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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 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

JOE BARTON, Texas 

Chairman Emeritus 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

GREG WALDEN, Oregon 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

Vice Chairman 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

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 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California7 

SUBCOMMITTEE ON HEALTH

JOSEPH R. PITTS, Pennsylvania 

Chairman 

BRETT GUTHRIE, Kentucky 

Vice Chairman 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

LARRY BUCSHON, Indiana 

SUSAN W. BROOKS, Indiana 

CHRIS COLLINS, New York 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

GENE GREEN, Texas 

Ranking Member 

ELIOT L. ENGEL, New York 

LOIS CAPPS, California 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

DORIS O. MATSUI, California 

BEN RAY LUJA ́ N, New Mexico 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(II) 

(III) 

C O N T E N T S 

Page 

Hon. Joseph R. Pitts, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 1 

Prepared statement .......................................................................................... 2 

Hon. Ben Ray Luja ́n, 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. lll, 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. Luja ́n .................................. 126 

Letter from Andrew Slavitt, Acting Administrator, Centers for Medicare & 

Medicaid Services, to Hon. Chuck Grassley, U.S. Senator, submitted by 

Mr. Luja ́n and Mr. Bilirakis ................................................................................ 129 

Page

IV 

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 

1The 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. 

(1) 

EXAMINING POTENTIAL WAYS TO IMPROVE 

THE MEDICARE PROGRAM 

THURSDAY, OCTOBER 1, 2015 

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON HEALTH, COMMITTEE ON ENERGY AND COMMERCE, Washington, DC. 

The subcommittee met, pursuant to call, at 10:00 a.m., in room 

2322, Rayburn House Office Building, Hon. Joseph R. Pitts (chairman of the subcommittee) presiding. 

Members present: Representatives Pitts, Guthrie, Shimkus, Burgess, Lance, Griffith, Bilirakis, Elmers, Bucshon, Brooks, Collins, 

Green, Schakowsky, Butterfield, Castor, Matsui, Luja ́n, 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; 

2 

Thirdly, draft legislation, authored by Representative Greg Walden of Oregon, would make changes to documentation and face-toface 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. Luja ́n of New Mexico for 5 minutes for his opening statement. 

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

Mr. LUJA ́ N. 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. 

3 

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. 

4 

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 Luja ́n. 

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 shortstaffed 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 

5 

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.] 

6 

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. 

7 

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 faceto-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. 

8 

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 Luja ́n. 

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. 

9 

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. 

10 

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 

11 

Medicare beneficiaries in nearly 2,000 rural counties relied on 

home health services in 2013. 

That is why I am here today, to speak to you and ask you to help 

us continue serving the frail seniors who need our care and the 

rural communities who depend on our delivery system. 

One of the greatest burdens we face today is the implementation 

of the face-to-face requirement; but let me be clear: We strongly 

supported your action to require that no claim would be paid unless it was for services ordered by a physician as a result of the 

face-to-face encounter with the patient. That is good medicine, and 

that is good program integrity policy. 

We need to keep in mind that the physician also certifies the patient’s eligibility for Medicare coverage under penalty of various 

anti-fraud laws. What has created the burden on physicians and 

home health providers is not the policy but how it has been implemented with impossible-to-meet documentation requirements that 

are not in the law enacted by Congress. 

Inconsistencies in the lack of standardization have forced providers to chase physicians multiple times to address issues of semantics, not to improve patient care or to improve quality performance. Documentation compliance has become a moving target, resulting in countless hours of providers and physicians attempting 

to meet Medicare’s unclear documentation rules, resulting in thousands of denied claims. Whether it is a missing signature on a completed form or an insufficient description regarding a patient’s clinical condition, the implementation has resulted in a process that 

has, ultimately, created a paperwork mess of what should be 

straightforward documentation. Patient care is the priority. Burdensome paperwork and navigating red tape should not be. 

What is most alarming with the documentation demands is that 

thousands of claims have been denied based on insufficient documentation even though a review of the full patient record reveals 

that the patient meets Medicare coverage criteria. This is not happening in a vacuum either. It is occurring at the same time home 

health providers are struggling under an unprecedented 14 percent, 4-year cut. A cut which is pushing home health agencies to 

the brink. 

Medicare has tried to fix the documentation nightmare. However, 

its efforts have fallen far short. Fortunately, there is a solution. 

Congressman Walden is authoring legislation that would establish 

a simple approach to documenting physicians’ face-to-face encounters with their patients. In place of confusing requirements, physicians would simply record the date of the encounter and use a form 

to identify the clinical condition for which home health is needed. 

We need this legislation. It will preserve your good policy while 

reducing unneeded paperwork and enabling us to continue serving 

homebound seniors in Oregon and all across America. 

In closing, I want to thank Congressman Walden and all of you 

for your support of home health care and your dedication to America’s rural communities. Your efforts mean very, very much to us. 

Thank you. 

[The prepared statement of Ms. Myers follows:] 

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Mr. PITTS. The Chair thanks the gentlelady. 

We still have 5 minutes, and 374 Members haven’t voted. We 

will try one more. 

Dr. Gould, you’re recognized for 5 minutes. 

STATEMENT OF BRUCE GOULD 

Dr. GOULD. Thank you. Chairman Pitts, Ranking Member Green, 

and members of the committee, I thank you for the opportunity to 

share my views on payment reform in oncology and specifically on 

the Cancer Care Payment Reform Act, H.R. 1934. 

I am a practicing medical oncologist and Medical Director of 

Northwest Georgia Oncology Centers, a private community oncology practice headquartered in Marietta, Georgia. Additionally, I 

serve as President of the Community Oncology Alliance, COA, a 

nonprofit organization dedicated to advocating for community oncology practices and, most importantly, the patients they serve. 

Close to 70 percent of Americans with cancer are treated by private 

practice clinics. I finally want to mention, of relevance here, that 

I am the son of two parents who passed away from cancer. 

Community oncology practices, such as mine, have struggled 

from major cuts to reimbursement by Medicare. For example, the 

decision by CMS to apply sequestration to the underlying costs of 

cancer drugs has led to many drugs being reimbursed for less than 

their acquisition price. As a result, over 300 practices have closed 

treatment sites and, more significantly, close to 550 practices have 

merged with hospital systems. 

The data is clear on the consolidation of cancer care in the 

United States. It is creating access to care problems for patients in 

rural areas and, very significantly, increasing the costs of cancer 

care for seniors in the Medicare program. This unwanted trend has 

been documented by reports this year by the GAO and MedPAC. 

Despite reimbursement pressures from Medicare, our practice, 

years ago, made a decision to ambitiously transform ourselves into 

a patient-centric Oncology Medical Home. Our goal was simple: to 

better control the costs of cancer care while enhancing the quality 

of the patient experience. Among other things, we improved care 

coordination for our patients, established a structured triage, initiated a comprehensive patient satisfaction survey, and developed 

our own treatment guidelines. 

One benefit of this transformation is that same-day appointments are rarely available in our nonclinics. Therefore, if our patients are ill, they can come to our clinics rather than going to the 

hospital emergency room. Medicare moneys are saved by the avoidance of needless emergency room visits and hospitalizations, and 

the patients are happier by not being subjected to hours of waiting 

in the emergency room. 

Our hard work has recently been recognized by the commission 

on cancer through their accreditation of our practice as one of the 

first Oncology Medical Homes. Our dedication to value-based care 

has led us to partnering with private payers and CMS on oncology 

payment reform pilots. 

One program we and several others completed with 

UnitedHealthcare resulted in cancer care savings of 34 percent as 

compared to a case control group. The results were published in the 

19 

peer-review ‘‘Journal of Oncology Practice,’’ a copy of which I have 

submitted with my remarks for the record. 

We are also part of a national $19 million grant from the Centers 

for Medicare & Medicaid Innovation, CMMI. The grant funded the 

‘‘COME HOME’’ pilot, which was designed to be a real world test 

of the oncology and medical home tenants. Findings from NORC at 

the University of Chicago, the independent research entity CMMI 

contracted with to measure results, were nothing short of remarkable. They showed an overall reduction of cancer care costs due to 

reduced hospitalizations, re-admissions, and emergency department 

utilizations. I have included these results with my written testimony. 

I am here today to implore Congress to immediately pass the 

Cancer Care Reform Act, H.R. 1934, a bipartisan bill, introduced 

by Representatives Cathy McMorris Rodgers and Steve Israel. The 

bill lays out the specific plans for a demonstration project based on 

the Oncology Medical Home. It is built on successful models that 

have already been tested in the oncology payment reform with both 

private payers and CMS. 

I commend Mrs. McMorris Rodgers for reaching out to practicing 

community oncologists for crafting her bill. In addition to support 

from oncologists, her legislation also has the support of patient 

groups, private payers, biotech companies, and pharmaceutical distributors. I also commend Congress for passing a fix to SGR, along 

with a path to meaningful payment reform. Community oncology 

practices like mine want to be part of the alternative payment reform path that the Energy and Commerce Committee developed in 

the SGR legislation. However, we need a Medicare alternative payment model in oncology for that to happen. 

H.R. 1934 is a critical bridge to getting us to that point. I ask 

Congress to pass this important legislation that will lower the costs 

of cancer care while enhancing the quality of care for patients. 

Thank you for your attention. 

[The prepared statement of Dr. Gould follows:] 

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Mr. PITTS. Thank you. 

Sorry to rush you here. We are going to do one more opening 

statement. No time left, but 290 people still haven’t voted. 

So, Ms. Norby, you’re recognized for 5 minutes for your opening 

statement. 

STATEMENT OF SANDRA NORBY 

Ms. NORBY. Chairman Pitts, Ranking Member Green, and members of the committee, thank you for holding today’s hearing highlighting these important legislative issues. 

My name is Sandra Norby, and I appreciate the opportunity to 

discuss my strong support for H.R. 556, the Prevent Interruptions 

in Physical Therapy Act of 2015. 

I would like to especially thank Congressmen Bilirakis and Luja ́n 

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 

34 

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. Builtin safeguards control fraud and abuse as all locum tenens arrangements must meet regulatory standards that includes identification 

of services on the Medicare claim form and a 60-day limit to use 

the provider. 

Senator Charles Grassley recently received a letter stating quote: 

‘‘CMS does not have evidence indicating that locum tenens, as used 

by physicians under current law, has led to a general increase in 

utilization of services; or that industry practices generally lead to 

the provision of unnecessary services related to the use of locum 

tenens; or that the use of locum tenens under current law in the 

Medicare program is generally inappropriate, wasteful, or fraudulent’’ close quote. Preventing the disruption of Medicare patients’ 

therapy, as this bill will do, would likely result in lower costs to 

the Medicare program. 

I truly appreciate the committee’s interest in addressing this regulatory burden that impacts access to care. I am hoping that this 

simple technical correction can be achieved and that Medicare patients will be allowed to continue to access medically necessary PT 

services without disruption. 

I look forward to working with the committee, and I am happy 

to answer any questions you may have. 

[The prepared statement of Ms. Norby follows:] 

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Mr. PITTS. Thank you very much. 

I appreciate your patience due to the votes on the floor. We are 

going to have to take a brief recess. We will reconvene immediately 

after the votes. There are still 160 people who haven’t voted, so we 

have time. 

So, without objection, the subcommittee stands in recess. 

[Recess.] 

Mr. PITTS. The time for the recess having expired, the subcommittee will come to order. I will begin the questioning and recognize myself for 5 minutes for that purpose. Can I get staff to 

come over here and operate this clock? One of you. I am sorry, that 

is OK. 

We will start with you, Dr. Gould. One thing this committee focused on during the SGR debate, the sustainable growth rate—you 

are familiar with that I am sure—— 

Dr. GOULD. Yes. 

Mr. PITTS [continuing]. Was creating a new framework for alternative payment models, and the goal was to encourage specialties 

to develop their own best practices that could ultimately lead to 

more coordinated care and better patient outcomes. How do you see 

H.R. 1934 conforming to this goal? 

Dr. GOULD. Well, I see H.R. 1934 fitting like a hand in a glove 

with that mandate. As medical specialists, we all want to be judged 

on the quality of our work, and we want to be judged on measures 

that are relevant to our specialty, and we want to be judged on how 

satisfied patients are with the care they receive from us. 

In addition, we understand in these days that costs are important, and we also want to take responsibility for our part of the rising health care costs. So the alternative payment model, H.R. 1934, 

meets all those needs in terms of payment reform, in which I applaud Medicare in terms of their moving from paying for the volume of services utilized to the quality of the services rendered to 

the patient. 

Mr. PITTS. Thank you. Ms. Norby, what safeguards and fraud 

and abuse controls, if any, are built into locum tenens agreements? 

Ms. NORBY. As I indicated in my testimony, we have to identify 

who the provider was on the claim form by reporting their NPI 

number, and also, there is the 60-day limit that they can be utilized as a locum tenens as well. 

As the letter from CMS had indicated, that these were physicians, they have not seen any problems with any kind of fraud or 

abuse when the locum tenens physician is in, so we assume the 

same would happen with physical therapists. 

Mr. PITTS. Thank you. Ms. Myers, in your testimony you discuss 

how vulnerable a population the home health beneficiaries are. 

Can you elaborate on that a little bit? 

Ms. MYERS. Absolutely. In a number of cases that we provide 

services to Medicare homebound beneficiaries, some of them are 

wheelchair bound, many of them are in very rural areas with very 

little access to community and/or family support systems. There are 

certainly a number of patients that we serve that are severely 

homebound, and without assistance, truly cannot get out of the 

home, even to simply get to a physician’s office for a visit. So there 

43 

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 Medicareenrolled 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 

44 

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. 

45 

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 

46 

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 comVerDate Mar 15 2010 11:28 Jun 03, 2016 Jkt 037690 PO 00000 Frm 00050 Fmt 6633 Sfmt 6633 C:\USERS\WLAUFERT\DESKTOP\114X81IMPROVEMEDICAREPDFMADE WAYNE
47 

mitment 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 stateof-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 

48 

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. 

49 

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. Luja ́n, for 5 minutes for questions. 

Mr. LUJA ́ N. 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. LUJA ́ N. Thank you very much, Mr. Chairman. 

50 

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. LUJA ́ N. 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. 

51 

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. LUJA ́ N. 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 actuVerDate Mar 15 2010 11:28 Jun 03, 2016 Jkt 037690 PO 00000 Frm 00055 Fmt 6633 Sfmt 6633 C:\USERS\WLAUFERT\DESKTOP\114X81IMPROVEMEDICAREPDFMADE WAYNE
52 

ally 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. 

53 

1The 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. 

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-inlaw 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-yearold 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

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. 

54 

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 

55 

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. 

56 

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-toface 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 faceto-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 necVerDate Mar 15 2010 11:28 Jun 03, 2016 Jkt 037690 PO 00000 Frm 00060 Fmt 6633 Sfmt 6633 C:\USERS\WLAUFERT\DESKTOP\114X81IMPROVEMEDICAREPDFMADE WAYNE
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essary care was provided. I believe this is creating an access-tocare 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. 

58 

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. Luja ́n, 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. Luja ́n 

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? 

59 

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-toface 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. 

60 

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. 

61 

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. 

62 

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 Luja ́n, 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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