    [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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                            energycommerce.house.gov
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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:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        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:]

      [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        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:]

      [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        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.
    ---------------------------------------------------------------------------
        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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