Advocacy & Day on the Hill



Senator Debbie Stabenow and Adam deJong, MA, FAACVPR, FACSM

Senator Bob Menendez

Congressman Paul Ryan


Day on the Hill (DOTH) 2015
March 3-4, 2015, Washington DC

The Issue in 2015 - Supervision of Cardiac and Pulmonary Rehabilitation Services
AACVPR members are asking Congress to support legislation that would amend the Social Security Act to allow physician assistants, nurse practitioners and clinical nurse specialists to supervise cardiac and pulmonary rehabilitation programs on a day-to-day basis. This change would not alter the requirement for medical direction of these programs – it would simply remove the requirement for a physician to be immediately available and accessible at all times when services are being furnished under these programs. In 2010, direct physician supervision was extended to non-physician practitioners for other outpatient services in regulatory guidance. However, language included in Public Law 110-275 (enacted in 2008) imposed a legislative requirement which inadvertently contained a legislative requirement for direct physician supervision that could not be reversed through regulation. As a result – cardiac and pulmonary rehabilitation require a level of physician supervision that is not commensurate with patient risk; creates access issues in rural and other areas with physician shortages, and creates unnecessary costs for these low-revenue programs.

Cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) are medically directed and supervised programs designed to improve a patient’s physical, psychological, and social functioning. Both programs utilize supervised exercise, risk factor modification, education, counseling, behavioral intervention, psychosocial assessment and outcomes assessment. A physician, who serves as Medical Director, is responsible for ensuring that the program is safe, comprehensive, cost effective, and medically appropriate for individual patients. This individual typically leads a multidisciplinary team of healthcare professionals that may include nurses, exercise physiologists, respiratory therapists, dietitians, health educators, behavioral medicine specialists, and other healthcare professionals.

Separate and distinct from medical direction is “direct physician supervision” which requires a physician to be immediately available for each session. This individual is typically not the Medical Director and is mainly responsible for responding if an emergency arises. In similar outpatient environments, non-physician practitioners, such as physician assistants and nurse practitioners, are allowed to provide certain aspects of “direct physician supervision” in accordance with scope of practice and state licensure laws. This authority was granted in regulatory guidance effective January 1, 2010. However, the public law that created the Medicare coverage of cardiac and pulmonary rehabilitation services included a provision that has been interpreted to preclude non-physician practitioners from acting in place of a physician in a supervisory capacity to meet Medicare requirements for physician supervision. The current regulations impose a more stringent requirement for physician supervision on CR and PR than they do on the staffing of emergency departments. Although the legislative sponsors made it clear that this was not their intent, CMS believes the law must be changed to allow them to extend the same flexibility to cardiac and pulmonary rehabilitation that is now available for other hospital outpatient services.

The change being contemplated would allow non-physician practitioners to provide day-to-day supervision of these programs. The Medicare statute identifies these individuals as physician assistants, nurse practitioners and clinical nurse specialists under the broad category of non-physician practitioners (NPPs). Today, NPPs are utilized in a number of critical care environments, including critical access hospital emergency departments (without an MD on site), hospitals and hospital clinics, emergency rooms, intensive care units, recovery rooms, cardiac catheterization laboratories, heart failure and arrhythmia clinics, community clinics, health centers, urgent care centers, walk-in clinics, and many other sites. These individuals are highly trained to respond should cardiac emergencies arise.

The safety of cardiac rehabilitation in a medically supervised, community-based program is well established. The requirement that a physician be immediately present (i.e., physically within a short distance) makes it difficult for cardiac and pulmonary rehabilitation programs to operate in rural areas where physicians are scarce and imposes unnecessary costs in both rural and urban areas. Program closures result in a lack of access for patients to receive the standard of care for these high value medical services. This change is supported by the American Heart Association,the National Association for Medical Direction of Respiratory Care (NAMDRC), along with other professional associations concerned about this issue.

The Legislative Correction
U.S. Senate bill, S.488, introduced in the 114th Congress would amend title XVIII (Medicare) of the Social Security Act to allow physician assistants, nurse practitioners, and clinical nurse specialists to supervise cardiac, intensive cardiac, and pulmonary rehabilitation programs.

In the last Congress, the legislation was co-introduced by Senators Chuck Schumer (D-NY) and Michael Crapo (R-ID). The bill had 13 bipartisan cosponsors including Senators Baldwin (D-WI), Blumenthal (D-CT) , Boxer (D-CA), Crapo (R-ID), Durbin (D-IL), Franken (D-MN), Gillibrand (D-NY), Grassley (R-IA), Harkin (D-IA), Markey (D-MA), Risch (R-ID), Thune (R-SD) and Warren (D-MA).


All the information you need to explain this issue to your US. Congressional members

AACVPR Focus on Advocacy

As an AACVPR member, you play a large role in this process by coming to D.C. each year. You meet with your two U.S. Senators, your state’s U.S. House of Representatives, and represent your state affiliate in those Congressional offices. Your elected officials who vote on the bills and make Medicare decisions stay informed on what is important to us, as constituents and providers of cardiopulmonary rehabilitation. Especially in this time of looking for “what works best”, we need to be more attentive to how any changes will shape the services we provide and less secretive about how beneficial our services are. Otherwise, cardiac and pulmonary rehabilitation will remain the best kept secrets in secondary prevention. Day on the Hill gives AACVPR members an opportunity to meet with their legislators and legislative staffs as constituents, as voters and healthcare professionals.


How to find your U.S. House Representative:

For the contact information of your House Representative, Click Here.

How to find your U.S. Senators:

For the contact information of your two Senators, Click Here.

Contacting and Locating Your U.S. Senators in Washington D.C.

  1. Click on link below to find D.C. address and office main phone #.
  2. Ask for the person responsible for health care issues.
  3. Request a meeting with that person AND the Senator.
  4. You may be told you will be meeting with someone else and you may be instructed to schedule an appointment through a scheduling person. Each office varies and you will be assisted through the process for that particular Senator.

Map of Capitol Hill and Congressional Buildings

You may find it helpful to print out this map.

Map of Washington D.C. Metro Line

You may find it helpful to print out this metro line map (color version is more helpful if possible).

How to communicate with your U.S. Senators' and U.S. House Members' DC offices:

  • Call the office and ask first for the name of the person who is responsible for health care issues.
  • Ask if that person prefers to be contacted by telephone or by email on an issue of concern to you.
  • If by email, send it to health staffer with a brief summary of what you are asking for.
    • Include in an email the attachments posted below:
      • Copy of Senate bill (number will be known when introduced)
      • Leave behind document (which summarizes our ask)
      • Letter to CMS from Senate Finance Committee (SFC) members regarding statues' intent
      • Berwick (CMS) response to SFC
    • OR carry the SFC and CMS letters with you to make the case in person
  • Let him/her know you will call on ___ (date) (5 days is fair) for the Senator’s decision or to answer any questions he/she may have.
  • Continue calling weekly until you receive an answer (or unless you are told to proceed otherwise by the health staffer).
  • If health staffer prefers telephone over email for initial contact, follow talking points below to explain your task. 

Communication Tips

  • You are representing cardiac and pulmonary rehabilitation for your state’s providers and patients.
  • Try to immediately speak with the person responsible for health issues, but understand that every office operates by its own rules and email may be the preferred method of initial contact.
  • Address an email to the congressional member AND to the person whose name you’ve been given as responsible for health care issues for the member.
  • Follow-up when you said you would and keep trying. It is their job to be aware of and care about health care issues that could ultimately help or hinder access of vital services for Medicare beneficiaries.



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Pulmonary Rehabilitation Toolkit
Frequently Asked Questions - Cardiac Rehab
Frequently Asked Questions - Pulmonary Rehab