significant symptom), and 
     for those who are terminally ill, and include the 
     recommendations of the Commission on ways to eliminate those 
     barriers that the Commission may identify;
       (3) the reimbursement barriers that exist, if any, in 
     providing pain and symptom management through hospice care, 
     particularly in rural areas, and if barriers exist, 
     recommendations concerning adjustments that would assist in 
     assuring patient access to pain and symptom management 
     through hospice care in rural areas;
       (4) whether the medicare reimbursement system provides 
     incentives to providers to delay informing terminally ill 
     patients of the availability of hospice and palliative care; 
     and
       (5) the impact of providing payments for medication therapy 
     management services in pain and symptom management and 
     palliative care services.

     SEC. 302. INSURANCE COVERAGE OF PAIN AND SYMPTOM MANAGEMENT.

       (a) In General.--The General Accounting Office shall 
     conduct a survey of public and private health insurance 
     providers, including managed care entities, to determine 
     whether the reimbursement policies of such insurers inhibit 
     the access of chronic pain patients to pain and symptom 
     management and pain and symptom management for those in need 
     of end-of-life care (including patients who are chronically 
     ill for whom pain is a significant symptom). The survey shall 
     include a review of  formularies for pain medication and the 
     effect of such formularies on pain and symptom management.
       (b) Report.--Not later than 1 year after the date of 
     enactment of this Act, the General Accounting Office shall 
     prepare and submit to the appropriate committees of Congress 
     a report concerning the survey conducted under subsection 
     (a).

   TITLE IV--IMPROVING FEDERAL COORDINATION OF POLICY, RESEARCH, AND 
                              INFORMATION

     SEC. 401. ADVISORY COMMITTEE ON PAIN AND SYMPTOM MANAGEMENT.

       (a) Establishment.--The Secretary shall establish an 
     advisory committee, to be known as the Advisory Committee on 
     Pain and Symptom Management, to make recommendations to the 
     Secretary concerning a coordinated Federal agenda on pain and 
     symptom management.
       (b) Membership.--The Advisory Committee established under 
     subsection (a) shall be comprised of 11 individuals to be 
     appointed by the Secretary, of which at least 1 member shall 
     be a representative of--
       (1) physicians (medical doctors or doctors of osteopathy) 
     who treat chronic pain patients or the terminally ill;
       (2) nurses who treat chronic pain patients or the 
     terminally ill;
       (3) pharmacists;
       (4) hospice;
       (5) pain researchers;
       (6) patient advocates;
       (7) caregivers; and
       (8) mental health providers.
     The members of the Committee shall designate 1 member to 
     serve as the chairperson of the Committee.
       (c) Meetings.--The Advisory Committee shall meet at the 
     call of the chairperson of the Committee.
       (d) Agenda.--The agenda of the Advisory Committee 
     established under subsection (a) shall include--
       (1) the development of recommendations to create a 
     coordinated Federal agenda on pain and symptom management;
       (2) the development of proposals to ensure that pain is 
     considered as the fifth vital sign for all patients;
       (3) the identification of research needs in pain and 
     symptom management, including gaps in pain and symptom 
     management guidelines;
       (4) the identification and dissemination of pain and 
     symptom management practice guidelines, research information, 
     and best practices;
       (5) proposals for patient education concerning how to 
     access pain and symptom management across health care 
     settings;
       (6) the manner in which to measure improvement in access to 
     pain and symptom management and improvement in the delivery 
     of care;
       (7) the development of ongoing strategies to assure the 
     aggressive use of pain medications, including opiods, 
     regardless of health care setting; and
       (8) the development of an ongoing mechanism to identify 
     barriers or potential barriers to pain and symptom management 
     created by Federal policies.
       (e) Recommendation.--Not later than 2 years after the date 
     of enactment of this Act, the Advisory Committee established 
     under subsection (a) shall prepare and submit to the 
     Secretary recommendations concerning a prioritization of the 
     need for a

[[Page S4944]]

     Federal agenda on pain and symptom management, and ways in 
     which to better coordinate the activities of entities within 
     the Department of Health and Human Services, and other 
     Federal entities charged with the responsibility for the 
     delivery of health care services or research on pain and 
     symptom management with respect to pain management.
       (f) Consultation.--In carrying out this section, the 
     Advisory Committee shall consult with all Federal agencies 
     that are responsible for providing health care services or 
     access to health services to determine the best means to 
     ensure that all Federal activities are coordinated with 
     respect to research and access to pain and symptom 
     management.
       (g) Administrative Support; Terms of Service; Other 
     Provisions.--The following shall apply with respect to the 
     Advisory Committee:
       (1) The Committee shall receive necessary and appropriate 
     administrative support, including appropriate funding, from 
     the Department of Health and Human Services.
       (2) The Committee shall hold open meetings and meet not 
     less than 4 times per year.
       (3) Members of the Committee shall not receive additional 
     compensation for their service. Such members may receive 
     reimbursement for appropriate and additional expenses that 
     are incurred through service on the Committee which would not 
     have incurred had they not been a member of the Committee.
       (4) The requirements of Appendix 2 of title 5, United 
     States Code.

     SEC. 402. INSTITUTES OF MEDICINE REPORT ON CONTROLLED 
                   SUBSTANCE REGULATION AND THE USE OF PAIN 
                   MEDICATIONS.

       (a) In General.--The Secretary, acting through a contract 
     entered into with the Institute of Medicine, shall review 
     findings that have been developed through research conducted 
     concerning--
       (1) the effects of controlled substance regulation on 
     patient access to effective care;
       (2) factors, if any, that may contribute to the underuse of 
     pain medications, including opiods;
       (3) the identification of State legal and regulatory 
     barriers, if any, that may impact patient access to 
     medications used for pain and symptom management; and
       (4) strategies to assure the aggressive use of pain 
     medications, including opiods, regardless of health care 
     setting.
       (b) Report.--Not later than 18 months after the date of 
     enactment of this Act, the Secretary shall prepare and submit 
     to the appropriate committees of Congress a report concerning 
     the findings described in subsection (a).

     SEC. 403. CONFERENCE ON PAIN RESEARCH AND CARE.

       Not later than December 31, 2007, the Secretary, acting 
     through the National Institutes of Health, shall convene a 
     national conference to discuss the translation of pain 
     research into the delivery of health services including 
     mental health services to chronic pain patients and those 
     needing end-of-life care. The Secretary shall use unobligated 
     amounts appropriated for the Department of Health and Human 
     Services to carry out this section.

                    TITLE V--DEMONSTRATION PROJECTS

     SEC. 501. PROVIDER PERFORMANCE STANDARDS FOR IMPROVEMENT IN 
                   PAIN AND SYMPTOM MANAGEMENT.

       (a) In General.--The Secretary, acting through the Health 
     Resources Services Administration, shall award grants for the 
     establishment of not less than 5 demonstration projects to 
     determine effective methods to measure improvement in the 
     skills, knowledge, and attitudes and beliefs of health care 
     personnel in pain and symptom management as such skill, 
     knowledge, and attitudes and beliefs apply to providing 
     services to chronic pain patients and those patients 
     requiring pain and symptom management at the end of life.
       (b) Evaluation.--Projects established under subsection (a) 
     shall be evaluated to determine patient and caregiver 
     knowledge and attitudes toward pain and symptom management.
       (c) Application.--To be eligible to receive a grant under 
     subsection (a), an entity shall prepare and submit to the 
     Secretary an application at such time, in such manner and 
     containing such information as the Secretary may require.
       (d) Termination.--A project established under subsection 
     (a) shall terminate after the expiration of the 2-year period 
     beginning on the date on which such project was established.
       (e) Authorization of Appropriations.--There is authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.

     SEC. 502. END OF LIFE CARE DEMONSTRATION PROJECTS.

       The Secretary, acting through the Health Resources and 
     Services Administration, shall--
       (1) not later than January 1, 2007, carry out not less than 
     5 demonstration and evaluation projects that implement care 
     models for individuals at the end of life, at least one of 
     which shall be developed to assist those individuals who are 
     terminally ill and have no family or extended support, and 
     each of which may be carried out in collaboration with 
     domestic and international entities to gain and share 
     knowledge and experience on end of life care;
       (2) conduct 3 demonstration and evaluation activities 
     concerning the education and training of clinicians in end of 
     life care, and assist in the development and distribution of 
     accurate educational materials on both pain and symptom 
     management and end of life care;
       (3) in awarding grants for the training of health 
     professionals, give priority to awarding grants to entities 
     that will provide training for health professionals in pain 
     and symptom management and in end-of-life care at the 
     undergraduate level;
       (4) shall evaluate demonstration projects carried out under 
     this section within the 5-year period beginning on the 
     commencement of each such project; and
       (5) develop a strategy and make recommendations to Congress 
     to ensure that the United States health care system--
       (A) has a meaningful, comprehensive, and effective approach 
     to meet the needs of individuals and their caregivers as the 
     patient approaches death; and
       (B) integrates broader supportive services.

                                S. 1000

       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 ``Palliative Care Training 
     Act''.

     SEC. 2. PALLIATIVE CARE TRAINING PROGRAM.

       (a) In General.--Section 753 of the Public Health Service 
     Act (42 U.S.C. 294c) is amended by adding at the end the 
     following:
       ``(d) Hospice and Palliative Care Academic Career Awards.--
       ``(1) In general.--The Secretary shall establish a program 
     to provide Hospice and Palliative Care Academic Career Awards 
     to eligible individuals under this subsection.
       ``(2) Eligibility.--To be eligible to receive an Award 
     under this subsection, an individual shall--
       ``(A) be board certified or board eligible in internal 
     medicine, family practice, or pediatrics and their 
     subspecialties including geriatrics, palliative medicine, or 
     other specialties as determined by the Secretary;
       ``(B) have completed an approved fellowship program or 
     demonstrated specialized experience in palliative medicine as 
     determined by the Secretary; and
       ``(C) have a junior faculty appointment at an accredited 
     (as determined by the Secretary) school of medicine 
     (allopathic or osteopathic) and within an internship or 
     residency program that is approved by the Accreditation 
     Council on Graduate Medical Education or the American 
     Osteopathic Association.
       ``(3) Amount and term.--
       ``(A) Amount.--The amount of an Award to an individual 
     under this subsection shall be equal to $75,000 for fiscal 
     year 2006, adjusted for subsequent fiscal years to reflect 
     the increase in the Consumer Price Index.
       ``(B) Term.--The term of any Award made under this 
     subsection shall not exceed 5 years.
       ``(4) Service requirement.--An individual who receives an 
     Award under this subsection shall provide training in hospice 
     care and palliative medicine, including the training of 
     interdisciplinary teams of health care professionals. The 
     provision of such training shall constitute at least 75 
     percent of the obligations of such individual under the terms 
     of the Award.
       ``(5) Effective date.--This subsection shall take effect 90 
     days after the date of enactment of the Palliative Care 
     Training Act.''.
       (b) Authorization of Appropriations.--Section 757 of the 
     Public Health Service Act (42 U.S.C. 294g) is amended--
       (1) in subsection (a), by striking ``through 2002'' and 
     inserting ``through 2010'';
       (2) in subsection (b)(1)(C), by striking ``$22,631,000'' 
     and inserting ``$55,779,000''; and
       (3) in subsection (c), by adding at the end the following:
       ``(3) Geriatric education and training.--Of the amount made 
     available under subsection (b)(1)(C) for fiscal year 2006, 
     the Secretary may obligate for awards under subsections (a), 
     (b), and (c) of section 753 an amount not less than 
     $31,805,000.''.

                                S. 1001

       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 
     Demonstration Act of 2005''.

     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.
       (6) Data of the Centers for Medicare & Medicaid Services 
     show that beneficiaries were enrolled in hospice for an 
     average of less than 7 weeks in 1998, far less than the full 
     6-month benefit under the medicare program.
       (7) According to the most recent data available, although 
     more medicare beneficiaries are enrolled in hospice, the 
     medicare length of stay has declined.

[[Page S4945]]

       (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 PROJECTS AND HOSPICE EDUCATION 
                   GRANTS.

       (a) Definitions.--In this section:
       (1) Demonstration project.--The term ``demonstration 
     project'' means a demonstration project established by the 
     Secretary under subsection (b)(1).
       (2) Hospice care.--The term ``hospice care'' means the 
     items and services described in subparagraphs (A) through (I) 
     of section 1861(dd)(1) of the Social Security Act (42 U.S.C. 
     1395x(dd)(1)) that are provided to a seriously ill medicare 
     beneficiary under a demonstration project by a hospice 
     program (or by others under an arrangement with such a 
     program) under a written plan for providing such care to such 
     beneficiary established and periodically reviewed by the 
     beneficiary's attending physician, by the medical director of 
     the program, and by the interdisciplinary group described in 
     section 1861(dd)(2)(B) of such Act (42 U.S.C. 
     1395x(dd)(2)(B)).
       (3) Hospice program.--The term ``hospice program'' has the 
     meaning given that term in section 1861(dd)(2) of the Social 
     Security Act (42 U.S.C. 1395x(dd)(2)).
       (4) Medicare beneficiary.--The term ``medicare 
     beneficiary'' means any individual who is entitled to 
     benefits under part A or enrolled under part B of the 
     medicare program.
       (5) Medicare program.--The term ``medicare program'' means 
     the health benefits program under title XVIII of the Social 
     Security Act (42 U.S.C. 1395 et seq.).
       (6) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (7) Seriously ill.--The term ``seriously ill'' has the 
     meaning given such term by the Secretary (in consultation 
     with hospice programs and academic experts in end-of-life 
     care), except that the Secretary may not limit such term to 
     individuals who are terminally ill (as defined in section 
     1861(dd)(3)(A) of the Social Security Act (42 U.S.C. 
     1395x(dd)(3)(A))).
       (b) Hospice Demonstration Projects.--
       (1) Establishment.--The Secretary shall establish 
     demonstration projects in accordance with the provisions of 
     this subsection to increase the utility of the hospice care 
     for seriously ill medicare beneficiaries.
       (2) Participation.--
       (A) Hospice programs.--Except as provided in paragraph 
     (4)(A), only a hospice program with an agreement under 
     section 1866 of the Social Security Act (42 U.S.C. 1395cc), a 
     consortium of such hospice programs, or a State hospice 
     association may participate in the demonstration program.
       (B) Seriously ill medicare beneficiaries.--The Secretary 
     shall permit any seriously ill medicare beneficiary residing 
     in the service area of a hospice program participating in a 
     demonstration project to participate in such project on a 
     voluntary basis.
       (3) Services under demonstration projects.--The provisions 
     of section 1814(i) of the Social Security Act (42 U.S.C. 
     1395f(i)) shall apply to the payment for hospice care 
     provided under the demonstration projects, except that--
       (A) notwithstanding section 1862(a)(1)(C) of such Act (42 
     U.S.C. 1395y(a)(1)(C)), the Secretary shall provide for 
     reimbursement for items and services provided under the 
     supportive and comfort care benefit established under 
     paragraph (3);
       (B) any licensed nurse practitioner or physician assistant 
     may admit a seriously ill medicare beneficiary as the primary 
     care provider when necessary and within the scope of practice 
     of such practitioner or assistant under State law;
       (C) if an underserved community included in a demonstration 
     project does not have a qualified social worker, any 
     professional (other than a social worker) who has the 
     necessary knowledge, skills, and ability to provide medical 
     social services may provide such services;
       (D) the Secretary shall waive any requirement that nursing 
     facilities used for respite care have skilled nurses on the 
     premises 24 hours per day;
       (E) the Secretary shall permit respite care to be provided 
     to the seriously ill medicare beneficiary at home; and
       (F) the Secretary shall waive reimbursement regulations to 
     provide--
       (i) reimbursement for consultations and preadmission 
     informational visits, even if the seriously ill medicare 
     beneficiary does not elect hospice care at that time;
       (ii) except with respect to the supportive and comfort care 
     benefit under paragraph (3), a minimum payment for hospice 
     care provided under the demonstration projects based on the 
     provision of hospice care to a seriously ill medicare 
     beneficiary for a period of 14 days, that--

       (I) the Secretary shall pay to any hospice program 
     participating in a demonstration project and providing such 
     care (regardless of the length of stay of the seriously ill 
     medicare beneficiary); and
       (II) may not be less than the amount of payment that would 
     have been made for hospice care if payment had been made at 
     the daily rate of payment for such care under section 1814(i) 
     of the Social Security Act (42 U.S.C. 1395f(i));

       (iii) an increase in the reimbursement rates for hospice 
     care to offset--

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

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

       (I) in the case of a seriously ill medicare beneficiary 
     that needs routine care, is not less than 150 percent, and 
     not more than 200 percent, of the routine home care rate for 
     hospice care; and
       (II) in the case of a seriously ill medicare beneficiary 
     that needs acute care, is equal to the continuous home care 
     day rate for hospice care.

       (4) Supportive and comfort care benefit.--
       (A) In general.--For purposes of the demonstration 
     projects, the Secretary shall establish a supportive and 
     comfort care benefit for any eligible seriously ill medicare 
     beneficiary (as defined in subparagraph (C)).
       (B) Participation.--Any individual or entity with an 
     agreement under section 1866 of the Social Security Act (42 
     U.S.C. 1395cc) may furnish items or services covered under 
     the supportive and comfort care benefit.
       (C) Benefit.--Under the supportive and comfort care 
     benefit, any eligible seriously ill medicare beneficiary 
     may--
       (i) continue to receive benefits for disease and symptom 
     modifying treatment under the medicare program (and the 
     Secretary may not require or prohibit any specific treatment 
     or decision);
       (ii) receive case management and hospice care through a 
     hospice program participating in a demonstration project (for 
     which payment shall be made under paragraph (2)(F)(ii)); and
       (iii) receive information and education in order to better 
     understand the utility of hospice care.
       (D) Payment.--The Secretary shall establish procedures 
     under which the Secretary pays for items and services 
     furnished to seriously ill medicare beneficiaries under the 
     supportive and comfort care benefit on a fee-for-service 
     basis.
       (E) Eligible seriously ill medicare beneficiary defined.--
       (i) In general.--In this paragraph, the term ``eligible 
     seriously ill medicare beneficiary'' means any seriously ill 
     medicare beneficiary that meets the criteria approved by the 
     Secretary under clause (ii).
       (ii) Approval of criteria.--

       (I) In general.--With respect to each demonstration 
     project, the Secretary shall approve criteria for determining 
     whether a seriously ill medicare beneficiary is eligible for 
     hospice care under a demonstration project that has been 
     developed by hospice programs in consultation with 
     researchers in end-of-life care and the broader medical 
     community.
       (II) Data comparability.--The Secretary may only approve 
     criteria that ensures that each demonstration project yields 
     comparable data with respect to eligible seriously ill 
     medicare beneficiaries on--

       (aa) the utilization of services by such beneficiaries;
       (bb) the cost of providing services to such beneficiaries, 
     including any costs associated with providing services before 
     an individual is terminally ill (as defined in section 
     1861(dd)(3)(A) of the Social Security Act (42 U.S.C. 
     1395x(dd)(3)(A))); and
       (cc) the effect of the demonstration project on the quality 
     of care of such beneficiaries.

       (III) Limitation.--The Secretary may not approve criteria 
     if the purpose of such criteria is to segment services or to 
     provide a benefit for the chronically ill.

       (5) Conduct of demonstration projects.--
       (A) Sites.--The Secretary shall conduct demonstration 
     projects in at least 3, but not more than 6, sites (which may 
     be statewide).
       (B) Selection of sites.--
       (i) In general.--Except as provided in clause (ii), the 
     Secretary shall select demonstration sites on the basis of 
     proposals submitted under subparagraph (C) that are located 
     in geographic areas that--

       (I) include both urban and rural hospice programs; and
       (II) are geographically diverse and readily accessible to a 
     significant number of seriously ill medicare beneficiaries.

       (ii) Exceptions.--

       (I) Underserved urban areas.--If a geographic area does not 
     have any rural hospice program available to participate in a 
     demonstration project, such area may substitute an 
     underserved urban area, but the Secretary shall give priority 
     to those proposals that include a rural hospice program.
       (II) Specific site.--The Secretary shall select as a 
     demonstration site the State in which (according to the 
     Hospital Referral Region of Residence, 1994-1995, as listed 
     in the Dartmouth Atlas of Health Care 1998) the largest 
     metropolitan area of the State had the lowest percentage of 
     medicare beneficiary deaths in a hospital when compared to 
     the largest metropolitan area of each other State, and the 
     percentage of enrollees who experienced intensive care during 
     the last 6 months of life was 21.5 percent.

       (C) Proposals.--

[[Page S4946]]

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