I 
108TH CONGRESS 
1ST SESSION H. R. 2507
To amend the Public Health Service Act to provide for a public response 
to the public health crisis of pain, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JUNE 18, 2003
Ms. HOOLEY of Oregon introduced the following bill; which was referred to 
the Committee on Energy and Commerce, and in addition to the Com-
mittee on Ways and Means, for a period to be subsequently determined 
by the Speaker, in each case for consideration of such provisions as fall 
within the jurisdiction of the committee concerned 
A BILL 
To amend the Public Health Service Act to provide for 
a public response to the public health crisis of pain, 
and for other purposes.
Be it enacted by the Senate and House of Representa-
tives 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 2003’’. 
(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 symp-
tom 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 af-
fecting 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 experi-
ence 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 profes-
sionals, pain is often under-treated because of the 
inadequate training of clinicians in pain manage-
ment; 
(7) despite the best intentions of physicians, 
nurses, pharmacists, mental health professionals, 
and other health care professionals, pain and symp-
tom 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 ade-
quately 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 termi-
nally 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 other-
wise 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 condi-
tions for which treatment toward a cure or reason-
able improvement is not possible, and whose focus of 
care is palliative rather than curative. 
(3) FAMILY
SUPPORT
NETWORK.—The term 
‘‘family support network’’ means an association of 2 
or more individuals or entities in a collaborative ef-
fort to develop multi-disciplinary integrated patient 
care approaches that involve medical staff and ancil-
lary services to provide support to chronic pain pa-
tients and patients at the end of life and their care-
givers 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 SERV-
ICES.—The term ‘‘medication therapy management 
services’’ means consultations with a physician or 
other health care professional (including a phar-
macist) who is practicing within the scope of the 
professional’s license, concerning a patient which re-
sults 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 harm-
ful 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 care-
giver 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 medica-
tion therapy. 
(6) PAIN AND SYMPTOM MANAGEMENT.—The 
term ‘‘pain and symptom management’’ means serv-
ices provided to relieve physical or psychological pain 
or suffering, including any 1 or more of the fol-
lowing 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 dis-
tressing symptoms; 
(D) integrates the psychological and spir-
itual aspects of patient care; 
(E) offers a support system to help pa-
tients 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 
RE-
SPONSE 
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 Sec-
retary, acting through the Agency for Healthcare Re-
search 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 require-
ments 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 un-
derserved 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 avail-
able 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 per-
mitting 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 pub-
lished 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 infor-
mation, 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 re-
lief, when receiving benefits under such program. 
(b) PROGRAMS.—The programs described in this sub-
section 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 Pro-
gram 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 Sec-
retary. 
SEC. 103. QUALITY IMPROVEMENT EDUCATION PROJECTS. 
The Secretary shall provide funds for the implemen-
tation of special education projects, in as many States as 
is practicable, to be carried out by peer review organiza-
tions 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 man-
agement 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 IN-
FORMATION. 
(a) IN GENERAL.—Section 1851(d)(4) of the Social 
Security Act (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 eval-
uation (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 symp-
tom management, including such manage-
ment as part of end of life care. Data shall 
be posted in a comparable manner for con-
sumer 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 sec-
tion 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, 2004, 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 lev-
els to providing adequate pain and symptom man-
agement; 
(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 ac-
cess 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 facili-
ties; 
(5) an identification of patient and family atti-
tudes that may exist which pose barriers in access-
ing pain and symptom management or in the proper 
use of pain medications; 
(6) an evaluation of medical, nursing, and phar-
macy 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 pa-
tients at the end of life.
TITLE II—DEVELOPING 
COMMUNITY RESOURCES 
SEC. 201. FAMILY SUPPORT NETWORKS IN PAIN AND SYMP-
TOM 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 re-
ferred 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 chron-
ically ill patients for whom pain is a significant symptom) 
and those individuals in need of pain and symptom man-
agement 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 symp-
tom management and palliative care services; 
and 
(B) prepare and submit to the Secretary 
an application (to be peer reviewed by a com-
mittee established by the Secretary), at such 
time, in such manner, and containing such in-
formation as the Secretary may require.
(2) DISTRIBUTION.—In providing for the estab-
lishment of Networks under subsection (a), the Sec-
retary 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 interdiscipli-
nary approach, that includes psychological and coun-
seling services, to the delivery of pain and symptom 
management; 
(2) shall provide community leadership in estab-
lishing 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 edu-
cation 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 manage-
ment; 
(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 manage-
ment of a patient’s pain 24 hours a day, 7 days a 
week; and 
(8) may include complimentary medicine pro-
vided in conjunction with traditional medical serv-
ices. 
(d) PROVIDER PAIN AND SYMPTOM MANAGEMENT 
COMMUNICATIONS PROJECTS.—
(1) IN GENERAL.—Each Network shall estab-
lish a process to provide health care personnel with 
information 24 hours a day, 7 days a week, con-
cerning pain and symptom management. Such proc-
ess shall be designed to test the effectiveness of spe-
cific forms of communications with health care per-
sonnel so that such personnel may obtain informa-
tion to ensure that all appropriate patients are pro-
vided with pain and symptom management. 
(2) TERMINATION.—The requirement of para-
graph (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 evalua-
tion and prepare and submit to the Secretary a re-
port 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 sup-
port 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 2004 through 2006. 
TITLE III—REIMBURSEMENT 
BARRIERS 
SEC. 301. REIMBURSEMENT BARRIERS REPORT. 
The 
Medicare 
Payment 
Advisory 
Commission 
(MedPac) established under section 1805 of the Social Se-
curity Act (42 U.S.C. 1396b–6) shall conduct a study, and 
prepare and submit to the appropriate committees of Con-
gress a report, concerning—
(1) the manner in which medicare policies may 
pose barriers in providing pain and symptom man-
agement and palliative care services in different set-
tings, 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 inter-
disciplinary 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 Commis-
sion 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 ad-
justments that would assist in assuring patient ac-
cess to pain and symptom management through hos-
pice 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 medi-
cation 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 insur-
ance providers, including managed care entities, to deter-
mine whether the reimbursement policies of such insurers 
inhibit the access of chronic pain patients to pain and 
symptom management and pain and symptom manage-
ment for those in need of end-of-life care (including pa-
tients 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
(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 Com-
mittee established under subsection (a) shall include—
(1) the development of recommendations to cre-
ate a coordinated Federal agenda on pain and symp-
tom management; 
(2) the development of proposals to ensure that 
pain is considered as the fifth vital sign for all pa-
tients; 
(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, re-
search 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 improve-
ment in access to pain and symptom management 
and improvement in the delivery of care; 
(7) the development of ongoing strategies to as-
sure the aggressive use of pain medications, includ-
ing 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 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 manage-
ment with respect to pain management. 
(f) CONSULTATION.—In carrying out this section, the 
Advisory Committee shall consult with all Federal agen-
cies 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 man-
agement. 
(g) ADMINISTRATIVE SUPPORT; TERMS OF SERVICE; 
OTHER PROVISIONS.—The following shall apply with re-
spect to the Advisory Committee: 
(1) The Committee shall receive necessary and 
appropriate administrative support, including appro-
priate 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 in-
curred had they not been a member of the Com-
mittee.
(4) The requirements of Appendix 2 of title 5, 
United States Code. 
SEC. 402. INSTITUTES OF MEDICINE REPORT ON CON-
TROLLED 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 regula-
tion 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 regu-
latory barriers, if any, that may impact patient ac-
cess to medications used for pain and symptom man-
agement; 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 includ-
ing mental health services to chronic pain patients and 
those needing end-of-life care. The Secretary shall use un-
obligated 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 IM-
PROVEMENT IN PAIN AND SYMPTOM MAN-
AGEMENT. 
(a) IN GENERAL.—The Secretary, acting through the 
Health Resources Services Administration, shall award 
grants for the establishment of not less than 5 demonstra-
tion projects to determine effective methods to measure 
improvement in the skills, knowledge, and attitudes and 
beliefs of health care personnel in pain and symptom man-
agement 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 sub-
section (a) shall be evaluated to determine patient and 
caregiver knowledge and attitudes toward pain and symp-
tom 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 man-