II 113th CONGRESS 1st Session S. 641 IN THE SENATE OF THE UNITED STATES March 21, 2013 Mr. Wyden (for himself and Mr. Reed ) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL To amend the Public Health Service Act to increase the number of permanent faculty in palliative care at accredited allopathic and osteopathic medical schools, nursing schools, and other programs, to promote education in palliative care and hospice, and to support the development of faculty careers in academic palliative medicine.

1. Short title This Act may be cited as the Palliative Care and Hospice Education and Training Act . 2. Findings Congress makes the following findings: (1) Health care providers need better education about pain management and palliative care. Students graduating from medical school have very little, if any, training in the core precepts of pain and symptom management, advance care planning, communication skills, and care coordination for patients with serious, life-threatening, or terminal illness. (2) Palliative care is interdisciplinary, patient- and family-centered health care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness, whatever the diagnosis. The goal of palliative care is to relieve suffering and improve quality of life for both patients and their families. Palliative care is provided by a team of doctors, nurses, social workers, chaplains, and other specialists who work with a patient’s other health care providers to provide an extra layer of support, including assistance with difficult medical decisionmaking and coordination of care among specialists. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment. Palliative care is not dependent on a life-limiting prognosis and may actually help an individual recover from illness by relieving symptoms, such as pain, anxiety, or loss of appetite, while undergoing sometimes difficult medical treatments or procedures, such as surgery or chemotherapy. There were 1,623 hospitals with palliative care programs in 2012. (3) Hospice is palliative care for patients in their last year of life. Considered the model for quality compassionate care for individuals facing a life-limiting illness, hospice provides expert medical care, pain management, and emotional and spiritual support expressly tailored to the patient’s needs and wishes. In most cases, care is provided in the patient’s home but may also be provided in freestanding hospice centers, hospitals, nursing homes, and other long-term care facilities. In 2011, an estimated 1,650,000 patients received services from hospice, and nearly 45 percent of all deaths in the United States occurred under the care of a hospice program. Hospice is a covered benefit under the Medicare program. There were 3,630 Medicare-certified hospices serving more than 1,200,000 beneficiaries in 2011. (4) A 2005 study at Michigan State University found that the formal training of United States doctors in palliative care is grossly inadequate . When the American Society of Clinical Oncology surveyed their members, 65 percent said they had received inadequate education in controlling symptoms associated with cancer, and 81 percent felt they had inadequate mentoring in discussing a poor prognosis with their patients and families. Training in pediatric palliative care is also seriously lacking according to physicians, residents, and medical students responding to a survey presented at a meeting of American Federation for Medical Research. (5) The American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education (ACGME) provided formal subspecialty status for hospice and palliative medicine (HPM) in 2006, and the Centers for Medicare & Medicaid Services recognized hospice and palliative medicine as a medical subspecialty in October of 2008. (6) As of February 2013, there were a total of 89 hospice and palliative medicine training programs accredited by the Accreditation Council for Graduate Medical Education. For the 2012–2013 academic year, these programs were training 206 physicians in hospice and palliative medicine. Some programs include an additional track in research, geriatrics, or public health. (7) There is a large gap between those practicing in the palliative medicine field and the number of physicians needed. A mid-range estimate by the American Academy of Hospice and Palliative Medicine’s Workforce Task Force calls for 6,000 or more full time equivalents to serve current needs in hospice and palliative care programs. At maximum capacity, the current system would produce roughly 4,600 new hospice and palliative medicine certified physicians over the next 20 years, during which time some 70,000,000 new Medicare beneficiaries will enter the Medicare program. At the same time, there is expected to be increasing acceptance of the hospice and palliative approach to care among the general population and health care providers. 3. Palliative care and hospice education and training (a) In general Part D of title VII of the Public Health Service Act (42 U.S.C. 294 et seq.) is amended by adding at the end the following: 759A. Palliative care and hospice education and training (a) Palliative care and hospice education centers (1) In general The Secretary shall award grants or contracts under this section to entities described in paragraph (1), (3), or (4) of section 799B, and section 801(2), for the establishment or operation of Palliative Care and Hospice Education Centers that meet the requirements of paragraph (2). (2) Requirements A Palliative Care and Hospice Education Center meets the requirements of this paragraph if such Center— (A) improves the training of health professionals in palliative care, including residencies, traineeships, or fellowships; (B) develops and disseminates curricula relating to the palliative treatment of the complex health problems of individuals with serious or life-threatening illnesses; (C) supports the training and retraining of faculty to provide instruction in palliative care; (D) supports continuing education of health professionals who provide palliative care to patients with serious or life-threatening illness; (E) provides students (including residents, trainees, and fellows) with clinical training in palliative care in the home, long-term care facilities, home care, hospices, chronic and acute disease hospitals, and ambulatory care centers; (F) establishes traineeships for individuals who are preparing for advanced education nursing degrees in palliative care nursing, home care, hospice, in the home, long-term care, or other nursing areas that specialize in palliative care; and (G) does not duplicate the activities of existing education centers funded under this section or under section 753 or 865. (3) Expansion of existing centers Nothing in this section shall be construed to— (A) prevent the Secretary from providing grants to expand existing education centers, including geriatric education centers established under section 753 or 865, to provide for education and training focused specifically on palliative care, including for non-geriatric populations; or (B) limit the number of education centers that may be funded in a community. (b) Palliative medicine physician training (1) In general The Secretary may make grants to, and enter into contracts with, schools of medicine, schools of osteopathic medicine, teaching hospitals, and graduate medical education programs, for the purpose of providing support for projects that fund the training of physicians (including residents, trainees, and fellows) who plan to teach palliative medicine. (2) Requirements Each project for which a grant or contract is made under this subsection shall— (A) be staffed by full-time teaching physicians who have experience or training in palliative medicine; (B) be based in a hospice and palliative medicine fellowship program accredited by the Accreditation Council for Graduate Medical Education; (C) provide training in palliative medicine through a variety of service rotations, such as consultation services, acute care services, extended care facilities, ambulatory care and comprehensive evaluation units, hospice, home health, and community care programs; (D) develop specific performance-based measures to evaluate the competency of trainees; and (E) provide training in palliative medicine through one or both of the training options described in subparagraphs (A) and (B) of paragraph (3). (3) Training options The training options referred to in subparagraph (E) of paragraph (2) shall be as follows: (A) 1-year retraining programs in hospice and palliative medicine for physicians who are faculty at schools of medicine and osteopathic medicine, or others determined appropriate by the Secretary. (B) 1- or 2-year training programs that shall be designed to provide training in hospice and palliative medicine for physicians who have completed graduate medical education programs in any medical specialty leading to board eligibility in hospice and palliative medicine pursuant to the American Board of Medical Specialties. (4) Definitions For purposes of this subsection the term graduate medical education means a program sponsored by a school of medicine, a school of osteopathic medicine, a hospital, or a public or private institution that— (A) offers postgraduate medical training in the specialties and subspecialties of medicine; and (B) has been accredited by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association through its Committee on Postdoctoral Training. (c) Palliative medicine and hospice academic career awards (1) Establishment of program The Secretary shall establish a program to provide awards, to be known as the Palliative Medicine and Hospice Academic Career Awards , to eligible individuals to promote the career development of such individuals as academic hospice and palliative care physicians. (2) Eligible individuals To be eligible to receive an award under paragraph (1), an individual shall— (A) be board certified or board eligible in hospice and palliative medicine; and (B) have a junior (non-tenured) faculty appointment at an accredited (as determined by the Secretary) school of medicine or osteopathic medicine. (3) Limitations No award under paragraph (1) may be made to an eligible individual unless the individual— (A) has submitted to the Secretary an application, at such time, in such manner, and containing such information as the Secretary may require, and the Secretary has approved such application; (B) provides, in such form and manner as the Secretary may require, assurances that the individual will meet the service requirement described in paragraph (6); and (C) provides, in such form and manner as the Secretary may require, assurances that the individual has a full-time faculty appointment in a health professions institution and documented commitment from such institution to spend a majority of the total funded time of such individual on teaching and developing skills in interdisciplinary education in palliative care. (4) Maintenance of effort An eligible individual who receives an award under paragraph (1) shall provide assurances to the Secretary that funds provided to the eligible individual under this subsection will be used only to supplement, not to supplant, the amount of Federal, State, and local funds otherwise expended by the eligible individual. (5) Amount and term (A) Amount The amount of an award under this subsection shall be equal to the award amount provided for under section 753(c)(5)(A) for the fiscal year involved. (B) Term The term of an award made under this subsection shall not exceed 5 years. (C) Payment to institution The Secretary shall make payments for awards under this subsection to institutions which include schools of medicine and osteopathic medicine. (6) Service requirement An individual who receives an award under this subsection shall provide training in palliative care and hospice, including the training of interdisciplinary teams of health care professionals. The provision of such training shall constitute a majority of the total funded obligations of such individual under the award. (d) Palliative care workforce development (1) In general The Secretary shall award grants or contracts under this subsection to entities that operate a Palliative Care and Hospice Education Center pursuant to subsection (a)(1). (2) Application To be eligible for an award under paragraph (1), an entity described in such paragraph shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require. (3) Use of funds Amounts awarded under a grant or contract under paragraph (1) shall be used to carry out the fellowship program described in paragraph (4). (4) Fellowship program (A) In general Pursuant to paragraph (3), a Palliative Care and Hospice Education Center that receives an award under this subsection shall use such funds to offer short-term intensive courses (referred to in this subsection as a fellowship ) that focus on palliative care that provide supplemental training for faculty members in medical schools and other health professions schools with programs in psychology, pharmacy, nursing, social work, chaplaincy, or other health disciplines, as approved by the Secretary. Such a fellowship shall be open to current faculty, and appropriately credentialed volunteer faculty and practitioners, who do not have formal training in palliative care, to upgrade their knowledge and clinical skills for the care of individuals with serious or life-threatening illness and to enhance their interdisciplinary teaching skills. (B) Location A fellowship under this paragraph shall be offered either at the Palliative Care and Hospice Education Center that is sponsoring the course, in collaboration with other Palliative Care and Hospice Education Centers, or at medical schools, schools of nursing, schools of pharmacy, schools of social work, schools of chaplaincy or pastoral care education, graduate programs in psychology, or other health professions schools approved by the Secretary with which the Centers are affiliated. (C) CME credit Participation in a fellowship under this paragraph shall be accepted with respect to complying with continuing health profession education requirements. As a condition of such acceptance, the recipient shall subsequently provide a minimum of 18 hours of voluntary instruction in palliative care content (that has been approved by a palliative care and hospice education center) to students or trainees in health-related educational, home, hospice, or long-term care settings. (5) Targets A Palliative Care and Hospice Education Center that receives an award under this subsection shall meet targets approved by the Secretary for providing palliative care training to a certain number of faculty or practitioners during the term of the award, as well as other parameters established by the Secretary. (6) Amount of award An award under this subsection shall be in an amount of $150,000. Not more than 24 Palliative Care and Hospice Education Centers may receive an award under this subsection. (7) Maintenance of effort A Palliative Care and Hospice Education Center that receives an award under this subsection shall provide assurances to the Secretary that funds provided to the Center under the award will be used only to supplement, not to supplant, the amount of Federal, State, and local funds otherwise expended by such Center. (e) Palliative care and hospice career incentive awards (1) In general The Secretary shall award grants or contracts under this subsection to individuals described in paragraph (2) to foster greater interest among a variety of health professionals in entering the field of palliative care. (2) Eligible individuals To be eligible to receive an award under paragraph (1), an individual shall— (A) be an advanced practice nurse, a clinical social worker, a pharmacist, a chaplain, or student of psychology who is pursuing a doctorate or other advanced degree in palliative care or related fields in an accredited health professions school; and (B) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require. (3) Conditions of award As a condition of receiving an award under this subsection, an individual shall agree that, following completion of the award period, the individual will teach or practice palliative care in health-related educational, home, hospice or long-term care settings for a minimum of 5 years under guidelines established by the Secretary. (4) Payment to institution The Secretary shall make payments for awards under this subsection to institutions which include schools of medicine, osteopathic medicine, nursing, social work, psychology, chaplaincy or pastoral care education, dentistry, and pharmacy, or other allied health discipline in an accredited health professions school that is approved by the Secretary. (f) Authorization of appropriations There are authorized to be appropriated to carry out this section, $44,100,000 for each of the fiscal years 2014 through 2018. . (b) Effective date The amendment made by this section shall be effective beginning on the date that is 90 days after the date of enactment of this Act. 4. Application to advanced practice nurses (a) Advanced education nursing grants Section 811(a) of the Public Health Service Act ( 42 U.S.C. 296j(a) ) is amended— (1) in paragraph (1), by striking and at the end; (2) by redesignating paragraph (2) as paragraph (3); and (3) by inserting after paragraph (1), the following: (2) palliative care and hospice career incentive awards authorized under section 759A(e); and . (b) In general Part D of title VIII of the Public Health Service Act (42 U.S.C. 296p et seq.) is amended by adding at the end the following: 832. Palliative care and hospice education and training (a) Program authorized The Secretary shall award grants to eligible entities to develop and implement, in coordination with programs under section 759A, programs and initiatives to train and educate individuals in providing palliative care in health-related educational, hospice, home, or long-term care settings. (b) Use of funds An eligible entity that receives a grant under subsection (a) shall use funds under such grant to— (1) provide training to individuals who will provide palliative care in health-related educational, home, hospice, or long-term care settings; (2) develop and disseminate curricula relating to palliative care in health-related educational, home, hospice, or long-term care settings; (3) train faculty members in palliative care in health-related educational, home, hospice, or long-term care settings; or (4) provide continuing education to individuals who provide palliative care in health-related educational, home, hospice, or long-term care settings. (c) Application An eligible entity desiring a grant under subsection (a) shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may reasonably require. (d) Eligible entity For purposes of this section, the term eligible entity shall include a school of nursing, a health care facility, a program leading to certification as a certified nurse assistant, a partnership of such a school and facility, or a partnership of such a program and facility. (e) Authorization of appropriations There are authorized to be appropriated to carry out this section $5,000,000 for each of fiscal years 2014 through 2018. .