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107TH CONGRESS

1ST SESSION S. 1425

To establish hospice demonstration projects and a hospice grant program

for beneficiaries under the medicare program under title XVIII of the

Social Security Act, and for other purposes.

IN THE SENATE OF THE UNITED STATES

SEPTEMBER 13, 2001

Mr. WYDEN introduced the following bill; which was read twice and referred

to the Committee on Finance

A BILL

To establish hospice demonstration projects and a hospice

grant program for beneficiaries under the medicare program under title XVIII of the Social Security Act, and

for other purposes.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Hospice Improvement

5 Program Act of 2001’’.

6 SEC. 2. FINDINGS.

7 Congress makes the following findings:
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(1) Each year more than 1 1 ⁄3 of the people who

2 die suffer from a chronic illness.

(2) Approximately 1 3 ⁄3 of Americans are unsure

4 about whom to contact to get the best care during

5 life’s last stages.

6 (3) Americans want a team of professionals to

7 care for the patient at the end of life.

8 (4) Americans want emotional and spiritual

9 support for the patient and family.

10 (5) Ninety percent of Americans do not realize

11 that hospice care is a benefit provided under the

12 medicare program under title XVIII of the Social

13 Security Act.

14 (6) Data of the Centers for Medicare & Med15 icaid Services show that beneficiaries were enrolled

16 in hospice for an average of less than 7 weeks in

17 1998, far less than the full 6-month benefit under

18 the medicare program.

19 (7) According to the most recent data available,

20 although more medicare beneficiaries are enrolled in

21 hospice, the medicare length of stay has declined.

22 (8) Use of hospice among medicare beneficiaries

23 has been decreasing, from a high of 59 days in 1995

24 to less than 48 days in 1998.
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1 SEC. 3. HOSPICE DEMONSTRATION PROJECTS AND HOS2 PICE EDUCATION GRANTS.

3 (a) DEFINITIONS.—In this section:

4 (1) DEMONSTRATION PROJECT.—The term

5 ‘‘demonstration project’’ means a demonstration

6 project established by the Secretary under sub7 section (b)(1).

8 (2) HOSPICE CARE.—The term ‘‘hospice care’’

9 means the items and services described in subpara10 graphs (A) through (I) of section 1861(dd)(1) of the

11 Social Security Act (42 U.S.C. 1395x(dd)(1)) that

12 are provided to a seriously ill medicare beneficiary

13 under a demonstration project by a hospice program

14 (or by others under an arrangement with such a

15 program) under a written plan for providing such

16 care to such beneficiary established and periodically

17 reviewed by the beneficiary’s attending physician, by

18 the medical director of the program, and by the

19 interdisciplinary group described in section

20 1861(dd)(2)(B) of such Act (42 U.S.C.

21 1395x(dd)(2)(B)).

22 (3) HOSPICE PROGRAM.—The term ‘‘hospice

23 program’’ has the meaning given that term in sec24 tion 1861(dd)(2) of the Social Security Act (42

25 U.S.C. 1395x(dd)(2)).
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1 (4) MEDICARE BENEFICIARY.—The term

2 ‘‘medicare beneficiary’’ means any individual who is

3 entitled to benefits under part A or enrolled under

4 part B of the medicare program.

5 (5) MEDICARE PROGRAM.—The term ‘‘medicare

6 program’’ means the health benefits program under

7 title XVIII of the Social Security Act (42 U.S.C.

8 1395 et seq.).

9 (6) SECRETARY.—The term ‘‘Secretary’’ means

10 the Secretary of Health and Human Services.

11 (7) SERIOUSLY ILL.—The term ‘‘seriously ill’’

12 has the meaning given such term by the Secretary

13 (in consultation with hospice programs and academic

14 experts in end-of-life care), except that the Secretary

15 may not limit such term to individuals who are ter16 minally ill (as defined in section 1861(dd)(3) of the

17 Social Security Act (42 U.S.C. 1395x(dd)(3))).

18 (b) HOSPICE DEMONSTRATION PROJECTS.—

19 (1) ESTABLISHMENT.—The Secretary shall es20 tablish demonstration projects in accordance with

21 the provisions of this subsection to increase the util22 ity of the hospice care for seriously ill medicare

23 beneficiaries.

24 (2) PARTICIPATION.—
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1 (A) HOSPICE PROGRAMS.—Except as pro2 vided in paragraph (4)(A), only a hospice pro3 gram with an agreement under section 1866 of

4 the Social Security Act (42 U.S.C. 1395cc), a

5 consortium of such hospice programs, or a

6 State hospice association may participate in the

7 demonstration program.

8 (B) SERIOUSLY ILL MEDICARE BENE9 FICIARIES.—The Secretary shall permit any se10 riously ill medicare beneficiary residing in the

11 service area of a hospice program participating

12 in a demonstration project to participate in

13 such project on a voluntary basis.

14 (3) SERVICES UNDER DEMONSTRATION

15 PROJECTS.—The provisions of section 1814(i) of the

16 Social Security Act (42 U.S.C. 1395f(i)) shall apply

17 to the payment for hospice care provided under the

18 demonstration projects, except that—

19 (A) notwithstanding section 1862(a)(1)(C)

20 of such Act (42 U.S.C. 1395y(a)(1)(C)), the

21 Secretary shall provide for reimbursement for

22 items and services provided under the sup23 portive and comfort care benefit established

24 under paragraph (3);
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1 (B) any licensed nurse practitioner or phy2 sician assistant may admit a seriously ill medi3 care beneficiary as the primary care provider

4 when necessary and within the scope of practice

5 of such practitioner or assistant under State

6 law;

7 (C) if a community does not have a quali8 fied social worker, any professional (other than

9 a social worker) who has the necessary knowl10 edge, skills, and ability to provide medical social

11 services may provide such services;

12 (D) the Secretary shall waive any require13 ment that nursing facilities used for respite

14 care have skilled nurses on the premises 24

15 hours per day;

16 (E) the Secretary shall permit respite care

17 to be provided to the seriously ill medicare ben18 eficiary at home; and

19 (F) the Secretary shall waive reimburse20 ment regulations to provide—

21 (i) reimbursement for consultations

22 and preadmission informational visits, even

23 if the seriously ill medicare beneficiary

24 does not elect hospice care at that time;
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1 (ii) except with respect to the sup2 portive and comfort care benefit under

3 paragraph (3), a minimum payment for

4 hospice care provided under the dem5 onstration projects based on the provision

6 of hospice care to a seriously ill medicare

7 beneficiary for a period of 14 days, that—

8 (I) the Secretary shall pay to any

9 hospice program participating in a

10 demonstration project and providing

11 such care (regardless of the length of

12 stay of the seriously ill medicare bene13 ficiary); and

14 (II) may not be less than the

15 amount of payment that would have

16 been made for hospice care if payment

17 had been made at the daily rate of

18 payment for such care under section

19 1814(i) of the Social Security Act (42

20 U.S.C. 1395f(i));

21 (iii) an increase in the reimbursement

22 rates for hospice care to offset—

23 (I) changes in hospice care and

24 oversight under the demonstration

25 projects;
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1 (II) the higher costs of providing

2 hospice care in rural areas due to lack

3 of economies of scale or large geo4 graphic areas; and

5 (III) the higher costs of pro6 viding hospice care in urban under7 served areas due to unique costs spe8 cifically associated with people living

9 in those areas, including providing se10 curity;

11 (iv) direct payment of any nurse prac12 titioner or physician assistant practicing

13 within the scope of State law in relation to

14 hospice care provided by such practitioner

15 or assistant; and

16 (v) a per diem rate of payment for in17 home care under subparagraph (E) that

18 reflects the range of care needs of the seri19 ously ill medicare beneficiary and that—

20 (I) in the case of a seriously ill

21 medicare beneficiary that needs rou22 tine care, is not less than 150 percent,

23 and not more than 200 percent, of the

24 routine home care rate for hospice

25 care; and
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1 (II) in the case of a seriously ill

2 medicare beneficiary that needs acute

3 care, is equal to the continuous home

4 care day rate for hospice care.

5 (4) SUPPORTIVE AND COMFORT CARE BEN6 EFIT.—

7 (A) IN GENERAL.—For purposes of the

8 demonstration projects, the Secretary shall es9 tablish a supportive and comfort care benefit

10 for any eligible seriously ill medicare beneficiary

11 (as defined in subparagraph (C)).

12 (B) PARTICIPATION.—Any individual or

13 entity with an agreement under section 1866 of

14 the Social Security Act (42 U.S.C. 1395cc) may

15 furnish items or services covered under the sup16 portive and comfort care benefit.

17 (C) BENEFIT.—Under the supportive and

18 comfort care benefit, any eligible seriously ill

19 medicare beneficiary may—

20 (i) continue to receive benefits for dis21 ease and symptom modifying treatment

22 under the medicare program (and the Sec23 retary may not require or prohibit any spe24 cific treatment or decision);
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1 (ii) receive case management and hos2 pice care through a hospice program par3 ticipating in a demonstration project (for

4 which payment shall be made under para5 graph (2)(F)(ii)); and

6 (iii) receive information and education

7 in order to better understand the utility of

8 hospice care.

9 (D) PAYMENT.—The Secretary shall estab10 lish procedures under which the Secretary pays

11 for items and services furnished to seriously ill

12 medicare beneficiaries under the supportive and

13 comfort care benefit on a fee-for-service basis.

14 (E) ELIGIBLE SERIOUSLY ILL MEDICARE

15 BENEFICIARY DEFINED.—

16 (i) IN GENERAL.—In this paragraph,

17 the term ‘‘eligible seriously ill medicare

18 beneficiary’’ means any seriously ill medi19 care beneficiary that meets the criteria ap20 proved by the Secretary under clause (ii).

21 (ii) APPROVAL OF CRITERIA.—

22 (I) IN GENERAL.—With respect

23 to each demonstration project, the

24 Secretary shall approve criteria for

25 determining whether a seriously ill
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1 medicare beneficiary is eligible for

2 hospice care under a demonstration

3 project that has been developed by

4 hospice programs in consultation with

5 researchers in end-of-life care and the

6 broader medical community.

7 (II) DATA COMPARABILITY.—The

8 Secretary may only approve criteria

9 that ensures that each demonstration

10 project yields comparable data with

11 respect to eligible seriously ill medi12 care beneficiaries on—

13 (aa) the utilization of serv14 ices by such beneficiaries;

15 (bb) the cost of providing

16 services to such beneficiaries, in17 cluding any costs associated with

18 providing services before an indi19 vidual is terminally ill (as defined

20 in section 1861(dd)(3)(A) of the

21 Social Security Act (42 U.S.C.

22 1395x(dd)(3)(A))); and

23 (cc) the effect of the dem24 onstration project on the quality

25 of care of such beneficiaries.
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1 (III) LIMITATION.—The Sec2 retary may not approve criteria if the

3 purpose of such criteria is to segment

4 services or to provide a benefit for the

5 chronically ill.

6 (5) CONDUCT OF DEMONSTRATION

7 PROJECTS.—

8 (A) SITES.—The Secretary shall conduct

9 demonstration projects in at least 3, but not

10 more than 6, sites (which may be statewide).

11 (B) SELECTION OF SITES.—

12 (i) IN GENERAL.—Except as provided

13 in clause (ii), the Secretary shall select

14 demonstration sites on the basis of pro15 posals submitted under subparagraph (C)

16 that are located in geographic areas that—

17 (I) include both urban and rural

18 hospice programs; and

19 (II) are geographically diverse

20 and readily accessible to a significant

21 number of seriously ill medicare bene22 ficiaries.

23 (ii) EXCEPTIONS.—

24 (I) UNDERSERVED URBAN

25 AREAS.—If a geographic area does
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1 not have any rural hospice program

2 available to participate in a dem3 onstration project, such area may sub4 stitute an underserved urban area,

5 but the Secretary shall give priority to

6 those proposals that include a rural

7 hospice program.

8 (II) SPECIFIC SITE.—The Sec9 retary shall select as a demonstration

10 site the State in which (according to

11 the Hospital Referral Region of Resi12 dence, 1994–1995, as listed in the

13 Dartmouth Atlas of Health Care

14 1998) the largest metropolitan area of

15 the State had the lowest percentage of

16 medicare beneficiary deaths in a hos17 pital when compared to the largest

18 metropolitan area of each other State,

19 and the percentage of enrollees who

20 experienced intensive care during the

21 last 6 months of life was 21.5 percent.

22 (C) PROPOSALS.—

23 (i) IN GENERAL.—The Secretary shall

24 accept proposals by any State hospice asso25 ciation, hospice program, or consortium of
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1 hospice programs at such time, in such

2 manner, and in such form as the Secretary

3 may reasonably require.

4 (ii) RESEARCH DESIGNS.—The Sec5 retary shall permit research designs that

6 use time series, sequential implementation

7 of the intervention, randomization by wait

8 list, and other designs that allow the

9 strongest possible implementation of the

10 demonstration projects, while still allowing

11 strong evaluation about the merits of the

12 demonstration projects.

13 (D) FACILITATION OF EVALUATION.—The

14 Secretary shall design the program to facilitate

15 the evaluation conducted under paragraph (7).

16 (6) DURATION.—The Secretary shall complete

the demonstration projects within a period of 61 17 ⁄2

18 years that includes a period of 18 months during

19 which the Secretary shall complete the evaluation

20 under paragraph (7).

21 (7) EVALUATION.—During the 18-month period

22 following the first 5 years of the demonstration

23 projects, the Secretary shall complete an evaluation

24 of the demonstration projects in order to

25 determine—
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1 (A) the short-term and long-term costs and

2 benefits of changing hospice care provided

3 under the medicare program to include the

4 items, services, and reimbursement options pro5 vided under the demonstration projects;

6 (B) whether any increase in payments for

7 the hospice care provided under the medicare

8 program are offset by savings in other parts of

9 the medicare program;

10 (C) the projected cost of implementing the

11 demonstration projects on a national basis; and

12 (D) in consultation with hospice organiza13 tions and hospice programs (including organiza14 tions and providers that represent rural areas),

15 whether a payment system based on diagnosis16 related groups is useful for administering the

17 hospice care provided under the medicare pro18 gram.

19 (8) REPORTS TO CONGRESS.—

20 (A) PRELIMINARY REPORT.—Not later

21 than 3 years after the date of enactment of this

22 Act, the Secretary shall submit to the Com23 mittee on Ways and Means of the House of

24 Representatives and to the Committee on Fi-
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1 nance of the Senate a preliminary report on the

2 progress made in the demonstration projects.

3 (B) INTERIM REPORT.—Not later than 30

4 months after the implementation of the dem5 onstration projects, the Secretary, in consulta6 tion with participants in the projects, shall sub7 mit to the committees described in subpara8 graph (A) an interim report on the demonstra9 tion projects.

10 (C) FINAL REPORT.—Not later than the

11 date on which the demonstration projects end,

12 the Secretary shall submit a final report to the

13 committees described in subparagraph (A) on

14 the demonstration projects that includes the re15 sults of the evaluation conducted under para16 graph (7) and recommendations for appropriate

17 legislative changes.

18 (9) WAIVER OF MEDICARE REQUIREMENTS.—

19 The Secretary shall waive compliance with such re20 quirements of the medicare program to the extent

21 and for the period the Secretary finds necessary to

22 conduct the demonstration projects.

23 (10) SPECIAL RULES FOR PAYMENT OF

24 MEDICARE+CHOICE ORGANIZATIONS.—The Sec25 retary shall establish procedures under which the
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1 Secretary provides for an appropriate adjustment in

2 the monthly payments made under section 1853 of

3 the Social Security Act (42 U.S.C. 1395w–23) to

4 any Medicare+Choice organization offering a

5 Medicare+Choice plan to reflect the participation of

6 each seriously ill medicare beneficiary enrolled in

7 such plan in a demonstration project.

8 (c) HOSPICE EDUCATION GRANT PROGRAM.—

9 (1) IN GENERAL.—The Secretary shall establish

10 a Hospice Education Grant program under which

11 the Secretary awards education grants to entities

12 participating in the demonstration projects for the

13 purpose of providing information about—

14 (A) the hospice care under the medicare

15 program; and

16 (B) the benefits available to medicare

17 beneficiaries under the demonstration projects.

18 (2) USE OF FUNDS.—Grants awarded under

19 paragraph (1) shall be used—

20 (A) to provide—

21 (i) individual or group education to

22 medicare beneficiaries and the families of

23 such beneficiaries; and
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1 (ii) individual or group education of

2 the medical and mental health community

3 caring for medicare beneficiaries; and

4 (B) to test strategies to improve the gen5 eral public knowledge about hospice care under

6 the medicare program and the benefits available

7 to medicare beneficiaries under the demonstra8 tion projects.

9 (d) FUNDING.—

10 (1) HOSPICE DEMONSTRATION PROJECTS.—

11 (A) IN GENERAL.—Except as provided in

12 subparagraph (B), the Secretary shall provide

13 for the transfer from the Federal Hospital In14 surance Trust Fund under section 1817 of the

15 Social Security Act (42 U.S.C. 1395i) such

16 sums as may be necessary to carry out this sec17 tion.

18 (B) SUPPORTIVE AND COMFORT CARE

19 BENEFIT.—The Secretary shall provide for the

20 transfer from the Federal Hospital Insurance

21 Trust Fund under section 1817 of the Social

22 Security Act (42 U.S.C. 1395i) and the Federal

23 Supplementary Medical Insurance Trust Fund

24 established under section 1841 of such Act (42

25 U.S.C. 1395t), in such proportion as the Sec-
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1 retary determines is appropriate, such sums as

2 may be necessary to provide for payment of the

3 costs attributable to the supportive and comfort

4 care benefit.

5 (2) HOSPICE EDUCATION GRANTS.—The Sec6 retary shall expend such sums as may be necessary

7 for the purposes of carrying out the Hospice Edu8 cation Grant program established under subsection

9 (c)(1) from the Research and Demonstration Budget

10 of the Centers for Medicare & Medicaid Services.

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