[Extensions of Remarks]
[Pages E133-E134]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

INTRODUCTION OF THE MEDICARE HOSPICE BENEFIT AMENDMENTS OF 1997

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HON. BENJAMIN L. CARDIN

of maryland

in the house of representatives

Tuesday, February 4, 1997

Mr. CARDIN. Mr. Speaker, I rise today with my colleague, Rob Portman,
and more than 50 additional colleagues to introduce the Medicare
Hospice Benefit Amendments of 1997. This legislation will make
technical changes and clarifications to improve the Medicare hospice
benefit. This is a noncontroversial bill that has true bipartisan
support and should be included as part of Medicare reform this year.
Hospice care is a vital Medicare benefit. It is a coordinated program
of palliative medicine and supportive services provided mainly in the
home but also in home-like settings that provides for physical,
psychological, social, and spiritual care for dying persons and their
families. Services are provided by a medically directed,
interdisciplinary team of professionals and volunteers. Hospice
recognizes dying as part of the normal process of living and focuses on
maintaining the quality of remaining life. Hospice affirms life and
neither hastens nor postpones death.
The concept of hospice care emerged in this country in response to
the unmet needs of dying patients and their families for whom
traditional medical care was no longer effective, appropriate, or
desired. Hospice has become an effective alternative to there being
``nothing else to do.'' The Nation's hospice programs currently provide
compassionate care to more than 390,000 patients and families each
year. In 1994, one out of every three people who died from cancer or
AIDS were cared for by hospice. Terminally ill Medicare patients who
elect hospice opt out of most other Medicare services related to their
terminal illness and instead receive all of their care through the
hospice program.
Hospice is not only a compassionate and appropriate form of care for
terminally ill individuals, it is also cost effective. A 1994 Lewin
study comparing the relative cost of hospice care to conventional care
for Medicare beneficiaries with cancer, found that for every dollar
Medicare spent on hospice patients, it saved $1.52 in Medicare part A
and B expenditures. Based on these findings, the growth and greater
utilization of hospice care should be viewed in a positive light and
should be encouraged.
The Medicare hospice benefit was adopted by Congress 1982. Since
then, more and

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more Americans have chosen to receive humane and cost-effective hospice
care. In recent years, it has become clear that certain technical
changes are necessary in the Medicare hospice benefit not only to
protect beneficiaries but to ensure that high quality and cost-
effective hospice services continue to be available.
The Medicare Hospice Benefit Amendments of 1997, will make six
technical changes to the Medicare hospice benefit.
First, the bill restructures the hospice benefit periods. Under
current law, the patient's attending physician and the hospice medical
director must certify that the patient electing hospice care in lieu of
other Medicare services is terminally ill--defined as having a
prognosis of 6 months or less to live if the illness runs its normal
course. There are four benefit periods, with recertifications of
terminal illness by the hospice physician at the beginning of each. The
first two periods last 90 days, the third is 30 days, and the fourth is
of unlimited duration.
If a beneficiary revokes a hospice election during a benefit period,
the remaining days in that period are forfeited. This existing
structure is especially troubling for patients who withdraw from
hospice during the fourth hospice period because they then forfeit
their ability to elect hospice services in the future. Thus, a patient
who goes into remission and is no longer eligible for hospice because
his or her life expectancy exceeds 6 months, is not able to return to
hospice when his or her condition worsens. Our bill would correct this
problem by restructuring the benefit periods so that there would be two
90-day periods, followed by an unlimited number of 60-day periods. This
would also result in more frequent reevaluation of patients who outlive
their original prognosis.
Second, our bill clarifies that additional Medicare services are
available--in addition to those specifically required by the hospice
rules--when these services are a necessary component of the plan of
care. This amendment is consistent with current HCFA policy. The
existing statute is ambiguous because the beneficiary must waive
coverage under part B for most services when they are related to the
terminal illness, but some items are not clearly listed as part of the
hospice benefit. For example, diagnostic tests and radiation therapy
are not listed in the definition of hospice care, but occasionally the
hospice team may agree with the attending physician that these services
are necessary to manage the patient's terminal illness. Our bill would
ensure that the hospice would be able to provide the appropriate care
and that beneficiaries would not be liable for the costs of that care.
Third, our bill amends the core services requirement to allow
hospices to contract for physician services with independent contractor
physicians or physician groups. HCFA has interpreted the existing
statute as requiring a W-2 employer/employee relationship between the
hospice and its medical director and other staff physicians. This
raises corporate practice of medicine problems in some States, and it
is increasingly difficult for hospices to recruit part-time physician
employees as the trend toward physician groups continues.
Fourth, the bill allows waivers of certain staffing requirements for
rural hospices to be granted. Some hospices in rural areas have
difficulty becoming Medicare-certified because of shortages of certain
professionals. Currently, approximately 80 percent of hospices are
Medicare-certified or pending certification.
Fifth, our bill amends the so-called waiver of liability provisions
to protect the beneficiary if a hospice claim is denied by Medicare
because the terminal illness eligibility requirement allegedly was not
met. While this bill does not reinstate the waiver of liability
presumption under which providers with low error rates were paid before
1996, waiver of liability for hospice reasonable and necessary denials
is still available on a case-by-case basis. This means that the hospice
may appeal the denials and the beneficiary is not liable for payment.
The same process and protection are needed for denials based on 6-month
prognosis issues.
Last, our legislation allows HCFA to set documentation requirements
for physician certifications. Currently, the statute requires that
paperwork documenting the physician certification of a patient's
terminal illness be completed within a certain number of days of the
patient's admission to hospice. This bill will eliminate the strict
statutory requirements and give HCFA the discretion, as it currently
has with home health certifications, to require hospice certifications
to be on file before a Medicare claim is submitted.
In summary, the Medicare Hospice Benefit Amendments of 1997 is very
similar to the bill we introduced last year. The major difference is
that we dropped a provision in the 1996 legislation to extend the
presumption of the waiver of liability that CBO scored with a budget
impact. Therefore, our new bill should be revenue neutral. This
Medicare Hospice Benefit Amendments of 1997 is noncontroversial and is
needed to ensure that we have a smoothly operating Medicare hospice
benefit for our Nation's seniors. I look forward to working with my
colleagues to enact this legislation in this Congress.

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