[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]





        EXAMINING POTENTIAL WAYS TO IMPROVE THE MEDICARE PROGRAM

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 1, 2015

                               __________

                           Serial No. 114-81


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



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                    COMMITTEE ON ENERGY AND COMMERCE

                          FRED UPTON, Michigan
                                 Chairman

JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Chairman Emeritus                    Ranking Member
ED WHITFIELD, Kentucky               BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
JOSEPH R. PITTS, Pennsylvania        ELIOT L. ENGEL, New York
GREG WALDEN, Oregon                  GENE GREEN, Texas
TIM MURPHY, Pennsylvania             DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas            LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee          MICHAEL F. DOYLE, Pennsylvania
  Vice Chairman                      JANICE D. SCHAKOWSKY, Illinois
STEVE SCALISE, Louisiana             G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio                DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington   KATHY CASTOR, Florida
GREGG HARPER, Mississippi            JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey            JERRY McNERNEY, California
BRETT GUTHRIE, Kentucky              PETER WELCH, Vermont
PETE OLSON, Texas                    BEN RAY LUJAN, New Mexico
DAVID B. McKINLEY, West Virginia     PAUL TONKO, New York
MIKE POMPEO, Kansas                  JOHN A. YARMUTH, Kentucky
ADAM KINZINGER, Illinois             YVETTE D. CLARKE, New York
H. MORGAN GRIFFITH, Virginia         DAVID LOEBSACK, Iowa
GUS M. BILIRAKIS, Florida            KURT SCHRADER, Oregon
BILL JOHNSON, Ohio                   JOSEPH P. KENNEDY, III, 
BILLY LONG, Missouri                 Massachusetts
RENEE L. ELLMERS, North Carolina     TONY CARDENAS, California7
LARRY BUCSHON, Indiana
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota

                         Subcommittee on Health

                     JOSEPH R. PITTS, Pennsylvania
                                 Chairman
BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
  Vice Chairman                        Ranking Member
ED WHITFIELD, Kentucky               ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois               LOIS CAPPS, California
TIM MURPHY, Pennsylvania             JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas            G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee          KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington   JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey            DORIS O. MATSUI, California
H. MORGAN GRIFFITH, Virginia         BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida            KURT SCHRADER, Oregon
BILLY LONG, Missouri                 JOSEPH P. KENNEDY, III, 
RENEE L. ELLMERS, North Carolina         Massachusetts
LARRY BUCSHON, Indiana               TONY CARDENAS, California
SUSAN W. BROOKS, Indiana             FRANK PALLONE, Jr., New Jersey (ex 
CHRIS COLLINS, New York                  officio)
JOE BARTON, Texas
FRED UPTON, Michigan (ex officio)

                                  (ii)
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Joseph R. Pitts, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     2
Hon. Ben Ray Lujan, a Representative in Congress from the State 
  of New Mexico, opening statement...............................     2
Hon. Gus M. Bilirakis, a Representative in Congress from the 
  State of Florida, opening statement............................     4
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     6
    Prepared statement...........................................     7
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, prepared statement......................................     8
Hon. Fred Upton, a Representative in Congress from the State of 
  Michigan, prepared statement...................................    62

                               Witnesses

Sarah Myers, Executive Director, Oregon Association for Home Care    10
    Prepared statement...........................................    12
Bruce Gould, M.D., Medical Director, Northwest Georgia Oncology 
  Centers, and President, Community Oncology Alliance............    18
    Prepared statement...........................................    20
Sandra Norby, Owner, HomeTown Physical Therapy, LLC..............    33
    Prepared statement...........................................    35

                           Submitted Material

H.R. 556, the Prevent Interruptions in Physical Therapy Act of 
  2015, submitted by Mr. Pitts...................................    63
H.R. 1934, the Cancer Care Payment Reform Act of 2015, submitted 
  by Mr. Pitts...................................................    65
Discussion Draft, H.R. ___, the Home Health Documentation and 
  Program Improvement Act of 2015, submitted by Mr. Pitts........    85
Statement of the Partnership for Quality Home Healthcare, October 
  1, 2015, submitted by Mr. Walden...............................    95
Statement of the National Association for Home Care & Hospice, 
  October 1, 2015, submitted by Mr. Walden.......................    96
Statement of the Visiting Nurse Associations of America, October 
  1, 2015, submitted by Mr. Walden...............................   108
Letter of May 17, 2011, from Maria Cantwell and Susan M. Collins, 
  U.S. Senators, et al., to Donald Berwick, Administrator, 
  Centers for Medicare & Medicaid Services, submitted by Mr. 
  Walden.........................................................   111
Letter of September 17, 2013, from Hon. Tom Reed, a 
  Representative in Congress from the State of New York, to 
  Marilyn Tavenner, Administrator, Centers for Medicare & 
  Medicaid Services, submitted by Mr. Walden.....................   115
Letter of August 11, 2014, from Hon. Tom Reed, a Representative 
  in Congress from the State of New York, to Marilyn Tavenner, 
  Administrator, Centers for Medicare & Medicaid Services, 
  submitted by Mr. Walden........................................   121
Letter of June 25, 2015, from Hon. Chuck Grassley and Hon. Robert 
  P. Casey, Jr., U.S. Senators, to Andrew Slavitt, Administrator, 
  Centers for Medicare & Medicaid Services, submitted by Mr. 
  Lujan..........................................................   126
Letter from Andrew Slavitt, Acting Administrator, Centers for 
  Medicare & Medicaid Services, to Hon. Chuck Grassley, U.S. 
  Senator, submitted by Mr. Lujan and Mr. Bilirakis..............   129
Article of Winter 2015, ``Pricing in the Market for Anticancer 
  Drugs,'' by David H. Howard, et al., Journal of Economic 
  Perspectives, Volume 29, Number 1, submitted by Ms. Schakowsky 
  \1\
Statement of Jeff Weil, Division Vice President, LHC Group--
  Western States, September 30, 2015, submitted by Mr. Walden....   130

----------
\1\ The information has been retained in committee files and also 
  is available at  http://docs.house.gov/meetings/IF/IF14/
  20151001/104006/HHRG-114-IF14-20151001-SD006.pdf.
 
        EXAMINING POTENTIAL WAYS TO IMPROVE THE MEDICARE PROGRAM

                              ----------                              


                       THURSDAY, OCTOBER 1, 2015

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:00 a.m., in 
room 2322, Rayburn House Office Building, Hon. Joseph R. Pitts 
(chairman of the subcommittee) presiding.
    Members present: Representatives Pitts, Guthrie, Shimkus, 
Burgess, Lance, Griffith, Bilirakis, Elmers, Bucshon, Brooks, 
Collins, Green, Schakowsky, Butterfield, Castor, Matsui, Lujan, 
Schrader, Kennedy, and Pallone (ex officio).
    Also present: Representative Walden.
    Staff present: Clay Alspach, Chief Counsel, Health; Rebecca 
Card, Staff Assistant; Noelle Clemente, Press Secretary; Graham 
Pittman, Legislative Clerk; Heidi Stirrup, Policy Coordinator, 
Health; Christine Brennan, Democratic Press Secretary; Jeff 
Carroll, Democratic Staff Director; Tiffany Guarascio, 
Democratic Deputy Staff Director and Chief Health Advisor; 
Meredith Jones, Democratic Director of Communications, Member 
Services, and Outreach; Samantha Satchell, Democratic Policy 
Analyst; Matt Schumacher, Democratic Press Assistant; and 
Arielle Woronoff, Democratic Health Counsel.
    Mr. Pitts. It is 10 o'clock, so we will begin.
    The subcommittee will come to order.
    The Chair will recognize himself for an opening statement.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Today's hearing will consider three bipartisan legislative 
bills designed to strengthen the Medicare program:
    H.R. 556, the Prevent Interruptions in Physical Therapy 
Act, sponsored by our colleague Representative Gus Bilirakis of 
Florida, would add therapists--physical, occupational, and 
speech--to the list of providers allowed to transfer care for a 
Medicare patient in circumstances of illness, pregnancy, or 
vacation;
    H.R. 1934, the Cancer Care Payment Reform Act, sponsored by 
the House Republican Conference chairman, Cathy McMorris 
Rodgers of Washington, establishes a national Oncology Medical 
Home Demonstration Project to improve Medicare payments for 
cancer care;
    Thirdly, draft legislation, authored by Representative Greg 
Walden of Oregon, would make changes to documentation and face-
to-face requirements for home health providers under the 
Medicare program.
    Together, these three bills continue the commitment this 
Congress has to strengthen the Medicare program and to keep the 
promise for seniors, which was started earlier this year by 
permanently repealing and replacing the broken sustainable 
growth rate, the SGR, an effort spanning several years to 
enactment this past April.
    I want to thank our witnesses for agreeing to testify 
today. They bring real world experience regarding problems in 
the Medicare program, and we welcome their views on the 
legislation before us today.
    [The prepared statement of Mr. Pitts follows:]

               Prepared statement of Hon. Joseph R. Pitts

    The subcommittee will come to order.
    The chairman will recognize himself for an opening 
statement.
    Today's hearing will consider three bipartisan legislative 
bills designed to strengthen the Medicare program.
    H.R. 556, the Prevent Interruptions in Physical Therapy 
Act, sponsored by our colleague Rep. Gus Bilirakis (FL) would 
add therapists (physical, occupational, and speech) to the list 
of providers allowed to transfer care for a Medicare patient in 
circumstances of illness, pregnancy, or vacation.
    H.R. 1934, the Cancer Care Payment Reform Act, sponsored by 
the House Republican Conference chairman, Cathy McMorris 
Rodgers (WA), establishes a national Oncology Medical Home 
Demonstration Project to improve Medicare payments for cancer 
care.
    Draft legislation authored by Rep. Greg Walden (OR) would 
make changes to documentation and face-to-face requirements for 
home health providers under the Medicare program.
    Together these three bills continue the commitment this 
Congress has to strengthen the Medicare program and keep the 
promise for seniors--which was started earlier this year by 
permanently repealing and replacing the broken Sustainable 
Growth Rate (SGR)--an effort spanning several years to 
enactment this past April.
    I want to thank our witnesses for testifying today. They 
bring with them real world experience of problems in the 
Medicare program and I look forward to their testimony on these 
pieces of legislation.
    Finally, I would like to commend the sponsors of these 
pieces of legislation for their efforts in bringing these 
various pieces of legislation forward.

    [The proposed legislation appears at the conclusion of the 
hearing.]
    Mr. Pitts. And I will yield to any of my colleagues on my 
side of the aisle if they would like to make any statements. 
None?
    All right. I yield back.
    I recognize Mr. Lujan of New Mexico for 5 minutes for his 
opening statement.

 OPENING STATEMENT OF HON. BEN RAY LUJAN, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF NEW MEXICO

    Mr. Lujan. Thank you very much, Chairman Pitts. And I 
appreciate you and the ranking member and all the members of 
the subcommittee for allowing us to be here today for this 
important conversation.
    I am pleased that, today, the committee is considering H.R. 
556, the Prevent Interruptions to Physical Therapy Act. 
Physical therapy.
    Congressman Bilirakis and I introduced this bill in the 
previous Congress and again at the beginning of this Congress 
because, under current law, physical therapists are not allowed 
to enter locum tenens agreements. The physical therapy act 
changes this by allowing physical therapy practices to hire a 
qualified locum tenens physical therapist to treat Medicare 
patients during an absence by one of the practice's regular 
physical therapists.
    For many seniors, physical therapy services provide a path 
to restore mobility after an injury or a medical procedure and 
a way to restore function and return to the activity level that 
they have long enjoyed. With the help of their physical 
therapists many patients are able to recover and continue to 
live independently with a higher quality of life.
    There are times, however, when physical therapy services 
can be interrupted due to the provider having an illness, 
taking a vacation, maternity leave, or continuing their 
professional education. In other words, Mr. Chairman, you know, 
life moves on as well; but, unfortunately, physical therapists 
aren't able to try to bring in some of their peers to provide 
coverage, like doctors, osteopathic physicians, dental 
surgeons, podiatrists, optometrists, or chiropractors.
    These interruptions can easily be handled by entering into 
what is called a locum tenens agreement with another qualified 
provider. Under these arrangements, the regular provider is 
able to bill and receive payment under Medicare part B for the 
locum tenens provider services as if they had performed them 
themselves. The locum tenens provider is compensated directly 
by the practice of the regular provider.
    These arrangements are common and extremely beneficial to 
patients and providers alike as the relationship between the 
patient and the practice is continued by another licensed, 
qualified provider during their short-term leave. Especially in 
isolated rural areas, a locum tenens provider can keep a small 
medical practice open to serve patients who would otherwise 
have to travel long distances to another provider. By hiring a 
locum tenens, a provider is able to ensure that their patient 
care does not lapse.
    The Senate companion bill was voted out of committee in 
June, and I am pleased that our bill is before the committee 
today; and I look forward to the testimony and questions about 
this commonsense legislation.
    And, again, I want to thank Congressman Bilirakis for his 
leadership. It has been a pleasure and an honor to work with 
him on this important issue.
    With that, Mr. Chairman, I yield back.
    Mr. Pitts. The Chair thanks the gentleman.
    In lieu of the chairman, the Chair recognizes Mr. Bilirakis 
of Florida for 5 minutes for an opening statement.

OPENING STATEMENT OF HON. GUS M. BILIRAKIS, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF FLORIDA

    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it 
very much. Thanks for also addressing this particular bill this 
morning. The Prevent Interruptions in Physical Therapy Act is a 
bipartisan bill that I introduced, along with my good friend 
and colleague, Ben Ray Lujan.
    Currently, Medicare allows a wide range of medical 
providers, including doctors of medicine, osteopathy, and 
chiropractors, the ability to bring in other licensed 
professionals under their provider number. This allows for 
substitutes for when a practice is short-staffed for a short 
period of time for reasons such as illness, maternity or 
paternity leave, or vacation. Such instances are referred to as 
``locum tenens arrangements.'' Physical therapists currently 
are excluded from employing locum tenens in their practices, 
forcing seniors to either find a new physical therapist or not 
receive treatment during the time their therapist is out.
    To illustrate the problem that occurs, this is a letter 
from Alicia Nixon, a physical therapist in Hillsborough County, 
Florida, and I quote, ``I am a private practice owner and have 
served mostly Medicare patients for the last 11 years. The 
current Medicare rules have been very difficult and 
detrimental, at times, to my practice's viability. Just as 
important, there have been times that were completely 
unavoidable and that the Medicare patients were not able to be 
seen in order to remain in compliance with the current 
regulations. It has been almost impossible to take a vacation 
or time to attend conferences or seminars because of my need to 
be onsite at the clinic. I was recommended to have surgery 6 
years ago that I still have not had because it would require me 
to be away from the practice for over 6 weeks for recovery. 
When I received a court summons, I had to close the clinic for 
2 days, with patient visits having to be canceled, and all 
staff lost wages from the necessary closure,'' end quote.
    At one point, this practice lost a physical therapist. It 
took about a year to fill that vacancy, and then she writes 
again and I quote: ``In the timeframe that I was looking to 
fill the vacancy here at the practice, my biggest fear was 
that, if I was in an accident and physically not able to be 
onsite for a period of time, it would mean certain closure of 
the office. It is very sad that an office that has provided 
excellent services to the Medicare community is so vulnerable 
because of the current regulations.'' We need to pass this 
bill, Mr. Chairman. It is pro-patient and pro-physical 
therapist.
    I yield back. Actually, I would like to yield the rest of 
my time to Chairman Greg Walden. Thank you.
    Mr. Walden. I thank the gentleman very much.
    Mr. Chairman and Ranking Member, thank you for holding this 
hearing. It is a very important issue. We need to explore the 
problems with this face-to-face regulation.
    Our Nation has made a promise to seniors who rely on 
Medicare, and we must keep it, and one way to keep this promise 
is through home health services.
    So I am happy to introduce Sarah Myers, who will be sharing 
her knowledge about what is going on out there. She is the 
Executive Director of the Oregon Association of Home Health 
Care. Sarah has been recognized for her outstanding 
contribution to the Oregon home care community and has provided 
the Oregon delegation with a wealth of information on the 
critical issues facing home health providers and the patients 
that they serve.
    In general, home health, as you know, is less expensive, 
more convenient, and just as effective as care in a skilled 
nursing facility. Receiving care at home gives seniors more 
control over their health care, and it provides a sense of 
comfort, familiarity, and normalcy for the patient and for 
their loved ones.
    I know this firsthand because it was the choice my parents 
and I made, and, in Oregon, more than 20,000 Medicare 
beneficiaries make that same choice.
    However, under current documentation requirements 
associated with a so-called ``face-to-face requirement'' have 
placed significant pressures on the home health care community 
and the people they serve. In order for a patient to meet the 
eligibility criteria for home health, a physician must document 
that a face-to-face meeting occurred between the patient and a 
physician or a nonpatient practitioner--or a nonphysician 
practitioner.
    While intended to be a way to reduce waste, fraud, and 
abuse by ensuring the orders and certification of home health 
care are based on actual knowledge of the patient's condition, 
unclear documentation requirements from the Government have led 
to a slew of payment denials and additional documentation 
requests.
    So we have a situation in which a complicated regulatory 
process simply needs to be streamlined and standardized, and 
that is what this election would do.
    First, it requires the Secretary to develop a single 
standardized form which satisfies the requirements of the home 
health certification;
    And second, the bill streamlines the process and eases the 
requirements if the patient has been discharged from the 
hospital or skilled nursing facility;
    Third, anyone who uses this form must receive proper 
notification and education on the documentation requirements;
    And finally, the Secretary must implement a process to 
reopen review claims which were denied solely due to the face-
to-face documentation concerns and issue revised decisions if 
the claims were denied because of the patient narrative--a 
requirement that even CMS recently dropped because of the 
burden on providers.
    So, Mr. Chairman, this isn't just about a backlog of 
appeals and red tape. It is about improving access to and 
quality care of our seniors, and that is why this legislation 
has the support of the home health providers, including the 
Partnership for Quality Home Healthcare, the National 
Association for Home Care & Hospice, and the Visiting Nurse 
Associations of America.
    Mr. Chairman, I ask unanimous consent to submit their 
statements for the record.
    I also would like to submit into the record three letters 
to CMS from 2011, 2013, and 2014 from the House and Senate, 
expressing concerns with the face-to-face documentation 
request.
    Mr. Pitts. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Walden. I thank the chairman, and I appreciate his 
indulgence and your work on this legislation.
    I yield back.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the ranking member of the full committee, Mr. 
Pallone, for 5 minutes for an opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Mr. Chairman.
    I am always happy to come together to examine bipartisan 
ways to improve the Medicare program and beneficiary access, 
and I would be remiss in not mentioning that a witness from the 
administration would have made this hearing more informative. 
The administration would have been able to speak to whether 
these bills are implementable and what we could do to improve 
them.
    The first bill under discussion today is an example of why 
the administration's input would help inform our 
decisionmaking. The bill would set up a national Oncology 
Medical Home Demonstration Project in the Medicare program 
through care coordination management fees based on performance 
and shared savings and arrangements with oncology practices.
    We laid the foundation for these types of payment reform 
demonstrations in the Affordable Care Act through the 
establishment of accountable care organizations, medical homes, 
and demonstrations within the Centers for Medicare & Medicaid 
Innovation, CMMI.
    If someone from the administration were here, they would be 
able to tell us about the oncology care model, a demonstration 
project that the Center for Medicare & Medicaid Innovation has 
initiated. The oncology care model would also pay coordination 
management fees to practices and require performance and 
financial accountability.
    I think this type of model is worthwhile. We should 
absolutely be looking at ways to improve oncology care in our 
country; but I am interested in learning why the legislation is 
necessary when CMMI is already implementing a similar model.
    The second bill we are considering is H.R. 556, the Prevent 
Interruption in Physical Therapy Act, which would expand the 
locum tenens designation to include physical therapists.
    Currently, Medicare allows physicians who are absent from 
their practices for extended periods--for reasons such as 
illness, pregnancy, vacation, or continuing medical education, 
to retain substitute physicians to take over their practices 
until they return. The ability to bring in a substitute 
physician is called ``locum tenens,'' and this bill would allow 
physical therapists to enter into these arrangements.
    When there are limited options in rural or in medically 
underserved areas, I understand the concerns for patients' 
access when a physical therapist needs to be absent from his or 
her practice; and I look forward to working with my colleagues 
on this legislation to ensure it helps those who need it most.
    Last, the committee is considering a discussion draft of a 
bill that would change the Medicare home health face-to-face 
requirement.
    Understand that this bill is a discussion draft that has 
yet to be introduced, but I have concerns with further walking 
back the face-to-face requirement that we put in place in the 
Affordable Care Act.
    This requirement was the result of both the inspector 
general and MedPAC recommendations to root out waste and fraud 
in the Medicare system. CMS has been listening to industry's 
concerns about the requirement, and work with them to make it 
more streamlined and easy to comply with. In fact, over the 
last few years, my staff and I have advocated us for these 
actions; however, we must be extremely careful when removing 
requirements that shore up program integrity.
    So, again, thank you, Mr. Chairman.
    [The prepared statement of Mr. Pallone follows:]

             Prepared statement of Hon. Frank Pallone, Jr.

    Mr. Chairman, thank you for holding this hearing today. I 
am always happy to come together to examine bipartisan ways to 
improve the Medicare program and beneficiary access. I would be 
remiss in not mentioning that a witness from the administration 
would have made this hearing more informative. The 
administration would have been able to speak to whether these 
bills are implementable and what we could do to improve them.
    The first bill under discussion today is an example of why 
the administration's input would help inform our decision-
making. The bill would set up a national Oncology Medical Home 
Demonstration Project in the Medicare program through care 
coordination management fees based on performance and shared 
savings arrangements with oncology practices. We laid the 
foundation for these types of payment reform demonstrations in 
the Affordable Care Act through the establishment of 
Accountable Care Organizations, Medical Homes, and 
demonstrations within the Centers for Medicare & Medicaid 
Innovation (CMMI).
    If someone from the administration were here, they would be 
able to tell us about the Oncology Care Model, a demonstration 
project that the Center for Medicare and Medicaid Innovation 
has initiated. The Oncology Care Model would also pay 
coordination management fees to practices and require 
performance and financial accountability. I think this type of 
model is worthwhile-we should absolutely be looking at ways to 
improve oncology care in our country, but I am interested in 
learning why legislation is necessary when CMMI is already 
implementing a similar model.
    The second bill we are considering today is H.R. 556, the 
Prevent Interruptions in Physical Therapy Act, which would 
expand the ``locum tenens'' designation to include physical 
therapists. Currently, Medicare allows physicians who are 
absent from their practices for extended periods for reasons 
such as illness, pregnancy, vacation, or continuing medical 
education to retain substitute physicians to take over their 
practices until they return. The ability to bring in a 
substitute physician is called locums tenens, and this bill 
would allow physical therapists to enter into these 
arrangements. When there are limited options in rural or 
medically underserved areas, I understand the concerns for 
patient access when a physical therapist needs to be absent 
from his or her practice. I look forward to working with my 
colleagues on this legislation to ensure it helps those who 
need it most.
    Last, the committee is considering a discussion draft of a 
bill that would change the Medicare home health face-to-face 
requirement. I understand that this bill is a discussion draft 
that has not yet been introduced, but I have concerns with 
further walking back the face-to-face requirement that we put 
in place in the Affordable Care Act. This requirement was a 
result of both Inspector General and MedPAC recommendations to 
root out waste and fraud in the Medicare system. CMS has been 
listening to industry's concerns about the requirement and 
worked with them to make it more streamlined and easy to comply 
with. In fact, over the last few years, my staff and I have 
advocated for these actions. However, we must be extremely 
careful when removing requirements that shore up program 
integrity.
    Again, thank you, Mr. Chairman, for holding this hearing, 
and I yield the rest of my time to the Democratic sponsor of 
the Prevent Interruptions in Physical Therapy Act, Congressman 
Lujan.

    Mr. Pallone. I yield the rest of my time to the ranking 
member, Mr. Green.
    Mr. Green. Thank you, Mr. Chairman, and I thank our ranking 
member.
    And I would like to ask unanimous consent that my full 
statement be placed in the record.
    Mr. Pitts. Without objection, so ordered.
    Mr. Green. I want to thank the Chair for calling this 
hearing today.
    This marks the 50th anniversary of Medicare, and since 
1965, the landmark program has provided affordable health 
insurance coverage and access to care for our Nation's seniors. 
Few programs have improved the lives of Americans as 
significantly as Medicare.
    Today, we have three separate bills. The first is H.R. 556, 
the Prevent Interruptions in Physical Therapy Act.
    It would allow physical therapists to employ locum tenens 
in their practices. Under Medicare law, health care providers 
are permitted to employ only licensed professionals under their 
provider number to care if they are temporarily unable to do 
so. H.R. 556 would add physical therapists to the list of 
providers who would enter into these agreements, known as 
``locum tenens agreements,'' so that patients do not see a 
disruption in care.
    H.R. 1934, the Cancer Care Payment Reform Act, would 
establish a national Oncology Medical Home Demonstration 
Project. Research has shown there is a disconnect between cost 
and the quality of cancer care for Medicare beneficiaries, and 
many have suggested the fee-for-service model is inappropriate. 
I know, recently, the Center for Medicare & Medicaid Innovation 
announced at launch a 5-year oncology care model starting next 
spring. The demonstration proposed in H.R. 1934 shares many of 
the characteristics of that Center for Medicare & Medicaid 
Innovation.
    Mr. Chairman, like I said, I would like to ask unanimous 
consent for the full statement to be placed in the record.
    Again, thank you for calling the hearing.
    Mr. Pitts. The Chair thanks the gentleman.
    [The prepared statement of Mr. Green follows:]

                 Prepared statement of Hon. Gene Green

    Good morning, and thank you all for being here today.
    This hearing is titled ``Examining Potential Ways to 
Improve the Medicare Program.''
    I want to thank the chairman for having this hearing. 
Before we get in to the legislative proposals we will be 
discussing, I think it is important to reflect on the Medicare 
program at large.
    This year marks the 50th anniversary of Medicare.
    Since 1965, this landmark program has provided affordable 
health insurance coverage and access to care for our Nation's 
seniors.
    Few programs have improved the lives of Americans as 
significantly as Medicare.
    Fifty years ago, almost half of elderly Americans lacked 
health insurance.
    Today, Medicare provides lifesaving insurance to nearly 100 
percent of adults over 65.
    Fifty-four million elderly and individuals with 
disabilities have health insurance through Medicare.
    At the anniversary of this historic law, we celebrate the 
successes of the Medicare program.
    We must also renew our commitment to further strengthening 
it, so that it remains available in perpetuity for generations 
to come.
    Today we are considering three pieces of legislation.
    The first is H.R. 556, the Prevent Interruptions in 
Physical Therapy Act.
    This bill will allow physical therapists to employ locum 
tenens in their practices.
    Under current Medicare law, a variety of health care 
providers are permitted to employ other licensed professionals 
under their provider number to care for their patients if they 
are temporarily unable to do so.
    H.R.556 will add physical therapists to the list of 
providers who can enter into these agreements, known as ``locum 
tenens arrangements,'' so their patients do not see a 
disruption in care.
    H.R. 1934, the Cancer Care Payment Reform Act, will 
establish a national Oncology Medical Home Demonstration 
Project to examine changing the structure of Medicare payments 
for cancer care.
    The intent of this bill is to test the potential of 
alternative payment models in oncology.
    Research has identified a disconnect between the costs and 
the quality of cancer care for Medicare beneficiaries.
    Many have suggested that the fee-for-service model is 
inappropriate, and have suggested that Congress explore the 
potential of alternate models, including oncology patient-
centered medical homes, ACOs and bundled payments for oncology 
services.
    Recently, the Center for Medicare and Medicaid Innovation 
(CMMI) announced the launch of a 5-year Oncology Care Model 
starting next spring.
    The demonstration project proposed by H.R. 1934 shares many 
characteristics of the CMMI demo.
    It is important we do not waste resources by duplicating 
efforts, or undermine ongoing demonstrations without good 
reason, but I thank the bill sponsors for their commitment to 
improving oncology care for Medicare beneficiaries.
    I look forward to furthering the discussion on how we can 
continue to build on the promise of the new provider delivery 
model advanced in the Medicare Access and CHIP Reauthorization 
Act.
    The final piece of legislation we will discuss is a draft 
bill to amend the Medicare home health face-to-face 
documentation requirements.
    Home health care is critically important to Medicare 
beneficiaries who are confined to their homes.
    While we must ensure that this service is available to 
individuals in need of care, substantial concerns about 
spending growth and quality within the home health benefit have 
been identified by the OIG, GAO and independent researchers.
    Since 2001, Medicare spending on home health services has 
doubled.
    In 2013, the cost of home health services reached almost 
$18 billion.
    In order to address concerns about the appropriateness of 
some services and vulnerability to fraud and waste, the 
Affordable Care Act included Medicare home health integrity 
provisions.
    The ACA mandated that physicians or another provider have a 
face-to-face encounter with the patient to attest to their 
eligibly for the home health benefit.
    CMS has implemented this requirement and simplified the 
certification and documentation process.
    However, many home health agencies have expressed concern 
that the mandate is overly burdensome.
    The intent of the draft bill is to address some of these 
documentation concerns.
    I look forward to hearing more about the implementation of 
the face-to-face requirement, ways the process can be improved, 
and how we can build on program integrity provisions of the 
Affordable Care Act.
    It would be difficult to overstate the importance of 
Medicare to our Nation's seniors--both today and future 
generations.
    I want to thank our witnesses for being here today and look 
forward to exploring the proposal, and other ways we can 
strength this vital safety net program.
    Thank you, and I yield back.

    Mr. Pitts. We are voting on the floor. We have 11 \1/2\ 
minutes to go, and 400 people haven't voted, so we are going to 
start the witnesses.
    As usual, all members' written opening statements will be 
made a part of the record; and I'll introduce them in the order 
of their testimony.
    First, we have Sarah Myers, CAE, Executive Director of the 
Oregon Association of Health Care. Welcome. Dr. Bruce Gould, 
President of the Community Oncology Alliance. Welcome. And 
Sandra Norby, PT, AT, owner, HomeTown Physical Therapy, LLC.
    Thank you each for coming. Your written testimony will be 
made a part of the record. You will be each given 5 minutes to 
summarize.
    Ms. Myers, you're recognized for 5 minutes.

     STATEMENTS OF SARAH MYERS, EXECUTIVE DIRECTOR, OREGON 
ASSOCIATION FOR HOME CARE; BRUCE GOULD, M.D., MEDICAL DIRECTOR, 
 NORTHWEST GEORGIA ONCOLOGY CENTERS, AND PRESIDENT, COMMUNITY 
 ONCOLOGY ALLIANCE; AND SANDRA NORBY, OWNER, HOMETOWN PHYSICAL 
                          THERAPY, LLC

                    STATEMENT OF SARAH MYERS

    Ms. Myers. Chairman Pitts, Ranking Member Green, members of 
the subcommittee, and Congressman Walden, thank you for this 
opportunity to speak with you today.
    My name is Sarah Myers, and I am the Executive Director of 
the Oregon Association for Home Care.
    Our organization represents over 58 home health agencies, 
employing over 2,000 professionals and providing Medicare home 
health services to more than 30,000 Medicare beneficiaries who 
are homebound and many of whom are rural.
    As you know, home health patients are among the most 
vulnerable in the Medicare program, and, in fact, Federal data 
shows that they are older, sicker, poorer, and more likely to 
be a minority and disabled than all other Medicare 
beneficiaries combined. Due to their frail condition, these 
seniors have been deemed homebound by their physicians, meaning 
they cannot leave their home without help or potential injury 
to themselves.
    That is where skilled home health care providers come in.
    We deliver nursing, therapy, infusion, medical social 
worker, and support services to patients recovering from an 
acute illness following a hospitalization. We also serve 
patients with severe disabilities that may confine them to a 
wheelchair or bed. Home health providers also care for patients 
whose disease state has advanced to the degree that their 
health and their mobility are now compromised, and compromises 
their continued ability to maintain independence without 
assistance.
    Not only do our professional home health services meet the 
clinical needs of our patients in the patient preferred home 
setting, but they help our patients avoid being rehospitalized, 
and as a result, they help generate significant savings from 
the Medicare program and taxpayers.
    Home health care is especially important to rural America. 
Without any access to hospitals, nursing homes, or other 
facilities, residents truly depend on home health. In fact, 
more than 630,000 Medicare beneficiaries in nearly 2,000 rural 
counties relied on home health services in 2013.
    That is why I am here today, to speak to you and ask you to 
help us continue serving the frail seniors who need our care 
and the rural communities who depend on our delivery system.
    One of the greatest burdens we face today is the 
implementation of the face-to-face requirement; but let me be 
clear: We strongly supported your action to require that no 
claim would be paid unless it was for services ordered by a 
physician as a result of the face-to-face encounter with the 
patient. That is good medicine, and that is good program 
integrity policy.
    We need to keep in mind that the physician also certifies 
the patient's eligibility for Medicare coverage under penalty 
of various anti-fraud laws. What has created the burden on 
physicians and home health providers is not the policy but how 
it has been implemented with impossible-to-meet documentation 
requirements that are not in the law enacted by Congress.
    Inconsistencies in the lack of standardization have forced 
providers to chase physicians multiple times to address issues 
of semantics, not to improve patient care or to improve quality 
performance. Documentation compliance has become a moving 
target, resulting in countless hours of providers and 
physicians attempting to meet Medicare's unclear documentation 
rules, resulting in thousands of denied claims. Whether it is a 
missing signature on a completed form or an insufficient 
description regarding a patient's clinical condition, the 
implementation has resulted in a process that has, ultimately, 
created a paperwork mess of what should be straightforward 
documentation. Patient care is the priority. Burdensome 
paperwork and navigating red tape should not be.
    What is most alarming with the documentation demands is 
that thousands of claims have been denied based on insufficient 
documentation even though a review of the full patient record 
reveals that the patient meets Medicare coverage criteria. This 
is not happening in a vacuum either. It is occurring at the 
same time home health providers are struggling under an 
unprecedented 14 percent, 4-year cut. A cut which is pushing 
home health agencies to the brink.
    Medicare has tried to fix the documentation nightmare. 
However, its efforts have fallen far short. Fortunately, there 
is a solution. Congressman Walden is authoring legislation that 
would establish a simple approach to documenting physicians' 
face-to-face encounters with their patients. In place of 
confusing requirements, physicians would simply record the date 
of the encounter and use a form to identify the clinical 
condition for which home health is needed.
    We need this legislation. It will preserve your good policy 
while reducing unneeded paperwork and enabling us to continue 
serving homebound seniors in Oregon and all across America.
    In closing, I want to thank Congressman Walden and all of 
you for your support of home health care and your dedication to 
America's rural communities. Your efforts mean very, very much 
to us. Thank you.
    [The prepared statement of Ms. Myers follows:]

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    Mr. Pitts. The Chair thanks the gentlelady.
    We still have 5 minutes, and 374 Members haven't voted. We 
will try one more.
    Dr. Gould, you're recognized for 5 minutes.

                    STATEMENT OF BRUCE GOULD

    Dr. Gould. Thank you. Chairman Pitts, Ranking Member Green, 
and members of the committee, I thank you for the opportunity 
to share my views on payment reform in oncology and 
specifically on the Cancer Care Payment Reform Act, H.R. 1934.
    I am a practicing medical oncologist and Medical Director 
of Northwest Georgia Oncology Centers, a private community 
oncology practice headquartered in Marietta, Georgia. 
Additionally, I serve as President of the Community Oncology 
Alliance, COA, a nonprofit organization dedicated to advocating 
for community oncology practices and, most importantly, the 
patients they serve. Close to 70 percent of Americans with 
cancer are treated by private practice clinics. I finally want 
to mention, of relevance here, that I am the son of two parents 
who passed away from cancer.
    Community oncology practices, such as mine, have struggled 
from major cuts to reimbursement by Medicare. For example, the 
decision by CMS to apply sequestration to the underlying costs 
of cancer drugs has led to many drugs being reimbursed for less 
than their acquisition price. As a result, over 300 practices 
have closed treatment sites and, more significantly, close to 
550 practices have merged with hospital systems.
    The data is clear on the consolidation of cancer care in 
the United States. It is creating access to care problems for 
patients in rural areas and, very significantly, increasing the 
costs of cancer care for seniors in the Medicare program. This 
unwanted trend has been documented by reports this year by the 
GAO and MedPAC.
    Despite reimbursement pressures from Medicare, our 
practice, years ago, made a decision to ambitiously transform 
ourselves into a patient-centric Oncology Medical Home. Our 
goal was simple: to better control the costs of cancer care 
while enhancing the quality of the patient experience. Among 
other things, we improved care coordination for our patients, 
established a structured triage, initiated a comprehensive 
patient satisfaction survey, and developed our own treatment 
guidelines.
    One benefit of this transformation is that same-day 
appointments are rarely available in our nonclinics. Therefore, 
if our patients are ill, they can come to our clinics rather 
than going to the hospital emergency room. Medicare moneys are 
saved by the avoidance of needless emergency room visits and 
hospitalizations, and the patients are happier by not being 
subjected to hours of waiting in the emergency room.
    Our hard work has recently been recognized by the 
commission on cancer through their accreditation of our 
practice as one of the first Oncology Medical Homes. Our 
dedication to value-based care has led us to partnering with 
private payers and CMS on oncology payment reform pilots.
    One program we and several others completed with 
UnitedHealthcare resulted in cancer care savings of 34 percent 
as compared to a case control group. The results were published 
in the peer-review ``Journal of Oncology Practice,'' a copy of 
which I have submitted with my remarks for the record.
    We are also part of a national $19 million grant from the 
Centers for Medicare & Medicaid Innovation, CMMI. The grant 
funded the ``COME HOME'' pilot, which was designed to be a real 
world test of the oncology and medical home tenants. Findings 
from NORC at the University of Chicago, the independent 
research entity CMMI contracted with to measure results, were 
nothing short of remarkable. They showed an overall reduction 
of cancer care costs due to reduced hospitalizations, re-
admissions, and emergency department utilizations. I have 
included these results with my written testimony.
    I am here today to implore Congress to immediately pass the 
Cancer Care Reform Act, H.R. 1934, a bipartisan bill, 
introduced by Representatives Cathy McMorris Rodgers and Steve 
Israel. The bill lays out the specific plans for a 
demonstration project based on the Oncology Medical Home. It is 
built on successful models that have already been tested in the 
oncology payment reform with both private payers and CMS.
    I commend Mrs. McMorris Rodgers for reaching out to 
practicing community oncologists for crafting her bill. In 
addition to support from oncologists, her legislation also has 
the support of patient groups, private payers, biotech 
companies, and pharmaceutical distributors. I also commend 
Congress for passing a fix to SGR, along with a path to 
meaningful payment reform. Community oncology practices like 
mine want to be part of the alternative payment reform path 
that the Energy and Commerce Committee developed in the SGR 
legislation. However, we need a Medicare alternative payment 
model in oncology for that to happen.
    H.R. 1934 is a critical bridge to getting us to that point. 
I ask Congress to pass this important legislation that will 
lower the costs of cancer care while enhancing the quality of 
care for patients.
    Thank you for your attention.
    [The prepared statement of Dr. Gould follows:]
    
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    Mr. Pitts. Thank you.
    Sorry to rush you here. We are going to do one more opening 
statement. No time left, but 290 people still haven't voted.
    So, Ms. Norby, you're recognized for 5 minutes for your 
opening statement.

                   STATEMENT OF SANDRA NORBY

    Ms. Norby. Chairman Pitts, Ranking Member Green, and 
members of the committee, thank you for holding today's hearing 
highlighting these important legislative issues.
    My name is Sandra Norby, and I appreciate the opportunity 
to discuss my strong support for H.R. 556, the Prevent 
Interruptions in Physical Therapy Act of 2015.
    I would like to especially thank Congressmen Bilirakis and 
Lujan for their sponsorship of this legislation.
    I am a physical therapist and a member of the American 
Physical Therapy Association and its private practice section. 
My small business consists of five clinics in Iowa in 
communities with populations ranging from 500 to 9,000.
    One of APTA's policy priorities is to improve access to 
care by physical therapists through the elimination of 
regulatory, legal, and payment policy barriers that impede 
patient care. Physical therapy is part of the comprehensive 
care model; therefore, it is high time that access to PT also 
receives the same protections against unavoidable absences by 
the therapy provider.
    H.R. 556 would improve access to care by providing needed 
regulatory relief with a simple technical fix. This bill would 
allow PTs to enter into locum tenens arrangements with other 
qualified therapists on a temporary basis in cases such as 
illness, pregnancy, or jury duty. This arrangement is available 
to numerous Medicare providers, but physical therapists were 
overlooked and are not included in the law that permits locum 
tenens.
    This means PTs in private practice are unable to be absent 
from the clinic, even in an emergency, without interrupting a 
Medicare patient's episode of care. Such interruption results 
in potential regression in the patient's condition. When care 
is resumed, the Medicare patient is likely to require more 
visits to achieve the original therapy goals, than what would 
have been realized sooner, had a locum tenens therapist been 
allowed. Thus, not allowing a locum tenens for PTs has the 
potential to increase costs to the Medicare program.
    It is currently possible to hire a substitute for a planned 
leave by arranging for a PT to be added to the practice's 
Medicare certification. However, such an arrangement is not 
realistic for emergencies or a short-term option. The 
certification process is complicated and time consuming, taking 
2 to 3 months under the best of circumstances, and includes an 
on-site visit. This cumbersome time requirement is certainly a 
reason that numerous other Medicare providers are permitted to 
use locum tenens arrangements. It only makes sense that PTs are 
afforded the same options.
    Practicing in rural communities, as I do, my colleagues and 
I are often the only physical therapists in town. When we have 
to be gone from our clinic, our practice must turn away our 
Medicare patients or take extraordinary measures for them to 
continue their care. During a recent maternity leave for one of 
my therapists, I spent 12 weeks driving from my home 3 hours 
away, sleeping at the clinic most nights, in order for our 
Medicare patients to receive their care.
    Under locum tenens, a clinic like mine would be allowed to 
bill and receive payment for the replacement therapist 
services. Built-in safeguards control fraud and abuse as all 
locum tenens arrangements must meet regulatory standards that 
includes identification of services on the Medicare claim form 
and a 60-day limit to use the provider.
    Senator Charles Grassley recently received a letter stating 
quote: ``CMS does not have evidence indicating that locum 
tenens, as used by physicians under current law, has led to a 
general increase in utilization of services; or that industry 
practices generally lead to the provision of unnecessary 
services related to the use of locum tenens; or that the use of 
locum tenens under current law in the Medicare program is 
generally inappropriate, wasteful, or fraudulent'' close quote. 
Preventing the disruption of Medicare patients' therapy, as 
this bill will do, would likely result in lower costs to the 
Medicare program.
    I truly appreciate the committee's interest in addressing 
this regulatory burden that impacts access to care. I am hoping 
that this simple technical correction can be achieved and that 
Medicare patients will be allowed to continue to access 
medically necessary PT services without disruption.
    I look forward to working with the committee, and I am 
happy to answer any questions you may have.
    [The prepared statement of Ms. Norby follows:]
    
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    Mr. Pitts. Thank you very much.
    I appreciate your patience due to the votes on the floor. 
We are going to have to take a brief recess. We will reconvene 
immediately after the votes. There are still 160 people who 
haven't voted, so we have time.
    So, without objection, the subcommittee stands in recess.
    [Recess.]
    Mr. Pitts. The time for the recess having expired, the 
subcommittee will come to order. I will begin the questioning 
and recognize myself for 5 minutes for that purpose. Can I get 
staff to come over here and operate this clock? One of you. I 
am sorry, that is OK.
    We will start with you, Dr. Gould. One thing this committee 
focused on during the SGR debate, the sustainable growth rate--
you are familiar with that I am sure----
    Dr. Gould. Yes.
    Mr. Pitts [continuing]. Was creating a new framework for 
alternative payment models, and the goal was to encourage 
specialties to develop their own best practices that could 
ultimately lead to more coordinated care and better patient 
outcomes. How do you see H.R. 1934 conforming to this goal?
    Dr. Gould. Well, I see H.R. 1934 fitting like a hand in a 
glove with that mandate. As medical specialists, we all want to 
be judged on the quality of our work, and we want to be judged 
on measures that are relevant to our specialty, and we want to 
be judged on how satisfied patients are with the care they 
receive from us.
    In addition, we understand in these days that costs are 
important, and we also want to take responsibility for our part 
of the rising health care costs. So the alternative payment 
model, H.R. 1934, meets all those needs in terms of payment 
reform, in which I applaud Medicare in terms of their moving 
from paying for the volume of services utilized to the quality 
of the services rendered to the patient.
    Mr. Pitts. Thank you. Ms. Norby, what safeguards and fraud 
and abuse controls, if any, are built into locum tenens 
agreements?
    Ms. Norby. As I indicated in my testimony, we have to 
identify who the provider was on the claim form by reporting 
their NPI number, and also, there is the 60-day limit that they 
can be utilized as a locum tenens as well.
    As the letter from CMS had indicated, that these were 
physicians, they have not seen any problems with any kind of 
fraud or abuse when the locum tenens physician is in, so we 
assume the same would happen with physical therapists.
    Mr. Pitts. Thank you. Ms. Myers, in your testimony you 
discuss how vulnerable a population the home health 
beneficiaries are. Can you elaborate on that a little bit?
    Ms. Myers. Absolutely. In a number of cases that we provide 
services to Medicare homebound beneficiaries, some of them are 
wheelchair bound, many of them are in very rural areas with 
very little access to community and/or family support systems. 
There are certainly a number of patients that we serve that are 
severely homebound, and without assistance, truly cannot get 
out of the home, even to simply get to a physician's office for 
a visit. So there are many cases where we are dealing with 
highly functionally impaired individuals.
    Mr. Pitts. So it is very important in a rural setting?
    Ms. Myers. Absolutely. Most specifically, we have a lot of 
patients in Congressman Walden's district who have very little 
access to care. They may live 60 miles, 100 miles from the 
nearest hospital, and it is very difficult, not only for 
clinicians to reach them due to the rural conditions and the 
areas in which they live, but also, certainly, very difficult 
for those patients to get out to basic health care so that they 
may continue to be independent.
    Mr. Pitts. Ms. Norby, how long does it take to hire a 
substitute provider for planned leave by arranging in advance 
for a Medicare-enrolled physician therapist to be added to the 
practice's CMS certification?
    Ms. Norby. As I understand, you are asking how long it 
would take for me to hire someone to replace the therapist? In 
the case of my story where I covered a maternity leave for a 
therapist that was leaving, I did reach out to some traveling 
companies to see if I could hire someone to fulfill that role. 
They could not guarantee me that I would know who the provider 
was more than 30 days in advance. And with Medicare's 
requirement for the certification enrollment, that can take 2 
to 3 months or longer. So if I had brought that person in, I 
would not be able to actually bill for their services for a 
significant duration of time, which then would put a financial 
hardship on our clinic because we still have payrolls to pay 
and those types of things as well.
    Mr. Pitts. I have just one more question for you, how does 
Medicare save money if PTs in private practice are allowed to 
enter into locum tenens arrangements?
    Ms. Norby. That is a great question. So right now, without 
locum tenens, if I had to be gone from my clinic, my Medicare 
patients are not receiving the care they need. And if someone 
had, for instance, a total knee replacement, any interruption 
in physical therapy to regain, for instance, their knee range 
of motion, is going to be very, very detrimental to the 
progress of their care. And so what would happen is they are 
going to create joint stiffness, and so then when I come back 
and they can get physical therapy, they are literally going to 
have to have more visits to achieve that goal that we set up in 
the first place, because they were put behind because of the 
absence.
    Mr. Pitts. All right, my time has expired. The Chair 
recognizes Mr. Schrader for 5 minutes for questions.
    Mr. Schrader. Thank you very much, Mr. Chairman. A couple 
of questions for Ms. Myers, if I could. You said that the 
current home health documentation requirements aren't working 
as needed. There have been a lot of denials that seem odd or 
problematic, to put it nicely. Could you give us some real-
world examples of some of the ridiculous things you have 
incurred from CMS in denial?
    Ms. Myers. Absolutely, and I thank you for the question. A 
lot of the examples that we are seeing on claims and denials 
and requests for additional documentation from the reviewers 
include things such as a missing date, a missing signature. One 
denial, in particular, was due to the fact that the reviewer 
could not read the handwriting of the physician, and in 
particular, could not read the physician's signature itself, 
which I find to be terribly odd because the record requires us 
to provide an NPI number to validate that the physician is 
actively billing Medicare and the system. And so it is a little 
bit of an oddity.
    The other denials that we do see are related to the status 
of the clinical condition of the patient and the homebound 
status. Some of the denials we have seen involve the 
description by the physician and how he or she may describe the 
patient's condition. For example, one physician described the 
patient and their need for skilled care as a double leg 
amputee. To me, that is pretty clear that that patient is not 
going to be able to get out of bed, into a wheelchair and to do 
the general things that we take for granted every day. But 
certainly, that particular instance did require some additional 
documentation on the part of the physician.
    Mr. Schrader. Very good. And as a veterinarian whose 
signature also is very illegible on a regular basis, yes, I 
think most people should assume that is the case.
    CMS has apparently recently released a draft form, a little 
different new form documenting patient eligibility. I wonder 
how that compares to what the current form is and if you think 
that is a step forward?
    Ms. Myers. Well, we have certainly have been working 
extensively as a stakeholder in that group, and with our 
national association through that process. And I think that we 
are seeing some movement forward, but I think that, to the 
extent that it goes far enough in order to avoid the thousands 
of denials we are seeing, we don't believe that it currently 
does. I think there are sections in the proposal for that new 
form that still require such documentation that could be 
subjectively denied by a reviewer and determined to be 
insufficient.
    Mr. Schrader. Very good, very good. Thank you for your 
testimony, and thank you for making the trip.
    Ms. Myers. Thank you.
    Mr. Pitts. The Chair thanks the gentleman, and now 
recognizes the gentleman from Texas, Dr. Burgess, for 5 minutes 
for questioning.
    Mr. Burgess. Thank you, Mr. Chairman. And thank you for the 
bills that we have got under consideration today. They are 
certainly worthy of discussion and certainly provide, I hope, 
some commonsense relief to people who are having difficulty 
with the agencies in trying to deliver care for their patients.
    I am a cosponsor of H.R. 556, which is to prevent 
interruptions in physical therapy. This does seem like a 
commonsense approach to allow physical therapists providing 
outpatient physical therapy services to use specified locum 
tenens arrangements.
    I have a constituent who wrote me, and this was a quote, 
``I am a contract therapist, and this bill directly affects my 
business and the therapists for whom I work. One private 
practice owner asked me 5 months in advance to cover her 
vacation. Although I am fully credentialed with Medicare, I 
have to submit paperwork to the Center for Medicare & Medicaid 
Services for reassignment of benefits to the clinic. By the 
time of the vacation, the paperwork was still not finalized.
    In lieu of denying the patient's care for the week, the 
business owner opted to have me proceed with providing the care 
her patients needed. I worked an entire week and she was not 
able to bill Medicare for the services I provided during that 
time. A significant loss of revenue for what is, after all, a 
small business.''
    So Mrs. Norby, for the record, can you explain why physical 
therapists weren't included in the first place? And why can't 
the payer, the agency, Center for Medicare & Medicaid Services, 
just simply pay the physical therapists through regulation?
    Ms. Norby. That is a great question. The language that 
included the physicians is over 40 years old. And at that time, 
there was not a prevalence of physical therapists in private 
practice, and so that is one of the reasons that they were 
overlooked, because there was not a need. The landscape today 
is completely different.
    In our State of Iowa alone, we have numerous physical 
therapists in small communities. In three of my clinics, we 
have one PT, including the clinic that I am currently 
practicing out of as well.
    We understand CMS has been approached many times by our 
association and asked can we correct this, and they have said 
that it requires legislation to correct the technical fix for 
it.
    Mr. Burgess. So it requires an act of Congress. Well, Mr. 
Chairman, I am grateful that we are stepping up to that 
challenge. Not that there aren't other challenges out there, 
but this is one that needs to be fixed.
    The face-to-face issue, man, oh, man, I have got a 
situation similar to what we just heard from Dr. Schrader, but 
we all agree it is important to combat fraud, we want to ensure 
patients are getting the care from the physician that was 
ordered. But then to deny them the care or delay it because the 
contractor, not anyone else in the equation, but a contractor, 
determined that the physician didn't do enough to meet the 
requirement; of course that burdens the doctor, of course it 
burdens the person who is the provider of the home health 
service, and I guess the main thing is it really does hurt the 
patient.
    Now, again, my question is going to be very similar to Dr. 
Schrader's, but in the answer to his question, you said that 
sometimes handwriting was hard to read. I am a physician, 
guilty as charged, but everybody has electronic health records 
now, so why is handwriting even an issue any longer?
    Ms. Myers. Well, I would argue that most of the 
documentation is done by hand. There are so many different 
electronic health record systems out there, they don't speak to 
each other, at least not as consistently as they could.
    Mr. Burgess. So with all of these billions of dollars we 
paid for electronic health records, we are now disrupting every 
private practice across the country with ICD-10 starting today, 
the system still doesn't work?
    Ms. Myers. And home health agencies, for the most part, do 
have some form of electronic record, but in rural communities, 
there is no capital funding for that. So, for example, in some 
of the areas where we have experienced issues with, for 
example, Veterans Administration, and a lot of our rural 
providers who provide care to patients who are serviced through 
the VA across the border, they are finding that the VA 
electronic records are not even being accepted by the 
contractors and reviewers, and they were previously approved. 
So there are some problems.
    Mr. Burgess. Let me just share with you, I asked a provider 
back home, Do you have any thoughts on this? And her quote to 
me is, ``This policy, as implemented, has cost my business 
almost $1 million. I have no issue with the requirement for a 
physician to visit in 99 percent of the cases, and there are 
great and respectable physicians across the country. Not all 
the time do they have time to hand documents over and over and 
over again for Medicare contractor employees, who, themselves, 
have little or no medical expertise to determine whether they 
have adequately described, according to very loosely fitting 
terms.''
    And I suspect this is something that people all over the 
country are encountering. Mr. Chairman, I hope today we are 
finally going to get that fixed. I will yield back the balance 
of my time.
    Mr. Pitts. The Chair thanks the gentleman. The Chair now 
recognizes the ranking member of the subcommittee, Mr. Green, 
for 5 minutes for questioning.
    Mr. Green. Thank you, Mr. Chairman. I want to thank our 
witnesses for joining us today. I know that home health care 
services are critically important for Medicare beneficiaries 
who are confined to their homes. I have a very urban area that 
it is important for. However, over the last two decades, a 
variety of the Office of Inspector General reports have found 
high levels of improper payments in Medicare reimbursement for 
home health care.
    Ms. Myers, can you describe any recent fraud reduction 
efforts, or any proposals underway at your agency or across the 
country?
    Ms. Myers. With respect to fraud reduction efforts, I might 
want to consult one of my national colleagues about that. 
Certainly with the Oregon Association for Home Care, we work 
with all of our providers to make sure they are knowledgeable 
about the laws and regulations, and to make sure that they 
understand what the guidance is relative to implementing that, 
those laws. And certainly, the physicians are subject to many 
antifraud laws, and so it is important--a critical piece of the 
process.
    Mr. Green. OK. Dr. Gould, thank you for your testimony. I 
think your testimony helped confirm something we in the 
committee have long thought, traditional fee-for-service has 
not done a great job of incentivizing care coordination. That 
is why we started moving towards alternative payment models in 
the Affordable Care Act, and then we built upon the reforms of 
the ACA in the recently passed Medicare Access and CHIP 
Reauthorization Act of 2015 for its repeal of the flawed 
sustainable growth rate formula, and replaced it with 
incentives that switched alternative payment models that put 
value and quality care over volume.
    Alternative payment models in cancer care have a lot of 
potential, both to improving care, coordination, and quality 
and reduced cost. It sounds like you are doing some of the work 
in cancer care, both through public and private partnerships to 
test payment reforms. Specifically, you testified you have 
successfully been able to reduce costs through alternative 
payment models. Can you talk a little bit about how you were 
able to achieve these lower costs?
    Dr. Gould. Yes, sir. I fully agree with your remarks. 
Basically, it comes down to the physicians within a practice 
making the commitment that they want to transform their 
practice from the old way of doing things to the new way of 
doing things, which is not only taking care of the patient 
medically, but being more thoughtful in terms of the resources 
utilized to take care of that patient in making sure that 
whatever we do for that patient is going to have a meaningful 
impact on their health. And our national societies have put out 
the Choosing Wisely program, which outlines things that 
physicians calmly do that do not add value to the care of the 
patients, and there are certainly many more examples than what 
is put out by our national societies. So in our practice, for 
instance, as I mentioned, one of the things that we did was to 
implement treatment guidelines to make sure that all patients 
got state-of-the-art care that was appropriate.
    Secondly, we talk at length about end-of-life care to make 
sure that the patient gets the appropriate end-of-life care, 
sometimes doing less is better than doing more.
    Thirdly, we have made a big investment in the 
infrastructure of our practice by hiring almost a 1-to-1 ratio 
of physician extenders to physicians so that we have plenty of 
room in the office schedule to take in patients who need to be 
seen urgently as opposed to sending them to the emergency room.
    A lot of times when patients get to the emergency room, 
they are seen by an ER doctor who doesn't have the level of 
comfort that we do in terms of treating these patients as an 
outpatient, and then these patients automatically get admitted.
    And then, finally, in the development of our treatment 
guidelines, we always put the interests of the patient first in 
terms of what is the most effective treatment and the least 
toxic, and we do not take economics into the equation. So, all 
of those practice processes have made us a leader in the 
oncology medical home. And then, I have been a leader, 
personally, in terms of helping educate and in disseminating 
this model across the country.
    Mr. Green. Well, obviously, I appreciate it and I know it 
is difficult for physicians to go between paper and electronic 
medical records, but also, with a lot of the things that are 
changing in the practice of medicine, and it affects Members of 
Congress, too. My staff finally told me I can't get a new--my 
old BlackBerry back because they don't have screens anymore, so 
I have to go to a new model. You know, change is tough for 
folks, how they do it. But again, electronic medical records 
and the coordination, and they need to talk to each other from 
practices. And it sounds like what you all have done has been 
able to do that, because I have a very urban district, but I 
have a group of physicians in the area that all go to one 
hospital, and they were able to do that and with their 
practices, and so, they could share, because they share their 
patients all the time with each other.
    Thank you, Mr. Chairman.
    Mr. Pitts. The Chair thanks the gentleman. Mr. Bucshon, you 
don't want to question?
    The Chair recognizes the vice chair, Mr. Guthrie, for 5 
minutes of questions.
    Mr. Guthrie. Thank you, Mr. Chairman. Thank you for 
yielding.
    Dr. Gould, my first question is, we are talking about the 
payment model established in the bill. How large is your 
practice? And I guess my question is, do you think this payment 
model would work for different-size practices and would 
hospitals be able to participate in the demonstration project 
created by the bill?
    Dr. Gould. Yes, sir. So, my practice has 21 physicians, and 
we have a pretty sophisticated management team. But at the end 
of the day, as I mentioned in my earlier remarks, it really 
takes the commitment of the physicians to want to change and do 
a better job in controlling costs.
    We all recognize that healthcare costs are spiraling out of 
control, and for us to get a handle on things is going to 
require that each stakeholder that has a hand in rising 
healthcare costs take responsibility. And the oncology medical 
home is the attempt by the community oncologists to control 
those things that they can, such as hospital utilization, 
making sure drug therapy is being used appropriately, doing a 
better job at the end of life where a lot of times treatments 
are not impactful in terms of the patient's quality and 
quantity of life.
    So obviously, it is going to be a little easier for larger 
practices to make the transformation, but there are a lot of 
well-run, smaller practices that should be able to make the 
transition as well.
    Mr. Guthrie. I believe you understand, or know, that CMS is 
in the process of developing an oncology care payment model. 
How does the model established in this bill, H.R. 1934, 
different to what CMS is trying to accomplish, and why is the 
bill better?
    Dr. Gould. So it is not like one is better than the other. 
First of all, both programs have, as their heart and soul, the 
oncology medical home. I, personally, along with a lot of my 
community oncology colleagues, gave input to the Brookings 
Institute which helped craft the oncology care model. But the 
big difference between the two programs, and I can say we 
applied for the oncology care model, by the way, is the number 
of physicians that the programs touch. In the oncology care 
model, it is only open to 100 practices, whereas the H.R. 1934, 
that opens this new payment, alternative payment model, to up 
to 1,500 physicians. So, the impact of H.R. 1934 potentially is 
going to be much larger than the OCM.
    Mr. Guthrie. We always appreciate when groups come forward, 
and this is an opportunity for us to help you save money within 
our field, because if it is bottom up, or driven up and brought 
to us and people are invested in it, and so they really make it 
work. So, I guess the question is, we all focus on saving money 
in the spiraling health care costs. But how does this benefit--
how would the medical home benefit patients specifically?
    Dr. Gould. Sure. Great, great point. Obviously, in my work 
as the chairman of the co-oncology medical steering committee, 
the first group that we interviewed to get their perspective on 
what is quality and value in terms of cancer care was the 
patients and the patients' advocacy groups. We interviewed a 
slew of patients and patient advocacy groups, and basically, 
kind of consolidated their needs, so to speak. And then, along 
with other providers we helped develop processes to make sure 
that those patient stakeholder needs are met. And as part of 
H.R. 1934, the oncology practices are not only required to 
report on quality measures that are driven by medical good 
care, but as part of that program, there is a patient 
satisfaction survey.
    Mr. Guthrie. I just have about a minute, and I want to ask 
one more question. I appreciate your--I think we got what we 
needed.
    Dr. Gould. So anyway, there is a patient satisfaction 
survey built into----
    Mr. Guthrie. So Ms. Norby, in the piece of legislation that 
you are here to testify, if it is passed, how would this 
legislation affect your business and businesses of other small 
PT clinic owners.
    Ms. Norby. It is critical for the continued longevity of 
our businesses, and really, critical for the Medicare patients 
in those communities. As I said, three of our five clinics have 
only one physical therapist in that clinic. When I go back to 
the maternity leave that I personally covered for--our only 
options were to either hire a substitute to come in, or to 
close the clinic for that length of time. Closing the clinic 
was not an option. We had a commitment to the community to 
bring our practice there and to treat the patients and provide 
them access to care that was local and convenient for them. So 
that was our first and foremost.
    To hire a substitute, as I indicated, we would have to 
enroll them in Medicare provider, and that can take up to 3 
months, which then we can't bill Medicare. Now, granted, we 
have had to do that when we hire new therapists, and we always 
bank locally in the communities that we do, and they have been 
very gracious to offer me a short-term line of credit to cover 
salaries and pay rent while we are waiting for Medicare 
enrollment, but this is a clinic in a town of 500, small 
margins, that was not an option either.
    Mr. Guthrie. Thanks, my time has expired. I appreciate the 
answer. My time has expired. I yield back, Mr. Chairman.
    Mr. Pitts. The Chair thanks the gentleman. I now recognize 
the gentleman from New Mexico, Mr. Lujan, for 5 minutes for 
questions.
    Mr. Lujan. Thank you, Mr. Chairman. Mr. Chairman, in June, 
the Congressional Budget Office provided a score to the Senate 
companion of the Prevent Interruptions to Physical Therapy Act 
as amended by the Senate Finance Committee. In determining the 
cost for the bill, CBO raised questions about increased 
utilization and suggested that locum tenens would result in a 
cottage industry. Fortunately, Senators Grassley and Casey, who 
are the lead sponsors of the Senate bill, wrote a letter to the 
Centers for Medicare & Medicaid Services asking if there was 
data to support CBO's assumptions.
    CBO responded, ``CMS does not have evidence indicating that 
locum tenens, as used by physicians under current law, has led 
to a general increase in utilization of services, or that the 
industry practices generally lead to provision of unnecessary 
services relating to the use of locum tenens, or that the use 
of locum tenens under current law in the Medicare program is 
generally inappropriate, wasteful or fraudulent.'' I would like 
to ask unanimous consent to enter into the record the letter 
from Senators Grassley and Casey to the Secretary of Health and 
Human Services and the response from HHS to both Senators 
Grassley and Casey.
    Mr. Pitts. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Lujan. Thank you very much, Mr. Chairman.
    Ms. Norby, you know, I had the honor, I guess you could 
call it, of getting to see firsthand the work of physical 
therapists and the benefit of therapy. In the early 1990s, I 
was sadly the victim in a head-on car accident with a drunk 
driver, and it was physical therapists who once the docs on the 
other side gave me the release that really put me back 
together, if you will, from being able to move, and being able 
to just walk around. So I just want to say thank you to you and 
to everyone we had the honor of working with.
    As you know, the locum tenens agreement is a longstanding 
and widespread practice for physicians to retain substitute 
positions in the professional practices when they are absent 
due to illness, pregnancy, maternity or paternity leave, jury 
duty, vacation or working to continue their medical education. 
This makes it acceptable for the regular physician to bill and 
receive payment for the substitute physician services as if 
they performed themselves. Physical therapist practices are 
similar to physician practices and like physicians, there are 
times when a physical therapist practice owner must be away for 
a short period of time. Under current law, physicians, 
osteopaths, dental surgeons, podiatrists, optometrists, and 
chiropractors can navigate these circumstances easily by 
entering into a locum tenens agreement with a qualified 
substitute provider.
    What options do physical therapy private practitioners 
currently have when they need a physical therapist to fill in? 
And I think you went over this quite substantially. You have 
already addressed the timeframe that it takes. Do you feel 
there is an opportunity for fraud and abuse if physical 
therapists in private practice are included as providers at 
locum tenens?
    Ms. Norby. No, I don't feel that there is a potential for 
fraud and abuse. The locum tenens physical therapist would be 
seeing the patient that I would have been seeing if I was in 
the clinic. And we would be reporting their services on the 
claim form by utilizing their NPI number reporting who provided 
that care. I feel very strongly that they don't have the access 
to their Medicare provider enrollment number to take after they 
leave, they are just being paid for services that they are 
providing at that time.
    Mr. Lujan. I appreciate that. You addressed the other 
questions that I had which are, what are the potential setbacks 
to patients and clients? I can attest that if there was an 
interruption of me being able to go to the therapist at that 
time, I can't imagine what would have occurred. So when we are 
talking about our parents, our grandparents, loved ones, 
constituents, it is important that they have the continuity of 
care. So thank you for being here today.
    Dr. Gould, I want to thank you for sharing a little bit of 
the unfortunate loss of your parents to cancer. I sadly lost my 
father to cancer a few years ago, but what you are testifying 
to today is very important, the legislation that both 
Congressman McMorris Rodgers and Congressman Israel have put 
forth is something that I am definitely very interested in. And 
I appreciate what you said when asked the question about the 
two programs: One is not necessarily better than the other, 
they both have different trajectories, different projects, 
different approaches, to making sure that we can provide the 
best care.
    Is there, in your mind, a professional opinion, sir, that 
maybe both programs could operate parallel to one another 
because of the focuses that they would both bring?
    Dr. Gould. Yes. I mean, I think they are designed to do 
exactly that. A lot of practices did not apply for the OCM 
because they just felt that the application was a bit onerous 
and opted not to apply, and if every practice in the country 
applied to OCM, it is only limited to 100 practices. So there 
has got to be another pathway, so to speak, that runs parallel 
to the OCM, and that is what H.R. 1934 is designed to fulfill.
    Mr. Lujan. I appreciate that, sir. And Mr. Chairman, I know 
my time has expired, but Ms. Myers, for traveling all the way 
from Oregon, thank you so much for taking the time. New Mexico, 
like Oregon, is a very rural State. It takes 8 \1/2\ hours to 
drive across my congressional district. And so it is not just a 
matter of the testimony that you are bringing today of the 
information being on paper, it is the sheer geography with 
physicians driving 2 and 3 hours to get into some of these 
communities. So thank you very much for what you are doing. I 
appreciate the work of Mr. Walden in this area, and I look 
forward to working with him and yourself, Mr. Chairman, and our 
members on this issue. Thank you very much for the time, sir
    Mr. Pitts. The Chair thanks the gentleman and agrees with 
his last statement. Thank you very much for coming.
    The Chair now recognizes Mr. Bilirakis from Florida 5 
minutes for questioning.
    Mr. Bilirakis. Thank you very much, Mr. Chairman.
    Ms. Norby, in your testimony, you very briefly talked about 
the challenge your practice faced when one of the therapists 
was away. So, again, it is the geography, but also, the small 
practice that has difficulties. Can you elaborate more on what 
happened with your business? What problems this created? And 
how badly this inconvenienced both patients and physical 
therapists, please? Thank you.
    Ms. Norby. Yes, I sure will. Thank you for the question. 
So, like I had indicated, we have made our mission to provide 
physical therapy care in communities that don't have access to 
care. And so when a therapist has to be gone for any type of 
reason, the Medicare patients within that community have been 
afforded to have local convenient care, and they are happy 
about that--physical therapists, we develop our relationship 
with our patients. They don't necessarily want to see anybody 
else.
    In the particular instance that I had, the next closest 
physical therapy clinic was 45 miles away, and it was winter. 
And so the Medicare patients, they were not going to drive to 
those clinics to be able to receive their care. So it was 
imperative and our commitment was to provide that. So that is 
why I went in and covered that maternity leave.
    When we set up a clinic, I have the flexibility at that 
time to be a substitute provider, and so I was an enrolled 
Medicare provider for that clinic. That situation has changed 
now, and I am currently practicing full-time in one of our 
clinics as the solo PT.
    So in the future, if this happens again, which it will, 
they will have more children, we do not have the opportunity 
for me to actually be the one to physically go there. So this 
is extremely important for the communities that we serve, and 
for our small business as well. As I had indicated, because we 
have to wait, we have to hold claims before we get the Medicare 
provider enrollment, that puts a significant hardship on our 
small business financially. And we have had local bankers that 
have been very generous to literally offer us a short-term line 
of credit to be able to continue to pay salaries, and pay rent 
and that type of thing. That is not an ideal situation, so 
locum tenens is crucial.
    Mr. Bilirakis. Thank you so much. Ms. Norby, will giving 
physical therapists the ability to use locum tenens 
arrangements increase waste, fraud and abuse in the system or 
cause excess utilization of services? Is there any evidence 
that locum tenens arrangements leads to these problems? I know 
that Ben and others have touched on this, but I want to give 
you the opportunity, and I have something to submit for the 
record as well.
    Ms. Norby. OK, awesome. No, the therapist would see my 
patients in my absence, and so that would be indicated on the 
Medicare claim form by their NPI number, so the visits that 
would have been scheduled for the patients to see me are now 
just rescheduled to see the substitute therapist.
    Mr. Bilirakis. Thank you. Mr. Chairman, I ask unanimous 
consent to submit this letter from CMS which states that CMS 
doesn't have evidence locum tenens leading to increased 
utilization, or that locum tenens leads to fraud.
    Mr. Pitts. Without objection so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Bilirakis. Thank you. If a physical therapist is out 
for an extended period of time, their patients may have to 
cancel or reschedule or may forget to reschedule future 
appointments. Can you talk about how important it is for 
seniors to maintain their physical therapy regimen?
    Ms. Norby. It is very important. Physical therapists, we 
are movement specialists, and we help people be able to stay 
functional in their homes, and to stay longer in their homes as 
well. And so when a patient, a Medicare patient accesses 
physical therapy, they have a problem with their movement. And 
when we determine our plan of care and start to treat that 
patient, we are progressing them through to be able to get 
their goals to move better, or to regain function.
    Postsurgical care is very, very critical to be able to have 
consistent physical therapy. Otherwise, stiffness of the joint 
can occur that then becomes very painful to try to regain that 
motion, and it does take longer for them to do that. I know two 
patients, in particular, that they had to interrupt their care 
because one had a gall bladder attack in surgery, the other 
their spouse died unexpectedly. And they came back after those 
incidences with very stiff joints, and it literally doubled the 
amount of visits that they needed to have to get to their 
original goal, because they were without care for a period of 
time. And so if I had to be absent and I couldn't have a 
substitute come in, that would be bad as well.
    Mr. Bilirakis. Thank you. I guess I have 3 seconds. Can I 
ask one more question, Mr. Chairman--actually, I am over.
    Mr. Pitts. You may proceed. Go ahead.
    Mr. Bilirakis. One more? Thank you.
    Can you describe how locum tenens works, and why a physical 
therapist can't just pick up a substitute for a physical 
therapist during staffing shortages? Does private insurance 
also allow for locum tenens? I just want you to have an 
opportunity to elaborate.
    Ms. Norby. No. A great question. Private payers do offer 
locum tenens, all of our commercial payers in Iowa do, and 
across the country. But in order, in a private practice 
setting, to be able to see a Medicare patient, as a physical 
therapist, I have to be provider-enrolled under that tax I.D. 
Number and that location. So I cannot just have another 
substitute come in and see my patients legally, because I 
cannot locum tenens without them going through that process.
    Mr. Bilirakis. I thank you very much. I yield back, Mr. 
Chairman.
    Mr. Pitts. The Chair thanks the gentleman and recognizes 
the gentlelady from Illinois, Ms. Schakowsky, for 5 minutes of 
questioning.
    Ms. Schakowsky. Thank you, Mr. Chairman. I want to 
apologize to the panel for missing your testimony, but I did 
have an important question to ask. But first, I just wanted to 
say, Ms. Norby, I am a happy user of physical therapy. I have 
very weird feet that I would like to keep working for another 
couple of decades, who knows, and so I am, right now, taking 
physical therapy and can see its results. So I just wanted to 
tell you that.
    So I wanted to talk about the staggering cost of 
prescription drug prices in this country and the burden this 
places on patients and families. Sadly, I am well aware of 
that. My precious daughter-in-law passed away from cancer, but 
it put a tremendous strain on the family financially, in terms 
of having a 5-year-old and a 3-year-old also left to my son.
    So it is an issue that I think we really have to be 
discussing more, and I know a majority of Americans agree. In 
fact, 73 percent of the public think that the cost of 
prescription drugs is unreasonable. Cancer treatments, in 
particular, are increasingly bankrupting patients. The average 
cost of new cancer drugs and other specialty drugs continue to 
increase each year at an unsustainable rate. We saw this 
dramatic example of the $13.50 pill that the hope of the owner 
of the company was to raise it to $750 a pill. But even less 
dramatic, a recent study from the American Economic 
Association's Journal of Economic Perspectives showed that 
cancer drug prices increased 10 percent every year from 1995 to 
2013. And Mr. Chairman, I would like unanimous consent to place 
that study in the record.
    Mr. Pitts. Without objection, so ordered.\1\
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    \1\ The information has been retained in committee files and also 
is available at  http://docs.house.gov/meetings/IF/IF14/20151001/
104006/HHRG-114-IF14-20151001-SD006.pdf.
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    Ms. Schakowsky. So while the average American family makes 
about $52,000 a year, there are cancer drugs on the market that 
cost more than $100,000 per year. Even those fortunate enough 
to have insurance can face out-of-pocket expenses that add up 
to more than half of the family's income.
    I think we can all agree that drugs only work if patients 
can actually afford to take them. And I worry that if we don't 
act soon, these skyrocketing prices will leave the majority of 
Americans literally priced out of a cure.
    So, Dr. Gould, I am sure you have seen firsthand how 
difficult it can be for a patient to pay for their treatment. I 
am wondering if you have any experiences as to how the rising 
drug costs have affected the patients that you are treating?
    Dr. Gould. What you are describing is a new concept in 
medical oncology that we hadn't talked about until a few years 
ago, and that is called the financial toxicities of our 
therapies, and not just the medical toxicities. Clearly, that 
is a concern to us at the Community Oncology Alliance, and we 
meet regularly with the pharmaceutical companies, and we make 
the points that you just made loud and clear.
    Unfortunately, at this point, we have got limited ability 
to influence how the manufacturers price.
    Ms. Schakowsky. Let me ask you this: I am wondering if you 
can discuss how the alternative payment methods, such as the 
Center for Medicare Medicaid Innovation, Oncology Care model, 
might address this issue?
    Dr. Gould. Yes, that is exactly where I was going.
    Ms. Schakowsky. Thank you.
    Dr. Gould. So as I was saying, to contrast, we don't have a 
lot of control over how the manufacturers price their drugs, 
but what we do have control over is, one, how we utilize those 
drugs and making sure that those drugs are being utilized with 
the right patients at the right time for the right disease.
    Secondly, we do control a large part of the healthcare 
dollars such as hospital utilization, emergency room 
utilization, and radiation therapies and radiology therapies. 
As community oncologists, we are imploring our colleagues to 
take more ownership of the health dollars that we do control, 
and the alternative payment models, such as the oncology care 
model and H.R. 1934, really not only give extra incentives to 
the practices to do a better job in controlling those dollars, 
because if they do a good job controlling the dollars, then 
there is a financial reward associated with that better 
utilization of the healthcare dollar, only if the quality of 
care is maintained.
    Ms. Schakowsky. Thank you so much. I just wanted to point 
out the oncology care model was part of, and CMMI, part of the 
Affordable Care Act that I think can help us all deliver better 
care, and do it at a better price. So thank you and I yield 
back.
    Mr. Pitts. The Chair thanks the gentlelady. I now recognize 
the gentleman from New York, Mr. Collins, 5 minutes for 
questions.
    Mr. Collins. Thank you, Mr. Chairman. I am very happy that 
we are having this hearing today on ways to improve our 
Medicare program. In a couple of the bills that are up for 
discussion are very important, including H.R. 556, the Prevent 
Interruptions in Physical Therapy Act, which was introduced by 
my good friend, Mr. Bilirakis, and I am a proud cosponsor of 
that bill. That bill came to my attention because of the 
significant number of physical therapists in my district, 
western New York, very rural, who reached out to my office, and 
pretty much articulated the same problem we have heard 
discussed already, finding someone else to take care of their 
patients if the PT needs to go out of town for any variety of 
reasons.
    Mark Howard, the owner and chief therapist of a very small 
private PT practice in Depew, New York, western New York again, 
recently wrote to me, and he said when he goes out of town, 
either to attend a seminar or perhaps getting the continuing 
education units that he would need to stay compliant with our 
State regulations, his wife, who is also a PT, takes over for 
him. So in that case, he doesn't have a problem. But he said 
there are times he and his wife travel together, and at that 
point, there is a problem. That is when they have to find a 
replacement therapist, assign their payments, which can take 
several weeks, and a lot of advanced planning, as you very well 
already discussed. If they didn't do this, the elderly patient 
care would be interrupted, obviously, as you again explain, 
setting back their treatment schedules.
    So I really think, Ms. Norby, you handle that very well, 
and Mr. Bilirakis covered that in a lot of detail which we, I 
suppose, could go back over, but I think that has been 
discussed. So I would like to maybe switch, and even though 
today, while we are primarily talking about patient payment 
plans, Dr. Gould, I would like to also talk about patient 
access, because they are kind of related. But in particular, in 
reading through your testimony, I noticed you reference that 
there is a large number of community oncology practices that 
have closed or have been forced or have chosen to merge with 
various hospitals. And certainly my concern in this regard is 
on the access piece.
    I just wondered if you could discuss any of the reasons, 
perhaps unintended or otherwise, but some of the reasons that 
have caused so many, especially oncology practices, to merge 
under hospitals?
    Dr. Gould. Yes, sir. I would say that there are two forces 
in play here, we have what I like to call a push, then we have 
the pull. The push forces I would characterize as four major 
forces. We have increase in cost of doing business. Our costs 
go up just like everybody else, including for health care.
    Secondly, we have had declining reimbursement, particularly 
from Medicare. And I mentioned one example, which was the 
sequestration cut.
    Thirdly, we have the increased cost of doing business, 
particularly with the increasing regulatory environment. And 
then fourthly, we have the uncertainty of future Government 
programs and how that is going to impact Medicare reimbursement 
and so forth.
    So on the other hand is the other force that I call the 
pull, which is that many hospitals have access to the 340B 
program, and for those hospitals to be able to access that 
program, they have to have contracted physicians, either 
directly employed or contracted through what we call a 
physician service agreement, or a PSA. And so, you know, with 
the increasing challenges in trying to run a practice, a lot of 
physicians are saying heck with it, I don't want to be bothered 
with all of this, I just want to be able to take care of my 
patients. And so the hospitals are singing a siren song, and 
these physicians are going to work for the hospitals and not 
worrying about the management of a practice.
    Mr. Collins. So let me interrupt there, because I heard 
this before. Is it safe to say a private oncology practice 
would not have 340B pricing?
    Dr. Gould. That is correct, sir.
    Mr. Collins. So in this case, if I have this right, a 340B 
hospital, and we are talking about very expensive oncology 
drugs, I mean, these could be $100,000-type drugs. So in the 
340B setting, there is a private oncology practice, they treat 
a patient, there is a $100,000 pharmaceutical, they are covered 
by Blue Cross/Blue Shield, it is prescribed, Blue Cross/Blue 
Shield pays it and we move on. But now, if the same practice 
merges under a hospital, the same drug is given, the same 
reimbursement is made by Blue Cross/Blue Shield, to give an 
example, but then that hospital turns around and gets a 
discount from the drug company and get that drug for $20,000.
    Dr. Gould. That is correct, I mean----
    Mr. Collins. In which case that $80,000 goes to the bottom 
line of the hospital, which actually, in a profit-motivating 
world, would allow them to pay a lot of money for private 
oncology practice. The primary financial driver of that is 
nothing more than telling the pharmaceutical companies they are 
going to take it on the chin, have to pass this discount on 
because it a 340B situation, but nothing else has changed. I 
know my time has expired, but is my understanding of that 
fairly accurate?
    Dr. Gould. Yes, sir. And what happens is, those hospital 
practices now have more monies to compete for employees and 
doctors than what I have in private practice, and so, I go out 
of business and have to partner with hospitals as well.
    Mr. Collins. I know my time has expired, but that goes back 
to picking winners and losers, and we are not supposed to be 
doing that. With that, Mr. Chairman, I yield back.
    Mr. Pitts. The Chair thanks the gentleman. I now recognize 
Mrs. Brooks from Indiana for 5 minutes of questions.
    Mrs. Brooks. Thank you, Mr. Chairman. I want to commend the 
chairman on continuing to tackle this complex and important 
issue by bringing up these bipartisan bills today and ensure 
that we keep moving forward to ensure that seniors get the 
access to the care that they need. And I think the bills before 
us today will strengthen existing programs and build upon the 
momentum that we started in the field with SGR reform.
    I am particularly happy and want to focus on Mr. Walden's 
bill before us today addressing the issue with CMS's current 
face-to-face rule. I have long said that these rules initially 
put forward by CMS are imposing crushing burdens on home health 
agencies rules and impair their ability to provide seniors the 
home health services that they deserve.
    Complicated, confusing, inconsistently enforced, the 
current face-to-face regulations have exceeded the intent of 
the law, and I believe has hindered the work of caregivers at 
home health agencies. And it is having three real-world 
implications for three home healthcare agencies operating 
within my district.
    The survey actually found that 52 percent of face-to-face 
claim denials resulted mainly from Medicare's determination 
that physician's documentation was insufficient, even though 
medically necessary care was provided. I believe this is 
creating an access-to-care crisis, particularly in rural parts, 
not only in my district, but across the country. And it is 
preventing providers from delivering vital services to those 
most in need. Speaking of, home health patients are more likely 
to be women, more likely to be older, more likely to be sicker, 
poorer, and minorities. And I think Mr. Walden's bill makes 
commonsense reforms to bring the CMS rule into the scope of the 
intent of the law.
    So I would like to just ask you, Ms. Myers, a few 
questions. Can you give us any real-world examples of issues 
about the current documentation requirements that aren't 
working as intended?
    Ms. Myers. Absolutely. Thank you for that question. We have 
spoken a little bit about some of the examples of claim 
denials. In one additional example that I have, an orthopedic 
surgeon was treating an 82-year-old patient and referred them 
to home health care following a total knee arthroplasty, which 
had to do with the knee itself. Certainly this woman was 
wheelchair bound.
    It took five attempts from the home health agency in 
working with the physician's office to get confirmation and 
documentation back from the physician. So that is one example 
where the physicians are extremely fed up with the 
documentation requirements and the difficulty.
    We have talked also about the fact that there are other 
issues related to things like signatures, dates, missing 
documentation, or descriptions of documentation that have 
fallen under that insufficient and subjective mode from the 
reviewers.
    Mrs. Brooks. Can you tell me whether or not the impact of 
these denials, or the problems with the documentation, how is 
it affecting the small and the rural agencies?
    Ms. Myers. Well, certainly, we have a number of small and 
rural agencies on the east side of Oregon, which comprises most 
of Congressman Walden's district. In those cases, there are 
certainly less staff, less ability to be competitive, to hire 
good clinical nurses and physical therapists to provide the 
care for the patients that is needed at home. So it has both an 
impact on the agency in terms of attempting to spend less time 
on paperwork, and chasing documentation, and more time in 
patient care.
    Mrs. Brooks. Do you have to, what I suspect, the agencies 
have to often hire extra administrative staff to take care of 
all of the documentation? Is that what you are seeing? Or is it 
actually the providers that are trying to do what is 
administrative work?
    Ms. Myers. It is a little of both. In the case of smaller 
and rural agencies, they have less of an ability to hire 
additional staff. I have one particular example of a provider 
in Wheeler County, and the agency is the only provider in that 
county, and faced closure this year. She is a nurse, she 
provides care in the community, she is traveling 60 miles to 
treat farmers, ranchers all over the county. And her inability 
to manage both patient care and handle denials and paperwork 
related to all of this documentation are really making that 
agency struggle significantly.
    Mrs. Brooks. Do you have any idea roughly how many patients 
she cares for?
    Ms. Myers. I think it is between 5 and 10 in the entire 
county.
    Mrs. Brooks. Can you talk to me a little bit more about the 
issues between how is the face-to-face requirement straining 
the relationship between the physicians and the home health 
providers? What is happening with that?
    Ms. Myers. It has created a relationship of almost 
antagonism, and it is as if the home health agency is the 
antagonizer, but certainly, we are just the bearer of the 
regulation and the rule and the requirement. So it is straining 
that relationship in ways that it normally wouldn't be.
    Mrs. Brooks. Thank you. My time is up.
    Mr. Pitts. The Chair thanks the gentlelady, and now 
recognizes the gentleman from Oregon, Mr. Walden, for 5 minutes 
of questioning.
    Mr. Walden. I thank the Chair for this hearing, and our 
witnesses for their testimony. I am going to follow up on what 
Ms. Myers said, Ms. Brooks, because when she talks about four 
or five patients being served in Wheeler County, there are only 
about 1,700 people in the entire county. And if you drove from 
Fossil, Oregon, the county seat to the nearest hospital, it 
would be 142 miles each way. These are enormous areas, and my 
colleague from New Mexico, Mr. Lujan, talked about the size of 
his district and everybody kind of gasped. His is 47,271 square 
miles. Mine is 69,341.
    So when we are talking about providing basic services in 
these remote areas, this is life and death, literally life and 
death. That is why this matters so much that when some 
contractors, some bureaucrats, some rule writer comes up with 
one of these things back here in Washington, they don't have a 
clue what they are doing in real life out on the ground, and 
that needs to change, and it needs to change now.
    Let me go to Ms. Myers. The original requirements for a 
physician face-to-face encounter were intended as a program 
integrity measure to protect waste, fraud and abuse. Do you 
think this bill that we have before us eliminates or dilutes 
that protection against fraud and abuse?
    Ms. Myers. Absolutely not. The requirement for the face-to-
face encounter with the patient is still fully maintained with 
the proposed bill. And it further is required, and a condition 
for payment under the Medicare home health benefit. The 
physicians still must certify the patient's eligibility for 
coverage, and the bill provides for a cleaner, more 
standardized process by which we would be able to operate and 
be able to focus more on patient care rather than chasing 
paperwork.
    Mr. Walden. I had a very positive discussion with Mr. Lujan 
during the break, when we went to vote on the House floor and 
come back, and he and I intend to work closely on this 
legislation.
    Mr. Griffith and I had a very good conversation. I imagine 
he won't talk about this, I won't steal his thunder, but I will 
give him full credit that is, perhaps, within the context of 
this legislation, we should allow face-to-face to qualify over 
electronic devices.
    Again, if I could take my phone into the home and have the 
doctor on the other side, which we all know can be done today, 
why should we have to transport a patient 142 miles over icy, 
foggy roads for a face-to-face so they can go back home?
    Ms. Myers. Absolutely, and in the case of my father, right 
before he passed away, I was attempting to get home care for 
him, but he couldn't stand up, literally, or make it to the car 
and have my mother help him to get into the car to make it into 
a physician's office. So it is very challenging, and that may 
present an opportunity.
    Mr. Walden. We went through the same sort of event with my 
mother-in-law, who had severe rheumatoid arthritis, who was in 
very bad shape, and they would have to transport her by 
ambulance or the equivalent, and they'd have to do the blood 
pressure test before she left, which drove excruciating pain 
throughout her body, and then as soon as she got to the 
hospital or whatever, they had to do it again.
    I mean, there are so many stupid things in delivery of care 
right now, driven by either litigation or regulation that we 
need to get past so we put the patients first.
    I ask unanimous consent, Mr. Chairman, to enter into the 
record a statement written by Jeffrey Weil, who is Division 
Vice President for Operations in the northwest for LHC Group. 
Jeff is responsible for the operations of Three Rivers Home 
Care in Grants Pass, in Medford, Oregon.
    He says that, just for 2014 and 2015, his company has had 
more than 393 claims denied for inadequate face-to-face 
documentation. Each and every one of these claims had 
documentation signed by a physician. However, in most cases, 
the Medicare administrative contractors denied the claims 
because they deemed the physician's narrative to be inadequate. 
Many of these denials were reversed, but they currently have 
more than $1.5 million of denied face-to-face encountered 
claims tied up in appeals at various stages.
    Mr. Pitts. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Walden. Oh, thank you, Mr. Chairman.
    Ms. Myers, can you describe in more detail the impact that 
claim denials and the subsequent appeals associated with the 
home health face-to-face requirement has on patient care and 
home health agency operations, particularly in these small and 
rural areas?
    Ms. Myers. Absolutely, and as Jeffrey Weil indicated, you 
know, many of the agencies across the State are experiencing 
very similar situations with thousands of dollars pending.
    Certainly, the impact to patients occurs where the 
physicians these days are getting, you know, arguably, very fed 
up with the documentation requirements and that they simply 
have said to some of our providers, ``Forget it.'' The 
documentation is too much. It takes too much time and too much 
time away from patient care. And unfortunately, in some cases 
where the physician is struggling with this documentation to 
make a referral for home health care, they are just simply 
saying no. So the patient gets caught in the middle.
    And, as I have said previously, the denials are, you know, 
plentiful on a lot of technicalities and semantic issues, and, 
certainly, that needs to be fixed, and we think that this bill 
would help tremendously to do that.
    Mr. Walden. Thank you, Mr. Chairman.
    Mr. Pitts. The Chair thanks the gentleman.
    I now recognize the gentlelady from North Carolina, Mrs. 
Ellmers, for 5 minutes for questions.
    Mrs. Ellmers. Thank you, Mr. Chairman. I didn't realize I 
was next, but I am very happy.
    Thank you to our panel for being here and for this 
particular subcommittee hearing. It is so important. I would 
like to associate myself with the gentleman from Oregon and his 
comments about the importance of us moving forward with good 
legislation so that we can take care of these patients in the 
way they need to be taken care of and stop having to jump 
through the hoops and put these patients and their families 
through this.
    I do want to ask a couple of questions. As far as, you 
know, the beneficiaries of Medicare--I mean, I know you have 
probably answered this a million times, but isn't that the 
effect--and it is really a ``yes'' or ``no'' answer for all 
three of you. The impact will be tremendous if we can change 
the legislation and move forward with much more--giving our 
physicians, our physical therapists much more control over this 
situation and payment and reimbursement. I mean, this will move 
mountains, do you agree?
    OK. You are all indicating ``yes.'' I agree with that as 
well. It is definitely something we have needed.
    And physical therapists in our rural communities, 
especially, are just vital, absolutely vital. Whether we are 
talking about physicians or whether we are talking about 
physical therapists in a home health setting, it is incredibly 
important to be able to allow the individuals to stay in their 
homes. We know that that has an impact on their health care.
    As far as locum tenens, how would this affect reimbursement 
or payment for locum tenens when--I know you were discussing 
how you would have had to have closed if you didn't have 
someone that could take that space and keep your operation 
going. What would you like to say about that, Ms. Norby?
    Ms. Norby. That is a great question. So, it affects payment 
because I would be able to bring in, under locum tenens, a 
licensed, qualified physical therapist to continue the care 
with my patients, and then we would submit the claims under my 
Medicare provider enrollment number to Medicare, so----
    Mrs. Ellmers. And it would all, basically, go under your 
Medicare number----
    Ms. Norby. Right.
    Mrs. Ellmers [continuing]. But that person would be fully 
qualified, able to do it, all checked out ahead of time----
    Ms. Norby. Yes.
    Mrs. Ellmers [continuing]. And would just fit into that 
space.
    So that is a very convenient and sensible way of dealing 
with that issue and is definitely something that I think is so 
important. Because, seriously, what are you doing? I mean, you 
really have no alternative right now the way the system is set 
up.
    Ms. Norby. That is correct. I am gone from my clinic 2 days 
this week to be here----
    Mrs. Ellmers. Yes.
    Ms. Norby [continuing]. With you, and it took creative 
scheduling. Now, my Medicare patients know I am very much an 
advocate for this, and they all know about this bill.
    Mrs. Ellmers. Good.
    Ms. Norby. So they were very supportive and willing to come 
at 7:00 at night or at 10:00 on Saturday morning.
    Mrs. Ellmers. To accommodate so you could be here.
    Ms. Norby. Yes, so I could be here, so----
    Mrs. Ellmers. Oh, that is awesome.
    See, this is what our health care providers do. I mean, the 
commitment that our health care providers have for their 
patients, for their families, and the role--that is why, I 
mean, I am so passionate about health care, being a nurse and 
being in that space and knowing what goes on behind the scenes 
that people are completely unaware of; and so, I am there with 
you.
    I do want to ask a little bit about the cumbersome nature 
of the paperwork, the documentation that our health care 
professionals-- right now, especially, is the most difficult 
time; and I am probably making more of a comment than I am 
asking a question, but I think you are going to agree with me, 
so I am going to assume that, and I will ask if you agree.
    Right now, our health care professionals are dealing with 
electronic health records, meaning meaningful use. They are 
moving forward with stage three, which I think is a big 
mistake. We have a very important letter with, gosh, well over 
120 cosponsors--bipartisan--asking them to step back from 
moving forward; and now we have ICD-10 that is added into the 
mix on top of the difficulties that are being experienced, 
especially in the home health setting. One ``i'' that isn't 
dotted, one ``t'' that isn't crossed can mean the difference 
between reimbursement for a health care professional or not.
    Do you agree that right now is just an incredibly difficult 
time for any health care provider when it comes to the 
documentation? And, mind you, we are all supposed to be going 
paperless. I will just throw that in there. Do you agree?
    Ms. Norby. And regulatory burden, too.
    Mrs. Ellmers. Yes, and the regulatory burdens.
    And that is what this legislation is about. We are trying 
to make things better. We are really trying to work behind the 
scenes, and I am just excited to be a part of it because I have 
been out in the real world. I know what it is like, and I know 
the commitment that our health care providers have. I know the 
dedication that the families of those patients have and the 
meanings. They will never forget the things that you have done 
for them ever, and any way we can make that better is exactly 
what we need to do.
    So, again, I thank you for your time. Thank you for really 
taking away from your back-home patients and care and families 
of your own to be here for this important, important 
subcommittee hearing. Thank you so much.
    And thank you, Mr. Chairman. I yield back.
    Mr. Pitts. The Chair thanks the gentlelady. That concludes 
the questions from the members present. We will have written 
questions and follow-up from other members who weren't able to 
attend sent to you. We ask that you please respond promptly.
    Ms. Myers. Absolutely.
    Mr. Pitts. Thank you. And I will remind members that they 
have 10 business days to submit the questions for the record, 
so they should submit those questions by the close of business 
on Thursday, October 15.
    A very informative, excellent hearing. Thank you for coming 
all the way to this hearing. We really appreciate it. Thank you 
for your expert testimony. These are very important, 
bipartisan, noncontroversial bills. We expect them to move very 
soon, and you have had a great part in that. So thank you very 
much.
    Without objection, the subcommittee stands adjourned.
    [Whereupon, at 11:59 a.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]

                 Prepared statement of Hon. Fred Upton

    For years we have been warned of the looming insolvency of 
Medicare. Those alarm bells cannot be ignored. To allow the 
program to fall into bankruptcy would be to abandon the solemn 
promise we have made to seniors in Michigan and across the 
Nation. As the committee of primary jurisdiction over much of 
the Medicare program, we cannot, and we will not let that 
happen. As the population ages with Baby Boomers entering 
retirement and the potential for provider shortages to increase 
in the near future, it is our duty to identify opportunities to 
improve the program. Today, we will examine bipartisan 
solutions to help put us back on track.
    H.R. 556, the Prevent Interruptions in Physical Therapy Act 
of 2015, introduced by Representatives Bilirakis and Lujan, 
would ensure that Medicare patients receiving therapy services 
do not have to delay care in the event their treating provider 
gets sick or married.
    H.R. 1934, the Cancer Care Payment Reform Act of 2015, is 
sponsored by Representatives McMorris Rodgers and Steve Israel. 
The legislation would build off of the promise in the SGR 
repeal legislation--also known as MACRA--by promoting 
innovative payment reforms designed to increase the quality of 
care delivered to Medicare seniors and reduce costs to the 
program.
    Finally, we will examine a discussion draft authored by 
Representative Greg Walden that would streamline documentation 
requirements related to home healthcare delivery.
    We will continue our work to keep the promise to seniors 
and improve the Medicare program.


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