II

106TH CONGRESS

2D SESSION S. 3026

To establish a hospice demonstration and grant program for beneficiaries

under the Medicare Program under title XVIII of the Social Security

Act, and for other purposes.

IN THE SENATE OF THE UNITED STATES

SEPTEMBER 12, 2000

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

to the Committee on Finance

A BILL

To establish a hospice demonstration and grant program

for beneficiaries under the Medicare Program under title

XVIII of the Social Security Act, and for other purposes.

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 2000’’.

6 SEC. 2. FINDINGS.

7 Congress makes the following findings:

(1) Each year more than 1 8 ⁄3 of the people who

9 die suffer from a chronic illness.
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(2) Approximately 1 1 ⁄3 of Americans are unsure

2 about whom to contact to get the best care during

3 life’s last stages.

4 (3) Americans want a team of professionals to

5 care for the patient at the end of life.

6 (4) Americans want emotional and spiritual

7 support for the patient and family.

8 (5) Ninety percent of Americans do not realize

9 that hospice care is a benefit provided under the

10 medicare program under title XVIII of the Social

11 Security Act (42 U.S.C. 1395 et seq.).

12 (6) Health Care Financing Administration data

13 show that beneficiaries were enrolled in hospice for

14 an average of less than 7 weeks in 1998, far less

15 than the full 6-month benefit under the medicare

16 program.

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

18 although the average hospice enrollment is longer,

19 half of the enrollees live only 30 days after admis20 sion and almost 20 percent die within 1 week of en21 rollment.

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 PROGRAM AND HOS2 PICE EDUCATION GRANTS.

3 (a) DEFINITIONS.—In this section:

4 (1) DEMONSTRATION PROGRAM.—The term

5 ‘‘demonstration program’’ means the Hospice Dem6 onstration Program established by the Secretary

7 under subsection (b)(1).

8 (2) MEDICARE BENEFICIARY.—The term

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

10 entitled to benefits under part A or enrolled under

11 part B of the medicare program, including any indi12 vidual enrolled in a Medicare+Choice plan offered

13 by a Medicare+Choice organization under part C of

14 such program.

15 (3) MEDICARE HOSPICE SERVICES.—The term

16 ‘‘medicare hospice services’’ means the items and

17 services for which payment may be made under sec18 tion 1814(i) of the Social Security Act (42 U.S.C.

19 1395f(i)).

20 (4) MEDICARE PROGRAM.—The term ‘‘medicare

21 program’’ means the health benefits program under

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

23 1395 et seq.).

24 (5) SECRETARY.—The term ‘‘Secretary’’ means

25 the Secretary of Health and Human Services, acting
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1 through the Administrator of the Health Care Fi2 nancing Administration.

3 (b) HOSPICE DEMONSTRATION PROGRAM.—

4 (1) ESTABLISHMENT.—The Secretary shall es5 tablish a Hospice Demonstration Program in accord6 ance with the provisions of this subsection to in7 crease the utility of the medicare hospice services for

8 medicare beneficiaries.

9 (2) SERVICES UNDER DEMONSTRATION PRO10 GRAM.—The provisions of section 1814(i) of the So11 cial Security Act (42 U.S.C. 1395f(i)) shall apply to

12 the payment for items and services provided under

13 the demonstration program, except that—

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

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

16 Secretary shall provide for reimbursement for

17 items and services provided under the sup18 portive and comfort care benefit established

19 under paragraph (3);

20 (B) any licensed nurse practitioner or phy21 sician assistant may certify a medicare bene22 ficiary as the primary care provider when nec23 essary and within the scope of practice of such

24 practitioner or assistant under State law;
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1 (C) if a community does not have a quali2 fied social worker, any professional who has the

3 necessary knowledge, skills, and ability (other

4 than social workers) to provide medical social

5 services shall provide such services;

6 (D) the Secretary shall waive any require7 ment that nursing facilities used for respite

8 care have skilled nurses on the premises 24

9 hours per day;

10 (E) the Secretary shall permit respite care

11 to be provided to the medicare beneficiary at

12 home; and

13 (F) the Secretary shall waive reimburse14 ment regulations to provide—

15 (i) reimbursement for consultations

16 and preadmission informational visits, even

17 if the medicare beneficiary does not choose

18 hospice care (including the supportive and

19 comfort care benefit under paragraph (3))

20 at that time;

21 (ii) a minimum payment for medicare

22 hospice services provided under the dem23 onstration program based on the provision

24 of medicare hospice services to a medicare

25 beneficiary for a period of 14 days, that
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1 the Secretary shall pay to any hospice pro2 vider participating in the demonstration

3 program and providing such services (re4 gardless of the length of stay of the medi5 care beneficiary);

6 (iii) an increase in the reimbursement

7 rates for hospice services to offset—

8 (I) changes in medicare hospice

9 services and oversight under the dem10 onstration program;

11 (II) the higher costs of providing

12 medicare hospice services in rural

13 areas due to lack of economies of

14 scale or large geographic areas; and

15 (III) the higher costs of pro16 viding medicare hospice services in

17 urban underserved areas due to

18 unique costs specifically associated

19 with people living in those areas, in20 cluding providing security;

21 (iv) direct payment of any nurse prac22 titioner or physician assistant practicing

23 within the scope of State law in relation to

24 medicare hospice services provided by such

25 practitioner or assistant; and
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1 (v) a per diem rate of payment for in2 home care under subparagraph (E) that

3 reflects the range of care needs of the

4 medicare beneficiary and that—

5 (I) in the case of a medicare ben6 eficiary that needs routine care, is not

7 less than 150 percent, and not more

8 than 200 percent, of the routine home

9 care rate for medicare hospice serv10 ices; and

11 (II) in the case of a medicare

12 beneficiary that needs acute care, is

13 equal to the continuous home care day

14 rate for medicare hospice services.

15 (3) SUPPORTIVE AND COMFORT CARE BEN16 EFIT.—

17 (A) IN GENERAL.—For purposes of the

18 demonstration program, the Secretary shall es19 tablish a supportive and comfort care benefit

20 for any eligible medicare beneficiary (as defined

21 in subparagraph (C)).

22 (B) BENEFIT.—Under the supportive and

23 comfort care benefit established under subpara24 graph (A), any eligible medicare beneficiary

25 may—
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1 (i) continue to receive benefits for dis2 ease and symptom modifying treatment

3 under the medicare program (and the Sec4 retary may not require or prohibit any spe5 cific treatment or decision);

6 (ii) receive case management and

7 medicare hospice services through a hos8 pice provider, which the Secretary shall re9 imburse on a fee-for-service basis; and

10 (iii) receive information and experi11 ence in order to better understand the util12 ity of medicare hospice services.

13 (C) ELIGIBLE MEDICARE BENEFICIARY DE14 FINED.—

15 (i) IN GENERAL.—In this paragraph,

16 the term ‘‘eligible medicare beneficiary’’

17 means any medicare beneficiary with a se18 rious illness that has been documented by

19 a physician to be at a level of severity de20 termined by the Secretary to meet the cri21 teria developed under clause (ii).

22 (ii) DEVELOPMENT OF CRITERIA.—

23 (I) IN GENERAL.—The Secretary,

24 in consultation with hospice providers

25 and experts in end-of-life care, shall
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1 develop criteria for determining the

2 level of severity of an established seri3 ous illness taking into account the

4 factors described in subclause (II).

5 (II) FACTORS.—The factors de6 scribed in this clause include the level

7 of function of the medicare bene8 ficiary, any coexisting illnesses of the

9 beneficiary, and the severity of any

10 chronic condition that will lead to the

11 death of the beneficiary.

12 (III) PROGNOSIS NOT A BASIS

13 FOR CRITERIA.—The Secretary may

14 not base the criteria developed under

15 this subparagraph on the prognosis of

16 a medicare beneficiary.

17 (4) CONDUCT OF PROGRAM.—Under the dem18 onstration program, the Secretary shall—

19 (A) accept proposals submitted by any

20 State hospice association;

21 (B)(i) except as provided in clause (ii),

22 conduct the program in at least 3, but not more

23 than 6, geographic areas (which may be state24 wide) that include both urban and rural hospice

25 providers; and
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1 (ii) if a geographic area does not have any

2 rural hospice provider available to participate in

3 the demonstration program, such area may sub4 stitute an underserved urban area, but the Sec5 retary shall give priority to those proposals that

6 include a rural hospice provider;

7 (C)(i) except for the geographic area des8 ignated under clause (ii), select such geographic

9 areas so that such areas are geographically di10 verse and readily accessible to a significant

11 number of medicare beneficiaries; and

12 (ii) designate as such an area 1 State in

13 which the largest metropolitan area of such

14 State had the lowest percentage of medicare

15 beneficiary deaths in a hospital compared to the

16 largest metropolitan area of each other State

17 according to the Hospital Referral Region of

18 Residence, 1994–1995, as listed in the Dart19 mouth Atlas of Health Care 1998;

20 (D) provide for the participation of medi21 care beneficiaries in such program on a vol22 untary basis;

23 (E) permit research designs that use time

24 series, sequential implementation of the inter25 vention, randomization by wait list, and other
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1 designs that allow the strongest possible imple2 mentation of the demonstration program, while

3 still allowing strong evaluation about the merits

4 of the demonstration program; and

5 (F) design the program to facilitate the

6 evaluation conducted under paragraph (6).

7 (5) DURATION.—The Secretary shall complete

the demonstration program within a period of 61 8 ⁄2

9 years that includes a period of 18 months during

10 which the Secretary shall complete the evaluation

11 under paragraph (6).

12 (6) EVALUATION.—During the 18-month period

13 following the first 5 years of the demonstration pro14 gram, the Secretary shall complete an evaluation of

15 the demonstration program in order to determine—

16 (A) the short-term and long-term costs and

17 benefits of changing medicare hospice services

18 to include the items, services, and reimburse19 ment options provided under the demonstration

20 program;

21 (B) whether increases in payments for the

22 medicare hospice benefit are offset by savings

23 in other parts of the medicare program;

24 (C) the projected cost of implementing the

25 demonstration program on a national basis; and
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1 (D) in consultation with hospice organiza2 tions and hospice providers (including organiza3 tions and providers that represent rural areas),

4 whether a payment system based on diagnosis5 related groups is useful for administering the

6 medicare hospice benefit.

7 (7) REPORTS TO CONGRESS.—

8 (A) PRELIMINARY REPORT.—Not later

9 than 3 years after the date of enactment of this

10 Act, the Secretary shall submit a preliminary

11 report to the Committee on Ways and Means of

12 the House of Representatives and to the Com13 mittee on Finance of the Senate on the

14 progress made in the demonstration program.

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

16 months after the implementation of the dem17 onstration program, the Secretary, in consulta18 tion with participants in the program, shall sub19 mit an interim report on the demonstration pro20 gram to the committees described in subpara21 graph (A).

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

23 date on which the demonstration program ends,

24 the Secretary shall submit a final report to the

25 committees described in subparagraph (A) on
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1 the demonstration program that includes the

2 results of the evaluation conducted under para3 graph (6) and recommendations for appropriate

4 legislative changes.

5 (8) WAIVER OF MEDICARE REQUIREMENTS.—

6 The Secretary shall waive compliance with such re7 quirements of the medicare program to the extent

8 and for the period the Secretary finds necessary for

9 the conduct of the demonstration program.

10 (9) SPECIAL RULES FOR PAYMENT OF

11 MEDICARE+CHOICE ORGANIZATIONS.—The Sec12 retary shall establish procedures under which the

13 Secretary provides for an appropriate adjustment in

14 the monthly payments made under section 1853 of

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

16 any Medicare+Choice organization offering a

17 Medicare+Choice plan in which a medicare bene18 ficiary that participates in the demonstration pro19 gram is enrolled to reflect such participation.

20 (c) HOSPICE EDUCATION GRANTS.—

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

22 a Hospice Education Grant program under which

23 the Secretary awards education grants to entities

24 participating in the demonstration program for the

25 purpose of providing information about—
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1 (A) the medicare hospice benefit; and

2 (B) the benefits available to medicare

3 beneficiaries under the demonstration program.

4 (2) USE OF FUNDS.—Grants awarded pursuant

5 to paragraph (1) shall be used—

6 (A) to provide—

7 (i) individual or group education to

8 medicare beneficiaries and their families;

9 and

10 (ii) individual or group education of

11 the medical and mental health community

12 caring for medicare beneficiaries; and

13 (B) to test strategies to improve the gen14 eral public knowledge about the medicare hos15 pice benefit and the benefits available to medi16 care beneficiaries under the demonstration pro17 gram.

18 (d) FUNDING.—

19 (1) HOSPICE DEMONSTRATION PROGRAM.—

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

21 subparagraph (B), expenditures made for the

22 demonstration program shall be in lieu of the

23 funds that would have been provided to partici24 pating hospices under section 1814(i) of the So25 cial Security Act (42 U.S.C. 1395f(i)).
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1 (B) SUPPORTIVE AND COMFORT CARE

2 BENEFIT.—The Secretary shall pay any ex3 penses for the supportive and comfort care ben4 efit established under subsection (a)(3) from

5 the Federal Hospital Insurance Trust Fund es6 tablished under section 1817 of the Social Secu7 rity Act (42 U.S.C. 1395i) and the Federal

8 Supplementary Medical Insurance Trust Fund

9 established under section 1841 of such Act (42

10 U.S.C. 1395t), in such proportion as the Sec11 retary determines is appropriate.

12 (2) HOSPICE EDUCATION GRANTS.—The Sec13 retary is authorized to expend such sums as may be

14 necessary for the purposes of carrying out the Hos15 pice Education Grant program established under

16 subsection (c)(1) from the Research and Demonstra17 tion Budget of the Health Care Financing Adminis18 tration.

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