[House Report 106-409]
[From the U.S. Government Publishing Office]





106th Congress                                                   Report
  1st Session           HOUSE OF REPRESENTATIVES                106-409

=======================================================================



 
PROVIDING FOR THE CONSIDERATION OF H.R. 2260, PAIN RELIEF PROMOTION ACT 
                                OF 1999

                                _______
                                

  October 21, 1999.--Referred to the House Calendar and ordered to be 
                                printed

                                _______


    Mr. Linder, from the Committee on Rules, submitted the following

                              R E P O R T

                       [To accompany H. Res. 339]

    The Committee on Rules, having had under consideration 
House Resolution 339, by a nonrecord vote, report the same to 
the House with the recommendation that the resolution be 
adopted.

                  summary of provisions of resolution

    The resolution provides for the consideration of H.R. 2260, 
the Pain Relief Promotion Act of 1999, under a structured rule. 
The rule provides one hour of general debate divided equally 
between the chairman and ranking minority member of the 
Committee on Commerce and the chairman and ranking minority 
member of the Committee on the Judiciary.
    The rule waives clause 4(a) of rule XIII (requiring the 
three-day layover of the committee report) against 
consideration of the bill. The rule makes in order as an 
original bill for the purpose of amendment the amendment in the 
nature of a substitute consisting of the bill as modified by 
the amendments recommended by the Committee on Commerce and now 
printed in the bill. The rule provides for consideration of 
only the amendments printed in this report. The rule further 
provides that the amendments shall be considered only in the 
order specified in this report, may be offered only by a Member 
designated in this report, shall be considered as read, shall 
be debatable for the time specified in this report equally 
divided and controlled by the proponent and an opponent and 
shall not be subject to amendment. Additionally, the rule 
allows the chairman of the Committee of the Whole to postpone 
votes during consideration of the bill and to reduce voting 
time to five minutes on a postponed question if the vote 
follows a fifteen minute vote. Finally, the rule provides one 
motion to recommit with or without instructions.
    The waiver of clause 4(a) of rule XIII (requiring the 
three-day layover of the committee report) against 
consideration of the bill is required because the Commerce 
Committee's report (H. Rpt. 106-378, Part II) was not printed 
until October 21, 1999 and the bill may be considered on the 
floor as early as October 22, 1999.

 summary of amendments made in order under the rule for h.r. 2260, the 
                   pain relief promotion act of 1999

    1. Scott/DeFazio: Strikes section 101 of the bill. (10 
minutes)
    2. Johnson (CT)/Rothman/Maloney (NY)/Hooley: Amendment in 
the nature of a substitute--Enhances professional education in 
palliative care and reduces excessive regulatory scrutiny in 
order to mitigate the suffering, pain, and desperation many 
sick and dying people face at the end of their life in order to 
carry out the clear opposition of the congress to physician-
assisted suicide. (40 minutes)
    Text of amendments made in order under the rule:

 1. An Amendment To Be Offered by Representative Scott of Virginia, or 
   Representative DeFazio of Oregon, or a Designee, Debatable for 10 
                                Minutes

    In title I, strike section 101 and redesignate succeeding 
sections and all cross references accordingly.
                              ----------                              


2. An Amendment To Be Offered by Representative Johnson of Connecticut 
 or Representative Rothman of New Jersey, or a Designee, Debatable for 
                               40 Minutes

  Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

  (a) Short Title.--This Act may be cited as the ``Conquering 
Pain Act of 1999''.
  (b) Table of Contents.--The table of contents for this Act is 
as follows:

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

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

Sec. 101. Guidelines for the treatment of pain.
Sec. 102. Quality improvement projects.
Sec. 103. 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. 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. 2. FINDINGS AND PURPOSE.

  (a) Findings.--Congress finds that--
          (1) pain is often left untreated or under-treated 
        especially among older patients, African Americans, 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) despite the best intentions of physicians, 
        nurses, pharmacists, and other health care 
        professionals, pain is often under-treated because of 
        the inadequate training of physicians in pain 
        management;
          (6) despite the best intentions of physicians, 
        nurses, pharmacists, 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;
          (7) the technology and scientific basis to adequately 
        manage most pain is known;
          (8) pain should be considered the fifth vital sign; 
        and
          (9) 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.
  (b) Purpose.--The purpose of this Act is to enhance 
professional education in palliative care and reduce excessive 
regulatory scrutiny in order to mitigate the suffering, pain, 
and desperation many sick and dying people face at the end of 
their lives in order to carry out the clear opposition of the 
Congress to physician-assisted suicide.

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 treated. Such 
        term includes pain that may be associated with long-
        term incurable or intractable medical conditions or 
        disease.
          (2) Drug therapy management services.--The term 
        ``drug therapy management services'' means 
        consultations with a physician concerning a patient 
        which results in the physician--
                  (A) changing the drug regimen of the patient 
                to avoid an adverse drug interaction with 
                another drug or disease state;
                  (B) changing an inappropriate drug dosage or 
                dosage form with respect to the patient;
                  (C) discontinuing an unnecessary or harmful 
                medication with respect to the patient;
                  (D) initiating drug therapy for a medical 
                condition of the patient; or
                  (E) consulting with the patient or a 
                caregiver in a manner that results in a 
                significant improvement in drug regimen 
                compliance.
        Such term includes services provided by a physician, 
        pharmacist, or other health care professional who is 
        legally authorized to furnish such services under the 
        law of the State in which such services are furnished.
          (3) 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.
          (4) 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.
          (5) 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)).
          (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) anxiety; and
                  (M) depression.
          (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 Health Care Policy Research, 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 pain.
  (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 
        ensure that such personnel have access to the website 
        through the computer equipment of the facility and 
        shall carry out efforts to inform personnel at the 
        facility of the location of such equipment.
          (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 
                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 
inpermitting 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. 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.

SEC. 103. SURGEON GENERAL'S REPORT.

  Not later than October 1, 2000, 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) and identification of patient and family 
        attitudes that may exist which pose barriers in 
        accessing pain and symptom management or in the proper 
        use of pain medications;
          (6) an evaluation of medical school training and 
        residency training for pain and symptom management; and
          (7) a review of continuing medical education programs 
        in pain and symptom management.

                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 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 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 shall--
          (1) provide for an integrated interdisciplinary 
        approach to the delivery of pain and symptom 
        management;
          (2) provide community leadership in establishing and 
        expanding public access to appropriate pain care, 
        including pain care at the end of life;
          (3) provide assistance through caregiver and 
        bereavement supportive services;
          (4) 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) 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) establish telemedicine links to provide education 
        and for the delivery of services in pain and symptom 
        management; and
          (7) 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.
  (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 Networkon 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 2000 through 2002.

                   TITLE III--REIMBURSEMENT BARRIERS

SEC. 301. 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. 
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 who treat chronic pain patients or 
        the terminally ill;
          (4) hospice;
          (5) pain researchers;
          (6) patient advocates;
          (7) caregivers; and
          (8) health insurance issuers (as such term is defined 
        in section 2791(b) of the Public Health Service Act (42 
        U.S.C. 300gg-91(b))).
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; and
          (7) 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 
Federal agenda on pain, 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, 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 opioids; and
          (3) the identification of State legal and regulatory 
        barriers, if any, that may impact patient access to 
        medications used for pain and symptom management.
  (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, 2003, 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 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 Public 
Health Service, shall award grants for the establishment of not 
less than 5 demonstration projects to determine effective 
methods to measure improvement in the skills and knowledge of 
health care personnel in pain and symptom management as such 
skill and knowledge applies 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.
  (d) Authorization of Appropriations.--There is authorized to 
be appropriated such sums as may be necessary to carry out this 
section.

                                

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