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Title II — Compassionate Care

S. 3009 · 113th Congress · Dec 12, 2014 · Lineage

II Compassionate Care

A Workforce development

I Education and training

Sec. 201 National Geriatric and Palliative Care Services Corps

Section 331 of the Public Health Service Act (42 U.S.C. 254d) is amended—
(1)
by redesignating subsection (j) as subsection (k); and
(2)
by inserting after subsection (i), the following:

“(j) National Geriatric and Palliative Care Services Corps

“(1) Establishment—Not later than January 1, 2017, the Secretary shall establish within the National Health Service Corps a National Geriatric and Palliative Care Services Corps (referred to in this subsection as the “Corps”) which shall consist of—

“(A) such officers of the Regular and Reserve Corps of the Service as the Secretary may designate;

“(B) such civilian employees of the United States as the Secretary may appoint; and

“(C) such other individuals who are not employees of the United States.

“(2) Duties—The Corps shall be utilized by the Secretary to provide geriatric and palliative care services within health professional shortage areas.

“(3) Application of provisions—The loan-forgiveness, scholarship, and direct financial incentives programs provided for under this section shall apply to physicians, nurses, and other health professionals (as identified by the Secretary) with respect to the training necessary to enable such individuals to become geriatric or palliative care specialists and provide geriatric and palliative care services in health professional shortage areas.

“(4) Report—Not later than 6 months prior to the date on which the Secretary establishes the Corps under paragraph (1), the Secretary shall submit to Congress a report concerning the organization of the Corps, the application process for membership in the Corps, and the funding necessary for the Corps (targeted by profession and by specialization).”

Sec. 202 Exemption of palliative medicine fellowship training from Medicare graduate medical education caps

(a)
Direct graduate medical education— Section 1886(h)(4)(F) of the Social Security Act (42 U.S.C. 1395ww(h)(4)(F)) is amended—
(1)
in clause (i), by inserting “clause (iii) and” after “subject to”; and
(2)
by adding at the end the following new clause:

“(iii) Increase allowed for palliative medicine fellowship training—For cost reporting periods beginning on or after January 1, 2016, in applying clause (i), there shall not be taken into account full-time equivalent residents in the field of allopathic or osteopathic medicine who are in palliative medicine fellowship training that is approved by the Accreditation Council for Graduate Medical Education.”

(b)
Indirect Medical Education— Section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended—
(1)
by redesignating the second clause (x), as added by section 5505(b) of the Patient Protection and Affordable Care Act (Public Law 111–148), as clause (xi) and moving such clause 4 ems to the left, and realigning the left margins of subclauses (II) and (III) of such clause and items (aa), (bb), (cc), and (dd) of subclause (II) of such clause appropriately; and
(2)
by adding at the end the following new clause:

“(xii) Clause (iii) of subsection (h)(4)(F) shall apply to clause (v) in the same manner and for the same period as such clause (iii) applies to clause (i) of such subsection.”

Sec. 203 Medical school curricula

(a)
In general— The Secretary, in consultation with the Association of American Medical Colleges, shall establish guidelines for the imposition by medical schools of a minimum amount of end-of-life training as a requirement for obtaining a Doctor of Medicine degree in the field of allopathic or osteopathic medicine.
(b)
Training— Under the guidelines established under subsection (a), minimum training shall include—
(1)
training in how to discuss and help patients and their loved ones with advance care planning;
(2)
with respect to students and trainees who will work with children, specialized pediatric training;
(3)
training in the continuum of end-of-life services and supports, including palliative care and hospice;
(4)
training in how to discuss end-of-life care with dying patients and their loved ones; and
(5)
medical and legal issues training.
(c)
Distribution— Not later than January 1, 2016, the Secretary shall disseminate the guidelines established under subsection (a) to medical schools.
(d)
Compliance— Effective beginning not later than July 1, 2017, a medical school that is receiving Federal assistance shall be required to implement the guidelines established under subsection (a). A medical school that the Secretary determines is not implementing such guidelines shall not be eligible for Federal assistance.

B Coverage under Medicare, Medicaid, and CHIP

I Coverage of advance care planning

Sec. 211 Medicare, Medicaid, and CHIP coverage

(a)
Medicare—
(1)
In general— Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended—
(A)
in subsection (s)(2)—
(i)
by striking “and” at the end of subparagraph (EE);
(ii)
by adding “and” at the end of subparagraph (FF); and
(iii)
by adding at the end the following new subparagraph:

“(GG) advance care planning consultation (as defined in subsection (iii)(1));”

(B)
by adding at the end the following new subsection:

“(iii) Advance care planning consultation

“(1) Subject to paragraphs (3) and (4), the term advance care planning consultation means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to subparagraphs (A) and (B) of paragraph (3), the individual involved has not had such a consultation within the last 5 years. Such consultation shall include the following:

“(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to.

“(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses.

“(C) An explanation by the practitioner of the role and responsibilities of a health care proxy.

“(D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act).

“(E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title.

“(F)

“(i) Subject to clause (ii), an explanation of orders regarding life sustaining treatment or similar orders, which shall include—

“(I) the reasons why the development of such an order is beneficial to the individual and the individual’s family and the reasons why such an order should be updated periodically as the health of the individual changes;

“(II) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and

“(III) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy).

“(ii) The Secretary may limit the requirement for explanations under clause (i) to consultations furnished in States, localities, or other geographic areas in which orders described in such clause have been widely adopted.

“(2) A practitioner described in this paragraph is—

“(A) a physician (as defined in subsection (r)(1)); and

“(B) a nurse practitioner or physician's assistant who has the authority under State law to sign orders for life sustaining treatments.

“(3)

“(A) An initial preventive physical examination under subsection (ww), including any related discussion during such examination, shall not be considered an advance care planning consultation for purposes of applying the 5-year limitation under paragraph (1).

“(B) An advance care planning consultation with respect to an individual shall be conducted more frequently than provided under paragraph (1) if there is a significant change in the health condition of the individual, including diagnosis of a chronic, progressive, life-limiting disease, a life-threatening or terminal diagnosis or life-threatening injury, or upon admission to a skilled nursing facility, a long-term care facility (as defined by the Secretary), or a hospice program.

“(4) A consultation under this subsection may include the formulation of an order regarding life sustaining treatment or a similar order.

“(5)

“(A) For purposes of this section, the term order regarding life sustaining treatment means, with respect to an individual, an actionable medical order relating to the treatment of that individual that—

“(i) is signed and dated by a physician (as defined in subsection (r)(1)) or another health care professional (as specified by the Secretary and who is acting within the scope of the professional’s authority under State law in signing such an order) and is in a form that permits it to stay with the patient and be followed by health care professionals and providers across the continuum of care, including home care, hospice, long-term care, community and assisted living residences, skilled nursing facilities, inpatient rehabilitation facilities, hospitals, and emergency medical services;

“(ii) effectively communicates the individual’s preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual;

“(iii) is uniquely identifiable and standardized within a given locality, region, or State (as identified by the Secretary);

“(iv) is portable across care settings; and

“(v) may incorporate any advance directive (as defined in section 1866(f)(3)) if executed by the individual.

“(B) The level of treatment indicated under subparagraph (A)(ii) may range from an indication for full treatment to an indication to limit some or all or specified interventions. Such indicated levels of treatment may include indications respecting, among other items—

“(i) the intensity of medical intervention if the patient is pulseless, apneic, or has serious cardiac or pulmonary problems;

“(ii) the individual’s desire regarding transfer to a hospital or remaining at the current care setting;

“(iii) the use of antibiotics; and

“(iv) the use of artificially administered nutrition and hydration.”

(2)
Payment— Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) is amended by inserting “(2)(GG),” after “(including administration of the health risk assessment),”.
(3)
Frequency Limitation— Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended—
(A)
in paragraph (1)—
(i)
in subparagraph (O), by striking “and” at the end;
(ii)
in subparagraph (P), by striking the semicolon at the end and inserting “, and”; and
(iii)
by adding at the end the following new subparagraph:

“(Q) in the case of advance care planning consultations (as defined in section 1861(iii)(1)), which are performed more frequently than is covered under such section;”

(B)
in paragraph (7), by striking “or (P)” and inserting “(P), or (Q)”.
(4)
Effective Date— The amendments made by this subsection shall apply to consultations furnished on or after January 1, 2016.
(b)
Medicaid—
(1)
Mandatory benefit— Section 1902(a)(10)(A) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended in the matter preceding clause (i) by striking “and (28)” and inserting “(28), and (29)”.
(2)
Medical assistance— Section 1905 of such Act (42 U.S.C. 1396d) is amended—
(A)
in subsection (a)—
(i)
in paragraph (28), by striking “and” at the end;
(ii)
by redesignating paragraph (29) as paragraph (30); and
(iii)
by inserting after paragraph (28) the following new paragraph:

“(29) advance care planning consultations (as defined in subsection (ee));”

(B)
by adding at the end the following:

“(ee)

“(1) For purposes of subsection (a)(29), the term advance care planning consultation means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years. Such consultation shall include the following:

“(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to.

“(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses.

“(C) An explanation by the practitioner of the role and responsibilities of a health care proxy.

“(D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act).

“(E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title.

“(F)

“(i) Subject to clause (ii), an explanation of orders for life sustaining treatments or similar orders, which shall include—

“(I) the reasons why the development of such an order is beneficial to the individual and the individual’s family and the reasons why such an order should be updated periodically as the health of the individual changes;

“(II) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and

“(III) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy).

“(ii) The Secretary may limit the requirement for explanations under clause (i) to consultations furnished in States, localities, or other geographic areas in which orders described in such clause have been widely adopted.

“(2) A practitioner described in this paragraph is—

“(A) a physician (as defined in section 1861(r)(1)); and

“(B) a nurse practitioner or physician's assistant who has the authority under State law to sign orders for life sustaining treatments.

“(3) An advance care planning consultation with respect to an individual shall be conducted more frequently than provided under paragraph (1) if there is a significant change in the health condition of the individual including diagnosis of a chronic, progressive, life-limiting disease, a life-threatening or terminal diagnosis or life-threatening injury, or upon admission to a nursing facility, a long-term care facility (as defined by the Secretary), or a hospice program.

“(4) A consultation under this subsection may include the formulation of an order regarding life sustaining treatment or a similar order.

“(5) For purposes of this subsection, the term orders regarding life sustaining treatment has the meaning given that term in section 1861(iii)(5).”

(c)
CHIP—
(1)
Child health assistance— Section 2110(a) of the Social Security Act (42 U.S.C. 1397jj) is amended—
(A)
by redesignating paragraph (28) as paragraph (29); and
(B)
by inserting after paragraph (27), the following:

“(28) Advance care planning consultations (as defined in section 1905(ee)).”

(2)
Mandatory coverage—
(A)
In general— Section 2103 of such Act (42 U.S.C. 1397cc), is amended—
(i)
in subsection (a), in the matter preceding paragraph (1), by striking “and (7)” and inserting “(7), and (9)”; and
(ii)
in subsection (c), by adding at the end the following:

“(9) End-of-life care—The child health assistance provided to a targeted low-income child shall include coverage of advance care planning consultations (as defined in section 1905(ee) and at the same payment rate as the rate that would apply to such a consultation under the State plan under title XIX).”

(B)
Conforming amendment— Section 2102(a)(7)(B) of such Act (42 U.S.C. 1397bb(a)(7)(B)) is amended by striking “section 2103(c)(5)” and inserting “paragraphs (5) and (9) of section 2103(c)”.
(d)
Definition of advance directive under Medicare, Medicaid, and CHIP—
(1)
Medicare— Section 1866(f)(3) of the Social Security Act (42 U.S.C. 1395cc(f)(3)) is amended by striking “means” and all that follows through the period and inserting “means a living will, medical directive, health care power of attorney, durable power of attorney, or other written statement by a competent individual that is recognized under State law and indicates the individual's wishes regarding medical treatment in the event of future incompetence. Such term includes an advance health care directive and a health care directive recognized under State law.”.
(2)
Medicaid and chip— Section 1902(w)(4) of such Act (42 U.S.C. 1396a(w)(4)) is amended by striking “means” and all that follows through the period and inserting “means a living will, medical directive, health care power of attorney, durable power of attorney, or other written statement by a competent individual that is recognized under State law and indicates the individual's wishes regarding medical treatment in the event of future incompetence. Such term includes an advance health care directive and a health care directive recognized under State law.”.
(e)
Effective date— The amendments made by this section take effect January 1, 2015.

II Hospice

Sec. 221 Adoption of MedPAC hospice payment methodology recommendations

Section 1814(i) of the Social Security Act (42 U.S.C. 1395f(i)) is amended by adding at the end the following new paragraph:

“(8)

“(A) The Secretary shall conduct an evaluation of the recommendations of the Medicare Payment Commission for reforming the hospice care benefit under this title that are contained in chapter 6 of the Commission's report entitled “Report to Congress: Medicare Payment Policy (March 2009)”, including the impact that such recommendations if implemented would have on access to care and the quality of care. In conducting such evaluation, the Secretary shall take into account data collected in accordance with section 263(b) of the Advance Planning and Compassionate Care Act of 2014.

“(B) Based on the results of the examination conducted under subparagraph (A), the Secretary shall make appropriate refinements to the recommendations described in subparagraph (A). Such refinements shall take into account—

“(i) the impact on patient populations with longer that average lengths of stay;

“(ii) the impact on populations with shorter that average lengths of stay; and

“(iii) the utilization patterns of hospice providers in underserved areas, including rural hospices.

“(C) Not later than January 1, 2018, the Secretary shall submit to Congress a report that contains a detailed description of—

“(i) the refinements determined appropriate by the Secretary under subparagraph (B);

“(ii) the revisions that the Secretary will implement through regulation under this title pursuant to subparagraph (D); and

“(iii) the revisions that the Secretary determines require additional legislative action by Congress.

“(D)

“(i) The Secretary shall implement the recommendations described in subparagraph (A), as refined under subparagraph (B).

“(ii) Subject to clause (iii), the implementation of such recommendations shall apply to hospice care furnished on or after January 1, 2019.

“(iii) The Secretary shall establish an appropriate transition to the implementation of such recommendations.

“(E) For purposes of carrying out the provisions of this paragraph, the Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817, of such sums as may be necessary to the Centers for Medicare & Medicaid Services Program Management Account.”

Sec. 222 Removing hospice inpatient days in setting per diem rates for critical access hospitals

Section 1814(l) of the Social Security Act (42 U.S.C. 1395f(l)), as amended by section 4102(b)(2) of the HITECH Act (Public Law 111–5), is amended by adding at the end the following new paragraph:

“(6) For cost reporting periods beginning on or after January 1, 2016, the Secretary shall remove Medicare-certified hospice inpatient days from the calculation of per diem rates for inpatient critical access hospital services.”

Sec. 223 Hospice payments for dual eligible individuals residing in long-term care facilities

(a)
In general— Section 1888 of the Social Security Act (42 U.S.C. 1395yy) is amended by adding at the end the following new subsection:

“(i) Payments for Dual Eligible Individuals Residing in Long-Term Care Facilities—For cost reporting periods beginning on or after January 1, 2016, the Secretary, acting through the Administrator of the Centers for Medicare & Medicaid Services, shall establish procedures under which payments for room and board under the State Medicaid plan with respect to an applicable individual are made directly to the long-term care facility (as defined by the Secretary for purposes of title XIX) the individual is a resident of. For purposes of the preceding sentence, the term applicable individual means an individual who is entitled to or enrolled for benefits under part A or enrolled for benefits under part B and is eligible for medical assistance for hospice care under a State plan under title XIX.”

(b)
State plan requirement—
(1)
In general— Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)) is amended—
(A)
in paragraph (74), by striking “and” at the end;
(B)
in paragraph (80), by striking “and” at the end;
(C)
in paragraph (81), by striking the period at the end and inserting “; and”; and
(D)
by inserting after paragraph (81) the following new paragraph:

“(82) provide that the State will make payments for room and board with respect to applicable individuals in accordance with section 1888(i).”

(2)
Effective date—
(A)
In general— Except as provided in subparagraph (B), the amendments made by paragraph (1) take effect on January 1, 2016.
(B)
Extension of effective date for state law amendment— In the case of a State plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) which the Secretary determines requires State legislation in order for the plan to meet the additional requirements imposed by the amendments made by paragraph (1), the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these additional requirements before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of the session is considered to be a separate regular session of the State legislature.

Sec. 224 Delineation of respective care responsibilities of hospice programs and long-term care facilities

Section 1888 of the Social Security Act (42 U.S.C. 1395yy), as amended by section 223(a), is amended by adding at the end the following new subsection:

“(j) Delineation of respective care responsibilities of hospice programs and long-term care facilities—Not later than July 1, 2016, the Secretary, acting through the Administrator of the Centers for Medicare & Medicaid Services, shall delineate and enforce the respective care responsibilities of hospice programs and long-term care facilities (as defined by the Secretary for purposes of title XIX) with respect to individuals residing in such facilities who are furnished hospice care.”

Sec. 225 Adoption of MedPAC hospice program eligibility certification and recertification recommendations

In accordance with the recommendations of the Medicare Payment Advisory Commission contained in the March 2009 report entitled “Report to Congress: Medicare Payment Policy”, section 1814(a)(7) of the Social Security Act (42 U.S.C. 1395f(a)(7)) is amended—
(1)
in subparagraph (C), by striking “and” at the end; and
(2)
by adding at the end the following new subparagraph:

“(E) on or after January 1, 2016—

“(i) a hospice physician or advance practice nurse visits the individual to determine continued eligibility of the individual for hospice care prior to the 180th-day recertification and each subsequent recertification under subparagraph (A)(ii) and attests that such visit took place (in accordance with procedures established by the Secretary, in consultation with the Administrator of the Centers for Medicare & Medicaid Services); and

“(ii) any certification or recertification under subparagraph (A) includes a brief narrative describing the clinical basis for the individual’s prognosis (in accordance with procedures established by the Secretary, in consultation with the Administrator of the Centers for Medicare & Medicaid Services); and”

Sec. 226 Concurrent care for children

(a)
Permitting Medicare hospice beneficiaries 18 years of age or younger To receive curative care—
(1)
In general— Section 1812 of the Social Security Act (42 U.S.C. 1395d) is amended—
(A)
in subsection (a)(4), by inserting “(subject to the second sentence of subsection (d)(2)(A))” after “in lieu of certain other benefits”; and
(B)
in subsection (d)—
(i)
in paragraph (1), by inserting “ , subject to the second sentence of paragraph (2)(A), ” after “instead”; and
(ii)
in paragraph (2)(A), by adding at the end the following new sentence: “Clause (ii)(I) shall not apply to an individual who is 18 years of age or younger.”
(2)
Conforming amendment— Section 1862(a)(1)(C) of the Social Security Act (42 U.S.C. 1395y(a)(1)(C)) is amended inserting “subject to the second sentence of section 1812(d)(2)(A), ” after “hospice care,”.
(b)
Application to Medicaid and CHIP—
(1)
Medicaid— Section 1905(o)(1)(A) of the Social Security Act (42 U.S.C. 1395d(o)(1)(A)) is amended by inserting “(subject, in the case of an individual who is a child, to the second sentence of such section)” after “section 1812(d)(2)(A)”.
(2)
CHIP— Section 2110(a)(23) of the Social Security Act (42 U.S.C. 1397jj(a)(23)) is amended by striking “(concurrent” and all that follows through the period and inserting “(concurrent, in the case of an individual who is a child, with care related to the treatment of the individual's condition with respect to which a diagnosis of terminal illness has been made).”.
(c)
Effective date— The amendments made by this section shall apply to items and services furnished on or after January 1, 2016.

Sec. 227 Making hospice a required benefit under Medicaid and CHIP

(a)
Mandatory benefit—
(1)
Medicaid—
(A)
In general— Section 1902(a)(10)(A) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)), as amended by section 211(b)(1), is amended in the matter preceding clause (i) by inserting “(18),” after “(17),”.
(B)
Conforming amendment— Section 1902(a)(10)(C) of such Act (42 U.S.C. 1396a(a)(10)(C)) is amended—
(i)
in clause (iii)—
(I)
in subclause (I), by inserting “and hospice care” after “ambulatory services”; and
(II)
in subclause (II), by inserting “and hospice care” after “delivery services”; and
(ii)
in clause (iv), by inserting “and (18)” after “(17)”.
(2)
CHIP— Section 2103(c)(9) of such Act (42 U.S.C. 1397cc(c)(9)), as added by section 211(c)(2)(A), is amended by inserting “and hospice care” before the period.
(b)
Effective date— The amendments made subsection (a) take effect on January 1, 2016.

Sec. 228 Medicare Hospice payment model demonstration projects

(a)
Establishment— Not later than July 1, 2017, the Secretary, acting through the Administrator of the Centers for Medicare & Medicaid Services and the Director of the Agency for Healthcare Research and Quality, shall conduct demonstration projects to examine ways to improve how the Medicare hospice care benefit predicts disease trajectory. Projects shall include the following models:
(1)
Models that better and more appropriately care for, and transition as needed, patients in their last years of life who need palliative care, but do not qualify for hospice care under the Medicare hospice eligibility criteria.
(2)
Models that better and more appropriately care for long-term patients who are not recertified in hospice but still need palliative care.
(3)
Any other models determined appropriate by the Secretary.
(b)
Waiver authority— The Secretary may waive compliance of such requirements of titles XI and XVIII of the Social Security Act as the Secretary determines necessary to conduct the demonstration projects under this section.
(c)
Reports— The Secretary shall submit to Congress periodic reports on the demonstration projects conducted under this section.

Sec. 229 MedPAC studies and reports

(a)
Study and report regarding an alternative payment methodology for hospice care under the Medicare program—
(1)
Study— The Medicare Payment Advisory Commission (in this section referred to as the “Commission”) shall conduct a study on the establishment of a reimbursement system for hospice care furnished under the Medicare program that is based on diagnoses. In conducting such study, the Commission shall use data collected under new provider data requirements. Such study shall include an analysis of the following:
(A)
Whether such a reimbursement system better meets patient needs and better corresponds with provider resource expenditures than the current system.
(B)
Whether such a reimbursement system improves quality, including facilitating standardization of care toward best practices and diagnoses-specific clinical pathways in hospice.
(C)
Whether such a reimbursement system could address concerns about the blanket 6-month terminal prognosis requirement in hospice.
(D)
Whether such a reimbursement system is more cost effective than the current system.
(E)
Any other areas determined appropriate by the Commission.
(2)
Report— Not later than June 15, 2018, the Commission shall submit to Congress a report on the study conducted under subsection (a) together with recommendations for such legislation and administrative action as the Commission determines appropriate.
(b)
Study and report regarding rural hospice transportation costs under the Medicare program—
(1)
Study— The Commission shall conduct a study on rural Medicare hospice transportation mileage to determine potential Medicare reimbursement changes to account for potential higher costs.
(2)
Report— Not later than June 15, 2018, the Commission shall submit to Congress a report on the study conducted under subsection (a) together with recommendations for such legislation and administrative action as the Commission determines appropriate.
(c)
Evaluation of reimbursement disincentives To elect medicare hospice within the medicare skilled nursing facility benefit—
(1)
Study— The Commission shall conduct a study to determine potential Medicare reimbursement changes to remove Medicare reimbursement disincentives for patients in a skilled nursing facility who want to elect hospice.
(2)
Report— Not later than June 15, 2018, the Commission shall submit to Congress a report on the study conducted under subsection (a) together with recommendations for such legislation and administrative action as the Commission determines appropriate.

Sec. 230 HHS Evaluations

(a)
Evaluation of Access to Hospice and Hospital-Based Palliative Care—
(1)
Evaluation— The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall conduct an evaluation of geographic areas and populations underserved by hospice and hospital-based palliative care to identify potential barriers to access.
(2)
Report— Not later than December 31, 2017, the Secretary shall report to Congress, on the evaluation conducted under subsection (a) together with recommendations for such legislation and administrative action as the Secretary determines appropriate to address barriers to access to hospice and hospital-based palliative care.
(b)
Evaluation of awareness and use of hospice respite care under Medicare, Medicaid, and CHIP—
(1)
Evaluation— The Secretary, acting through the Director of the Centers for Medicare and Medicaid Services, shall evaluate the awareness and use of hospice respite care by informal caregivers of beneficiaries under Medicare, Medicaid, and CHIP.
(2)
Report— Not later than December 31, 2015, the Secretary shall report to Congress, on the evaluation conducted under subsection (a) together with recommendations for such legislation and administrative action as the Secretary determines appropriate to increase awareness or use of hospice respite care under Medicare, Medicaid, and CHIP.

C Quality Improvement

Sec. 241 Patient satisfaction surveys

Not later than January 1, 2017, the Secretary, acting through the Administrator of the Centers for Medicare & Medicaid Services, shall establish a mechanism for—
(1)
collecting information from patients (or their health care proxies or families members in the event patients are unable to speak for themselves) in relevant provider settings regarding their care at the end of life; and
(2)
incorporating such information in a timely manner into mechanisms used by the Administrator to provide quality of care information to consumers, including the Hospital Compare and Nursing Home Compare websites maintained by the Administrator.

Sec. 242 Development of core end-of-life care quality measures across each relevant provider setting

(a)
In general— The Secretary, acting through the Administrator of the Agency for Healthcare Research and Quality (in this section referred to as the “Administrator”) and in consultation with the Director of the National Institutes of Health, shall require specific end-of-life quality measures for each relevant provider setting, as identified by the Administrator, in accordance with the requirements of subsection (b).
(b)
Requirements— For purposes of subsection (a), the requirements specified in this subsection are the following:
(1)
Selection of the specific measure or measures for an identified provider setting shall be—
(A)
based on an assessment of what is likely to have the greatest positive impact on quality of end-of-life care in that setting; and
(B)
made in consultation with affected providers and public and private organizations, that have developed such measures.
(2)
The measures may be structure-oriented, process-oriented, or outcome-oriented, as determined appropriate by the Administrator.
(3)
The Administrator shall ensure that reporting requirements related to such measures are imposed consistent with other applicable laws and regulations, and in a manner that takes into account existing measures, the needs of patient populations, and the specific services provided.
(4)
Not later than—
(A)
April 1, 2016, the Secretary shall disseminate the reporting requirements to all affected providers; and
(B)
April 1, 2017, initial reporting relating to the measures shall begin.

Sec. 243 Accreditation of Hospital-Based Palliative Care Programs

(a)
In General— The Secretary, acting through the Director of the Agency for Healthcare Research and Quality, shall designate a public or private agency, entity, or organization to develop requirements, standards, and procedures for accreditation of hospital-based palliative care programs.
(b)
Reporting— Not later than January 1, 2017, the Secretary shall prepare and submit a report to Congress on the proposed accreditation process for hospital-based palliative care programs.
(c)
Accreditation— Not later than July 1, 2017, the Secretary shall—
(1)
establish and promulgate standards and procedures for accreditation of hospital-based palliative care programs; and
(2)
designate an agency, entity, or organization that shall be responsible for certifying such programs in accordance with the standards established under paragraph (1).
(d)
Definitions— For the purposes of this section:
(1)
The term hospital-based palliative care program means a hospital-based program that is comprised of an interdisciplinary team that specializes in providing palliative care services and consultations in a variety of health care settings, including hospitals, nursing homes, and home and community-based services.
(2)
The term interdisciplinary team means a group of health care professionals (consisting of, at a minimum, a doctor, a nurse, and a social worker) that have received specialized training in palliative care.

Sec. 244 Survey and data requirements for all Medicare participating hospice programs

(a)
Hospice surveys— Section 1861(dd) of the Social Security Act (42 U.S.C. 1395x(dd)) is amended by adding at the end the following new paragraph:

“(6) In accordance with the recommendations of the Medicare Payment Advisory Commission contained in the March 2009 report entitled “Report to Congress: Medicare Payment Policy”, the Secretary shall establish, effective July 1, 2015, the following survey requirements for hospice programs:

“(A) Any hospice program seeking initial certification under this title on or after that date shall be subject to an initial survey by an appropriate State or local agency, or an approved accreditation agency, not later than 6 months after the program first seeks such certification.

“(B) All hospice programs certified for participation under this title shall be subject to a standard survey by an appropriate State or local agency, or an approved accreditation agency, at least every 3 years after initially being so certified.”

(b)
Required hospice resource inputs data— Section 1861(dd) of the Social Security Act (42 U.S.C. 1395x(dd)), as amended by subsection (a), is amended—
(1)
in paragraph (2)—
(A)
in subparagraph (F), by striking “and” at the end;
(B)
by redesignating subparagraph (G) as subparagraph (H); and
(C)
by inserting after subparagraph (F) the following new subparagraph:

“(G) complies with the reporting requirements under paragraph (7); and”

(2)
by adding at the end the following new paragraph:

“(7)

“(A) In accordance with the recommendations of the Medicare Payment Advisory Commission for additional data (as contained in the March 2009 report entitled “Report to Congress: Medicare Payment Policy”), beginning January 1, 2016, a hospice program shall report to the Secretary, in such form and manner, and at such intervals, as the Secretary shall require, the following data with respect to each patient visit:

“(i) Visit type (such as admission, routine, emergency, education for family, other).

“(ii) Visit length.

“(iii) Professional or paraprofessional disciplines involved in the visit, including nurse, social worker, home health aide, physician, nurse practitioner, chaplain or spiritual counselor, counselor, dietician, physical therapist, occupational therapist, speech language pathologist, music or art therapist, and including bereavement and support services provided to a family after a patient’s death.

“(iv) Drugs and other therapeutic interventions provided.

“(v) Home medical equipment and other medical supplies provided.

“(B) In collecting the data required under subparagraph (A), the Secretary shall ensure that the data are reported in a manner that allows for summarized cross-tabulations of the data by patients’ terminal diagnoses, lengths of stay, age, sex, and race.”

D Additional reports, research, and evaluations

Sec. 251 National Center On Palliative and End-of-Life Care

Part E of title IV of the Public Health Service Act (42 U.S.C. 287 et seq.) is amended by adding at the end the following:

“7 National Center on Palliative and End-of-Life Care

“485J. National Center On Palliative and End-of-Life Care

“(a) Establishment—Not later than July 1, 2016, there shall be established within the National Institutes of Health, a National Center on Palliative and End-of-Life Care (referred to in this section as the “Center”).

“(b) Purpose—The general purpose of the Center is to conduct and support research relating to palliative and end-of-life care interventions and approaches.

“(c) Activities—The Center shall—

“(1) develop and continuously update a research agenda with the goal of—

“(A) providing a better biomedical understanding of the end of life; and

“(B) improving the quality of care and life at the end of life; and

“(2) provide funding for peer-review-selected extra- and intra-mural research that includes the evaluation of existing, and the development of new, palliative and end-of-life care interventions and approaches.”

Sec. 252 National Mortality Followback Survey

(a)
In general— Not later than December 31, 2015, and annually thereafter, the Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall renew and conduct the National Mortality Followback Survey (referred to in this section as the “Survey”) to collect data on end-of-life care.
(b)
Purpose— The purpose of the Survey shall be to gain a better understanding of current end-of-life care in the United States.
(c)
Questions—
(1)
In general— In conducting the Survey, the Director of the Centers for Disease Control and Prevention shall, at a minimum, include the following questions with respect to the loved one of a respondent:
(A)
Did he or she have an advance directive, and if so, when it was completed.
(B)
Did he or she have an order for life-sustaining treatment, and if so, when was it completed.
(C)
Did he or she have a durable power of attorney, and if so, when it was completed.
(D)
Had he or she discussed his or her wishes with loved ones, and if so, when.
(E)
Had he or she discussed his or her wishes with his or her physician, and if so, when.
(F)
In the opinion of the respondent, was he or she satisfied with the care he or she received in the last year of life and in the last week of life.
(G)
Was he or she cared for by hospice, and if so, when.
(H)
Was he or she cared for by palliative care specialists, and if so, when.
(I)
Did he or she receive effective pain management (if needed).
(J)
What was the experience of the main caregiver (including if such caregiver was the respondent), and whether he or she received sufficient support in this role.
(2)
Additional questions— Additional questions to be asked during the Survey shall be determined by the Director of the Centers for Disease Control and Prevention on an ongoing basis with input from relevant research entities.

Sec. 253 Demonstration Projects for Use of Telemedicine Services in Advance Care Planning

(a)
In General— Not later than July 1, 2018, the Secretary shall establish a demonstration program to reimburse eligible entities for costs associated with the use of telemedicine services (including equipment and connection costs) to provide advance care planning consultations with geographically distant physicians and their patients.
(b)
Duration— The demonstration project under this section shall be conducted for at least a 3-year period.
(c)
Definitions— For purposes of this section:
(1)
The term eligible entity means a physician or an advance practice nurse who provides services pursuant to a hospital-based palliative care program (as defined in section 262(d)(1)).
(2)
The term geographically distant has the meaning given that term by the Secretary for purposes of conducting the demonstration program established under this section.
(3)
The term telemedicine services means a service or consultation provided via telecommunication equipment that allows an eligible entity to exchange or discuss medical information with a patient or a health care professional at a separate location through real-time videoconferencing, or a similar format, for the purpose of providing health care diagnosis and treatment.
(d)
Funding— There are authorized to be appropriated to the Secretary such sums as may be necessary to carry out this section.

Sec. 254 Inspector General investigation of fraud and abuse

In accordance with the recommendations of the Medicare Payment Advisory Commission for additional data (as contained in the March 2009 report entitled “Report to Congress: Medicare Payment Policy”), the Secretary shall direct the Office of the Inspector General of the Department of Health and Human Services to investigate, not later than January 1, 2017, the following with respect to hospice benefit under Medicare, Medicaid, and CHIP:
(1)
The prevalence of financial relationships between hospices and long-term care facilities, such as nursing facilities and assisted living facilities, that may represent a conflict of interest and influence admissions to hospice.
(2)
Differences in patterns of nursing home referrals to hospice.
(3)
The appropriateness of enrollment practices for hospices with unusual utilization patterns (such as high frequency of very long stays, very short stays, or enrollment of patients discharged from other hospices).
(4)
The appropriateness of hospice marketing materials and other admissions practices and potential correlations between length of stay and deficiencies in marketing or admissions practices.

Sec. 255 GAO study and report on provider adherence to advance directives

Not later than January 1, 2017, the Comptroller General of the United States shall conduct a study of the extent to which providers comply with advance directives under the Medicare and Medicaid programs and shall submit a report to Congress on the results of such study, together with such recommendations for administrative or legislative changes as the Comptroller General determines appropriate.