[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]
Printed for the use of the Committee on Energy and Commerce
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
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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
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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.
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Ms. Schakowsky. So while the average American family makes
about $52,000 a year, there are cancer drugs on the market that
cost more than $100,000 per year. Even those fortunate enough
to have insurance can face out-of-pocket expenses that add up
to more than half of the family's income.
I think we can all agree that drugs only work if patients
can actually afford to take them. And I worry that if we don't
act soon, these skyrocketing prices will leave the majority of
Americans literally priced out of a cure.
So, Dr. Gould, I am sure you have seen firsthand how
difficult it can be for a patient to pay for their treatment. I
am wondering if you have any experiences as to how the rising
drug costs have affected the patients that you are treating?
Dr. Gould. What you are describing is a new concept in
medical oncology that we hadn't talked about until a few years
ago, and that is called the financial toxicities of our
therapies, and not just the medical toxicities. Clearly, that
is a concern to us at the Community Oncology Alliance, and we
meet regularly with the pharmaceutical companies, and we make
the points that you just made loud and clear.
Unfortunately, at this point, we have got limited ability
to influence how the manufacturers price.
Ms. Schakowsky. Let me ask you this: I am wondering if you
can discuss how the alternative payment methods, such as the
Center for Medicare Medicaid Innovation, Oncology Care model,
might address this issue?
Dr. Gould. Yes, that is exactly where I was going.
Ms. Schakowsky. Thank you.
Dr. Gould. So as I was saying, to contrast, we don't have a
lot of control over how the manufacturers price their drugs,
but what we do have control over is, one, how we utilize those
drugs and making sure that those drugs are being utilized with
the right patients at the right time for the right disease.
Secondly, we do control a large part of the healthcare
dollars such as hospital utilization, emergency room
utilization, and radiation therapies and radiology therapies.
As community oncologists, we are imploring our colleagues to
take more ownership of the health dollars that we do control,
and the alternative payment models, such as the oncology care
model and H.R. 1934, really not only give extra incentives to
the practices to do a better job in controlling those dollars,
because if they do a good job controlling the dollars, then
there is a financial reward associated with that better
utilization of the healthcare dollar, only if the quality of
care is maintained.
Ms. Schakowsky. Thank you so much. I just wanted to point
out the oncology care model was part of, and CMMI, part of the
Affordable Care Act that I think can help us all deliver better
care, and do it at a better price. So thank you and I yield
back.
Mr. Pitts. The Chair thanks the gentlelady. I now recognize
the gentleman from New York, Mr. Collins, 5 minutes for
questions.
Mr. Collins. Thank you, Mr. Chairman. I am very happy that
we are having this hearing today on ways to improve our
Medicare program. In a couple of the bills that are up for
discussion are very important, including H.R. 556, the Prevent
Interruptions in Physical Therapy Act, which was introduced by
my good friend, Mr. Bilirakis, and I am a proud cosponsor of
that bill. That bill came to my attention because of the
significant number of physical therapists in my district,
western New York, very rural, who reached out to my office, and
pretty much articulated the same problem we have heard
discussed already, finding someone else to take care of their
patients if the PT needs to go out of town for any variety of
reasons.
Mark Howard, the owner and chief therapist of a very small
private PT practice in Depew, New York, western New York again,
recently wrote to me, and he said when he goes out of town,
either to attend a seminar or perhaps getting the continuing
education units that he would need to stay compliant with our
State regulations, his wife, who is also a PT, takes over for
him. So in that case, he doesn't have a problem. But he said
there are times he and his wife travel together, and at that
point, there is a problem. That is when they have to find a
replacement therapist, assign their payments, which can take
several weeks, and a lot of advanced planning, as you very well
already discussed. If they didn't do this, the elderly patient
care would be interrupted, obviously, as you again explain,
setting back their treatment schedules.
So I really think, Ms. Norby, you handle that very well,
and Mr. Bilirakis covered that in a lot of detail which we, I
suppose, could go back over, but I think that has been
discussed. So I would like to maybe switch, and even though
today, while we are primarily talking about patient payment
plans, Dr. Gould, I would like to also talk about patient
access, because they are kind of related. But in particular, in
reading through your testimony, I noticed you reference that
there is a large number of community oncology practices that
have closed or have been forced or have chosen to merge with
various hospitals. And certainly my concern in this regard is
on the access piece.
I just wondered if you could discuss any of the reasons,
perhaps unintended or otherwise, but some of the reasons that
have caused so many, especially oncology practices, to merge
under hospitals?
Dr. Gould. Yes, sir. I would say that there are two forces
in play here, we have what I like to call a push, then we have
the pull. The push forces I would characterize as four major
forces. We have increase in cost of doing business. Our costs
go up just like everybody else, including for health care.
Secondly, we have had declining reimbursement, particularly
from Medicare. And I mentioned one example, which was the
sequestration cut.
Thirdly, we have the increased cost of doing business,
particularly with the increasing regulatory environment. And
then fourthly, we have the uncertainty of future Government
programs and how that is going to impact Medicare reimbursement
and so forth.
So on the other hand is the other force that I call the
pull, which is that many hospitals have access to the 340B
program, and for those hospitals to be able to access that
program, they have to have contracted physicians, either
directly employed or contracted through what we call a
physician service agreement, or a PSA. And so, you know, with
the increasing challenges in trying to run a practice, a lot of
physicians are saying heck with it, I don't want to be bothered
with all of this, I just want to be able to take care of my
patients. And so the hospitals are singing a siren song, and
these physicians are going to work for the hospitals and not
worrying about the management of a practice.
Mr. Collins. So let me interrupt there, because I heard
this before. Is it safe to say a private oncology practice
would not have 340B pricing?
Dr. Gould. That is correct, sir.
Mr. Collins. So in this case, if I have this right, a 340B
hospital, and we are talking about very expensive oncology
drugs, I mean, these could be $100,000-type drugs. So in the
340B setting, there is a private oncology practice, they treat
a patient, there is a $100,000 pharmaceutical, they are covered
by Blue Cross/Blue Shield, it is prescribed, Blue Cross/Blue
Shield pays it and we move on. But now, if the same practice
merges under a hospital, the same drug is given, the same
reimbursement is made by Blue Cross/Blue Shield, to give an
example, but then that hospital turns around and gets a
discount from the drug company and get that drug for $20,000.
Dr. Gould. That is correct, I mean----
Mr. Collins. In which case that $80,000 goes to the bottom
line of the hospital, which actually, in a profit-motivating
world, would allow them to pay a lot of money for private
oncology practice. The primary financial driver of that is
nothing more than telling the pharmaceutical companies they are
going to take it on the chin, have to pass this discount on
because it a 340B situation, but nothing else has changed. I
know my time has expired, but is my understanding of that
fairly accurate?
Dr. Gould. Yes, sir. And what happens is, those hospital
practices now have more monies to compete for employees and
doctors than what I have in private practice, and so, I go out
of business and have to partner with hospitals as well.
Mr. Collins. I know my time has expired, but that goes back
to picking winners and losers, and we are not supposed to be
doing that. With that, Mr. Chairman, I yield back.
Mr. Pitts. The Chair thanks the gentleman. I now recognize
Mrs. Brooks from Indiana for 5 minutes of questions.
Mrs. Brooks. Thank you, Mr. Chairman. I want to commend the
chairman on continuing to tackle this complex and important
issue by bringing up these bipartisan bills today and ensure
that we keep moving forward to ensure that seniors get the
access to the care that they need. And I think the bills before
us today will strengthen existing programs and build upon the
momentum that we started in the field with SGR reform.
I am particularly happy and want to focus on Mr. Walden's
bill before us today addressing the issue with CMS's current
face-to-face rule. I have long said that these rules initially
put forward by CMS are imposing crushing burdens on home health
agencies rules and impair their ability to provide seniors the
home health services that they deserve.
Complicated, confusing, inconsistently enforced, the
current face-to-face regulations have exceeded the intent of
the law, and I believe has hindered the work of caregivers at
home health agencies. And it is having three real-world
implications for three home healthcare agencies operating
within my district.
The survey actually found that 52 percent of face-to-face
claim denials resulted mainly from Medicare's determination
that physician's documentation was insufficient, even though
medically necessary care was provided. I believe this is
creating an access-to-care crisis, particularly in rural parts,
not only in my district, but across the country. And it is
preventing providers from delivering vital services to those
most in need. Speaking of, home health patients are more likely
to be women, more likely to be older, more likely to be sicker,
poorer, and minorities. And I think Mr. Walden's bill makes
commonsense reforms to bring the CMS rule into the scope of the
intent of the law.
So I would like to just ask you, Ms. Myers, a few
questions. Can you give us any real-world examples of issues
about the current documentation requirements that aren't
working as intended?
Ms. Myers. Absolutely. Thank you for that question. We have
spoken a little bit about some of the examples of claim
denials. In one additional example that I have, an orthopedic
surgeon was treating an 82-year-old patient and referred them
to home health care following a total knee arthroplasty, which
had to do with the knee itself. Certainly this woman was
wheelchair bound.
It took five attempts from the home health agency in
working with the physician's office to get confirmation and
documentation back from the physician. So that is one example
where the physicians are extremely fed up with the
documentation requirements and the difficulty.
We have talked also about the fact that there are other
issues related to things like signatures, dates, missing
documentation, or descriptions of documentation that have
fallen under that insufficient and subjective mode from the
reviewers.
Mrs. Brooks. Can you tell me whether or not the impact of
these denials, or the problems with the documentation, how is
it affecting the small and the rural agencies?
Ms. Myers. Well, certainly, we have a number of small and
rural agencies on the east side of Oregon, which comprises most
of Congressman Walden's district. In those cases, there are
certainly less staff, less ability to be competitive, to hire
good clinical nurses and physical therapists to provide the
care for the patients that is needed at home. So it has both an
impact on the agency in terms of attempting to spend less time
on paperwork, and chasing documentation, and more time in
patient care.
Mrs. Brooks. Do you have to, what I suspect, the agencies
have to often hire extra administrative staff to take care of
all of the documentation? Is that what you are seeing? Or is it
actually the providers that are trying to do what is
administrative work?
Ms. Myers. It is a little of both. In the case of smaller
and rural agencies, they have less of an ability to hire
additional staff. I have one particular example of a provider
in Wheeler County, and the agency is the only provider in that
county, and faced closure this year. She is a nurse, she
provides care in the community, she is traveling 60 miles to
treat farmers, ranchers all over the county. And her inability
to manage both patient care and handle denials and paperwork
related to all of this documentation are really making that
agency struggle significantly.
Mrs. Brooks. Do you have any idea roughly how many patients
she cares for?
Ms. Myers. I think it is between 5 and 10 in the entire
county.
Mrs. Brooks. Can you talk to me a little bit more about the
issues between how is the face-to-face requirement straining
the relationship between the physicians and the home health
providers? What is happening with that?
Ms. Myers. It has created a relationship of almost
antagonism, and it is as if the home health agency is the
antagonizer, but certainly, we are just the bearer of the
regulation and the rule and the requirement. So it is straining
that relationship in ways that it normally wouldn't be.
Mrs. Brooks. Thank you. My time is up.
Mr. Pitts. The Chair thanks the gentlelady, and now
recognizes the gentleman from Oregon, Mr. Walden, for 5 minutes
of questioning.
Mr. Walden. I thank the Chair for this hearing, and our
witnesses for their testimony. I am going to follow up on what
Ms. Myers said, Ms. Brooks, because when she talks about four
or five patients being served in Wheeler County, there are only
about 1,700 people in the entire county. And if you drove from
Fossil, Oregon, the county seat to the nearest hospital, it
would be 142 miles each way. These are enormous areas, and my
colleague from New Mexico, Mr. Lujan, talked about the size of
his district and everybody kind of gasped. His is 47,271 square
miles. Mine is 69,341.
So when we are talking about providing basic services in
these remote areas, this is life and death, literally life and
death. That is why this matters so much that when some
contractors, some bureaucrats, some rule writer comes up with
one of these things back here in Washington, they don't have a
clue what they are doing in real life out on the ground, and
that needs to change, and it needs to change now.
Let me go to Ms. Myers. The original requirements for a
physician face-to-face encounter were intended as a program
integrity measure to protect waste, fraud and abuse. Do you
think this bill that we have before us eliminates or dilutes
that protection against fraud and abuse?
Ms. Myers. Absolutely not. The requirement for the face-to-
face encounter with the patient is still fully maintained with
the proposed bill. And it further is required, and a condition
for payment under the Medicare home health benefit. The
physicians still must certify the patient's eligibility for
coverage, and the bill provides for a cleaner, more
standardized process by which we would be able to operate and
be able to focus more on patient care rather than chasing
paperwork.
Mr. Walden. I had a very positive discussion with Mr. Lujan
during the break, when we went to vote on the House floor and
come back, and he and I intend to work closely on this
legislation.
Mr. Griffith and I had a very good conversation. I imagine
he won't talk about this, I won't steal his thunder, but I will
give him full credit that is, perhaps, within the context of
this legislation, we should allow face-to-face to qualify over
electronic devices.
Again, if I could take my phone into the home and have the
doctor on the other side, which we all know can be done today,
why should we have to transport a patient 142 miles over icy,
foggy roads for a face-to-face so they can go back home?
Ms. Myers. Absolutely, and in the case of my father, right
before he passed away, I was attempting to get home care for
him, but he couldn't stand up, literally, or make it to the car
and have my mother help him to get into the car to make it into
a physician's office. So it is very challenging, and that may
present an opportunity.
Mr. Walden. We went through the same sort of event with my
mother-in-law, who had severe rheumatoid arthritis, who was in
very bad shape, and they would have to transport her by
ambulance or the equivalent, and they'd have to do the blood
pressure test before she left, which drove excruciating pain
throughout her body, and then as soon as she got to the
hospital or whatever, they had to do it again.
I mean, there are so many stupid things in delivery of care
right now, driven by either litigation or regulation that we
need to get past so we put the patients first.
I ask unanimous consent, Mr. Chairman, to enter into the
record a statement written by Jeffrey Weil, who is Division
Vice President for Operations in the northwest for LHC Group.
Jeff is responsible for the operations of Three Rivers Home
Care in Grants Pass, in Medford, Oregon.
He says that, just for 2014 and 2015, his company has had
more than 393 claims denied for inadequate face-to-face
documentation. Each and every one of these claims had
documentation signed by a physician. However, in most cases,
the Medicare administrative contractors denied the claims
because they deemed the physician's narrative to be inadequate.
Many of these denials were reversed, but they currently have
more than $1.5 million of denied face-to-face encountered
claims tied up in appeals at various stages.
Mr. Pitts. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Walden. Oh, thank you, Mr. Chairman.
Ms. Myers, can you describe in more detail the impact that
claim denials and the subsequent appeals associated with the
home health face-to-face requirement has on patient care and
home health agency operations, particularly in these small and
rural areas?
Ms. Myers. Absolutely, and as Jeffrey Weil indicated, you
know, many of the agencies across the State are experiencing
very similar situations with thousands of dollars pending.
Certainly, the impact to patients occurs where the
physicians these days are getting, you know, arguably, very fed
up with the documentation requirements and that they simply
have said to some of our providers, ``Forget it.'' The
documentation is too much. It takes too much time and too much
time away from patient care. And unfortunately, in some cases
where the physician is struggling with this documentation to
make a referral for home health care, they are just simply
saying no. So the patient gets caught in the middle.
And, as I have said previously, the denials are, you know,
plentiful on a lot of technicalities and semantic issues, and,
certainly, that needs to be fixed, and we think that this bill
would help tremendously to do that.
Mr. Walden. Thank you, Mr. Chairman.
Mr. Pitts. The Chair thanks the gentleman.
I now recognize the gentlelady from North Carolina, Mrs.
Ellmers, for 5 minutes for questions.
Mrs. Ellmers. Thank you, Mr. Chairman. I didn't realize I
was next, but I am very happy.
Thank you to our panel for being here and for this
particular subcommittee hearing. It is so important. I would
like to associate myself with the gentleman from Oregon and his
comments about the importance of us moving forward with good
legislation so that we can take care of these patients in the
way they need to be taken care of and stop having to jump
through the hoops and put these patients and their families
through this.
I do want to ask a couple of questions. As far as, you
know, the beneficiaries of Medicare--I mean, I know you have
probably answered this a million times, but isn't that the
effect--and it is really a ``yes'' or ``no'' answer for all
three of you. The impact will be tremendous if we can change
the legislation and move forward with much more--giving our
physicians, our physical therapists much more control over this
situation and payment and reimbursement. I mean, this will move
mountains, do you agree?
OK. You are all indicating ``yes.'' I agree with that as
well. It is definitely something we have needed.
And physical therapists in our rural communities,
especially, are just vital, absolutely vital. Whether we are
talking about physicians or whether we are talking about
physical therapists in a home health setting, it is incredibly
important to be able to allow the individuals to stay in their
homes. We know that that has an impact on their health care.
As far as locum tenens, how would this affect reimbursement
or payment for locum tenens when--I know you were discussing
how you would have had to have closed if you didn't have
someone that could take that space and keep your operation
going. What would you like to say about that, Ms. Norby?
Ms. Norby. That is a great question. So, it affects payment
because I would be able to bring in, under locum tenens, a
licensed, qualified physical therapist to continue the care
with my patients, and then we would submit the claims under my
Medicare provider enrollment number to Medicare, so----
Mrs. Ellmers. And it would all, basically, go under your
Medicare number----
Ms. Norby. Right.
Mrs. Ellmers [continuing]. But that person would be fully
qualified, able to do it, all checked out ahead of time----
Ms. Norby. Yes.
Mrs. Ellmers [continuing]. And would just fit into that
space.
So that is a very convenient and sensible way of dealing
with that issue and is definitely something that I think is so
important. Because, seriously, what are you doing? I mean, you
really have no alternative right now the way the system is set
up.
Ms. Norby. That is correct. I am gone from my clinic 2 days
this week to be here----
Mrs. Ellmers. Yes.
Ms. Norby [continuing]. With you, and it took creative
scheduling. Now, my Medicare patients know I am very much an
advocate for this, and they all know about this bill.
Mrs. Ellmers. Good.
Ms. Norby. So they were very supportive and willing to come
at 7:00 at night or at 10:00 on Saturday morning.
Mrs. Ellmers. To accommodate so you could be here.
Ms. Norby. Yes, so I could be here, so----
Mrs. Ellmers. Oh, that is awesome.
See, this is what our health care providers do. I mean, the
commitment that our health care providers have for their
patients, for their families, and the role--that is why, I
mean, I am so passionate about health care, being a nurse and
being in that space and knowing what goes on behind the scenes
that people are completely unaware of; and so, I am there with
you.
I do want to ask a little bit about the cumbersome nature
of the paperwork, the documentation that our health care
professionals-- right now, especially, is the most difficult
time; and I am probably making more of a comment than I am
asking a question, but I think you are going to agree with me,
so I am going to assume that, and I will ask if you agree.
Right now, our health care professionals are dealing with
electronic health records, meaning meaningful use. They are
moving forward with stage three, which I think is a big
mistake. We have a very important letter with, gosh, well over
120 cosponsors--bipartisan--asking them to step back from
moving forward; and now we have ICD-10 that is added into the
mix on top of the difficulties that are being experienced,
especially in the home health setting. One ``i'' that isn't
dotted, one ``t'' that isn't crossed can mean the difference
between reimbursement for a health care professional or not.
Do you agree that right now is just an incredibly difficult
time for any health care provider when it comes to the
documentation? And, mind you, we are all supposed to be going
paperless. I will just throw that in there. Do you agree?
Ms. Norby. And regulatory burden, too.
Mrs. Ellmers. Yes, and the regulatory burdens.
And that is what this legislation is about. We are trying
to make things better. We are really trying to work behind the
scenes, and I am just excited to be a part of it because I have
been out in the real world. I know what it is like, and I know
the commitment that our health care providers have. I know the
dedication that the families of those patients have and the
meanings. They will never forget the things that you have done
for them ever, and any way we can make that better is exactly
what we need to do.
So, again, I thank you for your time. Thank you for really
taking away from your back-home patients and care and families
of your own to be here for this important, important
subcommittee hearing. Thank you so much.
And thank you, Mr. Chairman. I yield back.
Mr. Pitts. The Chair thanks the gentlelady. That concludes
the questions from the members present. We will have written
questions and follow-up from other members who weren't able to
attend sent to you. We ask that you please respond promptly.
Ms. Myers. Absolutely.
Mr. Pitts. Thank you. And I will remind members that they
have 10 business days to submit the questions for the record,
so they should submit those questions by the close of business
on Thursday, October 15.
A very informative, excellent hearing. Thank you for coming
all the way to this hearing. We really appreciate it. Thank you
for your expert testimony. These are very important,
bipartisan, noncontroversial bills. We expect them to move very
soon, and you have had a great part in that. So thank you very
much.
Without objection, the subcommittee stands adjourned.
[Whereupon, at 11:59 a.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
Prepared statement of Hon. Fred Upton
For years we have been warned of the looming insolvency of
Medicare. Those alarm bells cannot be ignored. To allow the
program to fall into bankruptcy would be to abandon the solemn
promise we have made to seniors in Michigan and across the
Nation. As the committee of primary jurisdiction over much of
the Medicare program, we cannot, and we will not let that
happen. As the population ages with Baby Boomers entering
retirement and the potential for provider shortages to increase
in the near future, it is our duty to identify opportunities to
improve the program. Today, we will examine bipartisan
solutions to help put us back on track.
H.R. 556, the Prevent Interruptions in Physical Therapy Act
of 2015, introduced by Representatives Bilirakis and Lujan,
would ensure that Medicare patients receiving therapy services
do not have to delay care in the event their treating provider
gets sick or married.
H.R. 1934, the Cancer Care Payment Reform Act of 2015, is
sponsored by Representatives McMorris Rodgers and Steve Israel.
The legislation would build off of the promise in the SGR
repeal legislation--also known as MACRA--by promoting
innovative payment reforms designed to increase the quality of
care delivered to Medicare seniors and reduce costs to the
program.
Finally, we will examine a discussion draft authored by
Representative Greg Walden that would streamline documentation
requirements related to home healthcare delivery.
We will continue our work to keep the promise to seniors
and improve the Medicare program.
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