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[DOCID: f:s1425is.txt]






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.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Hospice Improvement Program Act of 
2001''.

SEC. 2. FINDINGS.

    Congress makes the following findings:
            (1) Each year more than \1/3\ of the people who die suffer 
        from a chronic illness.
            (2) Approximately \1/3\ of Americans are unsure about whom 
        to contact to get the best care during life's last stages.
            (3) Americans want a team of professionals to care for the 
        patient at the end of life.
            (4) Americans want emotional and spiritual support for the 
        patient and family.
            (5) Ninety percent of Americans do not realize that hospice 
        care is a benefit provided under the medicare program under 
        title XVIII of the Social Security Act.
            (6) Data of the Centers for Medicare & Medicaid Services 
        show that beneficiaries were enrolled in hospice for an average 
        of less than 7 weeks in 1998, far less than the full 6-month 
        benefit under the medicare program.
            (7) According to the most recent data available, although 
        more medicare beneficiaries are enrolled in hospice, the 
        medicare length of stay has declined.
            (8) Use of hospice among medicare beneficiaries has been 
        decreasing, from a high of 59 days in 1995 to less than 48 days 
        in 1998.

SEC. 3. HOSPICE DEMONSTRATION PROJECTS AND HOSPICE EDUCATION GRANTS.

    (a) Definitions.--In this section:
            (1) Demonstration project.--The term ``demonstration 
        project'' means a demonstration project established by the 
        Secretary under subsection (b)(1).
            (2) Hospice care.--The term ``hospice care'' means the 
        items and services described in subparagraphs (A) through (I) 
        of section 1861(dd)(1) of the Social Security Act (42 U.S.C. 
        1395x(dd)(1)) that are provided to a seriously ill medicare 
        beneficiary under a demonstration project by a hospice program 
        (or by others under an arrangement with such a program) under a 
        written plan for providing such care to such beneficiary 
        established and periodically reviewed by the beneficiary's 
        attending physician, by the medical director of the program, 
        and by the interdisciplinary group described in section 
        1861(dd)(2)(B) of such Act (42 U.S.C. 1395x(dd)(2)(B)).
            (3) Hospice program.--The term ``hospice program'' has the 
        meaning given that term in section 1861(dd)(2) of the Social 
        Security Act (42 U.S.C. 1395x(dd)(2)).
            (4) Medicare beneficiary.--The term ``medicare 
        beneficiary'' means any individual who is entitled to benefits 
        under part A or enrolled under part B of the medicare program.
            (5) Medicare program.--The term ``medicare program'' means 
        the health benefits program under title XVIII of the Social 
        Security Act (42 U.S.C. 1395 et seq.).
            (6) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
            (7) Seriously ill.--The term ``seriously ill'' has the 
        meaning given such term by the Secretary (in consultation with 
        hospice programs and academic experts in end-of-life care), 
        except that the Secretary may not limit such term to 
        individuals who are terminally ill (as defined in section 
        1861(dd)(3) of the Social Security Act (42 U.S.C. 
        1395x(dd)(3))).
    (b) Hospice Demonstration Projects.--
            (1) Establishment.--The Secretary shall establish 
        demonstration projects in accordance with the provisions of 
        this subsection to increase the utility of the hospice care for 
        seriously ill medicare beneficiaries.
            (2) Participation.--
                    (A) Hospice programs.--Except as provided in 
                paragraph (4)(A), only a hospice program with an 
                agreement under section 1866 of the Social Security Act 
                (42 U.S.C. 1395cc), a consortium of such hospice 
                programs, or a State hospice association may 
                participate in the demonstration program.
                    (B) Seriously ill medicare beneficiaries.--The 
                Secretary shall permit any seriously ill medicare 
                beneficiary residing in the service area of a hospice 
                program participating in a demonstration project to 
                participate in such project on a voluntary basis.
            (3) Services under demonstration projects.--The provisions 
        of section 1814(i) of the Social Security Act (42 U.S.C. 
        1395f(i)) shall apply to the payment for hospice care provided 
        under the demonstration projects, except that--
                    (A) notwithstanding section 1862(a)(1)(C) of such 
                Act (42 U.S.C. 1395y(a)(1)(C)), the Secretary shall 
                provide for reimbursement for items and services 
                provided under the supportive and comfort care benefit 
                established under paragraph (3);
                    (B) any licensed nurse practitioner or physician 
                assistant may admit a seriously ill medicare 
                beneficiary as the primary care provider when necessary 
                and within the scope of practice of such practitioner 
or assistant under State law;
                    (C) if a community does not have a qualified social 
                worker, any professional (other than a social worker) 
                who has the necessary knowledge, skills, and ability to 
                provide medical social services may provide such 
                services;
                    (D) the Secretary shall waive any requirement that 
                nursing facilities used for respite care have skilled 
                nurses on the premises 24 hours per day;
                    (E) the Secretary shall permit respite care to be 
                provided to the seriously ill medicare beneficiary at 
                home; and
                    (F) the Secretary shall waive reimbursement 
                regulations to provide--
                            (i) reimbursement for consultations and 
                        preadmission informational visits, even if the 
                        seriously ill medicare beneficiary does not 
                        elect hospice care at that time;
                            (ii) except with respect to the supportive 
                        and comfort care benefit under paragraph (3), a 
                        minimum payment for hospice care provided under 
                        the demonstration projects based on the 
                        provision of hospice care to a seriously ill 
                        medicare beneficiary for a period of 14 days, 
                        that--
                                    (I) the Secretary shall pay to any 
                                hospice 
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program participating in a 
                                demonstration project and providing 
                                such care (regardless of the length of 
                                stay of the seriously ill medicare 
                                beneficiary); and
                                    (II) may not be less than the 
                                amount of payment that would have been 
                                made for hospice care if payment had 
                                been made at the daily rate of payment 
                                for such care under section 1814(i) of 
                                the Social Security Act (42 U.S.C. 
                                1395f(i));
                            (iii) an increase in the reimbursement 
                        rates for hospice care to offset--
                                    (I) changes in hospice care and 
                                oversight under the demonstration 
                                projects;
                                    (II) the higher costs of providing 
                                hospice care in rural areas due to lack 
                                of economies of scale or large 
                                geographic areas; and
                                    (III) the higher costs of providing 
                                hospice care in urban underserved areas 
                                due to unique costs specifically 
                                associated with people living in those 
                                areas, including providing security;
                            (iv) direct payment of any nurse 
                        practitioner or physician assistant practicing 
                        within the scope of State law in relation to 
                        hospice care provided by such practitioner or 
                        assistant; and
                            (v) a per diem rate of payment for in-home 
                        care under subparagraph (E) that reflects the 
                        range of care needs of the seriously ill 
                        medicare beneficiary and that--
                                    (I) in the case of a seriously ill 
                                medicare beneficiary that needs routine 
                                care, is not less than 150 percent, and 
                                not more than 200 percent, of the 
                                routine home care rate for hospice 
                                care; and
                                    (II) in the case of a seriously ill 
                                medicare beneficiary that needs acute 
                                care, is equal to the continuous home 
                                care day rate for hospice care.
            (4) Supportive and comfort care benefit.--
                    (A) In general.--For purposes of the demonstration 
                projects, the Secretary shall establish a supportive 
                and comfort care benefit for any eligible seriously ill 
                medicare beneficiary (as defined in subparagraph (C)).
                    (B) Participation.--Any individual or entity with 
                an agreement under section 1866 of the Social Security 
                Act (42 U.S.C. 1395cc) may furnish items or services 
                covered under the supportive and comfort care benefit.
                    (C) Benefit.--Under the supportive and comfort care 
                benefit, any eligible seriously ill medicare 
                beneficiary may--
                            (i) continue to receive benefits for 
                        disease and symptom modifying treatment under 
                        the medicare program (and the Secretary may not 
                        require or prohibit any specific treatment or 
                        decision);
                            (ii) receive case management and hospice 
                        care through a hospice program participating in 
                        a demonstration project (for which payment 
                        shall be made under paragraph (2)(F)(ii)); and
                            (iii) receive information and education in 
                        order to better understand the utility of 
                        hospice care.
                    (D) Payment.--The Secretary shall establish 
                procedures under which the Secretary pays for items and 
                services furnished to seriously ill medicare 
                beneficiaries under the supportive and comfort care 
                benefit on a fee-for-service basis.
                    (E) Eligible seriously ill medicare beneficiary 
                defined.--
                            (i) In general.--In this paragraph, the 
                        term ``eligible seriously ill medicare 
                        beneficiary'' means any seriously ill medicare 
                        beneficiary that meets the criteria approved by 
                        the Secretary under clause (ii).
                            (ii) Approval of criteria.--
                                    (I) In general.--With respect to 
                                each demonstration project, the 
                                Secretary shall approve criteria for 
                                determining whether a seriously ill 
                                medicare beneficiary is eligible for 
                                hospice care under a demonstration 
                                project that has been developed by 
                                hospice programs in consultation 
with researchers in end-of-life care and the broader medical community.
                                    (II) Data comparability.--The 
                                Secretary may only approve criteria 
                                that ensures that each demonstration 
                                project yields comparable data with 
                                respect to eligible seriously ill 
                                medicare beneficiaries on--
                                            (aa) the utilization of 
                                        services by such beneficiaries;
                                            (bb) the cost of providing 
                                        services to such beneficiaries, 
                                        including any costs associated 
                                        with providing services before 
                                        an individual is terminally ill 
                                        (as defined in section 
                                        1861(dd)(3)(A) of the Social 
                                        Security Act (42 U.S.C. 
                                        1395x(dd)(3)(A))); and
                                            (cc) the effect of the 
                                        demonstration project on the 
                                        quality of care of such 
                                        beneficiaries.
                                    (III) Limitation.--The Secretary 
                                may not approve criteria if the purpose 
                                of such criteria is to segment services 
                                or to provide a benefit for the 
                                chronically ill.
            (5) Conduct of demonstration projects.--
                    (A) Sites.--The Secretary shall conduct 
                demonstration projects in at least 3, but not more than 
                6, sites (which may be statewide).
                    (B) Selection of sites.--
                            (i) In general.--Except as provided in 
                        clause (ii), the Secretary shall select 
                        demonstration sites on the basis of proposals 
                        subm
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itted under subparagraph (C) that are 
                        located in geographic areas that--
                                    (I) include both urban and rural 
                                hospice programs; and
                                    (II) are geographically diverse and 
                                readily accessible to a significant 
                                number of seriously ill medicare 
                                beneficiaries.
                            (ii) Exceptions.--
                                    (I) Underserved urban areas.--If a 
                                geographic area does not have any rural 
                                hospice program available to 
                                participate in a demonstration project, 
                                such area may substitute an underserved 
                                urban area, but the Secretary shall 
                                give priority to those proposals that 
                                include a rural hospice program.
                                    (II) Specific site.--The Secretary 
                                shall select as a demonstration site 
                                the State in which (according to the 
                                Hospital Referral Region of Residence, 
                                1994-1995, as listed in the Dartmouth 
                                Atlas of Health Care 1998) the largest 
                                metropolitan area of the State had the 
                                lowest percentage of medicare 
                                beneficiary deaths in a hospital when 
                                compared to the largest metropolitan 
                                area of each other State, and the 
                                percentage of enrollees who experienced 
                                intensive care during the last 6 months 
                                of life was 21.5 percent.
                    (C) Proposals.--
                            (i) In general.--The Secretary shall accept 
                        proposals by any State hospice association, 
                        hospice program, or consortium of hospice 
                        programs at such time, in such manner, and in 
                        such form as the Secretary may reasonably 
                        require.
                            (ii) Research designs.--The Secretary shall 
                        permit research designs that use time series, 
                        sequential implementation of the intervention, 
                        randomization by wait list, and other designs 
                        that allow the strongest possible 
                        implementation of the demonstration projects, 
                        while still allowing strong evaluation about 
                        the merits of the demonstration projects.
                    (D) Facilitation of evaluation.--The Secretary 
                shall design the program to facilitate the evaluation 
                conducted under paragraph (7).
            (6) Duration.--The Secretary shall complete the 
        demonstration projects within a period of 6\1/2\ years that 
        includes a period of 18 months during which the Secretary shall 
        complete the evaluation under paragraph (7).
            (7) Evaluation.--During the 18-month period following the 
        first 5 years of the demonstration projects, the Secretary 
        shall complete an evaluation of the demonstration projects in 
        order to determine--
                    (A) the short-term and long-term costs and benefits 
                of changing hospice care provided under the medicare 
                program to include the items, services, and 
reimbursement options provided under the demonstration projects;
                    (B) whether any increase in payments for the 
                hospice care provided under the medicare program are 
                offset by savings in other parts of the medicare 
                program;
                    (C) the projected cost of implementing the 
                demonstration projects on a national basis; and
                    (D) in consultation with hospice organizations and 
                hospice programs (including organizations and providers 
                that represent rural areas), whether a payment system 
                based on diagnosis-related groups is useful for 
                administering the hospice care provided under the 
                medicare program.
            (8) Reports to congress.--
                    (A) Preliminary report.--Not later than 3 years 
                after the date of enactment of this Act, the Secretary 
                shall submit to the Committee on Ways and Means of the 
                House of Representatives and to the Committee on 
                Finance of the Senate a preliminary report on the 
                progress made in the demonstration projects.
                    (B) Interim report.--Not later than 30 months after 
                the implementation of the demonstration projects, the 
                Secretary, in consultation with participants in the 
                projects, shall submit to the committees described in 
                subparagraph (A) an interim report on the demonstration 
                projects.
                    (C) Final report.--Not later than the date on which 
                the demonstration projects end, the Secretary shall 
                submit a final report to the committees described in 
                subparagraph (A) on the demonstration projects that 
                includes the results of the evaluation conducted under 
                paragraph (7) and recommendations for appropriate 
                legislative changes.
            (9) Waiver of medicare requirements.--The Secretary shall 
        waive compliance with such requirements of the medicare program 
        to the extent and for the period the Secretary finds necessary 
        to conduct the demonstration projects.
            (10) Special rules for payment of medicare+choice 
        organizations.--The Secretary shall establish procedures under 
        which the Secretary provides for an appropriate adjustment in 
        the monthly payments made under section 1853 of the Social 
        Security Act (42 U.S.C. 1395w-23) to any Medicare+Choice 
        organization offering a Medicare+Choice plan to reflect the 
        participation of each seriously ill medicare beneficiary 
        enrolled in such plan in a demonstration project.
    (c) Hospice Education Grant Program.--
            (1) In general.--The Secretary shall establish a Hospice 
        Education Grant program under which the Secretary awards 
        education grants to entities participating in the demonstration 
        projects for the purpose of providing information about--
                    (A) the hospice care under the medicare program; 
                and
                    (B) the benefits available to medicare 
                beneficiaries under the demonstration projects.
            (2) Use of funds.--Grants awarded under paragraph (1) shall 
        be used--
                    (A) to provide--
                            (i) individual or group education to 
                        medicare beneficiaries and the families of such 
                        beneficiaries; and
                            (ii) individual or group education of the 
                        medical and mental health community caring for 
                        medicare beneficiaries; and
                    (B) to test strategies to improve the general 
                public knowledge about hospice care under the medicare 
                program and the benefits available to medicare 
                beneficiaries under the demonstration projects.
    (d) Funding.--
            (1) Hospice demonstration projects.--
                    (A) 
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In general.--Except as provided in subparagraph 
                (B), the Secretary shall provide for the transfer from 
                the Federal Hospital Insurance Trust Fund under section 
                1817 of the Social Security Act (42 U.S.C. 1395i) such 
                sums as may be necessary to carry out this section.
                    (B) Supportive and comfort care benefit.--The 
                Secretary shall provide for the transfer from the 
                Federal Hospital Insurance Trust Fund under section 
                1817 of the Social Security Act (42 U.S.C. 1395i) and 
                the Federal Supplementary Medical Insurance Trust Fund 
                established under section 1841 of such Act (42 U.S.C. 
                1395t), in such proportion as the Secretary determines 
                is appropriate, such sums as may be necessary to 
                provide for payment of the costs attributable to the 
                supportive and comfort care benefit.
            (2) Hospice education grants.--The Secretary shall expend 
        such sums as may be necessary for the purposes of carrying out 
        the Hospice Education Grant program established under 
        subsection (c)(1) from the Research and Demonstration Budget of 
        the Centers for Medicare & Medicaid Services.
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