[House Hearing, 106 Congress]
[From the U.S. Government Publishing Office]
TELEHEALTH: A CUTTING EDGE MEDICAL TOOL FOR THE 21ST CENTURY
=======================================================================
HEARING
before the
SUBCOMMITTEE ON
HEALTH AND ENVIRONMENT
of the
COMMITTEE ON COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 7, 2000
__________
Serial No. 106-144
__________
Printed for the use of the Committee on Commerce
__________
U.S. GOVERNMENT PRINTING OFFICE
67-112 WASHINGTON : 2000
COMMITTEE ON COMMERCE
TOM BLILEY, Virginia, Chairman
W.J. ``BILLY'' TAUZIN, Louisiana JOHN D. DINGELL, Michigan
MICHAEL G. OXLEY, Ohio HENRY A. WAXMAN, California
MICHAEL BILIRAKIS, Florida EDWARD J. MARKEY, Massachusetts
JOE BARTON, Texas RALPH M. HALL, Texas
FRED UPTON, Michigan RICK BOUCHER, Virginia
CLIFF STEARNS, Florida EDOLPHUS TOWNS, New York
PAUL E. GILLMOR, Ohio FRANK PALLONE, Jr., New Jersey
Vice Chairman SHERROD BROWN, Ohio
JAMES C. GREENWOOD, Pennsylvania BART GORDON, Tennessee
CHRISTOPHER COX, California PETER DEUTSCH, Florida
NATHAN DEAL, Georgia BOBBY L. RUSH, Illinois
STEVE LARGENT, Oklahoma ANNA G. ESHOO, California
RICHARD BURR, North Carolina RON KLINK, Pennsylvania
BRIAN P. BILBRAY, California BART STUPAK, Michigan
ED WHITFIELD, Kentucky ELIOT L. ENGEL, New York
GREG GANSKE, Iowa TOM SAWYER, Ohio
CHARLIE NORWOOD, Georgia ALBERT R. WYNN, Maryland
TOM A. COBURN, Oklahoma GENE GREEN, Texas
RICK LAZIO, New York KAREN McCARTHY, Missouri
BARBARA CUBIN, Wyoming TED STRICKLAND, Ohio
JAMES E. ROGAN, California DIANA DeGETTE, Colorado
JOHN SHIMKUS, Illinois THOMAS M. BARRETT, Wisconsin
HEATHER WILSON, New Mexico BILL LUTHER, Minnesota
JOHN B. SHADEGG, Arizona LOIS CAPPS, California
CHARLES W. ``CHIP'' PICKERING,
Mississippi
VITO FOSSELLA, New York
ROY BLUNT, Missouri
ED BRYANT, Tennessee
ROBERT L. EHRLICH, Jr., Maryland
James E. Derderian, Chief of Staff
James D. Barnette, General Counsel
Reid P.F. Stuntz, Minority Staff Director and Chief Counsel
______
Subcommittee on Health and Environment
MICHAEL BILIRAKIS, Florida, Chairman
FRED UPTON, Michigan SHERROD BROWN, Ohio
CLIFF STEARNS, Florida HENRY A. WAXMAN, California
JAMES C. GREENWOOD, Pennsylvania FRANK PALLONE, Jr., New Jersey
NATHAN DEAL, Georgia PETER DEUTSCH, Florida
RICHARD BURR, North Carolina BART STUPAK, Michigan
BRIAN P. BILBRAY, California GENE GREEN, Texas
ED WHITFIELD, Kentucky TED STRICKLAND, Ohio
GREG GANSKE, Iowa DIANA DeGETTE, Colorado
CHARLIE NORWOOD, Georgia THOMAS M. BARRETT, Wisconsin
TOM A. COBURN, Oklahoma LOIS CAPPS, California
Vice Chairman RALPH M. HALL, Texas
RICK LAZIO, New York EDOLPHUS TOWNS, New York
BARBARA CUBIN, Wyoming ANNA G. ESHOO, California
JOHN B. SHADEGG, Arizona JOHN D. DINGELL, Michigan,
CHARLES W. ``CHIP'' PICKERING, (Ex Officio)
Mississippi
ED BRYANT, Tennessee
TOM BLILEY, Virginia,
(Ex Officio)
(ii)
C O N T E N T S
__________
Page
Testimony of:
Berenson, Robert A., Director, Center for Health Plans and
Providers, Health Care Financing Administration............ 6
Burgiss, Sam, Project Director, Telemedicine, UTN Medical
Center at Knoxville........................................ 50
Davis, Sally, Program Director, Telehealth and Management
Development, Marquette General Health System............... 38
Grigsby, Jim, Study Manager, Center for Health Services and
Policy Research, University of Colorado Health Sciences
Center..................................................... 70
Patrick, Mary R., Director of Quality Improvement, Blue Cross
and Blue Shield of Montana................................. 60
Reid, James, Director of Telemedicine and Network Services,
West Rural Telemedicine Consortium, Mercy Hospital
Foundation, on behalf of Center for Telemedicine Law....... 46
Rheuban, Karen, Medical Director, Office of Telemedicine,
Professor of Pediatrics, University of Virginia Health
System, accompanied by Lisa Hubbard and Alexandra Bartley.. 27
Ross-Lee, Barbara, Dean, Ohio University College of
Osteopathic Medicine....................................... 53
Tracy, Joseph, Director of Telehealth, University of Missouri
Health Sciences Center..................................... 43
Material submitted for the record by:
Children's National Medical Center, prepared statement of.... 85
Thune, Hon. John R., a Representative in Congress from the
State of South Dakota, prepared statement of............... 84
(iii)
TELEHEALTH: A CUTTING EDGE MEDICAL TOOL FOR THE 21ST CENTURY
----------
THURSDAY, SEPTEMBER 7, 2000
House of Representatives,
Committee on Commerce,
Subcommittee on Health and Environment,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:05 a.m., in
room 2322, Rayburn House Office Building, Hon. Michael
Bilirakis (chairman) presiding.
Members present: Representatives Bilirakis, Burr, Bilbray,
Bryant, Brown, Stupak, Green, Strickland, Barrett, and Capps.
Staff present: Marc Wheat, majority counsel; Patrick
Morrisey, majority counsel; Kristi Gillis, legislative clerk;
Amy Droskoski, minority professional staff; and Bridgett
Taylor, minority professional staff.
Mr. Bilirakis. This hearing will come to order.
My thanks to all of the witnesses who have taken the time
to testify at this hearing on telemedicine and the role of
technology in improving the quality of health care, and I also
would like to particularly welcome little Alexandra Bartley,
whose story will be shared with us today.
We live in a time where every aspect of our life is being
transformed and improved by the convergence of technologies.
Today's hearing will focus on the union of medicine,
microelectronics and communications which promises to improve
the health of many Americans, especially patients in
geographically remote and medically underserved areas.
With more than a quarter of our Nation's elderly living in
medically underserved areas, telemedicine could improve access
to health care for many Medicare patients. This technology has
significantly matured since 1997 when the first telemedicine
Medicare reimbursement policies were signed into law, and I
would like to add that Ron Wyden, who is now over in the
Senate, formerly in the House, who had quite an interest in
this subject. He and I spent many hours discussing telemedicine
and, of course, some of the problems associated with it, which
I guess we will get into here today.
So now it is time for Congress to re-examine current
policies that may unfairly frustrate the development of this
promising health care delivery method. Significant barriers to
reimbursement of these services currently exist. For example,
only limited reimbursement is available in areas which face a
shortage of primary care physicians. While telemedicine is
perhaps more commonly recognized as a tool to increase access
to specialty treatment, it can also play an important role in
expanding access to primary care.
I hope that this hearing will illuminate some of the
shortcomings of current Medicare reimbursement policies, and
again I want to thank all of our witnesses who have taken the
time to share their expertise with us today.
I apologize to my ranking member for starting without him,
but Mr. Stupak was here, and I now yield to the gentleman from
Ohio.
Mr. Brown. Thank you, Mr. Chairman. I apologize for being a
bit late.
I would like to thank Dr. Berenson and our other
distinguished witnesses and especially Dr. Ross-Lee from Ohio.
It is nice to see you again. Thank you.
I don't want to minimize the importance of this hearing. It
clearly is appropriate and valuable for this subcommittee to
become more educated about and to promote beneficial uses of
telemedicine in the Medicare program. But we are taking up this
issue in the context of further changes to the 1997 Balanced
Budget Act. The fate of BBA changes likely will be determined
over the next few years.
Our jurisdiction over Medicare and Medicaid, particularly,
Mr. Chairman, our sole jurisdiction over Medicaid, demands that
we play a direct and active role in that process. This
subcommittee has held hearings on the BBA, the Plus Choice
program, Medicare prescription drug coverage. The value of
those hearings, like the value of our discussion today, depends
on what we do in response.
I hope this hearing signals our commitment to participate
fully and on a bipartisan basis in Medicare and Medicaid
decisionmaking that will be critical to the providers and
beneficiaries we represent; and in keeping with the
beneficiary-oriented goals of this hearing, I hope this
committee perceives this year's legislation not only as an
opportunity to address inadequate reimbursement but as an
opportunity to directly improve access and coverage for
Medicare and Medicaid beneficiaries.
Promoting telehealth in Medicare is just one of those
issues, but it is important for several reasons. Not only can
telehealth serve the best interests of Medicare beneficiaries,
but Medicare coverage policy sets a precedent for private
coverage.
In his written testimony, Mr. Joseph Tracy from the
University of Missouri makes a key observation. He said that
telemedicine has not proven to be a vehicle for overutilization
as some skeptics assumed it would be. Rather, it is serving as
a vehicle for adequate utilization in medically underserved
areas. He goes on to say that people living in these areas have
as much right to Medicare benefits, obviously, as every other
American. So Tracy has touched on a fundamental value in the
Medicare program and the most compelling reason to support
Medicare coverage for telehealth services, that Medicare is
grounded in universality.
The fundamental objective is to provide the same level of
quality care to all beneficiaries, regardless of location,
regardless of income, regardless of health status. In some
areas of the country, meeting that objective is especially
problematic. There are areas of Ohio, which has some of the top
health care in the country, where residents are literally hours
away from the kind of basic health care resources we take for
granted, something that Dr. Ross-Lee knows a lot about in the
part of State in which she is located.
All 50 States have areas where the number and diversity of
health care providers is limited by geography or poverty or
both. That is where telehealth comes in. The blending of health
care and telecommunications technology has enabled health care
providers to deliver care in new ways to new populations in the
United States and internationally.
As we look at Medicare and telehealth, as we evaluate the
impact of expanding coverage to include more providers and more
services in more areas of the country and as we discuss other
proposals like fees to help cover fixed costs, the fact that
telehealth promotes access in a targeted population has bearing
in two ways. The goal of equitable treatment for all Medicare
beneficiaries should heighten our interest in promoting
telehealth. The same goal should heighten our determination to
know exactly what we are getting into when we change telehealth
payment rules.
When we expand access to underserved populations we should
be careful to ensure that it is the proper care. Otherwise, we
are simply creating a new inequity. Equity for Medicare
beneficiaries must also be factored into the equation when we
weigh the pros and cons of establishing a fee to cover the
fixed costs associated with telehealth.
I look forward, Mr. Chairman, to hearing from our witnesses
on the opportunities, the risks and the variables that we
should consider as we look to expanding Medicare coverage for
telehealth.
Mr. Bilirakis. I thank the gentleman.
Mr. Stupak for an opening statement.
Mr. Stupak. Thank you, Mr. Chairman, and thank you very
much for holding this hearing and thank you for inviting Sally
Davis from Marquette, Michigan, to testify on the second panel.
Sally has been the director of telemedicine at Marquette
General Hospital since the programs inception. Their program is
the national leader and has really been a benefit to the Upper
Peninsula by increasing the ability of people to receive
quality health care from Mackinaw Island all the way up to the
Keweenaw Peninsula.
In areas like the Upper Peninsula, people are expected to
travel hours and hours to find specialty care. If they need
highly specialized care, that requires usually a trip to
Marquette General hospital. But if they can't provide it then
they must go to Detroit, Milwaukee, Minneapolis, St. Paul or
the Mayo Clinic. It requires at least one overnight stay and
hours of traveling.
Telemedicine allows people in remote rural areas the
ability to obtain first-rate health care without having
traveled hours or days in a motel. Telemedicine allows people
in Manistique, Michigan, to receive care from an expert, for
example, in Mayo Clinic without ever leaving their community.
I am convinced that telemedicine is the future of health
care in rural areas. I want to hear the witnesses explain their
programs in ways we can improve telemedicine. However, I would
like to make two quick comments to my colleagues and to Dr.
Berenson.
First, Federal grant funding for the development of
telemedicine networks is critical. Without this funding, many
of the projects that we will hear about today would never have
been started.
Second, HCFA needs to update its method for reimbursing on
telemedicine. As Sally will point out, the current rules
require a physician to present the patients case to a
specialist before the visit is reimbursed. Clearly, HCFA does
not require the primary care physician to walk you into the
office of a specialist before the specialist visit is
reimbursed. Likewise, a visit between a patient in Michigan and
a specialist in Minnesota does not require a physician to be
present in Michigan. A telemedicine transaction should be
reimbursed just the same as a face-to-face visit.
Mr. Chairman, thank you again for holding this hearing. I
look forward to the witnesses. Special welcome to Sally Davis,
and I look forward to addressing the critical health care needs
of rural America.
I yield back the balance of my time.
Mr. Bilirakis. I thank the gentleman for that; and I know
that he particularly, more so than most of us, is interested in
this subject principally because of the demographics of his
district.
Ms. Capps for an opening statement.
Mrs. Capps. Yes. Good morning, Mr. Chairman, and I want to
thank you also for holding this very important hearing this
morning on an issue of great significance, I believe, to
patients and providers across the country, telehealth. I also,
along with my colleague Bart Stupak, represent a district that
is predominantly rural; and, therefore, I am especially
interested in the ways that this new technology can be
utilized.
Telehealth is an exciting new way to deliver health
services to people in underserved areas. Patients are able to
receive specialty care that is not found in their own
community. Providers can now instantly share information that
previously would have taken hours or even days to access.
In my own district, Cottage Hospital in Santa Barbara has
been home to a teleradiology facility for about 2 years now. So
I went to them and found out exactly how this works.
Teleradiology is a method of distributing digital
diagnostic images such as X-rays, ultrasonography, magnetic
resonance and radio isotopes through local area or wide area
networks between remotely located facilities. A well-planned
teleradiology system can be a cost-effective and time-
efficient method that allows users to capture, transmit, store
and review patient studies.
In my own district a physician at a rural hospital such as
Santa Ynez can now quickly and easily share images with Cottage
Hospital in Santa Barbara, which is about 40 or 50 miles away,
thus cutting down on travel time for patients and hastening
their treatment regimen. In addition, providers can now sit at
a computer screen and share images with patients, showing them
a clear progression by easily clicking on present imaging and
contrasting them with previously taken X-rays.
Only 5 percent of hospitals in the country offer such
teleradiology services right now, and I believe it is our
responsibility here in Congress to work to expand this and
other telehealth capabilities across the Nation. That is
interesting to me that we look to the military as being one
area that brought this technology forward to us, and now we
can, I believe, in this legislative body work to make that
information and technology available across the country.
I understand that there are reimbursement issues
surrounding telehealth, and I look forward to a discussion of
how we can help to fund such groundbreaking technologies. And
here, again, I believe it is our responsibility and those of
the Federal agencies that we oversee to streamline our
permitting processes and our funding processes to stay up to
date with modern technology and not let that be the deterrent
for really improved patient care, patient health and, in many
instances, the difference between life and death.
As a nurse I am always interested in new and innovative
technology as the bottom line which will ultimately benefit
patient care. I commend the Chairman for holding this hearing
and look forward to an informative discussion. Thank you very
much.
Mr. Bilirakis. I thank the gentlewoman.
Mr. Green.
Mr. Green. Thank you, Mr. Chairman.
I have no prepared remarks, but during our break I had the
opportunity to be at the University of Texas medical branch in
Galveston, Texas, which is about 50 miles from Houston and
watched their telemedicine effort and the growth that they
have; and it is a great example. A year ago I was at M.D.
Anderson, a cancer center in Houston, and actually watched the
telemedicine conference between M.D. Anderson in Houston and
their facility in Orlando, Florida, and watched the doctors
consult. The success we have, Texas Childrens Hospital and
Texas Medical Center has the same capability.
Also, during the break, Congressman Nick Lampson--actually,
we used the telemedicine facilities to have a press conference
or really a town hall meeting from the University of Texas in
Houston Health Science Center with Galveston, with Beaumont,
Texas, and also with Washington with a representative from
HCFA.
So the technology is there, and we just need to make sure
that the reimbursement rates are there where you can, even
though the doctors not physically there--and I know that is a
problem across State lines and I would hope some of our
witnesses today would recognize that and address that.
Mr. Chairman, I don't know if she is here, but I would also
like to welcome Dr. Barbara Ross-Lee, the Dean of Ohio
University College of Osteopathic Medicine. Now, you are going
to wonder why a Texan is doing that. I happened to be there for
the graduation ceremony this last spring for my son-in-law, who
by the way is practicing his internship in Texas, but a great
university that is there in Ted Stricklands district.
Thank you, Mr. Chairman.
Mr. Bilirakis. I thank the gentleman.
[Additional statement submitted for the record follows:]
Prepared Statement of Hon. Tom Bliley, Chairman, Committee on Commerce
Thank you, Mr. Chairman.
I am pleased that the Health and Environment Subcommittee is
holding this hearing today. Given our Committee's strong interest in
both information technology and the delivery of high-quality health
care to seniors, it is critical for us to examine the potential of
telemedicine--a promising tool for the 21st Century.
It is a sad fact that many of our seniors today lack adequate
access to first rate medical facilities. Approximately 25% of seniors
currently live in areas that are medically underserved. This country
offers the best medical technology in the world, yet many seniors in
rural and inner city areas don't have enough access to services.
Today, we are examining one innovative delivery mechanism which may
help. Telemedicine may not be a panacea to all of the access problems,
but it could be an important first step.
During this hearing, our Committee will look at barriers impeding
the use of telemedicine in the Medicare Program. It is my goal to use
this hearing to help refine legislation which may be advanced by this
Committee during the final weeks of this session of Congress.
Folks seeking access to the use of telemedicine face many barriers.
However, I would like to focus on eight measures that I believe would
immediately increase access to telemedicine services. I would
appreciate it if our witnesses can focus their testimony on these
issues as well as any other legislative barriers which hamper the
development of telemedicine. These measures are as follows:
--Eliminating the provider ``fee sharing requirement;
--Eliminating the requirement for a ``telepresenter'';
--Allowing limited reimbursement for referring clinics to recover the
cost of their services;
--Expanding telemedicine services to non-metropolitan service areas;
--Making all providers eligible for HCFA reimbursement for services
delivered via telemedicine;
--Creating a federal demonstration project that permits telemedicine
reimbursement for ``store and forward'' consultations; and
--Permitting tele-home-care technologies to be used in prospective
payment system.
Mr. Chairman, I believe that these changes would have an extremely
positive impact on the delivery of health care to seniors, especially
in rural and underserved areas. Without these barriers, rural patients
may be able to travel shorter distances to ``see'' their specialists.
Additionally, services provided to patients in home health care
settings may prove more cost-effective to provide if performed through
a telecommunications system.
Mr. Chairman, the potential for linking information technology to
the delivery of health care services holds great promise for our
nation's seniors. This fall, our Committee can do a great deal to make
that a reality.
I look forward to hearing our witnesses speak on this important
subject. Furthermore, I would like to welcome Karen Rheuban, the
director of telemedicine at the University of Virginia. She has been a
strong advocate for this new service in my home state and I would like
to thank her for her work.
Mr. Bilirakis. Dr. Robert Berenson is our first panelist.
He is the Director of the Center for Health Plans and Providers
with HCFA. Dr. Berenson, welcome to our committee again. It is
always good to see you, sir. Please proceed and take all the
time you might feel you need, but hopefully not exceeding 10
minutes. Please proceed, sir.
STATEMENT OF ROBERT A. BERENSON, DIRECTOR, CENTER FOR HEALTH
PLANS AND PROVIDERS, HEALTH CARE FINANCING ADMINISTRATION
Mr. Berenson. Thank you, Mr. Chairman. And Congressman
Brown, distinguished subcommittee members, thank you for
inviting me here to discuss Medicare coverage of telemedicine
which, as you pointed out, is an important issue and one that
is a cutting-edge issue in terms of how we provide medical care
to senior citizens and others in this country.
I have provided written comments, and I just want to
briefly summarize some of the high points.
HCFA believes that telemedicine holds great promise for
extending access to care in rural and other medically
underserved areas. We understand that rural beneficiaries face
unique challenges in accessing the medical care they need,
particularly access to specialists. Helping them is a high
priority for us, and we share the Secretary's personal
commitment to promoting telemedicine where it is appropriate.
We worked together with Congress in the Balanced Budget Act
to move forward and expand coverage, but we did so cautiously.
Strict limits were placed on what could be covered, where it
could be provided and who could provide it. The caution was
well intended because there was and even now remains very
little published peer-reviewed scientific data available on
when telemedicine or telehealth is medically appropriate. It is
difficult to project potential cost implications, and there are
potential program integrity issues that should be addressed
proactively.
But the result is that today telemedicine usage in Medicare
has been limited, too limited. The field is moving very fast,
and we are moving very slowly. And I actually read the
testimony of all of the witnesses but in particular would point
to testimony from Dr. Grigsby who points out that the
technology that we basically tested and thought was going to be
the basis for telemedicine, the interactive video consultation,
is already somewhat outdated and the technology has moved much
faster than we have been able to keep up. Our demos were based
on a certain technology, and nobody came to the party, in
essence.
So we will have to figure out how to make policy judgments
to some extent in the absence of bona fide scientific findings
from good, peer-reviewed studies and at the same time remain
cautious in this area because of quality as well as program
integrity concerns that we will talk about.
And we are continuing to conduct research, will modify our
research given the constraints that your experts will talk
about in the form of several demonstration projects that we now
have ongoing.
We want to determine which health care providers are
clinically appropriate for telemedicine presentations. We want
to explore the potential uses and abuses of ``store-and-
forward'' technology in which there is no real-time interaction
between patient and provider, and we want to understand rural
physicians' perceived barriers to utilizing telemedicine. This
research is essential as we work to reach firm conclusions and
make responsible recommendations.
However, preliminary indications from our ongoing work
suggest there may well be additional clinical circumstances
beyond those paid under current Medicaid law where telemedicine
is appropriate. There also may well be additional health care
personnel, especially nurses, who are perfectly capable to make
telemedicine presentations.
Facility fees and fee splitting may warrant
reconsideration, and we may want to reconsider new
demonstration projects looking at telemedicine in underserved
urban settings as well. And right now we have a unique
opportunity to look at the use of telemedicine for home health
services, especially in relationship to our anticipated for
October 1 implementation of prospective payment for home health
services.
We will soon be compiling our findings in a report that
will make firm recommendations, and we are absolutely eager to
work with Congress as we proceed.
I thank you for again holding this hearing, and I will now
be happy to respond to questions. Thank you very much.
[The prepared statement of Robert A. Berenson follows:]
Prepared Statement of Robert A. Berenson, Director, Center for Health
Plans & Providers, Health Care Financing Administration
Chairman Bilirakis, Congressman Brown, distinguished Subcommittee
members, thank you for inviting me to discuss Medicare coverage of
telemedicine. Telemedicine, with its ability to provide medical
services via telecommunications systems, holds great promise for
extending access to care in rural and other medically underserved
areas. We understand that rural beneficiaries face unique challenges in
accessing the medical care they need, particularly access to
specialists. Helping them is a high priority for us. And we share the
Secretary's commitment to promoting telemedicine where appropriate.
To date, telemedicine usage in Medicare has been limited. The
Balanced Budget Act (BBA) of 1997 expanded coverage options, but also
included several restrictions that preclude telemedicine's use under
conditions where it is commonly being used outside of Medicare. We are
concerned that this is limiting the potential of telemedicine in
Medicare. However, we also have a number of concerns regarding broader
implementation of telemedicine. There is very little published, peer-
reviewed scientific data available on when telemedicine use is
medically appropriate. It is difficult to project potential cost
implications. And there are potential program integrity issues that
should be addressed proactively.
To help address these concerns, we are conducting extensive
research and several demonstration projects. We are particularly
interested in learning more about:
specific clinical circumstances when telemedicine is medically
appropriate;
which health care providers are clinically appropriate for
telemedicine presentations; and,
the potential uses and abuses of ``store-and-forward''
technology, in which there is no real-time interaction between
patient and provider.
We are conducting demonstration projects specifically examining:
the feasibility, acceptability, cost, and quality of
teleconsultation services;
the potential role of telemedicine in diabetes management;
and,
rural physicians' perceived barriers to utilizing
telemedicine.
We also are consulting with academic and military experts who are
using telemedicine in situations beyond those now allowed under the
Medicare statute. We are working with other Department of Health and
Human Services agencies, including the Health Resources and Services
Administration's Office of Rural Health Policy and Office for the
Advancement of Telehealth, as well as the Agency for Healthcare
Research and Quality. In addition, the Department's Assistant Secretary
for Planning and Evaluation has commissioned a study on assessing
approaches to evaluating telemedicine, which should further enlighten
our work.
These efforts are ongoing, and we are not yet able to reach firm
conclusions or make responsible recommendations. As mentioned above,
there is very little published, peer-reviewed scientific data in this
field, which makes our current research efforts all the more critical
for determining how telemedicine coverage should be expanded. However,
preliminary indications from our ongoing work suggest there may well be
additional clinical circumstances, beyond those paid under current
Medicare law, where telemedicine is appropriate. There also may well be
additional health care personnel able, but not allowed under current
law, to make telemedicine presentations. We will continue our
telemedicine research efforts and compile findings in a report that
will make firm recommendations on how the benefit should be expanded
and what program integrity protections may be needed. We want to work
with Congress as we proceed to develop the data necessary for
responsible decisions about how to expand the use of telemedicine in
Medicare.
To further help us in all our efforts to better serve rural
beneficiaries and providers, including the use of telemedicine
services, we have established a Rural Health Initiative within our
agency. This Initiative includes senior agency leaders and a direct
rural contact staffer in each of our Regional Offices to increase and
coordinate attention to rural issues and closely monitor how laws and
regulations governing our programs affect rural beneficiaries and
providers.
Background
The BBA significantly expanded Medicare's authority to cover
telemedicine. Previously, telemedicine coverage in Medicare was limited
to situations in which no face-to-face contact between patient and
provider is generally necessary; for example, in radiologic
interpretation of x-rays. However, the BBA expansion continued to place
strict limits on telemedicine coverage. For example:
Telemedicine services may only be provided to a beneficiary in
a rural health professional shortage area (HPSA);
Telemedicine services are limited to ``consultations'' for
which payment currently may be made under Medicare. This is a
key limitation, as the American Medical Association Physicians'
Current Procedure Terminology (CPT) defines consultation as a
``face-to-face'' physician and patient encounter, meaning that
the patient must be present at the time of the consultation.
Therefore, a Medicare ``teleconsultation,'' is a medical
examination under the control of the consulting practitioner,
in lieu of an actual face-to-face encounter, that must take
place via an interactive audio-video telecommunications system;
Only physicians or practitioners described in section
1842(b)(18)(C) of the Social Security Act may provide
teleconsultations. This also is a key limitation, as registered
nurses and other medical professionals not recognized as
practitioners under this section of the Medicare statute may
not receive payment for a teleconsultation, even though they
commonly serve as telepresenter outside of Medicare. Additional
health care professionals, such as clinical psychologists,
clinical social workers, and physical, occupational, or speech
therapists who are able to receive Medicare payment in limited
circumstances, but are not specifically listed in the statute
as Medicare providers, also are precluded from receiving
payment for teleconsultation; and,
The law specifically prohibits payment for line charges or for
facility fees, and mandates that consulting and referring
practitioners share payments.
On November 2, 1998, we published a final rule in the Federal
Register implementing the telemedicine provisions of the BBA. The rule
explains the geographic limits for reimbursement, the practitioners
that are eligible to present patients and act as consultants, the
teleconsultive services and technologies that are covered, and how
payment will be made.
Regarding the mandate that consulting and referring practitioners
must share payments, the rule stipulates that 75 percent of the fee go
to the consultant and the remaining 25 percent go to the referring
practitioners. This split is based on the relative work for
practitioners at both ends of the consultation and an inherent
recognition that different consultations call for different levels of
effort. As a result, the fee split reflects the projected level of new
work done by each practitioner over the course of various
teleconsultations.
The rule also specifies that the eligible CPT codes for
consultations that can be covered under the statute can be used for a
number of medical specialties, such as cardiology, dermatology,
gastroenterology, neurology, pulmonary, and psychiatry. We will cover
additional consultations for the same or a new problem if the attending
physician or practitioner requests the consultation, and if it is
documented in the medical records of the beneficiary.
Telemedicine in Other Settings
Outside of Medicare, telemedicine is being used in many
circumstances not allowed under current Medicare law. Again, there is a
paucity of published, peer-reviewed literature on the appropriateness
of many of these uses. However, telemedicine is being used for much
more than interactive consultations. These include evaluation and
management services that are common in physician office visits,
psychotherapy, pharmacologic management, sleep studies, physical and
occupational therapy evaluation, and speech therapy.
``Store-and-forward'' technology also is being used in which there
is no real-time interaction between patient and provider. Instead, a
referring provider will examine a patient and then send a video clip or
a photographic scan, along with the patient's medical record, to a
distant consulting practitioner. The consulting practitioner will then
review the file and make a diagnosis. Military and academic health care
providers, in particular, are having apparent success with ``store-and-
forward'' for diagnosing dermatology cases. And it is being used for
several other specialties, such as opthalmology, cardiology, nuclear
medicine, and sleep.
Also, outside of Medicare, telemedicine presentations are commonly
made by health care professionals, especially registered nurses and
licensed practical nurses, who are not allowed to make such
presentations under current Medicare law. Some telemedicine programs
use nurses for virtually all telepresentations, with generally high
satisfaction ratings from both patients and physicians. And we are
examining this through one of our demonstration projects where we are
allowing registered nurses to make telemedicine presentations.
In Medicaid, at least 17 States (Arkansas, California, Georgia,
Iowa, Illinois, Kansas, Louisiana, Montana, Nebraska, North Carolina,
North Dakota, Oklahoma, South Dakota, Texas, Utah, Virginia, and West
Virginia) are covering telemedicine, often under circumstances not now
allowed under Medicare law. States must satisfy Federal requirements of
efficiency, economy, and quality in telemedicine coverage, but
generally are encouraged to use the flexibility inherent in Federal law
to create innovative payment methodologies for telemedicine. For
example, States are not required to split fees as in Medicare, and may
make separate reimbursements to both the referring physician for an
office visit and to the consulting physician for a consultation. States
also can cover network line charges, facility fees, technical support,
depreciation on equipment, and other costs not allowed under Medicare
law, as long as the payment is consistent with the requirements of
efficiency, economy, and quality of care.
Current Research
We recognize the potential benefits these additional telemedicine
uses may offer in Medicare. But we feel compelled to proceed with due
caution because of the paucity of published, peer-reviewed scientific
literature on when and where these other uses are clinically
appropriate. We also are concerned about the effect of telemedicine on
quality or care, the potential for abuse, and the difficulty in
establishing program integrity parameters without the kinds of solid,
scientific, evidence we generally rely on in determining when a given
service is medically appropriate.
To address these outstanding concerns, we are conducting extensive
research and demonstration projects, and developing a report that will
include specific recommendations on how to expand the Medicare
telemedicine benefit. To collect data on these issues, we have worked
with telehealth projects receiving grant funding through the Office for
the Advancement of Telehealth at the Health Resources and Services
Administration. We also received data from the telemedicine directorate
at the Walter Reed Army Medical Center and the Telemedicine Center at
Ohio State University Medical Center.
Also, in conjunction with the Agency for Healthcare Research and
Quality, we have contracted with the Oregon Health Sciences University
to evaluate several issues pertaining to Medicare coverage policy.
These efforts have helped us understand how telemedicine is being used
outside Medicare. This study involved an assessment of the clinical and
scientific literature dealing with the cost-effectiveness of
telemedicine, specifically looking into the areas of ``store-and-
forward'' technology, patient self-testing and monitoring, and
potential telemedicine applications for non-surgical medical services.
Within Medicare, we are conducting research demonstration projects
to help us better understand telemedicine. We are working through
Columbia University to conduct the Informatics, Telemedicine, and
Education Demonstration Project, as required by the BBA. This
randomized, controlled study will explore whether the use of advanced
telemedicine technology improves clinical outcomes for diabetics in New
York City and rural, upstate New York.
Another demonstration to assess the feasibility, acceptability,
cost, and quality of teleconsultation services involves 110 Medicare-
certified facilities in North Carolina, Iowa, West Virginia, and
Georgia. It also includes a bundled payment rate that is negotiated to
cover both the facility and physician fees for telemedicine services.
Utilization of telemedicine in the project so far has been limited. And
we are now considering whether to remove the bundled payment feature,
which may be contributing to the low utilization levels, from the
project. To better understand usage patterns, we also are examining
rural providers' perceived barriers to telemedicine.
We also are examining whether it is appropriate to provide payments
for teleconsultation to beneficiaries in homebound settings. And we
also are working with the Center for Health Policy Research at the
University of Colorado to evaluate the impact of telemedicine coverage
on access to, and quality of, care, and to analyze rural physicians'
perceived barriers to telemedicine.
A key concern for us as we work with Congress in exploring possible
expansions is how to ensure that telemedicine is used appropriately.
There is significant potential for over-utilization that would be
difficult to monitor and prevent, since we have so little data to guide
us in determining when telemedicine is, in fact, medically appropriate.
``Store-and-forward'' technology, in particular, has the potential to
substantially increase the number of consultations billed to Medicare
without regard to medical necessity.
Another key concern is the difficulty in projecting costs for
telemedicine expansions. There are, as yet, no good data on the extent
to which expanded coverage for telemedicine would increase claims.
There are no reliable data on the extent to which additional claims
would represent appropriate care that should be, but is not now, being
delivered. And there are no reliable data on the extent to which
expanded coverage would invite inappropriate claims or other abuse. The
lack of data, as well as program and payment experience, in these areas
warrants a careful, measured approach as we proceed. Issues such as
scope of coverage and expansion of eligible areas need to be carefully
studied and considered. And we need reliable evidence to determine when
telemedicine is an appropriate substitute for services that
traditionally require the physical presence of a patient.
Rural Initiative
Telemedicine is only one part of our efforts to improve access and
services for rural beneficiaries. We are redoubling our efforts to more
clearly understand, and actively address, the special circumstances of
rural providers and beneficiaries. Last year we launched a new Rural
Health Initiative and are meeting with rural providers, visiting rural
facilities, reviewing the impact of our regulations on rural health
care providers, and conducting more research on rural health care
issues. We are participating in regularly scheduled meetings with the
Health Resources and Services Administration's Office of Rural Health
Policy to make sure that we stay abreast of emerging rural issues. And
we are working directly with the National Rural Health Association to
evaluate rural access to care and the impact of recent policy changes.
Our goal is to engage in more dialogue with rural providers and
ensure that we are considering all possible ways of making sure rural
beneficiaries get the care they need, including use of telemedicine. We
are looking at best practices and areas where research and
demonstration projects are warranted. We want to hear from those who
are providing services to rural beneficiaries about what steps we can
take to ensure they get the care they need.
We have put together a team for this rural initiative that includes
senior staff in our Central and Regional Offices and dedicated
personnel around the country. The work group is co-chaired by Linda
Ruiz in our Seattle regional office and Tom Hoyer in our central office
headquarters in Baltimore. Each of our ten regional offices now has a
rural issues point person that you and your rural provider constituents
can call directly to raise and discuss issues, ideas, and concerns. A
list of these contacts and their respective States is attached to my
testimony.
Conclusion
Telemedicine holds great promise for improving access to care,
particularly for beneficiaries in rural and other underserved areas.
Our ongoing research efforts should help address the lack of scientific
data on its appropriate uses. That will help us understand whether and
how current restrictions on Medicare coverage for telemedicine should
be changed.
We are very grateful for this opportunity to discuss our efforts to
help rural providers and beneficiaries, and to explore further actions
we might take to address their concerns in a prompt and fiscally
prudent manner. I thank you again for holding this hearing, and I am
happy to answer your questions.
Mr. Bilirakis. Thank you, Doctor.
Dr. Berenson, you have referred to them, virtually every
opening statement has, the barriers to the use of telemedicine,
particularly those involving Medicare but let us say barriers
in general. You have worked with it, and I am sure you are
familiar with many of those barriers. Can you share with us
what some of those barriers may be, how they might be
eliminated? Can some of them be eliminated administratively by
HCFA? Will it take legislation to do that?
This, I think we all agree, has the potential of being a
tremendous health care delivery vehicle, particularly in the
rural areas, Mr. Stupak's area and some others. So I think it
is significant that we concentrate and focus on this area in
addition to all the other things that we do, but we need some
help from HCFA, too. We need some recommendations from HCFA in
terms of certain areas where you might need us to act
legislatively and what areas you can cover. Proceed.
Mr. Berenson. I would defer to some of your other experts
on some of the sort of culture of medicine barriers about the
sort of willingness of physicians and other professionals to
participate. But, clearly, there are some reimbursement issues
that HCFA has or Medicare, the Medicare statute precludes or
influences in a profound way, which deserve attention; and, as
I indicated, we are about to issue recommendations on some of
those changes.
But, preliminarily, we would think that there could be an
expansion beyond the BBA definition of a teleconsultation which
has a fairly narrow meaning. It basically--and I think that
meaning at the time made some sense or the intent, but the
consultation, as defined in the AMA CPT manual, which we follow
for our policy, makes it clear that a consultant doesn't have
overall responsibility for the management of a patient. A
consultant provides advice to the physician, and it makes some
sense when you are dealing with somebody many miles away. At
least initially it made sense to restrict to a consultation,
because there would be a physician on the ground who ultimately
was accountable.
It turns out that many of the grantees who HRSA has funded
to do telemedicine finds applications for telemedicine that go
beyond just consultations, and we have not had a lot of
billings for consultations. Some other kinds of evaluation are
management services. Other specific kinds of services that are
akin, for example, to radiology or EKG readings which have been
done for a while perhaps in the area of pulmonary testing or
sleep studies. I mean, there are some specific areas in the
field that some of the people in the field might be ready for
expansion in this area.
We are limited again by the lack of either scientific peer-
reviewed studies or even consensus standards by the profession
themselves, and I think some of the witnesses will point out
that you have to get down into the details as to which kinds of
services are fully amenable to this telemedicine where you
don't need the patient and the practitioner in the same room
and which ones would raise concerns.
But, in any case, expanding the definition of consultation
is one area that we think should be considered and clearly the
area of presenter. The BBA contemplated pretty explicitly that
there would be a physician presenting to another physician, and
many of the grantees who use this, the Walter Reed Medical
Center and others, Ohio State, who have active telemedicine
programs find that RNs and LPNs in some situations are fully
capable to make presentations, and the way----
Mr. Bilirakis. Are they able to under the current law?
Mr. Berenson. They are not able to under the current
requirements, and the organization of health care in rural
areas doesn't permit--another example is we have said that, and
the law contemplated, that employees of physicians should be
presenting, either the physician or employees. Well, it may
well be that the RNs are at the hospital, that may be where the
equipment is, and the personal physician may be somewhere else.
We need to look for more flexibility in this area of
presentation.
Mr. Bilirakis. If you have a physician in point A
presenting to a physician in point B, 2 or 3,000 miles away,
are both physicians reimbursed by Medicare?
Mr. Berenson. Right now, again, the law actually called for
fee splitting, and I know there have been some concerns by some
physicians about whether this might run afoul of Stark. When it
is legislatively prescribed it really doesn't, but I think
there is a perception problem. There is still an issue.
Our systems were such that we said that the receiving
physician would receive the fee and would have to somehow
compensate the presenting physician. That is administratively
cumbersome, doesn't happen very well, and I think we need to
revisit this issue of the fee splitting. Both for conceptual
and as well as practical reasons, it doesn't work very well,
and I don't think it is really necessary, but especially if we
expand----
Mr. Bilirakis. Is that something that can be revisited by
HCFA administratively?
Mr. Berenson. Yes--no. As I understand it, the requirement
for the fee to be shared is legislative. What we did
administratively was not split the fee ourself and send the
apportionment to each one. We asked the consultant physician to
basically be responsible for sharing the fee with the
presenting physician and that we do have authority over. But we
want to look more broadly at whether we even need to do the fee
splitting at all, although it is in the statute, especially if
we move to expanding who the presenters are.
Again, I think it is fair to say that we all moved
cautiously, perhaps too cautiously, in the BBA, starting with a
concept of a consultation with a physician in one room, a
physician in a room somewhere far off, and it all made sense in
that construct. As we expand services and recognize that there
are other presenters who are fully capable of presenting I
think we can change some of these rules that are barriers to
the use of telemedicine.
Mr. Bilirakis. Thank you, Doctor.
My time has long expired. Mr. Brown.
Mr. Brown. Thank you, Mr. Chairman.
Dr. Berenson, as you said, there isn't much clinical
evidence about the safety and effectiveness of telehealth
services. Run through, if you would, so at least I better
understand, I think other members of the subcommittee, the
process--run through the process by which HCFA would gather
evidence to expand services that only Medicare would pay for.
If you would sort of run through that, how you gather the
evidence, what evidence you will gather, how you make those
final decisions based on congressional direction on what you
will cover.
Mr. Berenson. Yes. Well, we have a number of studies
ongoing. In fact, it is the Office of the Advancement of
Telehealth at HRSA that have a number of grantees, and we are
systematically collecting information from them about their
experiences. In fact, it is somewhat based on those
experiences, as well, I should add, the Telemedicine Center at
Walter Reed, the Telemedicine Center at Ohio State, and then
working with researchers at Oregon State Medical Center. We are
trying to compile what the findings are. So, for example, it
turns out that most of the grantees do use telemedicine beyond
just consultation for a couple of very specific visits, such as
other medical visits and such as evaluation/management visits.
But very few of them have expanded into some other areas that
have been recommended by some.
So we would sort of look at that experience, collect some
consensus around those experiences, try to get some outcome
studies, although that is very difficult. And, again, some of
the experts you will hear are more familiar with the
methodological barriers in doing those studies.
We would also look to specialty societies themselves to
begin to develop some standards and tell us what they are based
on. Ultimately, coverage decisions might require us to submit
the evidence to the new coverage process that HCFA does have
with a panel of experts who do look at the evidence and do make
judgments about coverage. I think it is fair to say that we are
relatively early in this process of actually having good
evidence to assure us that broad expansion is warranted.
We are just putting again, as I said, the final touches on
a report on some of these issues. For example, in the area of
dermatology, which is one of the very promising areas where it
makes sense that you need images, where experts in a place can
look at an image and help make a diagnosis, well, it turns out
for discrete lesions it seems to work pretty well. For diffuse
lesions it is very difficult for a consultant somewhere else to
look at even 6 or 8 images that have been provided and make an
accurate diagnosis.
So that is the kind of detail one needs to get into. It is
hard to say it is going to be covered for dermatology or not,
when in fact the clinical information is that for certain
situations it is perfectly reasonable and for certain
situations it is not. Mostly in medicine we rely on the
profession itself to develop standards and to provide that kind
of guidance.
To date, you know, that is in its beginning stages. So at
this moment we do have--again, I think we should be proceeding
somewhat cautiously--so we want to expand these demonstrations,
and I think it is reasonable, if we are focused on health
manpower shortage areas in rural areas, to do those expansions
that we had talked about and then look to see how that is
playing out. I don't have a neat road map. All of that is sort
of in play at the moment.
Mr. Bilirakis. If the gentleman would yield maybe for a
quick follow-up to that.
Elections take place every 4 years. We don't know what is
going to happen in November. If there is a change in
administrations, for instance, or maybe even in the sense the
same party controlling, God forbid, but--I had to say that.
Forgive me, I had to say that. But my point is you have these
studies taking place. Are they just interrupted right smack in
the middle of the studies? I mean, do they continue--what
happens from a practical standpoint? They are important
studies.
Mr. Brown. One reason not to change.
Mr. Berenson. Clearly certain high-level policy calls can
be put on hold when there is a change in administrations, but
these studies are ongoing. They are committed. We are making
some corrections, some improvements in some of these demos
because we are not getting enough volume in the original
construction of them.
This is an opportunity to say one other thing. I actually
was--I am sure you are aware that the President's proposal on
Medicare reform included a modernization piece, and I actually
had the privilege of chairing an activity this spring within
HCFA to look at where we need to modernize. We talked centers
of excellence and PPOs and other things like that. One thing
that became very clear was that modern medicine wants to use
new technology. When I was an internist practicing, I used the
telephone; that is what was available, but actually, that is a
form of telemedicine which I wasn't adequately reimbursed for.
Right now I know that some physicians spend a third of
their time on the Internet, and we need to figure out not only
for rural underserved areas but for the basic functioning of
the program how to incorporate some of these new technologies
to improve efficiency, communication, quality, but it is very
difficult in a fee-for-service construct. I mean, one of the
reasons I am sure HCFA didn't reimburse me for telephone calls
was that the cost of billing would be more than the
reimbursement for a 2-minute phone call.
So we in that process were looking at other funding
mechanisms, other reimbursement mechanisms. Actually, these two
activities need to come together, the specific focus on rural
underserved populations and modernizing the program, and
certainly my recommendation to the new administrator will be to
give very high priority to both and see them related.
Mr. Bilirakis. But you would anticipate, though, this
continuing on?
Mr. Berenson. These studies will absolutely continue, and I
think part of the function of hearings like this is to give
more vigor and light on some of these studies, and I think you
have gotten some of our attention.
Mr. Bilirakis. Thank you, Dr. Berenson.
I appreciate the gentleman yielding the balance his time.
Mr. Stupak.
Mr. Stupak. Thank you, Mr. Chairman, a good segue into my
questions.
Doctor, would HCFA support congressional language
supporting reimbursement in telemedicine in the same way that
person-to-person transaction? I indicated before that you don't
reimburse now unless your general doctor or your family doctor
does the introduction. That is really a hindrance on
telemedicine. Why do we need this introduction if we are trying
to save costs and everything else? Would you support changes
like that so it could be doctor to patient or I should say
patient to specialist without an intervening doctor needing to
be there?
Mr. Berenson. I guess we will have recommendations in this
report that is due soon, but it looks like many of the
successful programs use RNs. I think we would be a little
reluctant, at this point, to having the patients present
themselves without any intermediary do the presentation, but I
don't believe it needs to be a physician. So I think we are
looking at an expansion for RNs and perhaps LPNs, in some
circumstances, but that kind of modification we would look
favorably upon.
Mr. Stupak. What we are concerned about is there almost has
to be a hand-off like to a specialist for every transaction.
Couldn't there just be the recommendation from your physician
to do it? And if you live three blocks away from Marquette
General Hospital, it seems like you should be able to go there,
get in telecommunication----
Mr. Berenson. We would like to know if that works. I would
be concerned about coordination of care in that kind of
situation. In general, I mean if, in fact, there is a system
where the consultant--the specialist knows exactly who the
responsible physician is and provides a report as consultations
tend to happen, I think we could be going in that direction. I
think the first step would be to make sure it is safe and
effective with nonphysicians, and we would look toward that
other approach down the road.
Mr. Stupak. I mean, I am sure you would agree that I just
can't walk into Marquette General and boot up the telemedicine
and start talking to guys in Mayo Clinic. It is just not going
to work that way. I am going to have some kind of referral,
some kind of code, access to get in. They are using their
equipment all the time. I am sure they are just not going to
let anyone do it. There would almost have to be that referral
already established.
What we are hearing is every time you want to do it, it
can't be billed, this specialist time can't be billed. So we
are going through this shell game just to get the money there,
which seems like a lot of duplication----
Mr. Berenson. There is no question that under the current
system, we have very few claims for these services. It is not
working right now so we would be looking to expand it. I would
defer to some of the other witnesses about exactly how that
could work.
Mr. Stupak. Okay. Let me ask you this question and I know
the Chairman started along these lines, and let me ask you this
if I can. As I understand it, current Medicare policy does not
allow certain practitioners, you mentioned nurses, to
participate in provision of telehealth services. A number of
witnesses on the next panel will mention how this limitation is
hindering the spread of telemedicine in Medicare. What is the
policy rationale for the limitation?
Mr. Berenson. Again, I think it was an initial caution
that--encaptured in the language of BBA that teleconsultations
would be the initial focus of this activity. The fact that it
explicitly talked about a fee-splitting arrangement suggests
that the BBA contemplated that there would be two physicians
involved, and I think it just was an initial caution in a new
area where we appropriately should be concerned about patient
safety. But I think the experience is such that we now probably
can move off of that caution, but that caution is really
captured in the BBA language.
Mr. Stupak. And I think you said it well in your opening
statement. The technology is moving so quickly, the cautions we
have that probably make them sort of outdated. In order to have
a remedy there, would you need a legislative fix or would rules
and regulations within HCFA probably take care of it?
Mr. Berenson. I believe we need a legislative fix for that;
and, again, we would work with the committee on that.
Mr. Stupak. And you certainly--and I am sure from your
testimony you have sort of indicated RNs would be a logical
place where we would start to allow them to participate in
telehealth programs.
Mr. Berenson. I think that is right.
Mr. Stupak. Thank you, Mr. Chairman.
Mr. Bilirakis. I thank the gentleman.
So the recommendation from HCFA is that possibly LPNs, et
cetera, ought to be--RNs, should be reimbursed and that there
should be changes made to the bill?
Mr. Berenson. Well, reimbursement is a separate issue. I
think we are--and, again, it is a little awkward because we
don't have our final report done, but at least the preliminary
findings and where we are likely to come out--it hasn't been
through the Department yet--is that our current restriction to
physicians is too restrictive, and we should expand that. It is
a different question about reimbursement to the presenter from
a restriction as to who can present; that is a separate issue.
Mr. Bilirakis. Ms. Capps to inquire.
Mrs. Capps. Thank you for your testimony, Dr. Berenson. I
am going to ask you to talk to us and give some discussion to
the need for national standards in the provision of telehealth.
We have standards in hospitals and nursing homes, but I can't
resist beginning with some of the comments--responding to some
of the comments you have made already in that you said that we
are in a timeframe now where the progress and technology is so
astronomical that by the time HCFA rules or Medicare makes--the
rules are changed that it is already obsolete. And underlying a
lot of my concern about where we are in health care now is this
huge gap between the science advances and the regulating
agencies that have always been conservative or have always been
cautious and concerned about quality and program integrity but
that the paradigms, the framework is so dramatically different.
Before, you talked about a discrepancy in telephone use. We
are talking about I think rather revolutionary changes in
medicine and the gap, the lag results in almost a disconnect
and that creates a climate in the practice where practitioners
know the level of response to patients' needs that could be
made and yet they are constrained by really an archaic--what is
becoming an archaic system, and I wish--I mean, when you said
that you are looking to specialists for coming with standards
and they are not as forthcoming as you want, where are the
incentives that can be given to practitioners to help to
address this rather than seeing the whole process from
Medicare's side as dampening and delaying and onerous, if you
will, where they almost want to get out of it because they
can't do what they know they are equipped and capable of doing?
And I am talking not just about doctors but all kinds of
practitioners.
And I am looking for how we can help in the legislative
body, because we are not the experts, and I submit that the
experts are out in the field, and you are constrained--you as
representing Medicare or HCFA--by the BBA. You talk about that.
So maybe that is where I will stop my diatribe and let you
respond. You said in response to the previous question, perhaps
there is legislation required to give impetus for bridging some
of this gap, and if you would address also--perhaps do that in
the framework of how we can get standards there that can guide
us.
Mr. Berenson. That is a very sort of broad set of questions
there.
I guess what I am going to suggest is that medicine has
always assumed a personal interaction. If you look at the AMA
CPT definition of an office visit, it has three components.
They are the history, the physical examination and medical
decisionmaking; and a lot of doctors spend a lot of time
valuing those various components. The personal, hands-on as
part of a medical interaction has been considered necessary,
but it may not always the case that that physical hands-on is
necessary.
There is also the potential for a surrogate doing the
hands-on for somebody at some distance. So, No. 1 is really
understanding when safety and quality can permit a nonface-to-
face encounter.
Mrs. Capps. But haven't we moved--isn't it clear that we
had moved past that?
Mr. Berenson. In some areas we have.
Mrs. Capps. I go to get a mammogram, and the person who
gives it to me doesn't read it. I know that. I have to trust
somebody else, and this is not telemedicine.
Mr. Berenson. For some specific technologies we have. And I
think one of the issues, and again I am not in the field, but I
think there is some controversy about mental health visits with
a psychiatrist, whether you need an actual physical presence to
establish a relationship or whether it is just as effective to
be doing it via telemedicine. And I think there is a
particularly compelling case for underserved rural areas where
the absence of the perfect may be nothing. I wanted to raise
the issue that there are serious quality concerns, and I don't
think it has gotten yet enough attention. I think the Congress,
HCFA and organized medicine needs to tackle this at a little
higher level.
The other thing is serious concern about cost. One of the
protections that we have for our cost problem is relying on is
some cost associated with that face-to-face encounter. People
don't frivolously go to the doctor, at least most people, and
hang around for an hour or 2, and we rely to some extent in a
fee-for-service environment for the fact that a visit is a
physical encounter. If we make it very easy for communication
back and forth, at any time, about any problem, although that
potentially is improving quality, it potentially is no limit on
associated cost.
And so that is why, again, within capitated environments,
within bundled global payment environments, it makes perfect
sense and why I come back to home health as a perfect place to
begin to understand it. In a fee-for-service environment, when
you don't require a face-to-face encounter, the potential for
astronomical increases in utilization is there, and we really
need to understand and have some standards in place as to when
it is appropriate and when it is not appropriate.
Mrs. Capps. I grant you that. But just by your saying that
the standard for care is the face-to-face encounter between the
provider and the patient, I would submit that is almost
nonexistent, even in highly served areas, because of the
complexity of health care; and we need then to work together to
figure out a different standard that will be embracing of what
you--I know my colleague wants to jump in--but we have got to
get this at some point because----
Mr. Berenson. I think that is right, but at the same time
one of the complaints patients do have is that they don't have
enough time to talk to their physician.
Mrs. Capps. That is another issue. That is another kind of
issue. And I think we have got to--if we are looking at if HCFA
calls face-to-face encounter the standard of care and how far
are we from that, then I submit to you that we need to reframe
the whole relationship.
Mr. Berenson. HCFA is doing it, but it is the profession
right now. The standard that the AMA and others have
established is this face-to-face requirement. So we are doing
this with other parties.
Mrs. Capps. Yes. And then the profession has to be allowed
to come up with different criteria.
Mr. Stupak. And that is the point I was going to make. I
think we need the professionals in helping us out, as opposed
to HCFA and Congress trying to do it. I really think we need
their input. Because I agree with some of the things you are
saying, but, at the same time, we are making rules that affect
them but we are not getting their input. And I know you
practiced for a while. I am sure you would have some input in
it, but I think we also need professions in there.
Mrs. Capps. And we also need----
Mr. Bilirakis. We are well over.
Mrs. Capps. There has got to be----
Mr. Bilirakis. We have gone over with everybody. Why don't
you sum up, Lois?
Mrs. Capps. All right.
Mr. Bilirakis. You want to sum up?
Mrs. Capps. I just want to say that delay also carries a
price.
Mr. Bilirakis. Mr. Bilbray to inquire.
Mr. Bilbray. Thank you, and I appreciate my colleague from
California pointing out, I guess the term is a lack of
treatment sometimes is the worst treatment or at least it can
be as lethal as the wrong type of action.
Doctor, we can hold these hearings and we can talk about
use of the technology and we can talk about all the
opportunities out there, but if our structure does not allow
utilizing new technology, if our bureaucratic barriers--if I
may use a derogatory term--but let us just say our regulatory
safeguards are such that innovative opportunities cannot be
utilized, then all we are doing is sitting here and playing a
nice game of what if, how great it could be, without actually
providing the product to the consumer.
I want to get back to this issue. What barriers can be
eliminated by HCFA to be able to make not only the use of this
approach possible but to encourage it when practical and when
essential? And is HCFA predisposed to be able to change its
procedures or modify its procedures or accommodate these new
challenges and opportunities? I would like to know basically
what barriers right now need to be eliminated so these
opportunities can be utilized.
Mr. Berenson. I think the couple that we have talked about
include the definition in the BBA of a teleconsultation
limiting the application to a fairly narrow set of services,
and there can be an expansion to other kinds of medical visits
and perhaps to certain other kinds of interactions that go
beyond just consultations.
We have also talked about eliminating the requirement that
a physician have to be the presenter to another physician. I
think we want to revisit the requirement for the fee-splitting
arrangement and make it easier essentially for others to
present and not have the----
Mr. Bilbray. Is that fee-splitting arrangement part of the
BBA agreement or is that part of your own HCFA internal----
Mr. Berenson. Basically, the BBA required the fee
splitting. We, for systems reasons, required the receiving
physician to actually have to conduct the fee splitting, and
that has created a barrier. So we could revisit that, but I
think the more significant thing would be to relook at the
requirement that there be the fee splitting in the first place.
Mr. Bilbray. Doctor, my mother was an Australian tennis
champion for years before World War II, and I grew up watching
the ball be knocked on the other side of net and requiring the
other guy to try to handle it. I have asked you what can HCFA
specifically do, not what is Congress, and when I knock the
ball back into your court, what can HCFA do to be able to
eliminate the barriers to the utilization of this type of
approach and what is HCFA willing to do?
Mr. Berenson. I honestly have to say that we feel
constrained by the statutory language in these few areas and
would be happy to work to modify that. We need to change. I
mean, obviously a lot of our future recommendations as to
expansions in this area will be based on the results of our
demonstrations and consultations with experts in the field, and
we have learned that we have not been quick enough to modify
some of the flaws in our demos.
As I mentioned earlier, we were using a technology--
studying a technology that made sense at the time in 1997, but
we have not adjusted quickly enough to the fact that the
technology has left that or is leaving that behind to look into
new areas. And there are specific recommendations that you will
hear from Dr. Grigsby and others about the kinds of
demonstrations that we should be doing, and we need to be doing
that more quickly, but in terms right now of the changes that
could be made or should be made I think we don't have the
authority in most areas to do that ourselves.
Mr. Bilbray. Okay. Then let us call each others bluff and
we will try to see where your rulemaking could change
internally, and if you would specifically, specifically
identify where the changes need to be made to give you the
flexibility to do what we are asking.
And when we talk about the experts, I certainly hope my
colleagues and you recognize that the experts are not just the
medical providers and the people actually going to perform the
services. As you said, we are behind the curve in technology
again and again. Just about the time we think we are designing
something for cutting edge, we realize that it is 2 years
behind schedule even though we only worked on it for 6 months.
I would really encourage that when we talk about professionals
and experts that we talk about techies, talk about what is
going to be the technical capabilities at the time we implement
it so we are not always playing this catch-up.
I would ask--go ahead, Mr. Chairman. I yield back.
Mr. Bilirakis. Mr. Green.
Mr. Green. Thank you, Mr. Chairman; and Dr. Berenson, I am
glad you are here.
I have a very urban district in Houston, and I have watched
how telemedicine can help. Because the problem I noticed is the
quality of care at our teaching hospitals, particularly in
urban centers, is so much better. So you will have people who
will literally pass by suburban hospitals because they want to
go to the biggest medical center in the country in some cases.
What I look at it for is telemedicine can also help us
because not everybody can go to the Texas Medical Center, but
if we have telemedicine to the suburban hospitals or the
closest, so--because I have had experience of people who have
not gotten the quality of care at a hospital that is--even
though it is within 25 miles of a major medical center and they
actually have to be transferred, which has caused other
problems. So if we have telemedicine not just in the rural
areas but in the urban areas and suburban areas, we can make
sure the quality of care is available 20 miles from the M.D.
Anderson or from a Texas Childrens Hospital. So we can utilize
that, and so that is why it is just not applicable to rural
areas.
Following up on my colleague, Mrs. Capps, my wife had an
experience. She was here during the summer. She teaches school.
And former Governor Ann Richards mentioned to her you need to
go get a bone density test because you are at the age because
Ann had just had one and discovered she needed some medication.
So my wife called the doctor, never saw the doctor, went in for
the bone density test. Obviously, it showed she needed
medication. The medication was prescribed, and then she
received it. So real life is actually happening now even
without. So that is, I guess, basic telemedicine. Because
everything was on the phone, without having the consultation
between two physicians. So it is not just mammograms. It is
other things that are happening.
I was noticing in your testimony that Texas and a number of
States utilize Medicaid for telemedicine, and I know it is a
little further along. Could HCFA look at the successes--
obviously, we also have some problems of how Medicaid may be
reimbursed, but the successes of telemedicine and the Medicaid
experience in the 17 States that we have had in to both
rulemaking and also make suggestions to Congress on how we can
change Medicare law to take advantage of the technology?
Mr. Berenson. Yes. I think that in preparing for this
hearing it became clear that we also didn't know enough about
what private insurers were doing, as well as Medicaid agencies,
and I think we need to do a better job of convening the other
payers to see if we can't progress a little faster in this
area. But, yes, there are experiences clearly in both sectors,
Medicaid as well as the private sector, and in terms of dealing
with this concern about overexpansion but at the same time
getting the services out where they are needed. So we need to
do that, yes.
Mr. Green. I know right now Medicare only pays for the
consultations. And, again, I have seen actually observing
surgery and things like that that could help, and I understand
the concern about cost, and we share that, too, because I mean
every few years we have to deal with the expansion of Medicare
to make sure it is still there for our constituents. What do
you think that it would be for the cost of Medicare? Can you
give us some kind of idea what such expansion would be on a
cost basis, realizing we are the Commerce Committee and not the
Appropriations Committee?
Mr. Berenson. Again--and I should also say when we somehow
get perceived as being too slow and too bureaucratic--we are
aware that what we do which makes perfect sense in a health
manpower shortage area, in a rural area, where there is no
alternative, will often be looked at by others as a basis for
expansion into other areas.
I think we are quite confident that we can make significant
changes that would apply in rural areas, at not a significant
cost. There might even be a savings. There is no evidence of
program integrity problems thus far in the rural areas. But
what we are concerned about, and particularly on the cost side,
is what would happen if these technologies that are not
inherently limited to rural areas became the standard across
the entire program. That is where we have concern. So to the
extent that we are being perhaps a little too cautious in
expanding in rural areas, it is because what we do there
becomes the basis for expansion elsewhere.
I don't have a number for you on the cost. I think if it
were not done correctly and carefully, with standards in place,
it could be a huge expansion and cost to the program if it went
beyond the target, which are health manpower shortage areas.
Mr. Green. Well, maybe that is my concern.
Mr. Chairman, with just a little forbearance, I understand
the rural application, but, again, I think we could look at
some cost savings because the costs per bed at some of my
suburban hospitals is much cheaper than the cost at a major
medical center, but if you utilize the expertise at that
medical center for the suburban hospital, again, 20, 25 miles
away, it is not anywhere near rural, we could see some cost
benefits to the Medicare program.
Mr. Berenson. There could be, but there also could be just
a great expansion in utilization. That is why, as part of this
modernization activity that I talked to, we are looking at
other reimbursement mechanisms, perhaps an administrative fee,
to support telemedicine. That is not a reimbursement at a
specific service level rather a some modified forms of a
capitation payment system that provides a payment over a period
of time where the practitioners themselves then determine what
the utilization will be within that limitation.
That is why in the home health example, where we will now
be paying a 60-day episode fee to a home health agency for
taking care of a beneficiary with a certain medical problem, we
would encourage the agencies to provide an adjunct to the plan
of care that the physician has signed off to by incorporating
telemedicine into that whole plan of care. Again, inhome health
the payment will essentially be predetermined, such that we
have less concern about utilization. It may well be that we can
expand telemedicine very broadly in a fee-for-service
environment, but we are concerned about having the standards in
place to determine how to do that.
Mr. Bilbray [presiding]. The gentleman's time has expired.
The gentleman from Tennessee.
Mr. Bryant. Thank you, Mr. Chairman.
I apologize to the witnesses, but we are on different
schedules here. I have to come and go, and sometimes we are
late. I appreciate you coming and look forward to your
testimony, as well as the second panels testimony.
I represent a very diverse district. It has urban areas and
quite a bit of rural area, and I see telemedicine as being one
of the solutions that will go to a major problem that we have
in those areas of access to health care, and I have joined with
the Chairmans bill in cosponsoring that bill. I think it is a
good bill. I have questioned Mike Hash when he comes up about
this, and he is going to get back with me and follow up with
each other on this, and we have worked hard on this issue. We
also have Dr. Burgiss from the University of Tennessee here
today to testify on the second panel about what is happening
there with telemedicine.
So, with that said, I want to ask you a couple of
questions; and I hear the bells going off for us to go vote,
also. So we will probably get this in before we have to go, but
if you could keep your answers relatively short in light of the
bells.
But it is my understanding that under the new health care
Prospective Payment System, the PPS, home health care providers
may use PPS dollars in the manner they believe most appropriate
to improve the patient outcomes. Excepting that a telemedicine
encounter is technically not a visit for the purposes of PPS
payment, I assume then that the current policy allows a home
health agency to spend PPS dollars to utilize telemedicine
technology consistent with patient care standards. Is my
assumption consistent with HCFA's view on this subject?
Mr. Berenson. Yes, as long as the use of telemedicine
services is consistent with the plan of care that the physician
certifies. I don't think we would want telemedicine visits to
substitute completely for the services that are specified in
the plan of care, but there can be some minor substitution and
certainly adjunct use of telemedicine in the context of a plan
of care.
As we get more experience with the effectiveness,
physicians will then be more willing to sign off on plans of
care that do have telemedicine visits, in some cases perhaps
substituting with what would have been physical visits, but at
this moment we think that the requirement for a set of services
face-to-face should be maintained with the incentive now for
the agencies to use telemedicine as an adjunct to those
services.
Mr. Bryant. In regard to the demonstration projects, I
understand you are actually working on some now regarding
telemedicine, and you may not have these figures, I don't know,
and if you don't if you could late file this to your testimony
today, but could you give me the statistics on how many claims
have been submitted from these demonstration projects? You
expressed concern about the potential cost. So I just wonder
how many are actually being----
Mr. Berenson. There are very few. I don't have the exact
number on me. Remarkably few--and that has been one reason why
we believe we need to rethink these demonstrations. We are in
discussions to do that, as well as rethinking the narrowness of
the application to teleconsultations because there have been
very few. We will provide for the record the actual number.
Mr. Bryant. I am getting inquiries here, but can you give
me a ballpark figure, just an estimate before you submit the
actual figures? Could it be as low as 19,000?
Mr. Berenson. I think it is fewer.
Mr. Bryant. Fewer than 19,000?
Mr. Berenson. I think it is a couple of hundred for last
year. I don't have the cumulative number. I think last year was
perhaps 200 or something.
[The following was received for the record:]
There were 298 claims filed through the end of the second
quarter, 2000 under the Telemedicine Demonstration Project.
Mr. Bryant. One final question. I think Mike Hash said
this, and I understand you may have said this also, that HCFA
is going to be releasing recommendations on changes that should
be made to this issue of telehealth, telemedicine. Can you tell
me specifically when we can expect those recommendations from
HCFA?
Mr. Berenson. Well, it is anticipated for this fall. I
don't know whether prior to adjournment or not. I mean,
unfortunately, it is in a clearance process. The areas that we
will be addressing, some of them I have talked about today. One
is the expansion of services beyond teleconsultations, and we
are likely to be recommending an expansion to certain other
kinds of services. We will be making some comments about store-
and-forward technology, and we will be talking about
presenters. I don't have a specific date for you.
Mr. Bryant. Just for the record, we may well be celebrating
Christmas with you here before the adjournment----
Mr. Berenson. I have heard that.
Mr. Bryant. [continuing] which we all hope is not the case.
I also want to clarify that the 19,000 figure should have been
$19,000 rather than 19,000 claims. So if you could give us a
dollar amount and the actual number. I yield back my time.
Mr. Bilbray. Yes. Gentlemans time has expired.
Gentleman from Ohio will be recognized before we adjourn
for the vote.
Mr. Strickland. Thank you, Mr. Chairman.
Doctor, you mentioned this clearance process, and one of
the frustrations that I have had with HCFA--and I am not sure
it is HCFA's fault. There may need to be a legislative remedy.
But I reflect back on my colleague, Representative Capps', use
of language. She used words like ``archaic system'', ``lag'',
``slow'' and so on. My personal experience with HCFA has been
that these words are appropriate.
I don't want to lay blame, because the blame may rest up
here instead of with HCFA, but it seems to me that there is
legitimate reason to be concerned about the slowness with which
HCFA responds to legislation, to rulemaking, to clearance and
the like. Do you know if this is a concern within HCFA itself
and if there are any efforts under way to try to modernize or
update the system or is, in your judgment, legislation required
to reform this agency and some of the processes within the
agency in order for it to be appropriately responsive to modern
needs and situations?
Mr. Berenson. I am aware of one particular situation that
you are involved with where we have been very slow. We
obviously are concerned about it. It is, I think, a more
complex question, and I am probably not the appropriate person
to address it.
I think to some extent there are requirements associated
with the Administrative Procedures Act and FACA and some other
things. But part of it is, on an issue like this one, there
would be quality of care concerns, program integrity concerns,
payment concerns, and at least our process right now permits
all the parties who are responsible for those different areas
to weigh in. On important reports we also need to go through a
departmental clearance process which in some cases is where
some of the lag comes. It is of concern to me for sure, and I
don't have a facile answer for you.
Mr. Strickland. I understand that, but I guess what I come
back to in my own thinking is the fact that--I mean, we can and
have in the past made major national decisions regarding war
and peace in a relatively compressed period of time because we
considered it important or essential to do so; and, as I say, I
am not--you know, I don't want to lay blame at the feet of this
agency, because I am not sure that is where the appropriate
problem is, but it seems to me that as a Congress and as a
committee we ought to be concerned about how this agency is
able to carry out its responsibilities in a timely fashion. And
what we are talking about here in terms of telehealth is, you
know, I think is a good example of how we cannot allow
ourselves to be bogged down for years with arcane procedures
while the technology is escaping those who most truly need it.
Mr. Berenson. I appreciate that. I would take the
opportunity to make one point, however, which is that, and I am
the head of the Center for Health Plans and Providers which is
essentially the payment side of Medicare--both the payments to
Medicare+Choice plans and all of the payment policies to
hospitals and physicians and others. On a number of issues we
are 1 or 2 persons deep. If something else comes along,
something else literally gets put on the shelf for months at a
time. We have fewer employees now than 20 years ago.
So I am not coming here requesting a massive expansion. I
do think one of the issues in some of these areas is simply
resources and staff and contracting authority to be able to
move as quickly as I think this particular topic deserves, and
we have to continually make tradeoffs on which we are going to
do first, and I do think that is serious concern.
Mr. Strickland. Thank you, Mr. Chairman, and in view of our
time, I will yield my time.
Mr. Bilbray. Thank you. I appreciate the gentleman from
Ohio for yielding; and we will thank you very much, Doctor, and
dismiss you at this time.
We would call up the next panel. We are going to go vote,
so it gives you time to set up. And I appreciate the patience
of everyone. I apologize. It is a procedure that we all live
with. Thank you, Doctor.
[Brief recess.]
Mr. Bryant [presiding]. We are going to restart the
hearing, and Chairman Bilirakis will be delayed a little bit.
So we are going to move forward with the introductions.
Mr. Strickland from Ohio is not back yet from the vote but
would like to more formally introduce Dr. Ross-Lee whom I
believe is from Ohio.
Ms. Ross-Lee. Yes.
Mr. Bryant. We will interrupt whatever stage we are at that
point if it is not too disruptive to allow him to do that, but
for now I am just going to begin from my left and introduce
very briefly the witnesses.
We have Dr. Karen Rheuban, who is Medical Director, Office
of Telemedicine, and a professor of pediatrics at the
University of Virginia--with the University of Virginia Health
System in Charlottesville. Welcome.
We have Mr. Joe Tracy, I don't see where--all right. I am
not going right to left here. Well, I will introduce Mr. Tracy
anyway. He is the Director of Telehealth at the University of
Missouri Health Sciences Center in Columbia, Missouri. Welcome
to you.
And Ms. Sally Davis here, Program Director at Telehealth
and Management Development, Marquette General Health System in
Marquette, Michigan, Upper Peninsula, near what is the name----
Mr. Stupak. Now, I know why you are the substitute
chairman.
Mr. Bryant. Tryout, actually. Okay. These Michigan names
get me every time.
Mr. Jim Reid is here. He is Director of Telemedicine and
Network Services with the Midwest Rural Telemedicine Consortium
with Mercy Hospital Foundation, and he is testifying on behalf
of the Center for Telemedicine Law which is located here in
Washington, DC.
And then the gentleman I referred to in my statement, Dr.
Sam Burgiss, who is the Project Director of Telemedicine at the
University of Tennessee Medical Center in Knoxville, actually,
and the other end of the State from where I live.
And we will reserve--Dr. Ross-Lee is here, of course,
there; and she will be more formally introduced later by our
colleague from Ohio.
Let me jump back. Dr. Rheuban, you have a patient here, and
we have Ms. Lisa Hubbard, you are here, and this beautiful
young lady next to you is Alexandra Bartley, and she is the
patient.
Mr. Rheuban. That is correct.
Mr. Bryant. Great, welcome. Good to have you here.
Also, in finishing up the introductions very quickly, Ms.
Mary Patrick is here. She is Director of Quality Improvement
with Blue Cross and Blue Shield of Montana in Helena, Montana.
And Jim Grigsby, who is Study Manager with the Center for
Health Services and Policy Research at the University of
Colorado Health Sciences Center from Denver, Colorado, and
welcome to you, also.
If we could, I think each one of you, 5 minutes.
We will begin with Dr. Rheuban.
STATEMENTS OF KAREN RHEUBAN, MEDICAL DIRECTOR, OFFICE OF
TELEMEDICINE, PROFESSOR OF PEDIATRICS, UNIVERSITY OF VIRGINIA
HEALTH SYSTEM, ACCOMPANIED BY LISA HUBBARD AND ALEXANDRA
BARTLEY; SALLY DAVIS, PROGRAM DIRECTOR, TELEHEALTH AND
MANAGEMENT DEVELOPMENT, MARQUETTE GENERAL HEALTH SYSTEM; JOSEPH
TRACY, DIRECTOR OF TELEHEALTH, UNIVERSITY OF MISSOURI HEALTH
SCIENCES CENTER; JAMES REID, DIRECTOR OF TELEMEDICINE AND
NETWORK SERVICES, WEST RURAL TELEMEDICINE CONSORTIUM, MERCY
HOSPITAL FOUNDATION, ON BEHALF OF CENTER FOR TELEMEDICINE LAW;
SAM BURGISS, PROJECT DIRECTOR, TELEMEDICINE, UTN MEDICAL CENTER
AT KNOXVILLE; BARBARA ROSS-LEE, DEAN, OHIO UNIVERSITY COLLEGE
OF OSTEOPATHIC MEDICINE; MARY R. PATRICK, DIRECTOR OF QUALITY
IMPROVEMENT, BLUE CROSS AND BLUE SHIELD OF MONTANA; AND JIM
GRIGSBY, STUDY MANAGER, CENTER FOR HEALTH SERVICES AND POLICY
RESEARCH, UNIVERSITY OF COLORADO HEALTH SCIENCES CENTER
Ms. Rheuban. Thank you.
Mr. Chairman, distinguished members of the subcommittee, I
would like to express my gratitude to the Commerce Committee
for this opportunity to represent the University of Virginia
Health System today. My name is Dr. Karen Rheuban, and I am a
pediatric cardiologist at the University of Virginia where I
also serve as Medical Director of the Office of Telemedicine
and as Associate Dean for Continuing Medical Education.
I am pleased to introduce Ms. Lisa Hubbard of Honaker,
Virginia, and her daughter Miss Alexandra Bartley, who are here
to share with the committee their personal experience with
telemedicine services provided to Alexandra in a rural
community health center in Southwest Virginia.
For those who reside and work in and around Washington, DC,
it might seem difficult to imagine that amongst the many
counties of adjacent Virginia, those of mountainous Southwest
and Western Virginia are home to some of our Nation's most
medically underserved, geographically isolated and
socioeconomically disadvantaged citizens.
In Virginia, as in other rural States, it is not unusual
for patients to travel 5 to 7 hours to receive medical or
surgical consultative services if they seek medical attention
at all. When one considers the cost of lost wages, overnight
stays, food and automotive expenses, it is clear that this
travel imposes great burdens on our rural families.
In an effort to enhance access to a broad range of services
not locally available, in 1996 the University of Virginia
committed considerable internal resources to the development
and establishment of a telemedicine program. We faced the
significant barriers of high telecommunications costs,
expensive clinical workstations, nonreimbursement and
nonfamiliarity and/or lack of acceptance of advanced
technologies by many patients and physicians.
From the inception of our program we have provided clinical
services without charge to patients for whom no reimbursement
was available. We developed contractual relationships such as
our correctional telehealth program to allow us to recoup many
of our overhead costs. We successfully petitioned Virginia
Medicaid for a waiver of their policy of nonreimbursement.
Despite the prevailing policies of nonreimbursement by the
private sector, we continue to offer telemedicine consultative
services to all our citizens and have turned no one away.
In 1997, with Federal and other grant funding, we
established the Southwest Virginia Alliance for Telemedicine.
This partnership has established five operational telemedicine
sites, and we are in the process of installing two additional
facilities, all in medically underserved counties of Southwest
Virginia to date, our Office of Telemedicine has facilitated
more than 2,200 clinical encounters, linking remotely located
patients with UVA consultants representing 24 specialties and
subspecialties. Our network now consists of 20 remote sites in
the Commonwealth of Virginia.
We consider the services provided by telemedicine to be an
extension of our traditional mode of health care delivery.
Through these linkages we have saved the lives of infants and
adults by providing timely diagnostic services and therapeutic
intervention.
Last week, through a telemedicine linkage, a UVA
dermatologist diagnosed a life-threatening case of a flesh
eating streptococcal skin infection that had been thought to be
a case of shingles. We have diagnosed an infection in the heart
of a gravely ill adult patient whose diagnosis had eluded local
primary care practitioners. We have identified and offered
immediate treatment to an infant with a rare and complicated
congenital heart defect who would have died without immediate
intervention. We use these same networks to provide health
professional and patient education.
Much like our experience, most large-volume telehealth
programs are those that provide reimbursable correctional
telehealth services or are located in States wherein
legislative mandates have directed third party reimbursement.
Currently, inmates in our Virginia correctional facilities have
access to higher quality specialty care than do many of our
other tax-paying citizens.
These technologies with such vast potential to improve the
health of our citizens still face considerable barriers to full
deployment. We are thankful to the Congress for enacting the
1996 Telecommunications Law, following which we have witnessed
the barrier of high telecommunications costs fall substantially
with competition. In 1995, we were quoted a rate of $5,872 per
month for a T1 line linking our hospital to a hospital in
Southwest Virginia last month, we leased that same T1 line for
$775 per month. We thank the Commerce Committee for that.
However, without relief of the obstacle of limited
reimbursement, full deployment of these technologies will not
occur.
Virginia Medicaid has willingly endorsed reimbursement for
consultations and follow-up visits. Much like the Department of
Corrections, Medicaid, as a payer, funds the transportation of
patients. Astonishingly, the patient transportation budget of
Virginia Medicaid for fiscal year 2000 exceeded $53 million.
The Balanced Budget Act of 1997, with provisions for
reimbursement of telehealth services to Medicaid recipients, is
a step forward but falls short in its implementation. As they
establish reimbursement policies, many third party payers
follow closely the parameters established by HCFA. Legislation
before Congress offers further steps toward the achievement of
these goals.
Amongst the HCFA rules for reimbursement viewed to be an
obstacle include the following: Location of the remote site
from which the consult is originated. HCFA rules allow Medicare
to reimburse telemedicine consults only when the residence of
the patient or the location of the workstation falls within a
primary health professional shortage area. The Federal
classification of a primary HPSA does not take into account the
distribution of specialist physicians in that region. We
believe that all Medicare patients should have access to
consultative services via telemedicine when deemed appropriate
by their primary care provider, issues of licensure
notwithstanding.
Fee splitting. Nowhere else in clinical practice does the
consulting physician share the fee for a clinical encounter
with a referring physician. HCFA rules require that the
consultant paid by Medicare split the fee 75/25.
Reimbursement rates. Reimbursement should be at standard
Medicare rates to the consulting practitioner. When divided
with the remote referring practitioner, the lower fee and
greater administrative burden is a disincentive to
participation in telehealth programs.
Broader range of reimbursable CPT codes. Reimbursement
should also include a broader range of CPT codes to include ENM
codes rather than just consultation codes. It is also an equal
hardship for patients to travel many hours for a follow-up
appointment as it is for an initial encounter. In the case of a
post-operative visit, travel may be more difficult for a
patient recovering from surgery than for the initial
consultation.
Almost done. Telepresenter requirement----
Mr. Bryant. I notice you are reading quickly here.
Ms. Rheuban. It is our experience that the referring
clinician need not be in attendance during a telemedicine
encounter. When a patient travels to receive care from a
consultant, the referring health professional does not travel
along with the patient. A broader range of providers should
receive reimbursement for telehealth encounters.
And, last, remote site fee. Despite a reduction in costs,
many small rural clinics and hospitals are still unable to
afford the capital expenditures and ongoing telecommunications
costs inherent in the establishment and maintenance of a
telemedicine facility. We believe that Medicaid and if possible
Medicare should fund a small infrastructure fee to offset a
portion of the overhead of the rural telemedicine facility.
Alternatively, the patient receiving services could fund a
component of that expenditure in the form of a small co-pay
determined on a sliding scale.
On behalf of the University of Virginia, we thank the
subcommittee for holding this hearing and for considering
additional legislation that may abolish other barriers to the
full deployment and utilization of telehealth technologies.
Thank you.
[The prepared statement of Karen Rheuban follows:]
Prepared Statement of Karen Schulder Rheuban, Professor of Pediatrics,
Medical Director, Office of Telemedicine, Associate Dean for Continuing
Medical Education, University of Virginia Health System
Chairman Bilirakis, Distinguished members of the subcommittee, I
would like to express my gratitude to the Commerce Committee for this
opportunity to represent the Office of Telemedicine of the University
of Virginia Health System at this subcommittee hearing on reimbursement
for telehealth services. My name is Dr. Karen Rheuban and I am a
pediatric cardiologist at the University of Virginia where I also serve
as Medical Director of the Office of Telemedicine and as Associate Dean
for Continuing Medical Education. I am pleased to introduce Mrs. Lisa
Hubbard of Honaker, Virginia, who has agreed to share with the
Committee her experience with telemedicine and its role in the care
provided to her daughter, Alexandra Bartley.
For those who reside and work in and around Washington D.C., it
might seem difficult to imagine that amongst the many counties of
adjacent Virginia, those of mountainous southwest and western Virginia
are home to some of our nation's most medically underserved,
geographically isolated and socioeconomically disadvantaged citizens.
In Virginia, as in other rural states, it is not unusual for patients
with complex medical problems to travel five to seven hours to receive
medical or surgical consultative services, if they seek medical
attention at all. When one considers the cost of overnight stays, lost
time from work, the high cost of gasoline and other automotive
expenses, this travel imposes great burdens on these families. For more
than thirty years, in an effort to enhance access to a broad range of
clinical and educational services not locally available, University of
Virginia faculty have traveled throughout the Commonwealth to provide
on-site medical care to patients and educational programs for health
professionals. In 1996, to further enhance access to these clinical and
educational services, the University committed considerable internal
resources to the development and establishment of a Telemedicine
program. We faced the significant barriers of: a. High
telecommunications costs; b. Expensive clinical workstations; c. Non-
reimbursement for telehealth services by payers; and d. Non-familiarity
and/or lack of acceptance of advanced technologies applied to health by
many patients and physicians.
At the inception of our program, we provided clinical services
without charge to patients for whom no reimbursement was available. We
simultaneously began to develop contractual relationships and other
strategies to allow us to recoup many of our overhead costs. Despite a
persistent climate in Virginia of nonreimbursement by the private
sector for telehealth services, we continue to offer these services to
all our citizens, and have turned no one away, regardless of financial
or insurance status.
In 1997, with Federal funding through the Department of Commerce
NTIA Technology Opportunities Program, the USDA Rural Utilities Service
Telemedicine and Distance Learning Grant Program, state funding through
the Virginia Healthcare Foundation, an appropriation by the General
Assembly and with donations from Bell Atlantic, Sprint and GTE, we
established the Southwest Virginia Alliance for Telemedicine. This
partnership has established five operational telemedicine facilities
and we are in the process of installing two additional facilities, all
in medically underserved counties of SW Virginia (Appendix A). None of
our grant funds reimburse clinical consultative or educational
activities; rather they fund within the network, infrastructure,
technology and telecommunications costs.
To date, since fiscal year 1997, our Office of Telemedicine has
facilitated more than 2200 clinical encounters (Appendix B), linking
remotely located patients with consultants representing 24 specialties
and subspecialties (Appendix C). Of those encounters, since January
1999, when Medicare began authorizing reimbursement for telemedicine
services, we have seen only 22 Medicare eligible beneficiaries and of
these consultations, only 10 were eligible for reimbursement under
current HCFA rules.
Our network currently consists of 20 remote sites in the
Commonwealth of Virginia (Appendix A). We consider the services
provided via telemedicine to be an extension of our traditional mode of
health care delivery. We consider our office, an electronic clinic.
We have used these networks to provide the following services not
locally available: a. Care of patients with HIV/AIDS and/or Hepatitis
C, b. Interpretation of remotely obtained pediatric cardiac
ultrasounds, including life-saving initial assessments of neonates with
critical cardiovascular disease, c. Tele-dermatology consultations, d.
Cervical cancer screening and oncologist guided cervical biopsies, e.
Telepsychiatry services--including consultations for hearing impaired
patients by the Commonwealth's only sign language capable psychiatrist,
f. Postoperative care following corrective surgery for congenital
defects to children such as Alexandra, g. A collaborative Tumor board
linking our Cancer Center faculty with physicians at a remote community
hospital, h. Hundreds of hours of patient education for people
suffering from diabetes, i. Health professional education to aid remote
community hospitals and practitioners meet JCAHO, OSHA and state
licensure mandates, j. Educational programs for project Headstart
personnel by our developmental pediatricians, and k. Educational
programs for high school students interested in a career in the health
professions.
Through our telemedicine linkages, we have saved the lives of
infants and adults by providing timely diagnostic services and
therapeutic interventions. Last week a dermatologist diagnosed a case
of a ``flesh eating'' streptococcal skin infection that had been
thought to be a case of shingles. We have correctly diagnosed an
infection in the heart of a gravely ill adult patient whose diagnosis
eluded local primary care practitioners. We have identified and offered
immediate treatment to an infant with a rare and complicated congenital
heart defect, who would have died without immediate intervention.
As reported by the Association of Telehealth Providers, in 1999,
Virginia was ranked fourth in the nation in terms of numbers of
telemedicine consultations. In reality, much like our experience, most
large volume telehealth programs are those programs that provide
reimbursable correctional telehealth services, or are located in states
wherein legislative mandates have directed third party reimbursement.
Currently, inmates in our Virginia correctional facilities have access
to higher quality specialty care than do many of our other tax paying
citizens. As an example, the faculty of the University of Virginia and
those of Virginia Commonwealth University provide expert HIV/AIDS care
to Virginia inmates via telemedicine. The survival rates and viral
loads of our incarcerated populations have recently been reported to be
significantly better than that of patients similarly affected in the
non-incarcerated population. This is primarily because through our
correctional telemedicine program, inmates have access to AIDS experts
and they receive regular follow-up care.
These technologies with such vast potential to improve the health
of our citizens still face considerable barriers to full deployment. We
are thankful to the Congress for enacting the 1996 Telecommunications
Law. We have witnessed one barrier, high telecommunications costs, fall
substantially with the appearance of competition. For example, in 1995,
the University of Virginia was quoted a rate of $5872/month for a T1
line linking our hospital to a community hospital in Southwest
Virginia. In the year 2000, real competition has arrived, even to the
most remote regions of Appalachian Virginia. Last month, we leased that
same T1 line for $775/month. Similarly, videoconferencing workstations,
high-resolution cameras and other peripheral devices are now very
affordable. However, without relief of the obstacle of limited
reimbursement, full deployment of these technologies will not happen.
Virginia Medicaid has willingly endorsed reimbursement for
consultations and follow up visits, regardless of the geographic
location of the patient or the workstation, as long as the facility is
authorized to bill Medicaid. Much like the Department of Corrections,
Medicaid, as a payer, funds the transportation of patients. The
transportation budget of Virginia Medicaid patients for fiscal year
1999-2000 exceeded $53 million dollars. Reimbursement has been
authorized by Medicaid for a broad range of services to include
telehealth services provided to children eligible for the Children's
Health Insurance Program. They have also authorized reimbursement for
innovative programs that address specific local clinical needs. For
example, in the Lenowisco Planning District, there are no gynecologic
cancer specialists. In conjunction with the Scott County Health
Department, we have established a program to provide telehealth
facilitated cervical cancer screening.
The Balanced Budget Act of 1997, with provisions for reimbursement
of telehealth services to Medicare recipients falls short in its
implementation. Even for those services for which Medicare
reimbursement is available, the terms as established by HCFA are in
need of modification. Without a major revision of the rules adopted by
HCFA, telehealth programs will fall short of the goal of enhancing
access to quality healthcare for all our citizens. As they establish
reimbursement policies, many of the third party payers follow closely
the reimbursement parameters established by HCFA for Medicare
beneficiaries. Legislation before this Congress, to include SB 2505,
Telehealth Improvement and Modernization Act of 2000, and HR 4841,
Medicare Access to Telehealth Services Act of 2000, are steps towards
the achievement of these goals.
relevant issues for reimbursement for services provided to medicare
beneficiaries:
Location of remote site (site of origination of the consultation):
We believe that all patients should have access to services deemed
appropriate by their primary care provider--issues of licensure within
the state notwithstanding. HCFA rules allow Medicare to reimburse
telemedicine consultations only when either the residence of the
patient or the location of the workstation falls within a primary
health professional shortage area. Unfortunately, the federal
classification of a HPSA does not take into account the distribution of
specialist physicians in that region. A community may not be eligible
for HPSA classification because of its numbers of primary care
practitioners; yet that very region may have no specialist physicians
available to serve as consultants when needed. For some patients who
reside in counties that do not qualify as a HPSA or medically
underserved area because of relative to proximity to a nearby city,
geographic, medical or other socioeconomic considerations may preclude
access to clinical services.
Fee splitting:
Nowhere else in clinical practice does the consulting physician
share the fee for a clinical encounter with a referring physician. HCFA
rules require that the consultant, paid by Medicare, split the fee with
the referring physician 75%/25%. Such a policy may be viewed as a
violation of federal anti-kickback statutes, is cumbersome to
administrate, and for most hub sites will be difficult to implement.
Reimbursement rates:
Reimbursement should be at standard Medicare rates to the
consulting practitioner. When divided 75%/25% with the remote referring
practitioner, the lower fee and greater administrative burden is a
disincentive to participation in telehealth encounters for the
consultant physician.
Broader range of reimbursable CPT codes:
Reimbursement should also include a broader range of CPT codes
rather than consultation codes (99241-99275). It is an equal hardship
for patients to travel many hours for a follow-up appointment as it is
for an initial encounter. In the case of a postoperative visit, travel
may be more difficult for a patient recovering from surgery than for
the initial consultation. As long as the referring and specialist
physicians deem the technology adequate to provide the service, we
believe that all visits reimbursable under traditional Medicare
provisions should be reimbursable when provided via telemedicine
technologies.
Telepresenter requirement
It is our experience that a referring physician, nurse practitioner
or physician's assistant need not be in attendance during a
telemedicine encounter. When a patient travels to receive care from a
consultant, the referring health professional does not travel to
participate in that encounter. We believe any licensed healthcare
professional acting under the instructions of the referring health
professional or the consulting health professional to be effective
telepresenters at remote sites, and that the decision as to the
necessity for a telepresenter should be left to the referring or
consulting practitioner. In our correctional telemedicine program,
licensed registered nurses have proven themselves to be valuable
telepresenters. For mental health encounters, with their attendant
sensitive issues of confidentiality (and the lack of a need for
technical support inherent in the use of medical peripheral devices) we
do not believe personnel other than the patient and the consultant
mental health provider need be present.
Eligible provider
A broader range of providers should receive reimbursement for
telehealth encounters. Any licensed health professional eligible for
traditional Medicare reimbursement should be considered eligible for
reimbursement of services provided via telemedicine.
Remote site fee
In the absence of federal or grant funding, small clinics and
hospitals are least likely to afford the capital expenditures and the
ongoing telecommunications costs inherent in the establishment and
maintenance of a telemedicine facility. We believe that Medicaid, and
if possible, Medicare should fund a small infrastructure fee to offset
a portion of the overhead costs of the rural telemedicine facility.
Alternatively, the patient receiving services could fund a component of
that expenditure in the form of a small co-pay determined on a sliding
scale ($5-$20). In the former model, programs such as Medicaid stand to
save transportation dollars; in the latter model, it is the patient who
saves the expense of travel to the consultant.
Despite all the limitations outlined above, since FY 1997, the
Office of Telemedicine of the University of Virginia has facilitated
>2200 clinical encounters with patients in the Commonwealth of
Virginia. We have saved lives by providing timely diagnostic services
and therapeutic recommendations to patients of all ages. We have used
our linkages to provide patient education, health professional
education, and teacher training and even courses for local high school
students.
On behalf of the University of Virginia Health System, and other
academic medical centers dedicated to providing outreach to patients in
need, we thank the Commerce Committee and the Congress for enacting
legislation that has created competition in the telecommunications
marketplace. We also thank the Subcommittee on Health for considering
additional legislation that may abolish other barriers to the full
deployment and utilization of telehealth technologies that could
enhance access to quality healthcare for all our citizens.
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Mr. Bryant. We let you have that extra 2 minutes only
because you brought Miss Bartley with you. Let me warn you, the
rest of you haven't done that.
Ms. Davis--Ms. Hubbard, you have a statement? Okay. Great.
Thank you. I am just ignoring you all around today, aren't I?
STATEMENT OF LISA HUBBARD
Ms. Hubbard. That is all right.
Mr. Chairman and members of the subcommittee, I would like
to thank the U.S. Congress for inviting me to come here today
to tell you about my daughter Alex and how we feel about the
use of telemedicine to help provide care to the citizens of
rural America. My name is Lisa Hubbard and I live in Honaker,
Virginia, a small community in Southwest Virginia. My daughter
Alex is 5 years old, and she is a kindergarten student at
Honaker Elementary.
When Alex was born, we noticed she had what looked like a
small scratch on her right check. A few weeks later, we were
told that it was a hemangioma, a blood vessel tumor on her
face. The hemangioma grew and grew until it nearly covered her
entire cheek. She also had a cleft palate.
When Alex was 6 months old, we were referred to Dr. Kant
Lin, a pediatric plastic surgeon at the University of Virginia.
There was no doctor in our area who was qualified to treat our
daughter. Alex and I made our first trip to Charlottesville, a
6-hour drive each way.
Dr. Lin decided that he would first try to shrink the
hemangioma with conservative treatments, with oral steroids.
That meant we had to come to Charlottesville once per month for
him to look at the tumor. When that didn't work, he decided to
inject steroids directly into the tumor, which meant we had to
come every other week. Finally, he decided that surgery was the
only solution. Sometime after her surgery, a telemedicine
workstation was installed at the Thompson Family Health Center
in Vansant, Virginia. We made our first visit to Dr. Lin over
telemedicine linkages.
Our trips to Charlottesville were very difficult for Alex
who was, of course, as an infant still in diapers and bottle
fed. The trips were very difficult for me as well, both
financially and emotionally. I usually had to make this long
trip with my daughter alone. I had to find the money for a
hotel room, gas and food, plus I missed 2 days of work and pay
because, as you can imagine, sick time and vacation time
disappear pretty quickly.
It cost me more than $100 to make the trip, not to mention
my lost wages of $80 a day. Sometimes we only saw Dr. Lin for a
brief visit so that he could look and measure the hemangioma.
We drove all that way for such a short visit with her surgeon.
The telemedicine program has provided a wonderful service
to rural patients and families such as ours. Instead of driving
12 hours round trip, we now only travel 40 minutes round trip
to the Thompson Family Health Center in Vansant, Virginia, to
receive the same wonderful care from Dr. Lin.
Alex is currently enrolled in the Aetna Insurance Program,
but it does not cover the services provided through
telemedicine. The University of Virginia provides a sliding
scale fee program for indigent patients, but we do not qualify
for that program. If the University charged me for Dr. Lin's
fee, it would cost me $150 since Aetna will not cover this
visit. Thankfully, the University has waived this fee for me,
but if I made the long drive to Charlottesville facing the
hardship and expense of that trip, Aetna would reimburse Dr.
Lin, but I would be forced to bear the expenses of traveling to
see him.
There are so many other rural citizens who face these same
difficulties in receiving care from qualified specialists. I
hope that the U.S. Congress will consider enacting legislation
to make it easier for us to do so through the use of
telemedicine. Thank you very much.
Mr. Bilirakis. Thank you, Ms. Hubbard.
Alexandra, are we going to hear anything from Alexandra?
Would you like to say anything to us?
Ms. Bartley. Thank you for having me.
Mr. Bilirakis. Thank you for being here.
Ms. Sally Davis is a Program Director for Telehealth and
Management Development with Marquette General Health Systems.
Ms. Davis, welcome. Please proceed.
STATEMENT OF SALLY DAVIS
Ms. Davis. Thank you. I have a hard act to follow.
Mr. Chairman and members of the subcommittee, thank you for
paying attention to telehealth, especially as it pertains to
the delivery of health care in rural areas.
I am an employee of Marquette General Health System, a 352-
bed regional referral center in Michigan's Upper Peninsula;
and, as Congressman Stupak has been pointing out, we are a very
rural area.
The 15 counties of the Upper Peninsula span a distance east
to west of over 300 miles. It takes 6 hours to drive from one
end to the other--and that is in good weather--and we cover two
time zones. Our population density is just 19 people per square
mile, and in some counties it drops as low as six people per
square mile. In the middle of the peninsula sits Marquette. We
are not a large city by any means, only 22,000 people, yet we
have a regional referral with specialists whose skills parallel
those found in any metropolitan area.
When people want to come to access our specialty care, they
need to drive up to 3 hours per one-way visit. When residents
of the Upper Peninsula need to access subspecialty care outside
of the jurisdiction of Marquette General, they travel distances
such as Ms. Bartley. It is not unusual for people to spend 18
hours of drive time two ways, hotel room, 2 days off from work
and, of course, the other expenses that are incurred during
travel for a subspecialty appointment of 15 or 30 minutes.
Marquette General Health System, along with 15 other
independent community hospitals, make up the Upper Peninsula
health care network. Six of our network members are Critical
Access Hospitals. Another soon will be. Every county in our
region holds health professional shortage designation on a
partial basis. That is significant when it comes to the current
HCFA regulations for telemedicine reimbursement.
Our telehealth network began in the fall of 1994 with a
focus on professional education and a commitment to community
usage. Administrative applications were quickly incorporated
and are now a major application of our system. Clinical
applications began that first year but have progressed much
more slowly due to the same barriers that mirror other
telehealth programs.
At present, we are a 23-site network. Our utilization runs
48 percent education, 30 percent administration, 11 percent
clinical and 11 percent community usage. During the upcoming
year we are expecting tremendous growth in a lot of the areas
that other telehealth programs are moving in.
But I have traveled here not to speak of our program as
much to show my support of your interest in telehealth and to
encourage actions that can increase access to health care. My
comments center around grant programming and reimbursement.
The Upper Peninsula telehealth network has accomplished a
great deal in our last 5\1/2\ years, and we are very proud of
the impact we have had on health care efficiencies in our
region. Yet we would have accomplished none of this, not even
attempted telehealth programming, if it were not for Federal
grant funding.
Our six critical access hospitals with their 15 acute care
beds and an average daily census that would be a challenge to
even the most creative financial mind would not have been able
to justify the capital outlay. Yet our telehealth network has
provided its contribution to the improvement of the bottom line
for these hospitals.
I urge you to continue telehealth grant programming so that
other rural areas can reap the same benefits. Until these
technologies are routine within the delivery of medical care
and until transmission costs are reasonable and equitable, such
funding is needed. Federal grants have supported the pioneers
who are testing theories, identifying barriers and are paving
the roads around these barriers. We have made much progress,
but there is still work to be done.
Second, there is a very important issue of reimbursement. I
mentioned previously that every county in our area holds
partial HPSA designation. We should be the ideal candidates to
access the current HCFA standards. Yet we have not. We did not
come to that party, as Mr. Berenson said. Why? For the same
reasons that are listed here in your memo from the health team
that came out, for the same reasons I have put in my written
testimony and as in the written testimony of other members who
are testifying here today. Like us, most of the telehealth
programs do not use the right limitations in reimbursement.
What needs to be accomplished is patient access to
providers without the requirement of telepresenters, the
elimination of fee sharing and adequate compensation for the
delivery of services and increase in the scope of providers to
include all those currently eligible for reimbursement by HCFA,
the inclusion of store-and-forward technologies, access for
patients not residing in HPSAs, and the support of home health
telemedicine.
The model programs have come a long way in discovering
telehealth systems that work in appropriate applications.
Telehealth is an evolving norm and is making the difference
between access and no access to care. Unfortunately, it will
never leave the evolving stage until practitioners and services
are reimbursed appropriately.
Yesterday, I sat through some of the Firestone hearings and
listened to your colleagues question why some of the deaths and
some of the injuries were not prevented. I suggest to you that
access to health care through telemedicine is still a life and
death matter, and I appreciate your concern for all of those
rural health patients who will need to access specialty care in
the future, patients such as my parents who live in a community
of less than 2,000 people, who are in their mid-eighties, who
have multiple health problems, who are unable to drive and
whose specialty care is an hour and a half away.
Thank you.
[The prepared statement of Sally Davis follows:]
Prepared Statement of Sally Davis, Program Director, Telehealth and
Management Development, Marquette General Health System
Mr. Chairman and Members of the Subcommittee, thank you for the
opportunity to serve as a witness today regarding telehealth as it
pertains to rural health care. During my presentation you will hear
about the geographical area I represent, the accomplishments of our
telehealth network, the challenges we still face, and, most
importantly, how you can affect the further deployment of telehealth in
rural areas of the United States.
I am an employee of Marquette General Health System--a 352-bed
regional referral center. I initiated our region's telehealth network
during my tenure as the director of education for our institution, and
continue to serve as the director of telehealth.
Our area is very rural. Although the majority of the Michigan's
population and economy resides in its well-recognized lower peninsula,
Michigan also includes a second peninsula to the north. The fifteen
rural counties of the Upper Peninsula total an area of 16,452 square
miles. Its east west distance of over 300 miles includes communities in
two time zones, and is home to approximately 314,134 people. That's a
population density of 19 people per square mile. In some counties the
density drops to 6 people per square mile. It takes six hours to travel
from one end of the peninsula to the other. That's if the wildlife
stays off the roads and the weather conditions are good. We are known
for our severe weather, particularly the kind that closes roads during
the wintertime.
In the middle of the peninsula, sitting on the shores of Lake
Superior, is Marquette. We're not a large city by any means (22,000
people) yet we have a regional referral center with specialists whose
skills parallel those found in any metropolitan area. To access
specialty care, our patients drive up to three hours one-way. When
residents of the Upper Peninsula need sub-specialty care beyond the
services available at Marquette's regional referral center, they travel
to Detroit, Ann Arbor, Mayo Clinic or Milwaukee. A normal drive to seek
quaternary care is an 18 hour round trip, most often taken over a two-
day period. That's 18 hours of drive time, at least one night stay in a
hotel, two days off from work and meal expenses for a 15-30 minute sub-
specialty appointment.
My organization, Marquette General Health System, along with 15
other independent community hospitals and health care institutions make
up the Upper Peninsula Health Care Network. Six of our network members
hold Critical Access Hospital (CAH) designation. A seventh CAH hospital
is anticipated within the next year. Every county in our region holds
partial Health Professional Shortage Area (HPSA) designation. We
believe in the independence of the communities, the benefits derived
through the synergy of working together, and the connectivity to
quaternary care centers for those times when services cannot be
provided at the local or regional level.
Our telehealth network began in the fall of 1994 with a focus on
professional education and a commitment to community usage.
Administrative applications were quickly incorporated and are now a
major application of the system. Clinical applications began the first
year, but have progressed much more slowly due to barriers that mirror
other telehealth programs: lack of reimbursement, the need for
dedicated staff to promote clinical usage, the complexities of
developing systems to accommodate the applications, and the need for
technologies to be conveniently located for practitioners.
At present, we are a 23-site network with systems in critical
access hospitals, community hospitals, the regional referral center,
and rural health clinics. Our utilization runs 48% education, 30%
administration, 11% clinical, and 11% community usage. During the
upcoming year we anticipate tremendous growth. We will add sites,
increase the number of systems, focus on clinical applications, add
home health telemedicine in three counties, and merge Internet Protocol
with ISDN transmission.
Administrative applications provide direct travel savings and go
far beyond the often recognized convenience for CEOs and directors. The
ability to meet on a regular basis, and involve more of the key people,
has propelled our regional health care network partners toward our
goals faster, and on a greater scale, that anticipated. Video
conferenced meetings have proven to add efficiencies to the health care
systems in our region.
With education we bring improved knowledge and skills to the
isolated rural practitioners that would otherwise have to spend
extended time away from their patients to acquire necessary credits for
relicensure. We also increase the number of health care staff able to
participate in continuing education. This education of professionals is
essential for the community confidence in their small, struggling
hospitals. Through our educational programming we also provide support
group services to individuals who reside in communities without the
critical mass to maintain their own support group services. And we
bring health care information to rural residents who cannot otherwise
access the information needed to manage their diseases. Ontonagon is a
County with 5% of their population diagnosed as having diabetes. It was
also a county without outpatient diabetes and nutrition education until
such services became available through our telehealth network. The
skills of the providers, the emotional support in dealing with chronic
diseases, and the information necessary to control an individual's
diabetes--all are important components of improving health care that
often go unmeasured.
Our clinical applications allow rural residents to visit their
specialty provider when a specialist is not available locally. Patient
visits are available for cardiothoracic surgical follow-ups,
enterostomal/skin therapy, neonatology, psychiatry, psychology,
pediatrics, social work, obstetrics, oncology, physical therapy and
nutrition. Telehealth encounters often mean the difference between
getting care in a timely manner or waiting for care beyond an
acceptable time limit. Physician to physician consultations take place
when a diagnosis needs to be confirmed or when the need for a patient
transfer is in question.
I have traveled here not to speak of our program as much as to show
my support of your interest in telehealth and to encourage actions that
can increase access to health care through telehealth technologies. My
comments center around grant programming and reimbursement.
The Upper Peninsula Telehealth Network has accomplished a great
deal over the past 5\1/2\ years. We're very proud of the impact we have
had on health care in our region and the model that we provide for
other rural areas. Yet we would have accomplished none of this--
wouldn't have even attempted a telehealth program - without federal
grant support. The Upper Peninsula does not have a major research
university with a medical focus within our boundaries. Nor do we have a
large multi-hospital corporation for which the cost justification of a
telehealth network comes easier. We are simply a group of small,
independent health care organizations dedicated to bring the best
health care to our residents. Our six Critical Access Hospitals with
their 15 acute care beds and an average daily census that would be of
concern to even the most creative financial minds, would not have been
able to justify the initial capital outlay. Yet, the telehealth network
has provided its contribution to the improvement of the bottom line for
these hospitals.
I urge you to continue telehealth grant programming so that other
rural areas can provide improved access to care. Until these
technologies are a routine within the delivery of medical care, and
until transmission costs are reasonable and equitable, such funding is
needed. Federal grants have supported the pioneers who are testing and
proving the applications that improve access to care. The model
programs throughout the United States have tested theories, identified
barriers, and are paving the roads around these barriers. We have made
much progress, yet there is still work to be done.
Secondly, there's the very important issue of reimbursement. As I
mentioned, eleven percent (11%) of our applications are what we
consider clinical/medical connections. I am confident that this number
would be higher if reimbursement was more available. Although we have
received grant support, our history does not include the rural
telemedicine grant program through the Office for the Advancement of
Telehealth. To date, our practitioner incentive payments have been
restricted to a few consults for children with special health care
needs. Thus, our medical applications are reliant on contractual
arrangements, bundled services, and the pioneering spirit of
practitioners willing to forgo payment.
I mentioned previously that every county in the Upper Peninsula
holds partial HPSA designation. This is important since, under the
current HCFA rules, only those patients residing in HPSA areas can be
telemedicine beneficiaries. Ours should be an ideal network to access
practitioner reimbursement through the current HCFA guidelines, yet we
have not pursued this avenue. The reason we haven't is that the current
regulations don't reflect practice and efficiencies. Our applications
are not unlike other telehealth programs:
The person who presents the patient to the specialist is most
often a nurse, or in psychiatric cases a social worker. In some
situations, such as nutritional counseling for diabetic
patients, there is no telepresenter in the room with the
patient. Most often there is not a need for the patient to be
presented by another physician, physician assistant or nurse
practitioner for quality care to occur. In fact, an RN with
special training in chemotherapy administration is usually more
qualified to present a patient for pre chemotherapy assessment
than is the patient's family care doctor.
The 75/25-fee split is not attractive to the consulting
practitioner. Not only is the consultant providing expertise at
a reduced rate, the billing/fee sharing process is cumbersome.
Some of the services we provide, or would like to provide,
involve practitioners that are eligible for HCFA reimbursement
but are not eligible under the telehealth bill.
Some of the services we want to provide involve store and
forward technology, which does not qualify for HCFA telehealth
reimbursement. Yet this technology works very well in specialty
areas where the patient does not need to be present.
Like us, most of the telehealth programs do not utilize the
technologies to their fullest because of the limitations in
reimbursement. What needs to be accomplished is patient access to
providers without the requirement of telepresenters, the elimination of
fee sharing and adequate compensation for the delivery of services, an
increase in the scope of providers to include all those currently
eligible for reimbursement by HCFA, the inclusion of store and forward
technologies, access for patients not residing in HPSAs, and the
support of home health telemedicine.
It's not those of us who sit here before you as witnesses that need
reform in the reimbursement of telehealth and the assured continuation
of the technology within the routine. As an administrator, I'm far more
removed from the actual patient experience than I want to be. For you
as policy makers, it must be more so. Yet what you do here at the
nation's capital connects so tightly to very personal and highly
emotional experiences. What you do is for Emma who can now have her
dialysis monitored by a nephrologist at a hospital two hours away. It's
for the expectant mother whose closest obstetrical service is 87 miles
away. It's for five month old Rena who was born with just one finger on
each hand and one toe on each foot, so she can be assessed for
corrective surgery by her pediatric hand specialist 500 miles away.
The use of telehealth technologies allows for safe, efficient and
effective delivery of health care. The quality is assured through the
normal structure and function of health organizations and practitioner
guidelines. Contrary to some earlier predictions, there has not been
abuses of the systems and technology. These facts have been proven by
the current telehealth programs--most of which our government has
financially supported.
The model programs have come a long way in discovering telehealth
systems that work and appropriate applications. Telehealth is an
evolving norm and is making the difference between access and no access
to care. Unfortunately it will never leave the evolving stage until
practitioners and services are reimbursed appropriately. Your
committee's time and attention today is crucial for those of us
struggling to provide access to care through telehealth technologies.
And it is critical for the future patients who will receive care via
this technology. Thank you for the attention to this issue and for your
efforts toward increased access to care through telehealth.
Mr. Bilirakis. Thank you very much, Ms. Davis.
Mr. Joe Tracy is Director of Telehealth for University of
Missouri Health Sciences Center, Columbia, Missouri. Mr. Tracy,
welcome. Please proceed, sir.
STATEMENT OF JOSEPH TRACY
Mr. Tracy. Thank you. Mr. Chairman and committee members,
it is an honor to be here today to speak to you on the topic of
telehealth. Thank you for this opportunity.
I have been the director of the Missouri Telehealth Network
at the University of Missouri Health Science Center since 1995,
its very beginning. Our network has provided services to rural
patients from newborns to the frail elderly. We have seen
approximately 2,000 cases and multiple medical specialties via
the interactive video network, and we have conducted and
interpreted over 1,600 teleradiology exams.
Our program is based on the reality that telehealth is not
a new or different medical service but it is simply a new way
to deliver standard services to people in underserved areas.
Policies that discourage telehealth do not deprive these
communities of some exotic treatment but of the day-to-day
health care most Americans take for granted.
Patients are the main beneficiaries of telehealth. They
receive standard specialty care that is not typically found in
or near their community. Studies at the University of Missouri
indicate that about 25 percent of these patients would not have
received care until some later time, if at all, if telehealth
were unavailable. Even when patients would have received their
care anyway, using telehealth reduces their travel costs.
Travel savings for our patients in our rural network average
approximately $40 on automobile travel alone for every
telehealth visit.
In terms of some of our patients, I remember a newborn with
serious heart problems that was kept alive with the help of
telehealth by a very good but nervous rural physician until our
helicopter arrived. I remember a frail elderly woman in a
nursing home whose health severely limited her ability to
travel. She was able to see her doctor in a room down the hall
instead of taking a 4-hour round trip and possibly returning to
the nursing home with other problems brought on by the stress
of travel.
As the committee knows very well, rural hospitals and
clinics are struggling to stay alive. A small hospital that can
offer a wide range of specialty telehealth services is stronger
and more likely to survive. A rural doctors office where
patients can see their specialist in one of the exam rooms via
telehealth is more likely to hold onto those patients.
Telehealth is not only good for patients but it is also good
for rural doctors and hospitals.
Telehealth will not be mainstreamed unless the many
problems associated with the current laws and regulations
relating to Medicare reimbursement are resolved. Medicare
reimbursement alone will not make telehealth an automatic
success, but the lack of Medicare reimbursement will most
certainly mean failure.
Some of these reimbursement barriers seem to reflect the
fear that telehealth will result in overutilization of health
care. Experience in several dozen telehealth projects
nationwide has made it very clear that this fear is
unwarranted. But there is an even more basic reason to reject
this approach. What is being prevented by the barriers is not
overutilization but adequate access to health care for
Americans living in rural or other underserved areas. People
living in those areas have as much right to Medicare benefits
as any other American and allowing them to use telehealth to
exercise that right should not be considered an extraordinary
benefit.
There is no doubt the current laws and rules for Medicare
reimbursement have effectively prevented the submission of
claims to HCFA. Our most recent nationwide study of telehealth
networks indicated that 15 of 21 networks responding did not--
and I want to repeat that--did not submit a single claim for
telehealth between July and December 1999. This is explained by
several problems with the laws and regulations on telehealth.
One is the assumption that telehealth usually involves two
clinicians, a rural provider with the patient on one end and a
specialist on the other. But our research indicates this only
happens in 6 percent of cases. Whether by telehealth or in
person a primary care provider does not have the time to be
present when the patient sees the specialist. If that is
required for telehealth, telehealth will simply not happen.
Another problem is that HCFA reimbursement is currently
limited to services delivered in federally designated health
professional shortage areas or to patients who reside in those
areas. HPSAs are defined by a lack of primary care, while
telehealth usually provides specialty care. A rural community
with sufficient primary care can still be without the specialty
care that telehealth could provide.
I want to finish now by focusing on the most controversial
and problematic regulation and that is fee sharing. If a
telehealth claim is filed and subsequently paid, the current
rules mandate that 25 percent of the specialist fee for that
telehealth visit must be sent by the specialist to the
referring provider. In nontelehealth cases, this type of fee
sharing would be a Federal crime. Doctors cannot pay other
doctors for referrals, and they are reluctant to do something
via telehealth that would be illegal in person, no matter what
I tell them.
The language regarding fee sharing must be removed from the
law and regulations. HRSA's Office for the Advancement of
Telehealth, NIH's National Library of Medicine and several
other Federal agencies have made a large financial commitment
to the development of telehealth throughout the country. I
think we would all hate to see that investment wasted.
I sincerely hope that you will continue the effort to pass
new legislation and correct the problems associated with the
current laws and regulations. Thank you.
[The prepared statement of Joseph Tracy follows:]
Prepared Statement of Joseph Tracy, Director of Telehealth, University
of Missouri Health Sciences Center, Columbia Missouri
It is an honor to be here today to speak to the committee on the
topic of telehealth. Thank you for this opportunity.
I have been the Director of the Missouri Telehealth Network at the
University of Missouri Health Sciences Center since its beginning in
1995. Our network has provided services to rural patients ranging from
newborns to the frail elderly. We have seen approximately 2000 cases in
multiple medical specialties via the interactive video network and have
interpreted over 16,000 teleradiology exams.
Our program is based on the reality that telehealth is not a new or
different medical service but is simply a new way to deliver standard
services to people in underserved areas. Policies that discourage
telehealth do not deprive these communities of some exotic treatment
but of the day-to-day health care most Americans take for granted.
Patients are the main beneficiaries of telehealth. They receive
standard specialty care that is not typically found in or near their
community. Studies at the University of Missouri indicate that about
25% of these patients would not have received care until some later
time--if at all--if telehealth were unavailable. Even when the patient
would have received the care anyway, using telehealth reduces their
travel costs. Travel savings for patients in our rural network average
approximately $40 on automobile travel alone for every telehealth
visit.
We have had many experiences that bring these patient benefits down
to earth. I recall a newborn with serious heart problems kept alive,
with the help of telehealth, by a very good but scared rural physician
until the helicopter arrived. A frail elderly woman in a nursing home--
someone whose health severely limited her ability to be transported--
was able to see her doctor in a room down the hall instead of taking a
4-hour ride to our facility. These benefits were not created by some
wonderful new treatment, but by the kind of every-day access to
standard care that telehealth can bring to underserved communities.
As the committee knows very well, rural hospitals and clinics are
struggling to stay alive. A small hospital that can offer a wide range
of specialty telehealth services is stronger and more likely to
survive. A rural doctor's office where patients can see their
specialists in one of the exam rooms via telehealth is more likely to
hold onto those patients. Telehealth is good for rural doctors and
hospitals.
However, telehealth will not be mainstreamed unless the problems
associated with Medicare reimbursement are resolved. Many of these
problems are related to the BBA of 1997 and HCFA's interpretation of
the act. Medicare reimbursement alone will not make telehealth an
automatic success, but the lack of Medicare reimbursement will most
certainly mean failure.
Some of these reimbursement barriers seem to reflect the fear that
telehealth will result in over-utilization of health care. Experience
in several dozen telehealth projects nationwide has made it clear that
this fear is unwarranted. But there is an even more basic reason to
reject this approach. What is being prevented here is not over-
utilization but adequate health care for rural Americans and those
living in other underserved areas. People living in those areas have as
much right to Medicare benefits as any other American. Allowing them to
use telehealth to exercise that right should not be considered an
extraordinary benefit.
There can be no doubt that the current laws and rules for Medicare
reimbursement have effectively prevented the submission of telehealth
claims to HCFA. Our most recent nationwide study of telehealth networks
indicated that 15 of the 21 networks responding did not submit a single
telehealth Medicare claim between July and December 1999.
This is explained by several key problems with current laws and
regulations on telehealth. One is the assumption that telehealth
usually involves two clinicians, a rural primary care provider with the
patient and a specialist at the other end. Our research indicates that
this occurs in less than 6% of cases. Whether by telehealth or in
person, a primary care physician does not have time to be present when
the patient sees a specialist. If that is what is required for
telehealth, telehealth simply will not happen.
Another key problem is that HCFA reimbursement is currently limited
to services delivered in a Federally Designated Primary Care Health
Professional Shortage Area (HPSA) or to patients who reside in those
areas. HPSAs are defined by a lack of primary care, while telehealth
usually provides specialty care. A rural community with sufficient
primary care can still be without the specialty care telehealth could
provide.
I want to finish now by focusing on the most controversial
regulation and that is fee-sharing. If a telehealth claim is filed and
subsequently paid the current rules mandate that 25% of the
specialist's fee for the telehealth visit must be sent by the
specialist to the referring provider. In non-telehealth cases, fee-
sharing would be a federal crime. Doctors are understandably reluctant
to do something via telehealth that would be illegal in person, no
matter what I tell them. This barrier is a bit subtler than the others,
but it is a serious problem.
HRSA's Office for the Advancement of Telehealth, NIH's National
Library of Medicine, and several other Federal agencies have made a
large financial commitment to the development of telehealth throughout
the country. I think we would all hate to see that investment wasted. I
sincerely hope that you will continue the effort to pass new
legislation correcting problems with the 1997 BBA and HCFA's
interpretation of that act.
Mr. Bilirakis. Thank you very much, Mr. Tracy.
Mr. Jim Reid is Director of Telemedicine and Network
Services with Midwest Rural Telemedicine Consortium, Mercy
Hospital Foundation. He is here on behalf of the Center for
Telemedicine Law out of here, Washington, DC. Mr. Reid, please
proceed.
STATEMENT OF JAMES REID
Mr. Reid. Thank you, Mr. Chairman and members of the
subcommittee. I, as you have said, am Director of the Midwest
Rural Telemedicine Consortium, the MRTC, based at Mercy Medical
Center, Des Moines. It is a 45 node network serving hospitals,
clinics and nursing homes in 30 communities in north and south
central Iowa.
As you said, I am also on the Board of Directors for the
Center for Telemedicine Law here in Washington. The CTL is a
nonprofit organization that focuses on legal and regulatory
barriers to telemedicine. CTL has worked closely with
telemedicine providers, policymakers and the public to analyze
the effects and costs of current Federal and State telemedicine
reimbursement policies.
I should also indicate that I am physician assistant with
10 years experience practicing family and emergency medicine in
urban and extremely remote settings, and certainly I could not
come before this committee without recognizing the support of
this committee and its excellent staff that has been given to
improving the PA physician team practice environment. So thank
you for that.
Since its beginnings in 1993, the MRTC has played an
important role in efforts to evaluate the effects of
telemedicine on health care costs, quality and access. In 1994,
HCFA awarded its first telemedicine reimbursement demonstration
grants to the MRTC. MRTC's participation in that demonstration
has given us firsthand experience in dealing with impractical
and restrictive reimbursement regulations, and it is largely to
that experience that this testimony is prepared.
I also couldn't help but note Dr. Berenson's comment that
no one has come to their party. Frankly, we have been at their
party for their 4 years, and the reason that no one else is
coming is because they are only letting in people in checkered
suits, and they are not serving any food.
Well, having spent half my allotted time making
introductory comments, I feel compelled to cut to the chase for
you.
As you know, Medicare currently has two payment processes
in place for telemedicine services. The first established was
the telemedicine reimbursement demonstration, of which my
program is a part. The second involves the HPSA payment rules
enacted by HCFA in response to the Balanced Budget Act of 1997.
They are chillingly similar processes and equally ineffective
in enabling the delivery of telehealth care services. In short,
because of HCFA's overly narrow interpretation of the
telemedicine provisions in BBA, Medicare reimbursement for
telemedicine services has been limited in scope and
unreasonably restrained. Frankly, these restraints are
threatening the viability of many federally funded telemedicine
programs across the United States.
Congress can take five critical steps toward clarifying the
intent of the Balanced Budget Act and increasing access to
telemedicine services for America's seniors citizens. You asked
Mr. Berenson for specific directives, what could be done in a
regulatory fashion, what could be done statutorily. These are
my suggestions in that regard.
First, Congress should clarify the physicians providing
direct care through telemedicine may receive payment for the
evaluation and management services and medicine services
routinely employed in telemedicine patient care. Because of
their restrictive consultation-only rules, Medicare reimburses
for just 12 out of hundreds of CPT codes. These 12 codes
describe consultation services and assume that two
practitioners will be involved in every telemedicine encounter.
You have already heard the statistics on this from Mr. Tracy.
Only a small percentage really require to two providers.
Our own research shows that these 12 approved codes, the
codes under which our demonstration is currently run,
constitute only 5.6 percent of all outpatient codes, outpatient
services reimbursed by Medicare, and they ask us why we don't
have many patients in the study.
HCFA is denying reimbursement for the vast majority of
codes used in traditional and in telemedical patient care.
Congress should act immediately to ensure Medicare
beneficiaries have access to the full range of services
available through telemedicine.
Second, Congress should eliminate the requirement for a
telepresenter. We have heard these comments before. HCFA rules
require a patient be presented by a telepresenter which has
been defined in my written comments. As stated, the great
majority of telemedicine services provided involve only one
provider and one patient at each end of the connection.
Requiring two practitioners artificially inflates telehealth
encounter costs, needlessly wastes medical resources and
discourages patient access to telehealth services. HCFA should
be directed to remove the current requirement for a
telepresenter.
Third, Congress should extend the Medicare reimbursement
beyond HPSAs to all rural areas and medically underserved urban
areas. Based upon Medicare expenditures for telemedicine
services to date, there is absolutely no reason to be concerned
about runaway costs. Congress should authorize Medicare
reimbursement for telemedicine services provided to patients in
all nonmetropolitan statistical areas and in urban HPSAs.
Fourth, Congress should eliminate the cumbersome BBA fee-
splitting provisions. As previously stated, 94 percent of
telehealth encounters only require one provider and one
professional service payment. To require a treating
practitioner to send a part of a payment to another provider is
unrealistic, impractical and, frankly, impossible to implement.
It is also perceived as an inappropriate inducement to
services.
Fifth and finally, Congress should ensure that home health
patients can also benefit from telemedicine. Congress can
accomplish this goal by expressly authorizing home health
agencies to use PPS dollars for the deploying and use of
telehome services.
In summary, through MRTC and projects like it, we have
proven that telemedicine technology has the potential to
dramatically improve the lives of Americans who live in
medically underserved areas. I can't think of a better example
than we have had here today. We need your help to capture this
potential and to put it to work for America's senior citizens.
Thank you for the opportunity to share my thoughts with you
on this very important topic, and later on as time allows I
will welcome any questions you might have.
[The prepared statement of James Reid follows:]
Prepared Statement of James Reid, Director, Midwest Rural Telemedicine
Consortium
Mister Chairman and Members of the Committee, my name is Jim Reid,
and I am director of the Midwest Rural Telemedicine Consortium. MRTC is
a 45 node telemedicine network that serves hospitals, clinics, and
nursing homes in thirty communities in north and south central Iowa.
Program offices are at Mercy Medical Center in Des Moines, Iowa.
I also serve on the Board of Directors of the Center for
Telemedicine Law, based here in Washington. The CTL is a non-profit
organization that focuses on legal and regulatory barriers to
telemedicine. CTL has worked closely with telemedicine providers,
policy makers, and the public to analyze the effects and costs of
current federal and state telemedicine reimbursement policies.
I am particularly pleased to offer testimony before my own
Congressman and a member of my hospital's medical staff. We appreciate
Congressman Ganske's interest in and support for telemedicine.
Since its beginnings in 1993, MRTC has played an important role in
efforts to evaluate the effects of telemedicine on health care costs,
quality and access. In 1994, the Health Care Financing Administration
awarded its first telemedicine demonstration grant to the Mercy
Foundation to fund MRTC. MRTC's participation in the Medicare
Telemedicine Reimbursement Demonstration has given us first hand
experience in dealing with impractical and restrictive reimbursement
regulations and it is to that experience that this testimony is
prepared.
The success of MRTC in expanding access to health care and
improving the quality of care available to medically underserved areas
is a testament to the power of telemedicine to improve lives. But
despite the successes of MRTC and projects like it, the potential of
telemedicine to improve the lives of Americans is not being fully
realized. While more than 25 percent of our Nation's senior citizens
live in medically underserved areas, Medicare reimbursement for
telemedicine services has been limited in scope and unreasonably
restrained by HCFA's overly narrow interpretation of the telemedicine
provisions in the Balanced Budget Act of 1997. The limits on Medicare
reimbursement and narrow interpretation are threatening the viability
of telemedicine projects across the United States.
Congress can take five critical steps toward clarifying the intent
of the Balanced Budget Act and increasing access to telemedicine
services for America's senior citizens.
First, Congress should increase access to telemedicine services by
clarifying that physicians providing direct patient care through
telemedicine may receive payment for the ``evaluation and management''
services and ``medicine'' services routinely employed in telemedical
patient care. The BBA provided Medicare reimbursement for telemedicine
consultations provided to residents of Health Professional Shortage
Areas or HPSAs. Unfortunately, BBA language used the term
``teleconsultation'' throughout. To HCFA ``consultation'' has a very
specific meaning, which lead to their very narrow interpretation of
Congress' intent in the BBA, and their promulgation of very limited
telemedicine reimbursement rules which effectively discourage providers
and patients from using telehealth technologies.
Medical services are described and billed using Current Procedural
Terminology (CPT) codes. Because of their restrictive
``teleconsultation only'' rules, Medicare reimburses for just twelve
out of hundreds of CPT codes--all of which describe consultation
services and assume that two practitioners will be involved in the
telehealth encounter. Those twelve approved CPT codes describe only 5.6
percent of all outpatient Medicare services delivered in 1998 and
totally ignore the reality that the majority of telemedicine services
provided today are direct care visits involving a patient at one end
and a provider at the other. HCFA is denying reimbursement for the vast
majority of codes used in traditional and telemedical patient care.
Through MRTC and projects like it, we have proven that telemedicine
is an effective tool for providing direct patient care to patients in
medically underserved areas. Yet, HCFA's restrictive policy prevents
physicians from receiving Medicare reimbursement for direct telemedical
patient care. Congress should act immediately to ensure that Medicare
beneficiaries have access to the full range of telemedicine services.
Second, Congress should increase access to telemedicine services by
eliminating any requirement for a telepresenter. Current HCFA rules
require patients be ``presented'' by a telepresenter who is either the
referring practitioner--referring practitioner being defined by HCFA as
a physician, PA, NP, nurse midwife, clinical nurse specialist, clinical
psychologist or clinical social worker--or a direct employee of the
referring practitioner who is one of the listed practitioners. This is
an unduly restrictive requirement and totally ignores how medicine is
practiced. A recent assessment of telehealth encounters conducted by
the University of Missouri Health Sciences Center in conjunction with
21 U.S. telehealth networks revealed that only 261 (5.9%) of 4,424
telehealth encounters involved or required clinicians on both ends.
Requiring two practitioners artificially inflates telehealth encounter
costs, needlessly wastes medical resources, and discourages patient
access to telehealth services. HCFA should be directed to remove the
current requirement for a telepresenter.
Third, Congress should increase access to telemedicine services by
extending Medicare reimbursement to all rural areas and certain urban
areas. The BBA limited Medicare reimbursement services provided to
patients in certain rural areas underserved for primary care, MRTC's
experience suggests that telemedicine services can also meet the needs
of patients in other settings. Specifically, rural communities lacking
access to specialty care and urban areas lacking access to both primary
and specialty care can benefit from telemedicine technology. Based upon
Medicare expenditures for telemedicine services to date, there is no
reason to be concerned about runaway costs due to telemedicine
reimbursement. To improve access to health care in all medically
underserved communities, Congress should authorize Medicare
reimbursement for telemedicine services provided to patients in all
non-metropolitan statistical areas and urban HPSAs.
Fourth, Congress should eliminate the cumbersome BBA fee-splitting
provisions that were based on a misunderstanding of what constitutes a
telemedicine encounter. When BBA was written, the authors believed that
two physicians or other practitioners would participate in a
``consultation.'' Consequently BBA provided a fee splitting arrangement
to allow both practitioners to be paid out of a single fee. As
previously stated, only one professional service payment is necessary.
To require the treating practitioner to send a part of the payment to
another provider is unrealistic, impractical, and impossible to
implement. It also could be perceived as an inappropriate inducement to
provide telemedicine services.
Fifth, Congress should ensure that home health patients can also
benefit from telemedicine. Congress can accomplish this goal by
expressly authorizing home health agencies to use PPS dollars for the
deployment and use of telehomecare equipment.
Through MRTC and projects like it, we have proven that telemedicine
technology has the potential to dramatically improve the lives of
Americans who live in medically underserved communities. We need your
help to capture this potential and put it to work for America's senior
citizens.
Thank you for this opportunity to share my thoughts with you on
this important topic. I welcome any questions you might have for me.
Mr. Bilirakis. Thank you very much, Mr. Reid.
I am going to ask the gentleman from Tennessee to introduce
Dr. Burgiss.
Mr. Bryant. Thank you, Mr. Chairman.
I am once again pleased to acknowledge Dr. Burgiss from the
University of Tennessee at Knoxville, and we have a very
significant family--well, a residency practice up there at the
University of Tennessee at the other end of the State, and Dr.
Burgiss is extremely well qualified. He is one of the--
certainly in Tennessee--one of the pioneers in telemedicine,
and as mentioned, as we discussed beforehand, is also called
upon to help with inquiries from around the country, and we are
trying to focus those and his efforts more in Tennessee now so
that we can get all the benefits that we can have from
telemedicine in Tennessee. And thank you, Mr. Chairman, for
that.
Mr. Bilirakis. I thank the gentleman.
Dr. Burgiss, please proceed, sir.
STATEMENT OF SAM BURGISS
Mr. Burgiss. Thank you.
Mr. Chairman and members of the committee, thank you for
this opportunity to speak about the application of telehealth
in home care. In addition to responsibilities I have with the
University of Tennessee Medical Center Telemedicine Network at
Knoxville, I am also the Chair of the American Telemedicine
Association's special interest group in telehome care.
The University of Tennessee telemedicine network began its
telehealth program in 1995 with rural patients located in their
communities receiving care from physicians and other providers
located in our medical center. In April 1998, with a grant from
the Office for the Advancement of Telehealth of the Department
of Health and Human Services, the UT telemedicine network began
providing care in patient homes using home care agency nurses
located in their offices. We now have the capability of caring
for patients using telehealth in over 100 homes in congestive
heart failure, diabetes and other traditional home care
services.
As an example of this care, Ms. HY had a slow heart rate of
approximately 40 beats per minute. On one occasion, the
telehealth nurses in their office detected that Ms. HY's rate
in her home was 26. 911 was called. Ms. HY received a pacemaker
and has become more active.
The lowest cost of health care can be obtained by providing
the correct level of care at the correct time. To repeat, the
lowest cost of health care can be obtained by providing the
correct level of care at the correct time. Since care in the
home has the potential to be the lowest cost when compared with
assisted living facilities, nursing homes and hospitals,
national laws and policies should support quality home care
being provided cost effectively.
Telehealth has the potential to reduce the cost of home
care for suitable patients and conditions. Home care programs
that have used telehealth provide homes with video conferencing
and/or monitoring instruments. Video conferencing provides
interactive audio and video between the patient and nurse,
typically using standard home telephone lines. Monitoring
instruments at the patient's home transmit data to a central
station using the telephone line, or digital medical
instruments can be viewed by the video.
Home care by telehealth is typically provided by home
health nurses and may also be provided by physicians located in
their offices and consulting with patients in their homes.
In a study of 14 patients having 444 telehome visits in 15
months, patients reported the following: an increased sense of
security that medical help was readily available, reduced
confusion over medication use, time savings during the
televisit, increased sense of being in control, increased
personal attention from nursing staff, increased privacy, and
quality of care same as or better than a traditional in-home
visit. The cost saved for the televisit compared with a
traditional visit averaged $49.33 cents per visit for nurse
transportation and labor costs during travel.
Costs of equipment for telehome care use can range from
less than $1,000 to $10,000 per home. Assuming that two
telehome care visits occur per patient per week, it would take
10 to 100 weeks to amortize the cost of equipment based on the
travel cost savings of approximately $50, as stated previously.
It is evident that cost-effective home care depends on limiting
the cost of equipment taken to the home to that which is needed
by the patient.
In addition to a decreased cost of providing home care,
published telehealth studies have shown potential cost of care
benefits from fewer office visits for patients, reduced
emergency room visits, reduced hospitalization rates as much as
50 percent, reduced in-home visits, in-person home visits of 49
percent, and fewer long-term care placements. For example, Mr.
F, who has congestive heart failure, was being admitted for
hospital care an average of 7 days each quarter. After
telehealth care began in his home, he was admitted for only one
23-hour observation in a year.
In summary, as a leader in telehealth programs providing
home care, I request your support for laws and policies which
enable the cost-effective delivery of care for patients in
their home using both traditional and telehealth methods. For
high-quality and cost-effective telehealth care, these laws and
policies should, A, not require a professional medical person
as the presenter of patients in homes; B, permit the use of
store-and-forward technology which is used for patient
monitoring; and, C, recognize telehealth home care as a service
by HCFA under the prospective pay system for purposes of care
and accounting. None of these requests will require additional
funding from HCFA. They are all budget neutral.
Thank you.
[The prepared statement of Sam Burgiss follows:]
Prepared Statement of Sam Burgiss, Manager, UT Telemedicine Network,
University of Tennessee Medical Center
Chairman Bliley and Members of the Committee, thank you for this
opportunity to speak about the application of telehealth in home care.
I am Sam Burgiss, manager of the University of Tennessee Medical Center
Telemedicine Network at Knoxville. The University of Tennessee Medical
Center Telemedicine Network began its telehealth program in 1995 with
rural patients located in their communities receiving care from
physicians and other providers located in our medical center. This care
uses interactive video conferencing between the provider and a patient
presented by a nurse, and uses remote patient monitoring technologies.
In April 1998 with a grant from the Office for the Advancement of
Telehealth of the Department of Health and Human Services, the UT
Telemedicine Network began providing care in patient homes using home
health agency nurses located in their offices. Interactive video
equipment and hand held digital instruments are available for 29 homes
from UT Home Health Services. Another project funded by a charitable
trust began in 1999 to provide telehealth care in the homes of 35
congestive heart failure patients and 44 diabetic patients referred by
their primary care physicians. The project was developed to provide
care for the people of Scott County, Tennessee; to evaluate the
potential improvement in the physical function of the patients; and to
evaluate the potential decrease in health care costs due to hospital
readmissions. As an example of this care, Ms. HY had a slow heart rate
of approximately 40 beats per minute. On one occasion, the telehealth
nurses detected that the rate was 26, and 911 was called. Ms. HY
received a pacemaker and has become more active.
The lowest cost of health care can be obtained by providing the
correct level of care at the correct time. Certainly using a specialist
too soon increases cost. Delaying needed care can increase the
morbidity of the patient and increase the cost of treatment at a later
time. As shown in a study of 87 rural dermatology patients, the cost of
care for dermatologic conditions before examination by a dermatologist
using telehealth was twice that of the cost of care by the
dermatologist.\1\ Since care in the home has the potential to be the
lowest cost when compared with assisted living facilities, nursing
homes, and hospitals; national laws and policies should support quality
home care being provided cost-effectively.
Telehealth has the potential to reduce the cost of home care for
suitable patients and conditions. Home care programs that have used
telehealth provide homes with video conferencing and/or monitoring
instruments. Video conferencing provides interactive audio and video
between the patient and nurse typically using the standard home
telephone line. Monitoring instruments at the patient's home transmit
data to a central station using the telephone line, or digital medical
instruments can be viewed by the video. Home care by telehealth is
typically provided by home health nurses and may also be provided by
physicians located in their offices and consulting with patients in
their homes.
In a study of 14 patients having 444 telehome visits in 15 months,
patients reported the following: a) an increased sense of security that
medical help was readily available, b) reduced confusion over
medication use, c) time savings during the televisit, d) increased
sense of being in control, e) increased personal attention from nursing
staff, f) increased privacy, and g) quality of care same as or better
than a traditional in-home visit.2 The cost saved for the televisit
compared with a traditional visit averaged $49.33 per visit for nurse
transportation and labor cost during travel. Visit time in two studies
averaged 18 minutes for telehealth compared with a traditional average
time of 45 minutes.\2\,\3\ Nurse productivity more than
doubled during home televisits due to less distractions and more focus
while creating high levels of patient satisfaction.
Cost of equipment for telehomecare use can range from less than
$1,000 to $10,000. Assuming that two telehomecare visits occur per
patient per week, it would take from 10 to 100 weeks to amortize the
cost of the equipment based on the travel cost savings of approximately
$50 as stated previously. It is evident that cost-effective home care
depends on limiting the cost of the equipment taken to the home to that
which is needed by the patient.
In addition to a decreased cost of providing home care, telehealth
has shown potential cost of care benefits from fewer office visits for
patients, reduced emergency room visits, reduced in-patient
hospitalizations, and fewer long-term care placements.\4\ For example,
Mr. F., who has congestive heart failure, was being admitted for
hospital care on an average of seven days each quarter. After
telehealth care began in his home, he was admitted for only one 23 hour
observation in a year. Ten published or presented studies on the use of
telehealth in home care, by and large, show that: a) the need for in-
person home visits declines, b) patient satisfaction is excellent, c)
hospitalization rate decreases as much as 50% suggesting improved
patient care and reduced cost of care.\5\ None of the studies suggest
any decline in quality of care, or any negative outcomes.\5\
As a leader in telehealth programs providing home care, I request
your support for laws and policies which enable the cost-effective
delivery of care for patients in their homes utilizing both traditional
and telehealth methods. For high quality and cost-effective telehealth
care, these laws and policies should a) not require a professional
medical person as the presenter of patients in homes, b) permit the use
of store-and-forward technology which is used for patient monitoring,
and c) recognize telehealth home care as a service by HCFA under the
Prospective Pay System for purposes of care and costing.
References
\1\ Burgiss SG, Julius CE, Watson HW, Haynes BK, Buonocore E, Smith
GT. Telemedicine for dermatology care in rural patients. Telemedicine
Journal, 3(3), 1997, 227-233.
\2\ Dimmick SL, Mustaleski C, Burgiss SG, Welsh T. A case study of
benefits & potential savings in rural home telemedicine. Home
Healthcare Nurse, 18(2), February 2000, 125-135.
\3\ Johnston B, Wheeler L, Deuser J. Kaiser Permanente Medical
Center's pilot tele-home health project. Telemedicine Today, 4(7),
August 1997, 16-17, 19.
\4\ Jossey P, Gustke S. Financial feasibility of rural
telehomecare. Fourth Annual Meeting of the American Telemedicine
Association, April 1999, Salt Lake City, UT.
\5\ Mahmud K. E-mail communication. August 25, 2000.
UT Telemedicine Network, University of Tennessee, Center for Community
Health, Scott County Telemedicine
success stories
What a difference a pacemaker makes
As part of the UTCCH Program that cares for participants with
congestive heart failure, the physiologic monitoring equipment
determined that one of the new patients (HY) had a heart rate that was
consistently in the 40s, a slow heart rate. Her doctor was notified,
and he counseled observation. When HY's heart rate dropped into the
30s, and she complained of chest pain and shortness of breath, she was
sent to the Scott County Emergency Department. From there she was sent
to Oak Ridge Methodist Medical Center, where she was seen by a
cardiologist. He changed her medications and her heart rate rebounded
to between 50 and 60 beats per minute. However, on Feb. 24, HY's heart
rate dropped precipitously to 26, and 911 was called. HY was rushed to
the Scott County Emergency Department. She was transferred to Methodist
Medical Center, where a pacemaker was installed. Since she has returned
home, HY can now walk through her house and no longer needs her
nitroglycerine patch. She is taking fewer medications. She recently
went to the beauty shop, a special event because she had not been able
to leave her house and was confined much of the time to bed when she
entered the Scott County Telemedicine Program.
Controlling high blood pressure
Another Telemedicine Program participant with CHF had problems with
elevated blood pressure spikes that were detected through the
physiologic monitoring program. When her diastolic pressure exceeded
100, her doctor was notified. He adjusted her medication, which brought
her BP down. However, cardiac monitoring also showed an increasing
number of heart arrythmias. Her doctor was again notified and she was
sent to Parkwest Medical Center. As of this writing, she has fewer
life-threatening arrythmia episodes and her medications have been
reduced.
Video Monitoring in the Home
The ability to see Telemedicine Program participants in their homes
has been particularly beneficial. Two participants (IB and BS) had
developed blood clots in their legs. As usual during a video visit, the
participants were asked about new problems, and both IB and BS
complained of pain. Swelling and discoloration in their legs were
plainly visible on the monitor. Their doctors were promptly notified in
each case. A brief hospitalization ensued to start anti-coagulant
therapy for blood clot lysis. As a result, BS is back riding his
horses. IB is much more mobile around her home and was able to take her
planned vacation to Florida.
Summary
Ten of the 30 (33%) CHF Telemedicine Program participants have been
able to make significant lifestyle improvements and/or reduce their
dependence on medications. In the diabetes program, 8 of 30 (26%) have
been able to fine tune their diabetes management through either
medication changes or the initiation of insulin therapy. Additionally,
100% of these participants have said that they like their new blood
sugar monitors because the lancets are sharper and finer and their
fingers are not as sore.
Mr. Bilirakis. Thank you very much, Dr. Burgiss.
To introduce Dr. Ross-Lee, Mr. Strickland the gentleman
from Ohio.
Mr. Strickland. Thank you, Mr. Chairman.
It is my pleasure to welcome to this committee one of my
favorite constituents, Dr. Ross-Lee, who is the Dean of the
College of Osteopathic Medicine at Ohio University right in the
center of my Appalachian district.
I would like to share with my friend from Michigan, Mr.
Stupak, the fact that, prior to coming to Ohio, she was the
associate dean at the College of Osteopathic Medicine at
Michigan State University. Michigan's loss is Ohio's gain.
And, last but not least, the wonderful singer/entertainer
Diana Ross is the sister of our honored guest today. And Dr.
Ross-Lee, it is wonderful to have you and thank you for all you
do for Appalachia, Ohio.
Mr. Bilirakis. Doctor, please proceed.
STATEMENT OF BARBARA ROSS-LEE
Ms. Ross-Lee. She is my little sister, by the way.
I think it is still morning. Good morning, Mr. Chairman and
members of the Committee on Commerce. I would like to thank
you, the Subcommittee on Health and Environment, I would like
to thank you for inviting me to give testimony on this very
important issue, telehealth.
My name, as you know now, is Barbara Ross-Lee; and I am the
Dean of the College of Osteopathic Medicine at Ohio University.
I began my career in osteopathic medicine as a family physician
providing care for underserved populations. I have a long
acquaintance with the issues of access, particularly related to
preventive and primary care services.
Our college is located in the region of this country known
as Appalachia, in the southeastern part of the State of Ohio.
Sparsely populated, southeastern Ohio is a region that is
dominated by high poverty rates, limited employment
opportunities and poor health indicators. The counties are
primarily rural with limited transportation, government,
economic or communication infrastructure.
In addition, a majority of the rural southern Ohio counties
continue to hold designations as Health Professional Shortage
Areas by the Federal Government. Health care delivery depends
on a very fragile infrastructure of rural providers. Addressing
the issues of access within the bounds of acceptable costs,
available people and technology transcends issues of health
care and exemplifies the entrenched systemic disparities in
rural infrastructure.
The high rate of poverty in rural Appalachia, including
Southeast Ohio, is the most consistent single contributing
factor to limitations in transportation, economic development,
educational opportunities and medical services. Recently
identified discrepancies in access to digital information
technology by rural underrepresented populations which we refer
to as the digital divide are an additional symptom of the
larger problem. As the new E-service economy holds great
promise for one side of the digital divide, in rural
underserved areas it represents a new symptom of a preexisting
problem of limited resources and unmet basic service needs.
It is clear from a technical standpoint that telemedicine
works and can and does provide medical services for
geographically isolated populations. Financing for telemedicine
services is perhaps the most critical measure of the field's
maturity and prospects for growth. The availability of high-
capacity information infrastructure is a limiting factor to the
expansion of both telecommunications- based health care
delivery and economic development.
The anticipation that we saw or felt when HCFA announced
the changes to telemedicine reimbursement and designated HPSA
areas has changed from a mood of excitement to a mood of
frustration and despair over the last few years. The current
75/25 method of reimbursement for telemedicine and the absence
of bandwidth infrastructure in rural America does nothing to
promote the advantages of this new technology. It further feeds
the digital divide in rural America and deepens a preexisting
schism in health care service availability.
Not providing reimbursement for store-and-forward
consultation is another hindrance to further enhancing health
care delivery in rural America through the use of telemedicine
technology. These are the types of consults most often
compatible with rural practice. It is within this kind of
utilization that telemedicine really brings many benefits to an
underserved rural population.
At the Ohio University College of Osteopathic Medicine we
have great success in the utilization of a mobile van for the
delivery of preventive pediatric health care. In other words,
we took the service to the population. We have seen significant
positive health outcomes such as increased immunization rates
and pediatric screening examination through these efforts.
Through the combined hard work of community leaders working
with Congressman Ted Strickland's office we have secured
financing of a second van targeted toward the underserved adult
community in Southeastern Ohio. The new van will incorporate
telehealth to improve preventive screening for our underserved
and isolated adult populations. We will use this technology
through our existing technology infrastructure at existing
schools and community centers.
In addition to our vans, we also have a telepsychiatry
program that was launched and initiated through a collaboration
with many mental health providers in Southeast Ohio. The
reality is, without this telepsychiatry program, we would have
had no pediatric telepsychiatry in at least 10 counties in
Southeastern Ohio.
To sum this up, let me just say we would like to, based
upon our experience both in outreach as well as our experience
with telepsychiatry, we would like to be bold enough to suggest
a proposal for your consideration as it relates to rural
communities in this country. We would like to suggest that you
consider establishing digital health care empowerment zones for
rural America. Community leaders, volunteer organizations and
rural health care providers would partner in the development of
empowerment zones for the express purpose of developing
innovative methods of health care delivery utilizing digital
technology in all parts of rural America.
Empowerment zones would analyze the current digital
infrastructure, assess the health care needs of their
communities and develop strategies with measurable health
outcome objectives. The digital health care empowerment zone
for rural America could be funded by block grants. The proposed
empowerment zones would be granted waivers from existing
Federal Medicare and State Medicare reimbursement guidelines.
I could give you more, some specifics, but I would like to
thank you for inviting me here.
Mr. Bilirakis. Thank you, Dr. Ross. That is a good
suggestion.
One of the things we will tell you when we finish up here--
I guess I will tell you now--is that legislation to try to
cover many of the areas that have been discussed here today is
being worked on now. Majority and minority staffs have been
working on it for quite some time but certainly not going to be
enough to cover the entire waterfront. So the hope is that we
will not let this end with the legislation that I am talking
about.
Mr. Stupak has an awful lot to do with that legislation,
too. His input is based on his personal experiences.
So in that process we will, of course, take everything into
consideration. We appreciate very much suggestions and
recommendations made by the witnesses. That really helps a lot.
[The prepared statement of Barbara Ross-Lee follows:]
Prepared Statement of Barbara Ross-Lee, Dean, College of Osteopathic
Medicine, Ohio University
Good morning Mr. Chairman and Members of the Committee on Commerce,
Subcommittee on Health and Environment. I would like to thank you for
inviting me to give testimony on this very important issue--Telehealth.
My name is Barbara Ross-Lee, D.O. and I am the Dean of the College of
Osteopathic Medicine at Ohio University. I began my career in
osteopathic medicine as a family physician providing care for
underserved populations. I have a long acquaintance with the issues of
access.
My college is located in the region of this country known as
Appalachia, in the Southeastern part of the state of Ohio. Sparsely
populated, Southeastern Ohio as a region is dominated by high poverty
rates, limited employment opportunities, and poor health indicators.
The counties are primarily rural with limited transportation,
government, economic, or communication infrastructure. The area also
contains small communities that are lacking the resources and expertise
to access the telecommunications resources available to communities in
metropolitan areas of the state and to provide the professional
development necessary to be competitive in the technologically
advancing world.
In addition, a majority of rural southern Ohio counties continue to
hold designation as Health Professional Shortage Areas (HPSA) by the
federal government. Historically, rural medically underserved areas of
Southeast Ohio have experienced great difficulty in recruiting and
retaining primary care physicians. Because there is presently very
little economic and professional support, physicians choose to locate
in urban areas where they can access technologies and communicate with
large specialized medical groups.
Health care delivery in Appalachian Ohio depends on a fragile
infrastructure of rural providers. This region, consisting of 29
counties in the southeast quadrant, includes over 1.4 million
individuals living in the most impoverished conditions in the state.
Health care services are sparsely distributed, with 23 of the counties
designated as either full or partial primary care HPSA. Availability of
specialty providers is almost non-existent. Geographic isolation, a
poorly developed system of roads, inadequate levels of health
infrastructure, little employment-based insurance, inadequate
transportation systems, and diffusely distributed populations further
exacerbate the problem of providing adequate services under current
health care models. As a result, many inhabitants have no continuing
sources of care, do not seek or delay seeking medical care when
initially needed, instead showing up with more severe acute illnesses
in emergent care facilities. Similarly, patients with chronic disease
are less likely to receive adequate management of their condition
thereby increasing their risk of significant and debilitating
complications. Each of these scenarios results in poorer outcomes to
the patient and higher costs to the health care system.
These concerns are exemplified by the experience of Vinton County,
Ohio (right next door to my county). Its 12,000 residents are sparsely
distributed across several villages within the county's 414 square
miles. High rates of poverty (children--60.9% in 1999, #1 in Ohio) and
unemployment (10.9% in 1998; 153% state average), low rates of
insurance coverage, absence of a public transportation system, and
other factors associated with impoverished areas (41.3% of adults >25
did not have a high school education in 1998; 20% of households were
without a telephone in 1990) make health care unattainable to a large
segment of the area's residents. Donald Barton, DVM, County Health
Commissioner has repeatedly expressed concern about the ability of
resources within the community to meet the health care needs of the
populace. Only two physicians practice within the county, both in the
county seat of McArthur Village, qualifying it as a designated Health
Professional Shortage Area. It is unrealistic to expect that health
care providers can establish thriving practices in the county's other
smaller villages due to the limited patient base. Advances in
technology, more specifically telemedicine, would provide a feasible
model for meeting these needs without developing an unrealistic and
unsustainable bricks-and-mortar foundation in each of the communities.
Rural Healthcare Issues
Many residents in rural areas of Ohio have limited access to
preventive and primary health care services. Addressing the issue
within the bounds of acceptable cost, available people, and technology
transcends issues of healthcare and exemplifies the entrenched systemic
disparities in rural infrastructure. A study by the Office of
Technology Assessment (OTA) cited three problems that are specific to
residents of rural areas:
Although the rural population has relatively low mortality
rates, a disproportionate number of rural people suffer from
chronic illness. Furthermore, infant mortality is slightly
higher than in urban areas and the number of deaths from injury
are dramatically higher.
The lack of public transportation systems and the existence of
few local healthcare providers make it difficult for rural
individuals to reach facilities where they can obtain care.
The OTA found that physical barriers to access, difficult as
they are, might be overshadowed by financial barriers.
The high rate of poverty in rural Appalachia, including southeast
Ohio, is the most consistent single contributing factor to limitations
in transportation, economic development, educational opportunities,
political representation, and medical services. Recently identified
discrepancies in access to digital information technologies by rural
underrepresented populations (i.e. the ``digital divide'') are an
additional symptom of the larger problem. As the new e-service economy
holds great promise for one side of the digital divide, in rural
underserved areas, it represents a new symptom of a pre-existing
problem of limited resources and unmet basic service needs.
Studies suggest that rural communities have a disproportionately
greater need for health care services than their urban and suburban
counterparts. As an example, it has been estimated that nearly 60% of
traffic fatalities occur in rural areas.
Telemedicine
A significant outcome of many federally funded projects is an
overwhelmingly positive outcome in technological terms. It is clear,
from a technical standpoint, that telemedicine works and can (and does)
provide medical services for geographically isolated populations.
Financing for telemedicine services is perhaps the most critical
measure of the field's maturity and prospects for growth. Long enabled
by the crutch of public funding for program start-up, few managers have
had much incentive to justify services from a business perspective. As
a result, loss of federal or state grant funding has meant the end of
some otherwise worthwhile programs. As telemedicine services have
gained wider adoption, telecommunications cost still rank highest as an
operational barrier followed closely by the lack of a comprehensive
cost reimbursement plan. Without a stable reimbursement plan by
Medicare, Medicaid, and third party payers, implementation of
telemedicine will lag woefully behind the technological abilities to
make operational those needed services to rural healthcare consumers
and healthcare providers.
Limited Infrastructure
The availability of high capacity information infrastructure is a
limiting factor to the expansion of both telecommunications based
healthcare delivery and economic development. Live consultant
interactions depend more reliably on broadband services. As many rural
communities are still struggling to attain the most basic services
provided by limited local Internet Service Providers (ISPs), broadband
services are being deployed in more populous and prosperous areas
around the country. Broadband or high-speed Internet access is provided
by a series of technologies that give users the ability to send and
receive data at volumes and speeds far greater than current Internet
access over traditional telephone lines. High-speed two-way connections
can be used for interactive applications such as online classrooms,
economic development, or support services for rural healthcare.
The deployment of broadband to the American home is being financed
and implemented by the private sector as a business strategy. Less
dense populations are much less attractive to private sector
investment. Based on the economics of limited subscribers, geographic
barriers, and shortage of economic development opportunities, it is
unclear how advanced telecommunications services will be provided,
supported, and sustained in rural underserved areas.
Reimbursement
There are many issues surrounding the methodology HCFA has adopted
in reimbursing providers for Telehealth services, especially within
rural America. Recent U.S. data figures indicate that there are a
greater percentage of Medicare beneficiaries in rural America when
compared to urban settings. Medicare payments to those few physicians
that practice in the many small rural communities like those seen in
Southeastern Ohio account for over 60% of practice revenues. Within our
small rural hospitals in Appalachia, Medicare payments may run as high
as 90% at times. With counties that have as few as two physicians and
no mid-level health care providers, access to health care remains a
``high priority'' problem for the senior citizens in rural Southeastern
Ohio. This decreased access to health care in Appalachia is occurring
in a population that demonstrates a higher than expected incidence of
chronic debilitating diseases such as Diabetes, Chronic Obstructive
Lung Disease, Obesity, Heart Disease and elevated cholesterol levels.
Telemedicine offers much to aid in the care of these disease entities
as well as other disorders among rural residents. It remains true
however, that the methodology adopted by HCFA in promoting telemedicine
has hindered rather than helped bring healthcare to the Medicare
recipients of Southeastern Ohio, and other rural areas throughout our
country.
The anticipation that we saw when HCFA announced the changes to
telemedicine reimbursement in designated HPSA areas has changed from a
mood of excitement to a mood of frustration and despair over the last
year. The current 75/25 method of reimbursement for telemedicine in the
absence of bandwidth infrastructure in rural America does nothing to
promote the advantages of this new technology. It merely acts as a
disincentive to opportunities for expansion of access to care for
Medicare recipients who are already disadvantaged in the healthcare
provision continuum. It focuses on maintaining a bottom line cost
sharing by providers using a methodology that has been deemed illegal
when practiced independently by physicians (fee-splitting). It further
feeds the digital divide in rural America and deepens a pre-existing
schism in healthcare service availability.
Those of us in rural communities already experience great
difficulty in recruiting and sustaining an adequate supply of primary
care health providers. For the purposes of telemedicine, current HCFA
policies increase costs to provider participants in terms of time,
facility utilization, staffing, administration and equipment; further
burdening an already overburdened and fragile healthcare system. Rural
primary care providers are not reimbursed on a reasonable cost basis
for goods used, services rendered or time and effort provided as a
presenter. They are reimbursed at an arbitrary figure of 25% of the fee
received and administered by the consultant provider.
Potential reimbursement for ``store and forward'' consultation is
another possibility to further enhancing healthcare delivery in rural
America through the use of telemedicine technology. These are the type
of consults most often compatible with rural practice. In many
instances what is needed is a review of current lab data or tests to
enhance patient care. For a breast cancer patient, a review of current
red and white blood cell counts may allow the rural primary care doctor
or rural hospital to adjust and administer a dose of chemotherapy,
rather than requiring a three to four hour drive to see her oncologist.
For a patient with severe diabetes, the ability to store and forward
blood sugar measurements along with other lab data to their
endocrinologist will save time, effort and money. Surely a reasonable
rate of reimbursement for asynchronous medical care makes common sense.
It is within this kind of utilization that telemedicine really brings
many benefits to an underserved rural population, rather than HCFA's
insistence that any telemedicine involve a ``live'' interactive
conference.
At the Ohio University College of Osteopathic Medicine, we have had
great success in the utilization of a mobile van for the delivery of
preventive pediatric healthcare. We have seen significant positive
health outcomes, such increased immunization rates and pediatric
screening examinations, through these efforts. Through the combined
hard work of community leaders working with Congressman Ted
Strickland's office, we have secured financing of a second van targeted
toward the underserved adult community in Southeastern Ohio. The new
van will incorporate Telehealth to improve preventive screening for our
underserved adult populations. We will use this technology through our
existing infrastructure at schools and community centers in Ohio.
However, these services will be non-sustainable without changes to the
current Medicare reimbursement policies.1Telemedicine has already
enjoyed a positive track record at many locations. In order to best
provide these services to rural Medicare recipients, we advocate
further improvements to the Balanced Budget Act of 1997. We feel that
measures like Senate Resolution 2505 and House Resolution 4771, that
propose important changes to healthcare delivery through telemedicine
are steps in the right direction.
We further suggest the consideration of ``Digital Healthcare
Empowerment Zones for Rural America.'' Community leaders, volunteer
organizations and rural healthcare providers will partner in the
development of empowerment zones for the express purpose of developing
innovative methods of healthcare delivery utilizing digital technology
in rural America. Empowerment zones will analyze the current digital
infrastructure, assess the healthcare needs of their communities, and
develop strategies with measurable health outcome objectives. The
Digital Healthcare Empowerment Zones for Rural America will be funded
by block grants. Proposed empowerment zones will be granted waivers
from existing federal Medicare and state Medicaid reimbursement
guidelines, on a community-by-community basis, to incorporate cost-
based reimbursement that supports sustainable infrastructure and
healthcare delivery.
Supplement
advanced practice nurse/telemedicine program
A Collaborative Project of the Ohio University College of Osteopathic
Medicine and the Southern Consortium for Children
Background
The Southern Consortium for Children, a collaborative of four
Alcohol, Drug Addiction and Mental Health Services Boards (ADAMHS), has
been instrumental in bringing psychiatric services for children to ten
Appalachian counties in southern Ohio. Approximately seven years ago,
brokering services equivalent to one full-time child psychiatrist into
the local mental health provider agencies was the first step in meeting
the need for children's outpatient psychiatric services. Prior to that
time, no child psychiatry services were available through the local
agencies. The Advanced Practice Nurse/Telemedicine Program was designed
to further increase access to those services. The program was funded by
a grant from the Health Resources and Services Administration (HRSA),
Office of Rural Health Policy, Rural Outreach Program and covered seven
of the ten counties served by the Consortium. Additional funding was
obtained from the Substance Abuse and Mental Health Services
Administration (SAMHSA) in the second year to include the remaining
three counties in the program.
The collaborative partners and their responsibilities in the
program are:
The Southern Consortium for Children--fiscal agent, project
management
Four local mental health agencies--house collaborative
psychiatrist/nurse practices, provide support services
Two child psychiatrists--provide psychiatric services
(primarily prescribing and monitoring medications)
Two clinical nurse specialists (CNS)--provide psychiatric
services (primarily monitoring medications; will begin
prescribing in fall of 2001)
The Ohio University College of Osteopathic Medicine--
installation, management, and maintenance of video
teleconferencing system.
Services
The services provided through the program fall into two main
categories: direct service and education/consultation. The direct
services that are provided by the psychiatrist/nurse collaborative
practices include psychiatric assessment of children and adolescents,
prescription of medication, monitoring medication, and client and
family education. All clients receiving direct services are children
and adolescents between 4 and 18 years old and most (65-75%) are
Medicaid-eligible.
The Behavioral Pediatric Case Seminar Series makes up the majority
of the education/consultation piece. Initiated in September 1998, each
program in the series is a monthly hour-long presentation from noon to
1:00 PM. Each program consists of a case study that is presented to a
panel composed of a child psychiatrist, a CNS, and a psychologist. The
panel's review of the case is then followed by questions from the
audience. Each program is presented via video teleconference with seven
sites currently participating across the ten-county region. As of May
2000, 604 participants have attended 20 programs in the series. The
series began as a way to enhance communication between the child
psychiatrists and pediatricians in order to facilitate referrals and to
increase the appropriateness of referrals from pediatricians to the
mental health system. Now physicians, nurses, psychologists, social
workers, medical students, and school counselors among others attend
the series. The disciplines presenting cases have been equally diverse
with consumers participating as well.
Videoconferencing
Videoconferencing has proven to be a powerful tool for education
and consultation in this program. It has also been used extensively for
administrative functions. The guidance provided by OUCOM has been
instrumental in creating a videoconferencing network that has addressed
these functions effectively and in a trouble-free manner.
However, the original intent of the program was, and continues to
be, to use videoconferencing technology to provide direct services to
children. Ohio's lack of policy regarding Medicaid reimbursement for
clinical services delivered via videoconference is one of two problems
that have effectively prevented the use of the technology for direct
service. The other factor has been the lack of funds to connect each
satellite clinic to its parent clinic. The SCC has worked with the Ohio
Department of Mental Health (ODMH) and the Ohio Department of Human
Services (ODHS) to help forge a policy regarding reimbursement.
A policy proposed by ODMH but not yet implemented would allow no
more than 20% of services to be provided via videoconference. The SCC
believes that, due to the large geographical area, diffuse population
and shortage of clinicians, rural areas should be allowed more
flexibility to utilize technology to meet the mental health needs of
their children.
Several grant proposals have been submitted in order to fund
videoconferencing systems for the satellite clinics. The SCC remains
committed to the use of technology as an effective tool in addressing
the behavioral health needs of children in Appalachian Ohio.
Mr. Bilirakis. Well, Ms. Mary Patrick is Director of
Quality Improvement, Blue Cross and Blue Shield of Montana. Ms.
Patrick, please proceed.
Ms. Patrick. Just a side note here, do you sing, too?
Ms. Ross-Lee. I dance.
STATEMENT OF MARY R. PATRICK
Ms. Patrick. Mr. Chairman and committee members, it is an
honor and privilege to be here today from Blue Cross and Blue
Shield of Montana to share with you what has taken place in our
great State in the field of telemedicine. I thank you for your
interest and support for this technology.
Montana, the fourth largest State in the Union, has lots of
vast beauty and open frontiers, big sky country, has a small
population, approximately 880,000 people, and lots of land,
147,000 square miles, therefore making Montana a challenging
place to deliver health care. Almost half of our total
population is classified as rural. We have 56 hospitals and
critical access facilities located primarily in the western
part of our State.
We have a map up there to show you. You can just put a line
right down the center of the State, and you will see the
eastern part of our State is in great need of health care
delivery.
Seven counties out of 56 total have no health care facility
of any type. Forty-three of Montana's 56 counties have no
psychiatrists, and there are no psychologists and no
psychiatrists east of Billings, all the way up to the border of
Canada, as well as specialties. Great Falls, Missoula and
Billings, which are located predominantly in the western part
of the State, are considered our main medical hubs as they are
the only areas in the State that can provide all types of care,
including open heart surgery. In such a widespread and sparsely
populated State, many residents have to travel long distances
for health care services, particularly for specialty care.
Blue Cross and Blue Shield of Montana has been reimbursing
for telemedicine consults for almost 7 years, since first
requested to do so by several participating mental health
providers in our State and the Eastern Montana Telemedicine
Network. The Eastern Montana Telemedicine Network consists of
13 medical and mental health not-for-profit facilities located
primarily in the eastern part of our State capable of two-way
video conferencing, and they definitely fill a gap for delivery
of health care in this part of our State.
At this time, both Medicaid and Medicare reimburse for
these services in Montana. Medicaid has done so since the
inception of these services in Montana. Medicare currently
reimburses for consultations only and has several contingencies
related to payment for these services which most providers
perceive as a problem.
In addition to consultations, there will be other
telemedicine services that residents of Montana will need.
Telehome care is something that will eventually be available
for alternative health care delivery, for long-term disability
and home care. Montana is predicted to have the third highest
elderly per capita population in the year 2025.
In addition to consultations, telepsychiatry has many other
applications that could also benefit Montana's sparsely
distributed population. Medication review, discharge planning
and follow-up care, individual and family therapy, emergency
consultations are some of the additional realities of care
through telemedicine technology.
According to the Eastern Montana Telemedicine Network, an
average of 20 Medicare patients per month over 7 years utilized
telepsychiatry services and paid out of their own pockets.
Telemedicine does not create new or different health care
services. It simply provides a new way to deliver existing
medical or health care services. The day will come when
regulatory and payment issues will be resolved and telemedicine
will be fully integrated into our Nation's health care system.
Blue Cross and Blue Shield of Montana is proud to be a
leading participant in this process in our State. Thank you for
your time and for asking Blue Cross and Blue Shield of Montana
to participate in this hearing.
Mr. Bilirakis. I guess one of the questions might be asked
of you is what is their reimbursement policy, but I won't do
that at this point.
[The prepared statement of Mary R. Patrick follows:]
Prepared Statement of Mary R. Patrick, Blue Cross and Blue Shield of
Montana
introduction
It is an honor and privilege to be here today to share with you
what has taken place and is taking place in the great state of Montana
in the field of telemedicine. I have lived in Montana for almost 10
years and I have grown to appreciate the vast beauty and open frontiers
of the fourth largest state in the union. Our Big Sky country has a
population of some 880,000 people and covers a land area of more than
147,000 square miles. In size, our border can encompass Virginia,
Maryland, Delaware, Pennsylvania, and New York, and still have room for
the District of Columbia. Montana is a challenging environment for
delivery of healthcare because of our geography and demographics. While
telemedicine technology has many clinical and non-clinical uses in both
urban and suburban areas, it is the rural applications that are most
near and dear to Montanans.
I hope to provide you with some insights into why Blue Cross and
Blue Shield of Montana was one of the first commercial healthcare
payers to reimburse telemedicine services. Included in this overview
will be a look at Montana's demographics, Blue Cross and Blue Shield of
Montana's role in telemedicine, and some interesting outcomes and
satisfaction comments from a provider and member.
montana demographics
Overview
882,799--1999 estimated population.
Per capita personal income is $22,314.00 in 1999.
60,000 Native Americans from 11 federally recognized tribes,
residing on the 7 designated reservations.
Urban population accounts for 52.5% of the population.
Rural population accounts for 47.5% of the population.
Growth of the 65 and over population is expected to increase
from 13.1% in 1995 to 24.5% in 2025.
Montana is projected to have the third highest proportion of
elderly in 2025.
delivery of healthcare impact
In such a widespread and sparsely populated state, many residents
must travel long distances for healthcare services, particularly for
specialty care. If a person lives in Virginia City, Montana, and needs
open heart surgery, that person has to travel anywhere from 3 to 4
hours at a minimum, depending on where their cardiac surgeon is
located. These services are available only in Billings, Missoula and
Great Falls.
When someone in a major metropolitan area develops chest pain and
calls ``911,'' there is a good chance that an ambulance will respond
with Advanced Cardiac Life Support trained personnel within 10 minutes.
That person would likely be transported to a level of facility equipped
to handle all cardiac emergencies and situations within 10-20 minutes.
A rancher outside of Dillon, Montana, located in the southern
corner near the Idaho border, who develops chest pain and calls ``911''
may not see an ambulance arrive for an hour. There is also the
possibility that there are no Advanced Cardiac Life Support Personnel
on board the ambulance. It is also quite likely that once the patient
is on board the ambulance, it may take another hour or more to arrive
at a Critical Access Facility. This type of facility can only
temporarily stabilize an acute cardiac patient until they can be
airlifted to a facility equipped to handle this type of emergency.
Blue Cross and Blue Shield of Montana
Blue Cross and Blue Shield of Montana has been providing health
insurance to Montanans for 60 years. We are home-grown, based in
Helena, Montana. Overall, we serve 280,000--half of the state's insured
population--across our state. We also serve 140,000 seniors through
Medicare Parts A and B.
Our health plans offer choice and access to all types of healthcare
services for our consumers. Given the rural nature of our state, we
face challenges in providing quality primary, particularly specialty
care, to our members. An overview of specialty care availability in
Montana is specified in the five attached maps.
Blue Cross and Blue Shield of Montana contracts with 1,160 family
practice and specialty participating physicians in our traditional
indemnity network. A breakdown of numbers and distribution of specialty
physicians is as follows:
Four pediatric cardiologists--three are located in three out
of the four main medical hubs' in the western part of the
state, and one located in Billings.
One pediatric pulmonologist (located in the western part of
the state).
Thirteen cardiovascular surgeons, 38 cardiologists and 15
pulmonologists (none are located east of Billings).
Thirty-two neurologists and 23 neurosurgeons (none are located
east of Billings).
Three neonatologists (none are located east of Billings).
There are a total of 56 hospitals and Critical Access
Facilities in the state with only five considered to be Tier I
level facilities. Tier I facilities provide the highest level
of acute care (none are located east of Billings). Seven
counties are without any type of healthcare facility.
In late 1993, our company was asked by Eastern Montana Telemedicine
Network (EMTN) in Billings and several of our providers to reimburse
clinical services for our members via telemedicine technology. EMTN is
a consortium comprised of 13--notforprofit medical and mental health
facilities located primarily in counties east of Billings. Each site is
connected via two-way interactive videoconferencing technology to
provide medical and mental health consultations, medical and higher
education, and administrative and business services to residents in all
communities of the network. EMTN provided telemedicine services at
various sites in the eastern part of Montana.
Because of the potential benefits for our Blue Cross and Blue
Shield of Montana members, our Company initiated the process for
approval for reimbursement of telemedicine services just like face-to-
face consultations. Our multi-specialty physician advisory board
reviewed the proposal and advised that we should pay for telemedicine
consultations because we reimburse face-to-face encounters minus the
technology component. As a result, the referring health care
professional would be reimbursed for an office visit and the consulting
physician would be reimbursed for the consultation visit. Upon
initiation of reimbursement for these services, we asked the health
care professional community to include a specific modifier when billing
for these encounters to help us track utilization. We have not,
however, been able to track utilization through this technology due to
inconsistent compliance. While we don't want any extra burden on our
health care professionals for the purpose of tracking utilization, we
do want to foster compliance to better quantify all quality of care
issues.
value to our members:
Through the Eastern Montana Telemedicine Network, Montana has been
able to realize the positive outcomes of our Company's decision to
reimburse for telemedicine. Because psychiatry is consistently the
highest utilized specialty in Montana, and there are no psychiatrists
east of Billings, we have chosen the following provider and member
testimonials to share with you today:
A Billings, Montana psychiatrist has been providing psychiatric
services to patients throughout eastern Montana for over 15
years. Since the inception of EMTN (7years) this doctor has
transitioned a case-load of over two hundred patients to
telemedicine. His patients are always given a choice of coming
to see him in Billings or choosing to be seen over
telemedicine. Ninety nine percent of the time they chose to be
seen over telemedicine. During a recent televisit with this
psychiatrist, one patient commented on how much they liked
being able to see him this way. She said, `` you know my
daughter would have to take a day off from work and put her
child in day care to bring me to see you. This is so much
better for all of us.'' On a recent patient evaluation form
from EMTN, the following comment was made, ``This technology is
a must for rural areas like ours. This saved me a day's drive
down and a day's drive back plus the expense of a hotel for a
15 minute check.''
medicaid and medicare reimbursement in montana
Medicaid in Montana has reimbursed for telemedicine services since
the inception of telemedicine. In fiscal year 1995, Medicaid estimated
that using telemedicine saved Medicaid patients $65,000 in travel time,
lost wages, food and lodging. Since Medicaid reimburses for travel
expense, this item was a tangible outcome for them to measure and
track.
As a result of the Balanced Budget Act (BBA) of 1997, Health Care
Financing Administration (HCFA) was mandated to reimburse for select
teleheatlh consultations beginning January 1, 1999. This was an
important first step in recognizing telehealth as a reimbursable
service. The current rules remain in an evaluation period as evidenced
by the numerous federal bills that have been introduced to amend these
rules.
The BBA requires fees related to telemedicine encounters be shared
(split) between the referring health care professional and the
consulting specialist. The Healthcare Financing Administration (HCFA)
has interpreted this to mean that 75% of the normal consult fee should
go to the specialist and 25% should go to the referring health care
professional. Fee sharing is the area of most concern to health care
professionals and those involved in telemedicine programs.
At this time HCFA only recognizes physicians, physicians
assistants, nurse practitioners, nurse midwives, or clinical nurse
specialists as providers of telemedicine services who are eligible for
reimbursement. HCFA's rules exclude clinical psychologists and
physical, occupational, and speech therapists. These health care
professionals are normally reimbursed when providing services face-to-
face.
A large majority of telemedicine programs utilize registered
nurses, licensed practical nurses, or other health care professionals
to present the patient to the physician over the telehealth system. The
Health Care Financing Administration does not recognize these providers
to be eligible presenters of patients for reimbursement purposes. The
agency only recognizes the actual referring health care professional or
an employee of the referring health care professional, who could be a
registered nurse, licensed practical nurse, etc.
Telehomecare provides healthcare service delivery alternatives for
individuals with disabilities and home care clients with both acute and
long-term needs. Many patients or family member caregivers are capable
of presenting themselves or the family member to a health care
professional over a telemedicine network for care. Telehomecare lends
itself to this type of presentation, as do certain psychiatric
sessions. Self-presentation of a patient for telehomecare allows the
patient to become more involved in treatment and recovery. Also,
telehomecare allows a reduction in the number of visits by a nurse, who
in turn reduces costs and allows for increased interactions with the
medical staff via the telehomecare health system. For telepsychiatry,
those patients who can present themselves ensure confidentiality of
such sessions.
conclusion
Telemedicine is a tool for improving the rural health care system.
Telemedicine fosters the growth of integrated health care systems that
serve both rural patients and rural health care professionals. It
provides rural patients with access to comprehensive health care
services, both in their community and from distant health care
professionals. Rural health care professionals find their practice less
isolating because telemedicine facilitates contact with distant
colleagues who share their interests.
The day will come when telemedicine is fully integrated into the
rural health care system. The effectiveness of telemedicine will have
been established. The regulatory and payment issues will have been
resolved. Many players will have participated in this process including
Congress, states, telecommunications, health care professionals and
others. Blue Cross and Blue Shield of Montana is proud to be a leading
participant in the process in our state.
Thank you for your time and for inviting Blue Cross and Blue Shield
of Montana to provide you with information on our progressive support
and payment policies in the area of telemedicine.
Telemedicine Reimbursement References
1. Campbell, Paul R., 1996, ``Population Projections for States, by
Age, Sex, Race and Hispanic Origin: 1995 to 2025,'' Report PPL-47, U.S.
Bureau of the Census, Population Division
2. Census and Economics, Inc., 2000 State Profiles.
3. Department of Health and Human Services, HCFA, Medicare Program,
Payment for Teleconsultations in Rural Health Professional Shortage
Areas, Proposed rule, July 1998.
4. Eastern Montana Telemedicine Network, provider and member
comments on Telemedicine Service, 2000.
5. McLosky-Armstrong, Tracy, Sprang, Burgiss, Reid, Hammack,
``Medicare Reimbursement for Telehealth Encounters--Position Paper'',
October 5, 1999.
6. McLosky-Armstrong, Tracy, Sprang, Burgiss, ``Medicare
Reimbursement for Telehealth--An Assessment of Telehealth Encounters,
July 1, 1999-December, 1999, July 8, 2000.
7. Population Estimates Program, Population Division, U.S. Census
Bureau, Washington D.C., 2000.
8. Telemedicine--A Guide to Assessing Telecommunications in Health
Care, Marilyn J. Field, Editor, National Academy Press, Washington,
D.C., 1996.
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Mr. Bilirakis. Dr. Grigsby is the Study Manager for the
Center for Health Services and Policy Research with the
University of Colorado Health Sciences Center.
Dr. Grigsby, please proceed, sir.
STATEMENT OF JIM GRIGSBY
Mr. Grigsby. Thank you, Mr. Chairman, honorable members. I
appreciate the opportunity to speak with you today.
I think previous witnesses, because they tend to be
providers or involved in different aspects of telemedicine,
have presented a somewhat different perspective than I will. I
am in basic agreement with previous witnesses, as well as with
Dr. Berenson, that some fundamental changes are necessary in
coverage and payment policy toward telemedicine, but I should
say I am a research scientist primarily at the University of
Colorado. I am in the Division of Geriatric Medicine; and I do
a combination of medical outcomes research, primarily with
Medicare beneficiaries, and cognitive neuroscience looking at
neurologic functioning in older adults; and so many of my
remarks come from that perspective.
Telehealth, which is the use of telecommunications and
information technology, is a term we have thrown around quite a
bit today. The basic idea of it is to deliver health services.
It seems simple enough on its face, but it presents actually a
number of complex issues for policymakers, legislators and
health care practicers as well. The concept of telehealth is
nearly as broad, in fact, as is medical care itself; and
consequently it defies simplistic discussions of effectiveness
or cost effectiveness.
In general, it involves three components. First, it refers
to the provision of various kinds of health services, ranging
from information about health and illness to diagnostic
assessment, remote monitoring of patients and robotic
interventions. Second, the services involves persons that are
different from a provider. And, third, they are accomplished
using any of a variety of telecommunications, video and
information technologies.
Given the newness of the field and the wide range of
possible uses of the technology, some telehealth applications
are probably very effective and quite inexpensive. Others are
likely to be extremely expensive and of little use for most
practical purposes. What this means is if you ask whether
telehealth is effective or cost effective there is no answer to
your question. On the other hand, if you ask whether
interactive video is an effective means of allowing people in
remote rural communities to see specialists in urban areas, not
only can your question be answered but the answer is probably
yes.
Efforts to develop coverage and payment policies so far
have focused primarily on interactive video and in rural areas
in a fee-for-service environment. While this is an important
application, it appears that, over the coming years, it is
going to represent a diminishing percentage of what actually
transpires in telehealth; and it is important that we realize
that if a rational policy is to be devised what we have to do
is make relatively fine-grained distinctions among different
types of telemedicine practices and applications.
For a number of complex reasons, research data on
telehealth are very limited, often nonexistent. Because the
evaluation of new technology is an inherently time-consuming
process, we are constantly falling farther behind as the
technology and uses to which it is put develop rapidly. For
example, HCFA, at the direction of Congress, established
several telemedicine demonstration problems in the 1990's. At
the time they were established, these were state-of-the-art.
They were intended to use primarily interactive video for the
provision of specialty medical consultation to residents of
rural areas, and it was assumed that this was the primary
direction in which telemedicine was going to go.
An evaluation of these demonstrations was established, and
that demonstration project, the waiver that provided payment
for those demonstration programs and the evaluation itself were
narrowly defined. Initial projections were that there would be
a large number of patients who would receive services under
this program; and, in fact, it has been quite limited, as Dr.
Berenson and others have pointed out. That represents
historical factors, assumptions that were made at one point
about the direction of telemedicine and our own lack of
knowledge.
I am the principal investigator on the evaluation for HCFA
of the telemedicine demonstrations, and because the
demonstrations themselves have produced very low volumes of
patients, we have suggested a number of changes in direction in
the evaluation and in HCFA's approach to this, including
studies of home health care, of the use of store-and-forward
technology, and we are currently in negotiations with HCFA
about some of these possible changes. They are under
consideration, look upon them favorably, and we are hopeful
that in the very near future we will be able to redirect the
focus of our efforts to some extent.
Thank you.
[The prepared statement of Jim Grigsby follows:]
Prepared Statement of Jim Grigsby, Study Manager, Center for Health
Services and Policy Research, University of Colorado health Sciences
Center
definitions and applications of telemedicine, telehealth, and e-health
The terms telemedicine, telehealth, and e-health are often used
somewhat interchangeably, and each may be defined in a number of
different ways. In general, they involve the following three
components: 1) These terms refer to the provision of various kinds of
health services, ranging from information about health and illness
through diagnostic assessment, remote monitoring of patient condition,
and robotic interventions. 2) The services in question involve persons
who are at some distance from the provider. 3) They are accomplished
using any of a variety of telecommunications, video, and information
technologies. The Institute of Medicine, in its 1996 report on the
evaluation of telemedicine,1 discussed a number of
definitions, some of which also encompassed the use of these
technologies for administrative and educational purposes.
---------------------------------------------------------------------------
\1\ Institute of Medicine Committee on Evaluating Clinical
Applications of Telemedicine: (1996) Telemedicine: A guide to assessing
telecommunications in health care. MJ Field (ed.). Washington, DC:
National Academy Press.
---------------------------------------------------------------------------
While the term telemedicine is ordinarily used to refer to the
remote provision of medical care, the broader term telehealth often is
used to include such things as patient education, public health,
continuing education for health professionals, administrative meetings,
and psychiatric discharge planning, among many others. E-health is
frequently used to refer to commercial applications of Internet
technology that generate revenue either by selling health-related goods
and services, by advertising such goods and services, or by obtaining
and selling information about Internet users. Although the use of the
telephone by itself to provide health services could be considered to
fall under most definitions of telemedicine, and there are data showing
that many such uses are cost-effective, telephonically provided
services are not covered for Medicare beneficiaries, and most other
purchasers of health services also refuse to pay for telephone
consultations.
Discussion of the effects and effectiveness of telemedicine and
telehealth is often complicated by the fact that the terms encompass a
very wide array of technologies and applications, varying along several
different dimensions. For example, a telemedicine encounter may be
conducted in real time between two or more persons at different sites
using interactive video (IAV) or audio (radio or telephone) technology.
A substantial percentage of telemedicine currently is accomplished in
this manner using IAV, with a consulting provider at one end of the
link and a patient (and sometimes another provider) at the other end.
However, because of the high cost of transmission and limitations on
the local infrastructure, video technology is not available everywhere.
Consequently, in certain remote regions--such as much of Alaska--
paraprofessional community health aides may employ a kind of
telemedicine that uses radio to allow them to consult with physicians
or other providers about patient management.
While the use of videoconference technology links patients and
providers simultaneously, telemedicine and telehealth services also may
be provided asynchronously, in which case providers, or providers and
patients, interact with one another somewhat less directly, through
systems that transmit data by email, fax, or other means of data
transfer. Some systems of this sort involve personal computer-based
store-and-forward systems, which are essentially multimedia email
(i.e., containing images). Store-and-forward protocols generally
involve transmission of images (e.g., CT scans or x-rays), lab data,
history, and physical exam findings bundled into a single email message
that is transmitted to a medical specialist or subspecialist for
interpretation. The consultant then sends a report of findings and
impressions by return fax or email. Other telehealth systems involve
transmission of certain physiologic data--such as diabetics' blood
glucose values--generally over ordinary telephone lines, possibly by
means of a dedicated modem.
There is a broad and ever-expanding variety of uses of the various
technologies for providing different health services. Among others,
these include the use of IAV for specialty consultation, psychiatric
evaluation, and psychiatric treatment; store-and-forward consultation
and second opinions; compressed IAV for home health care; facsimile
transmission of EEG and EKG data; real-time telemetric transmission of
vital signs; and regular remote monitoring of respiratory status, using
spirometry, of persons with asthma. Some providers have established
World Wide Web sites that provide educational material to patients with
certain conditions, or that permit communication between patients and
providers. Should humans travel to Mars, a sophisticated telemedicine
system will assuredly be necessary, but the same might be said of many
remote terrestrial regions where access to health care is severely
limited.
Perhaps the most important point to be made here is that
telemedicine and telehealth are not unitary phenomena, but are
extremely variable in their specific aims and implementation. The
telemedicine programs of the early 1990s, which relied primarily on
remote videoconference technology, bore a striking resemblance to the
very first telemedicine programs established in the late 1950s.
However, recent advances in medical, computing, and telecommunications
technologies have led to the development of such a diverse range of
technologies and applications that it no longer makes sense to pose
questions about the effectiveness or cost-effectiveness of telehealth.
Some telehealth applications are very effective and quite inexpensive,
while others are likely to be extremely expensive and of little use for
most practical purposes. Therefore, the questions to which we should
turn our attention have to do with whether certain applications of
specific technologies are useful means of handling specific health
conditions.
For illustrative purposes, consider the question, ``is telehealth
effective?'' The question is commonly asked, and sounds reasonable
enough, but unfortunately is so broad it has no meaningful answer.
Because telehealth is really a vehicle for delivering health services
of all sorts, this is tantamount to asking whether telecommunications
systems work, and whether medical care is effective. If we are to learn
anything of value about the use of information and telecommunications
technology in providing health care, the questions we ask must be
precisely focused. We might, for example, ask, ``does the remote
monitoring of blood glucose levels, with transmission of the recorded
data via modem to a computer that analyzes the data and notifies
providers and/or patients when there are problems, result in better
control of blood glucose levels, less expensive management of diabetes,
and a lower rate of serious complications?''
the evaluation of telehealth
There exist limited data on the effectiveness and cost-
effectiveness of telehealth. In 1996, the Institute of Medicine of the
National Academy of Sciences compiled a comprehensive volume on
telemedicine, with detailed recommendations for its evaluation. This
worthwhile endeavor has thus far produced little fruit. This lack of
relevant data may be traced to many factors, including the following:
the constant change and refinement of the technology--by the
time a research study is published, the equipment, technology,
and applications studied may be obsolete;
an emphasis on the development and implementation of systems
intended to provide clinical services, by administrators and
clinicians for whom research is of secondary importance;
relatively poor compliance with data collection protocols,
even in programs that have attempted to evaluate their
telehealth services;
the very low volume of persons who receive telemedicine
services, which makes it difficult to obtain adequate samples
for analysis, especially within specific categories of disease;
the variability among telemedicine programs with respect to
equipment, technology, applications, and services provided;
the rapid pace of change in the telecommunications and
computer industries; for example, personal computers did not
even exist until the early 1980s, yet it is now possible to
purchase a desktop computer that meets the definition of a
supercomputer for under $3,000;
the use of telemedicine has not reached a sufficiently steady
state, even within most single programs, to permit
comprehensive cost-effectiveness analysis;
reluctance on the part of many health care providers to use
telemedicine--due in part to the lack of a national coverage
and payment policy, and in part to deeply entrenched habits of
practice;
policies, regulations, and legislation (e.g., limiting
coverage) that retard the proliferation of telehealth; and
failure of agencies that have funded telemedicine projects to
require systematic evaluation of outcomes.
Discussions of research on telehealth generally concern themselves
with three major issues: costs, quality, and access. The essential
question is whether these services provide care of adequate quality at
a reasonable cost. Also of interest is whether they permit access to
health care for persons for whom such care otherwise might not be
available. The issues that providers and policymakers would like to see
addressed include the following:
Is telehealth care comparable in quality to health services
provided in person?
How should such services be reimbursed?
Are the outcomes of in-person health care and telehealth care
equivalent?
Is the cost of telehealth services roughly equivalent to that
of face-to-face care?
Will telehealth increase access to health services? If so,
what will be the effect of telehealth on overall rates of use
of health services? Will increases in some areas (e.g.,
outpatient specialist consults) be offset by decreases in
others (e.g., inpatient admissions)?
Are patients satisfied with the care they receive via
telehealth?
Unfortunately, few data exist providing answers to these questions.
Moreover, the questions themselves are overly broad, and cannot
possibly be answered in a meaningful way in a reasonable period of
time. To a large extent, rapid technological change and the flow of
investment money drives the evolution and proliferation of telehealth.
New health care applications follow at a somewhat slower pace, while
the associated social, policy, and legislative issues lag well behind.
Because technology assessment moves far more slowly than technological
innovation and dissemination, the data required for planning and policy
making are inevitably late in coming, frequently out of date by the
time they are available, and of limited use for planning.
For example, the Health Care Financing Administration (HCFA), at
the direction of Congress, established five telemedicine demonstration
programs in the mid-1990s. These programs, which were state-of-the-art
at the time they were initially funded, were established primarily to
use interactive video for the provision of specialty and subspecialty
medical consultation to residents of rural areas. With the benefit of
hindsight, it appears that they were based on a model that some
telehealth providers now consider either unworkable or of limited
applicability. In addition, the payment waiver for the demonstration,
obtained by HCFA with the approval of the Office of Management and
Budget, was narrowly defined (covering only specialty consultation, and
not common patient evaluation and management codes), and was based on
projections of patient volumes that were considered realistic in 1995.
Subsequent experience, however, has shown that the number of persons
living in rural areas who require consultative services--and who are
likely to be referred for such services by their primary care
physicians--is significantly lower than anticipated. As a consequence,
the evaluation of the demonstrations and payment methodology has
collected minimal data. The problem of inadequate research data is not
unique to these demonstrations, however. For example, in the case of
one federal agency, an evaluation that had been in planning for several
years was canceled before it began.
what do we know about telehealth?
Certainly there are important reasons to evaluate the efficacy and
effectiveness of telehealth scientifically, and to assess its economic
effects on the health care system. It should be kept in mind, however,
that the effectiveness of most health services provided to Americans in
conventional face-to-face modes of delivery has never been evaluated.
In fact, only in recent years have scientists, providers, and the
government begun to place an emphasis on evidence-based medicine,
accompanied by the development of practice guidelines intended to
ensure a relatively uniform, empirically-based, acceptable standard of
care.
Although the evidence is quite limited, there are some data that
support the effectiveness of certain telehealth applications. For
example, interactive video consultation, evaluation, and management
have been practiced clinically off and on for over 40 years, and most
physicians who have used the technology--even the relatively
unsophisticated systems of the 1960s and 1970s--have found it an
acceptable means of providing a wide range of services. This general
conclusion has been supported by a handful of well-designed, but mostly
older studies. It appears that interactive video health care has some
limitations, but if these are kept in mind and the technology is used
appropriately, preliminary data suggest that it is generally safe and
effective.
Less is known about such applications as store-and-forward
telemedicine, remote monitoring of physiologic status, or the use of
telemedicine in home health care. Nevertheless there is reason to
believe that these may be useful additions to the more traditional
health care system if used judiciously. At this time, the bulk of the
limited data supporting these methods is anecdotal, but generally
positive.
We know very little about the actual costs of providing telehealth
services. It is clear that those applications involving interactive
video tend to require significant amounts of telecommunications
bandwidth, and consequently have rather high (and sometimes
prohibitive) recurring costs, despite the availability of Universal
Service subsidies in some areas. As a rule, the few studies that have
been conducted on costs suggest that as long as patient volumes remain
low (an almost ubiquitous problem, especially in rural areas),
interactive video health services are more costly than those provided
in person. This relationship may be reversed in the event that volume
could be increased, but if recent experience is a guide, it seems that
the number of telehealth encounters is liable to increase slowly. As a
consequence, the high telehealth encounter cost per patient is
particularly problematic in rural areas--especially those that are very
sparsely populated--since these areas may never have sufficient numbers
of telehealth encounters to generate the revenue that would support an
interactive video system. In fact, for some geographic areas it is
difficult to imagine any scenario in which interactive video telehealth
could become financially self-sustaining.
Although it has not been examined carefully, a reasonable case
could be made a priori for the use of telehealth in home health care.
Beginning 1 October 2000, HCFA will reimburse home health agencies
using a prospective payment system (PPS), according to which an agency
will receive lump sum payments (with certain defined exceptions) for
providing services to patients in the home, irrespective of the number
of visits required. Because preliminary data suggest that interactive
video may be useful for certain home health tasks, the home health
industry has shown considerable interest in implementing telehealth
systems that could substitute for, or augment, some in-person visits by
nurses, therapists, or aides. While this telehealth application might
reduce agency costs, and could potentially increase access to care for
patients, it also raises questions about the quality of care provided--
questions that presumably could be answered using data from the Outcome
Assessment and Information Set (OASIS) HCFA's instrument for assessing
quality of care and enabling outcome-based quality improvement. Thus,
although we don't currently have answers to these questions, their
evaluation in this case could be relatively straightforward.
There are limited data concerning the interpersonal/social aspect
of the quality of telemedicine. In general, however, studies of patient
and provider satisfaction with telemedicine have yielded mostly
positive results (as is the case for studies of satisfaction with
medical care in general).
The evaluation of telehealth is unique in that telehealth is not a
specific treatment or device, a diagnostic or interventional tool with
a fairly circumscribed use. Instead, it is essentially a means of
extending the services of health care providers to persons who are not
physically present in the provider's office. Hence its scope is
exceptionally broad. Even if those who conduct research on these
questions could keep pace with change in technology in applications, it
would be impossible to evaluate all the possible uses of telehealth/
telemedicine.
current trends in telemedicine
The early 1990s saw the proliferation of telemedicine systems
providing real-time, wide-bandwidth video consultations, generally from
a tertiary care hospital (often referred to as a ``hub'') to outlying
rural hospitals and clinics (the ``spokes'' in these systems). However,
the past few years have witnessed a shift toward PC-based store-and-
forward telemedicine, remote monitoring of patients' condition, and
home health. In many cases, the former ``hub and spoke'' systems have
diminished in importance, so that direct communications are
increasingly possible between outlying sites, and even between sites
within different programs. The systems being used are generally more
convenient and probably cost-effective means of providing services,
many of which can be delivered across a readily available, accessible,
and inexpensive Internet platform. Over time, the costs of equipment
have dropped considerably while its usefulness and usability have
increased concomitantly. Telecommunications charges have remained
relatively stable, but the availability of certain new digital services
has made the delivery of video-based services somewhat less expensive.
government telemedicine policy
Since the 1960s, the federal government has supported the
development of telemedicine through grants, contracts, and NASA or
Department of Defense budget line items that to date probably amount to
over a billion dollars. A number of agencies currently provide such
support, and their representatives have been actively involved in
discussions that shape both policy and directions of growth in
telemedicine. A comprehensive discussion of those policy issues is
beyond the scope of this testimony, but I will briefly mention two
important and problematic policy matters: coverage and payment for
telemedicine services, the potential for fraud and abuse, and
interstate licensure.
With a few circumscribed exceptions (e.g., Congress mandated that
coverage be extended to certain Health Professional Shortage Areas
effective January 1999), Medicare reimbursement of fee-for-service
telemedicine is not available, and it appears that HCFA may be
reluctant to permit telehealth services under prospective payment
programs. The agency has been criticized for its caution in moving
toward a general coverage policy, but has expressed concern that
insufficient data exist to inform policy decisions. Other payers have
been slow to set policies of their own, although some commercial
insurance companies pay for certain telemedicine services, as do Blue
Cross/Blue Shield organizations, and Medicaid covers some telehealth
encounters in nearly a third of the States.
Many of the issues involved in telehealth coverage policy are
admittedly somewhat complex. As noted previously, discussions of
telemedicine coverage policy tend to treat telehealth as though it were
a readily identifiable, unitary clinical phenomenon. A major problem
with this line of thinking is the protean nature of the health care
that can be provided using computer and telecommunications technology.
A comprehensive policy must take these important differences into
consideration. In addition, many telemedicine providers are moving
toward alternatives to IAV consultation systems. Yet the primary focus
of research for Medicare is on IAV systems used for specialty and
subspecialty consultation--systems which may represent a minority of
telehealth applications by the time a policy is finally promulgated.
Further research on the effects and effectiveness of telehealth is
clearly needed, although at the current pace, the scientific data
obtained are likely to lag many years behind the current status of the
technology and its applications.
An issue of some concern for policy makers is the potential for
fraud and abuse. Entrepreneurial health care providers have already
drawn attention for implementing questionable schemes using the
Internet, and similar operations--many frankly criminal in nature--
certainly will arise over time. Telehealth is not unique in this
regard, however, and it seems eminently reasonable to develop methods
for detection of such abuses in conjunction with the development of
coverage policies.
Finally, a lack of reimbursement for telehealth services is only
one of several factors slowing the expansion of telemedicine. Licensure
to practice medicine and other health professions, for example, is
regulated by the individual states, and bills have been introduced or
passed in some states that severely limit the interstate practice of
telehealth. Examinations assessing the competence of physicians are
conducted using national standards; patient outcome studies are done on
a national, not statewide basis; and practice standard guidelines are
developed on a national basis as well. State regulation of licensure
may well continue to hinder the spread of telehealth services.
Mr. Bilirakis. Thank you very much, Doctor.
I did want to announce before I go into my questions that
there will be a telemedicine demonstration immediately after we
finish up here, to be presented by Eastman Kodak, by VitelNet
and American Medical Development. Hopefully, most of us can
stay for that demonstration. They have gone to an awful lot of
trouble to present that to us.
Of course, the opening statements of all members of the
subcommittee are a part of the record.
Ms. Patrick, what reimbursement policies does Blue Cross
and Blue Shield of Montana follow? Do you follow the HCFA
reimbursement policies when you reimburse?
Ms. Patrick. No, we don't.
Mr. Bilirakis. You have your own criteria?
Ms. Patrick. We pay just as we would for any face-to-face
service encounter, patient encounter. We pay the referring
physician a visit, you know, for the initial diagnosis, and
then we pay the consulting physician for their consultation.
Mr. Bilirakis. Any comments regarding that? I think we are
all pleased to hear that.
You know, in the process of any piece of legislation we
have the Congressional Budget Office in our lives, and they
have to score, as we call it, all legislation, and in other
words price it. And of course, as much as we keep harping on
what we call dynamic scoring and things of that nature, we
never get it. They are concerned with the cost today and not
concerned, unfortunately, with the ultimate savings, the
preventative health care, for instance.
Dr. Burgiss, particularly in your case, looking over your
written submittal here you have given us an awful lot of
information that should be very helpful in terms of approaching
them and trying to get better scores, maybe not for this
immediate piece of legislation that I am talking about but
downstream as we go along. And so I would say to all of you,
any information you can furnish to us in that regard would be
very, very helpful in the ultimate savings that result.
I don't know, Ms. Patrick, whether Blue Cross and Blue
Shield of Montana has basically conducted some sort of a study
to determine is this costing them really more money or is it
really saving them money or whatever the case may be, but if
that is the case, please submit all that to us.
Ms. Davis, you indicate in your testimony that your region,
the Upper Peninsula, should be an ideal place for telemedicine
because every county in the UP, the Upper Peninsula, holds
partial Health Professional Shortage Area designation, which is
a prerequisite for HCFA reimbursement. And you state, current
HCFA policies frustrate even the UP with unrealistic
requirements regarding who can be a telepresenter--the 75/25
split fee that many of you have mentioned, the strange roles
governing store-and-forward technology and the ineligibility of
some services for reimbursement altogether.
Now, I know that Bart is aware of most of these, maybe all
of them, and he has had quite an input in what we are now
working on and hopefully will have an input on anything we do
in the future when we expand our look at this area. Would you
want to share with us which of those HCFA policies you feel are
most destructive to telemedicine in the Upper Peninsula?
Ms. Davis. I would suggest that when we work with
physicians and patients in putting together and coordinating
telemedicine consultations the two most restrictive are who the
presenter is. Most often we have an RN and sometimes an LPN,
and there are situations where the patient presents him or
herself. And then the fee-sharing usually comes up at a later
point when we talk to the physician about reimbursement; and,
to be honest, there are times when the physician is liable to
say, let us forget it; I will see the patient in my office.
Mr. Bilirakis. Any other comments from any other panelists
in that regard? Yes, Dr. Rheuban.
Ms. Rheuban. The issue of primary care practitioners
leaving their office to travel with a patient to the
workstation is problematic as well. These doctors are very busy
and for them to drive even, for example, as Ms. Hubbard
described, 40 minutes round trip to a workstation at another
clinic is an impediment because they have patients waiting in
their waiting room.
Mr. Bilirakis. Any further comments? Yes, Dr. Burgiss.
Mr. Burgiss. Yes. An example that well illustrates this, we
have a clinic in a rural area. The care provider is a nurse
practitioner, and that nurse practitioner is busy seeing the
patients that are in the waiting room. The nurse practitioner
doesn't have the time, even in the same building, to present
patients for telemedicine purposes. That should be done by her
nurse associate instead of the nurse practitioner who should be
caring for those in the waiting room.
Mr. Bilirakis. And do you feel that that nurse practitioner
is competent and capable to present this patient to----
Mr. Burgiss. Yes. The nurse practitioner or her nurse
associate, either one could do the presentation.
Mr. Bilirakis. My time is expired really, but just very
quickly, one of the areas that we are going to have to
address--and this is why telemedicine really did not take off a
few years ago the way some of us hoped it would--is the
licensure requirements in various States. Any quick comments
regarding that? Yes.
Mr. Reid. Mr. Chairman, in response to that, for some
medical centers and some telemedicine programs, licensure,
interstate licensure, cross-State licensure is an issue. But,
to be perfectly honest, I think that that falls about No. 6 or
seven on the list of things that might ought to be fixed. The
comparative number of people, patients and providers that that
issue affects is small, compared to the issues we brought up
about fee splitting, about scope of services and eligibility.
Mr. Bilirakis. Dr. Ross-Lee.
Ms. Ross-Lee. I just wanted to add, one of the areas that
we haven't touched on, because when you talk about the two ends
of the services, particularly in rural areas, the technical
personnel to support these systems is not there and very
difficult to access. It is interesting that becomes the pivotal
issue often.
Mr. Bilirakis. What would you say, though, to the medical
association that would demand that it be a licensed physician
on each end?
Ms. Ross-Lee. Licensed physician on each end of the
delivery?
Mr. Bilirakis. Yes or--well, licensed physician, a licensed
individual but----
Ms. Ross-Lee. Has to be on one end of the service.
Mr. Bilirakis. How about each end?
Ms. Ross-Lee. Not necessarily each end.
Mr. Bilirakis. Not necessarily each end.
All right. I am going to yield to Mr. Brown.
Mr. Brown. Thank you.
Dr. Grigsby, thank you for joining us. You provided us I
thought a pretty good definition of telehealth and some of the
things--and I think a pretty good understanding or gave us a
pretty good understanding of the sort of range of services.
Tell us, if you would, in terms of cost, in terms of
effectiveness, what aspects of telehealth have been most
successful, what have been least successful. Just sort of run
through that, if you would, for us.
Mr. Grigsby. It is difficult to do with any sort of
rigorous information because no good-quality, well-designed
cost-effectiveness studies have been conducted with the
exception of studies in very controlled populations like
prisons, that sort of thing. Anecdotal data suggests that many
applications of telemedicine may well be quite cost effective.
Certainly, there may be savings for patients who don't have to
do a lot of traveling. There may be other sorts of savings as
well.
Some people suggested store-and-forward technology might be
rather less expensive than face-to-face. Home care is a subject
that has been brought up considerably today, and a number
people think that the cost of home health visits could fall by
as much as 60 to 65 percent if they were conducted using
interactive video.
Mr. Brown. What role does volume have in that in terms of
comparing costs of telehealth versus patient service directly?
Mr. Grigsby. A significant role.
One of the difficulties, for example, in rural areas is
that the costs of providing the service remain relatively high
due usually to recurring costs that are fixed for
telecommunications, for example. So if you have a sparsely
populated rural area and the volume of referrals is low, then
the cost per patient consults will then be relatively high. So
as you are able to increase that volume, then you may get some
improvements in that ratio. The difficulty is, in many rural
areas there are some question whether it will ever be possible
to develop self-sustaining programs that will provide a wide
range of telemedicine services.
Mr. Brown. Dr. Ross-Lee, do you want to comment on that?
Ms. Ross-Lee. I was just agreeing with his comments that in
some rural areas, even using the technology, getting
sustainable services that are cost effective over time, I am
just not sure whether there is a formula to do that.
Mr. Brown. Thank you, Mr. Chairman.
Mr. Bilirakis. Mr. Stupak, to inquire.
Mr. Stupak. Thank you, Mr. Chairman.
Ms. Davis, assuming HCFA and private payers reimburse
telehealth in a sensible way--that is a big if, but let us say
they did--how would Marquette use its network? In short, I
guess what I am trying to drive at is how could a network work
more, better, get more use out of the network we currently
have?
Ms. Davis. Well, I think the fixes in reimbursement would
certainly go a long way to convince physicians that it is a
viable opportunity. We are also working on some other barriers
that we have. We feel that the convenience of the equipment to
the physician is a real detriment, and that is one of our new
initiatives for the upcoming year. Certainly staff needs to be
dedicated to promote and to set up the systems around the
telehealth consultations. Those don't come at the drop of a hat
either.
So reimbursement certainly is one issue; and, as Joe Tracy
pointed out, it is a significant issue in terms of furthering
telehealth. It won't make or break it itself. There are other
barriers out there. So we are working on the other barriers,
too, but certainly removing some of the restrictions in
reimbursement would open the doors.
We use the system for communities, the community hospitals
to allow their patients to present to our specialist. We have
some specialists at Marquette General that consult with
subspecialties at educated care centers like University of
Michigan.
We have used it when your specialists are traveling out
among the communities. For instance, in the case of pediatric
cardiology, we have one of them in the Upper Peninsula. So when
that pediatric cardiologist is out in, say, Houghton and we
have an infant in our neonatal intensive care unit that needs
the services immediately, we use it that way. So it is not
always how some people think of telemedicine consults with the
rural physician referring to the specialist.
And one thing that has been striking me today is that there
is no two or three set examples of telemedicine, that there are
so many different situations in which you could use it and you
would find so many different stories as you talk to each one of
us on how that happens.
Mr. Stupak. I was going to offer--anyone else want to
expand on that, how else can we have optimum use of
telemedicine, what barriers must we overcome? Mr. Reid.
Mr. Reid. Thank you, Mr. Stupak.
One of the clear issues as a HCFA demonstration program and
that I think as experienced by a lot of telehealth providers is
the scope of services currently reimbursed is so narrow it
defines a very small percentage of the patients that could
receive care. And I think that if we were going to try and
optimize the use of our network for clinical purposes, the
first thing I would ask is we be allowed to provide all the
services that we can over telemedicine, not just the very
narrow limited scope of consultation codes, the 12 CPT codes I
referred to earlier.
There has been a lot of discussion about we just don't
know, we don't know what is safe, we don't know what is
efficacious, there haven't been any randomized controlled
trials. To be perfectly honest, there are lots of services that
HCFA recommends or reimburses for today that have never been
proven with randomized controlled trials. They reimburse for
the remote interpretation of ECGs when faxed to the
cardiologist. I am not aware of any randomized controlled
trials to show the cardiologist could read faxed ECGs as well
as they could read the ECG they might hold in their hand.
And this speaks to the point we have already said, this is
not a new technology. It is not a new service. It is a new way
of providing the same old service. And with the limitations of
the obvious, like surgical procedures, there are systems in
place within HCFA's accounting and computer systems today that
say, whoops, this particular type of provider, this particular
type of specialist, why in the world is this person billing
this particular code that describes something that is totally
out of their presumed scope of practice? The same sort of check
and balance could be applied to the services if they were just
to be open to a broader service; okay, we are not going to
reimburse for surgical procedures performed over telemedicine.
Mind you, the military might suggest that is doable. In a
general civilian population, it is not. So it is not
unreasonable to think all services could be empowered to be
reimbursed with those sorts of checks, and that would be our
primary request.
Mr. Stupak. Let me ask this question and defer maybe to the
doctors on the panel. In telehealth how can we use that to
decrease patients costs like maybe allowing earlier
intervention such as diabetes management? Do you do that now?
How is it working? What other example besides diabetes would be
an example? Dr. Rheuban.
Ms. Rheuban. We primarily have done a lot of diabetes
education using our telehealth networks. We have actually done
hundreds of hours at multiple sites simultaneously and let them
all chat with our diabetes educators in Charlottesville. And we
think education plays a key role in improving the health of our
citizens. So that is sort of a tagalong extra by having these
networks in place to be able to use it for other applications
as well as for health professional education as well.
In terms of costs, pediatric cardiology seems to be coming
up, and that is my specialty. I would say we are also enrolled
in a multi-institutional collaborative study to look at the
costs of interpretation of pediatric cardiac ultrasounds
remotely via telemedicine versus the costs of transporting
through ambulances and helicopters and fixed-wing patients to
health care facilities where there are pediatric cardiology
services available.
We in Virginia also travel. We have field clinics all over
the Commonwealth of Virginia, but when we travel to Southwest
Virginia we are there 1 day out of every 2 months. With the
telemedicine services, we are there all the time.
Mr. Stupak. Thank you, Mr. Chairman. I see my time is up,
so thank you.
Mr. Bilirakis. Mr. Strickland.
Mr. Strickland. Thank you, Mr. Chairman.
Dr. Ross-Lee, you mentioned in your testimony this concept
of having digital health care empowerment zones for rural
America. It is an intriguing concept to me. Could you elaborate
on what you are thinking when you talk about that?
Ms. Ross-Lee. Well, even as I have listened to the
witnesses today, as we describe our communities, as much as
there is a significant need based on access both to primary
care services and specialty services, each of these communities
is different, and certainly the problems that we are attempting
to address are very complicated and include more than just
health care which seems to be a symptom of a broader
infrastructure problem. It makes sense to me, therefore, to
empower the communities themselves, to look at communities as
to what may be necessary for them to most efficiently and most
effectively use the technology to deliver the kinds of services
that would be appropriate for their community.
The earlier question about whether a licensed professional
should be on either end--I mean, I visited Alaska; and the
reality is they have lay people trained to deliver services,
and without them there would be no services. So I think we need
to deal with the specifics of the community, and this kind of
empowerment zone would allow you to do that. I mean, the
community comes together and plans, looks at what it needs,
assesses its challenges and then try and establish a system to
do that.
Now, how do we fund that? I am not sure that HCFA is going
to be the mechanism for which we effectively integrate
technology into the health care of this country anyway. It is a
reimbursement mechanism. Most of the programs that currently
exist exist by delivering services for free because the
reimbursement for these services is not what is driving, you
know, the train on the issue.
So I think that we should build an infrastructure,
particularly in rural America that already has fragile
infrastructure, in a whole bunch of ways. This may be the way
to bring some equity between urban and rural communities not
just for health care but for education and economics and
everything else.
Mr. Strickland. Would any of the others of you like to
comment on this concept? I saw some heads going up and down as
Dr. Ross-Lee was speaking.
Mr. Reid. As I think about the concept that she has
proposed, it certainly would be a challenge to implement, but
it holds all sorts of promise.
One of the things that we have all probably recognized is
that the technologies that we use, and particularly interactive
video technologies that we use, are rarely used exclusively for
the delivery of health care services; and several Federal
grantees today who have received telemedicine grants are using
their technologies for other purposes as well with regards to
continuing medical education, patient education, lay education,
continuing education for teachers and for other professionals
in the community.
My own experience in extremely rural settings is that this
technology becomes a resource to the entire community, not just
to the medical personnel, and so in that regard the concept of
empowering communities with digital technologies that would
include interactive video or a high-speed network for
information exchange will empower the whole community, and I
would think there would be great justification for that. If the
medical metaphor happens to be the sort of driving force for
that, so be it.
Mr. Strickland. Dr. Ross-Lee, you talked about our region,
the Appalachian region, and the high poverty rates and the high
infant mortality rates, more children dying as a result of
injuries and the like and the fact that you are going into some
of the schools. How do you get reimbursed for those kinds of
services?
Ms. Ross-Lee. We are usually grant funded. Grant funds
usually last 3 years. So we are out there beating the bushes
every 3 years to try and fund those programs. We are not
reimbursed through Medicare or Medicaid for those kinds of
services that we are delivering.
Mr. Strickland. So it is not just a Medicare reimbursement
problem, it is also Medicaid reimbursement problem we are
facing as well?
Ms. Ross-Lee. Absolutely.
Mr. Strickland. Mr. Chairman, I yield back my time.
Mr. Bilirakis. How about private insurance?
Ms. Ross-Lee. No private insurance payments.
Mr. Bilirakis. You tried and no private insurance will pay?
Ms. Ross-Lee. The populations we are dealing with, most of
them don't qualify. We have counties where 75 percent of the
population qualifies for Medicaid.
Ms. Rheuban. I would like to make a comment about private
insurance in Virginia. Most of the payers do not reimburse for
telehealth services. We have had on occasion an insurer comment
about the phenomenal response that the patient had and actually
eventually pay for that encounter primarily because then the
hospitalization is at the community hospital level which is at
lower cost than at a tertiary care or another care facility to
which the patient might have otherwise been transported.
I will also say--I will not mention the name of the managed
care entity, but when I approached one managed care entity
about reimbursing telehealth services I was told directly, why
would we ever want to enhance access?
Mr. Bilirakis. Wow.
Mr. Strickland. Mr. Chairman, could I ask a question?
Mr. Bilirakis. It is still your time, as a matter of fact.
Mr. Strickland. I am just curious as to why you wouldn't
want to give us the name of that HMO.
Mr. Reid. Because they are still a payer in her State.
Mr. Bilirakis. Let us shift that question, that point over
to Ms. Patrick, your comment.
Ms. Patrick. Now, what is the question again? I am still in
shock.
Mr. Bilirakis. I raised the point about private insurance
paying, and you have heard Dr. Rheuban's comment. Have you all
run studies to determine that it is actually advantageous--
obviously advantageous to the patient but I mean advantageous
to the company--to go ahead and pay for these services?
Ms. Patrick. You know, there currently is no identifiable
CPT code for telemedicine utilization. So up to this point we
have not been able to adequately track, you know, our
utilization. We do know that through Eastern Montana
Telemedicine Network data that we get from them as far as
utilization goes and also data that we get that we see from
Medicaid and the amount of savings that they have realized
through this, we know that this is something that we definitely
want to continue to support and even expand somehow and get
involved as one of the players in our State to see, you know,
what gaps we can help with to deliver more of this type of
care.
Mr. Bilirakis. What is the story with Blue Cross and Blue
Shield in the other States?
Ms. Patrick. You know, I have been asked to speak to this
in a couple of States, in Florida and in Utah, and I don't know
exactly what the reservation is. I think they may be perceiving
this as a new--another kind of technology that, you know, maybe
it is experimental, maybe it is not going to be cost effective.
But in all reality, to us at Blue Cross and Blue Shield of
Montana, the bottom line is it allows our members to have more
access to care. Otherwise, they wouldn't have.
Mr. Bilirakis. There are a number of payers, as I
understand it, that do pay for these services. I understand
that in Arizona and Wisconsin, the 22 payers, and in Arkansas,
6 payers cover these services.
Mr. Reid.
Mr. Reid. Thank you, Mr. Chairman.
I actually had the pleasure of conducting a survey of
telemedicine reimbursement practices in the States that are
covered by many of the Federal funded grant programs, and the
data that we collected suggested there were over 180 different
payers who paid for telemedicine services in some capacity in
most States. There were very few States who didn't have one or
more payers that paid. There are States where Blue Cross pays,
and States where Blue Cross doesn't.
I would say that I had the pleasure of working with eastern
Montana telemedicine, working with Ms. Patrick some 6 or 7
years ago, and the vision that they showed in stepping forward
and leading in that regard is unparalleled and, frankly, not
seen since.
We have the challenge in each of our States because whether
Aetna or Blue Cross or Prudential covers in one State, their
plan is different, maybe under a different policy, a different
intermediary in another State. So we as providers have the
challenge of going to each individual company within our State
and saying, well, come on, guys, why not, show us a good reason
not to. And the typical response is, well, because it is going
drive up costs.
I actually had the pleasure of asking Ms. Patrick to come
to my State of Iowa now and speak to several payers in a closed
door session. And you haven't said it yet, but I am going to
ask you to verify that indeed in that setting you said that it
has not driven up your costs; you have been able to identify no
additional cost.
Ms. Patrick. We are not aware of any additional costs, you
know, from this service. So we do not have a problem
whatsoever.
Mr. Bilirakis. You have not seen overutilization of the
service?
Ms. Patrick. We have--no.
Mr. Bilirakis. Taking advantage of the service.
Ms. Patrick. No. I think that our members are choosing
video conferencing, telemedicine instead of actually physically
going there, and understandably so.
Mr. Bilirakis. The bells have just sounded for a vote. With
the indulgence of my colleagues, Ms. Patrick--is it always an
MD or might the provider be someone other than an MD?
Ms. Patrick. It could be someone other, yes.
Mr. Bilirakis. So now they present this to, let us say, the
Mayo Clinic or wherever it might be. Have you run into any
problems or have there been any problems with your State
licensure board in other words practicing medicine in Montana
when you are not a Montana-licensed doctor?
Ms. Patrick. We haven't had any activity as far as that
goes, but I do know that our legislature is currently looking
at setting some kinds of fees for providers to be able to
participate or deliver this service. I don't think they are
astronomically high fees.
Mr. Bilirakis. But in the process of setting those fees
they would be then satisfying the licensure requirement? You
know--and talk about the Montana Medical Board, for instance,
practicing medicine without a license in Montana.
Ms. Patrick. I believe so.
Mr. Bilirakis. That used to be quite a problem. I don't
really know what the current picture is now since there has
been some reimbursement on the part of Medicare. That is an
obstacle--that is what I was really leading up to, Dr. Ross-
Lee, when I asked you my questions.
Ms. Ross-Lee. It might also be a problem even as the
licensure boards, at least among physicians, are sharing a lot
of information and setting similar standards. But for the
nonphysician providers that are also listed as potential
providers on either end the States vary significantly in the
licensure requirements there, and I am not sure they have come
very close.
Mr. Bilirakis. Anything further, Mr. Strickland or Mr.
Brown?
Mr. Strickland. No.
Mr. Bilirakis. All right. We are going to excuse you and
thank you, much gratitude for helping us out here, helping us
do good things.
We do have a vote on the floor. There will be a
demonstration presented. Certainly our staffs will be here if
we are not able to come back depending on what is happening
over there.
The hearing is adjourned. Thank you very, very much.
[Whereupon, at 1:05 p.m., the subcommittee was adjourned.]
[Additional material submitted for the record follows:]
Prepared Statement of Hon. John Thune, a Representative in Congress
from the State of South Dakota
Chairman Bilirakis and Ranking Member Brown: I commend you for your
leadership you and the members of this subcommittee have shown in the
area of Medicare modernization and reform. By holding today's hearing
on telehealth, you are recognizing the importance of this issue to both
patients and providers who live in rural and medically underserved
areas.
Telehealth as a method of health care delivery was, at one time, a
new concept in health care delivery, a theoretical way to connect
patients with their doctors. But telehealth is no longer an experiment,
it's a service that is used every day in rural areas across the
country. The district I represent comprises the entire state of South
Dakota. That's 66 counties and 77,000 square miles made up primarily of
farmland and grassland. When the citizens of South Dakota need to
access their health care provider, it is not uncommon to drive a
hundred miles just to make a regular appointment.
During the August work period, I traveled around the state visiting
rural hospitals, clinics, and nursing homes to get a closer look at the
challenges faced by rural health care providers. I saw some of the
amazing things health care providers are doing with telehealth
technology. Lung specialists in Sioux Falls are using electronic
stethoscopes to treat patients with pneumonia who live in Flandreau, a
town of 2,322 people. The Pine Ridge reservation, which sits in the
nation's poorest county per capita, is over 130 miles from the area's
major medical center in Rapid City. Residents of Pine Ridge who may be
dealing with depression no longer have to wait for months to see a
psychiatrist but can access a mental health provider using two-way
interactive video cameras. Expectant mothers in Hoven can get good pre-
natal care using OB ultrasounds transmitted over phone lines without
having to make the 90-minute drive to Aberdeen.
Telehealth services have become critical for these patients and the
providers who care for them. Back in 1997, Congress authorized several
telehealth demonstration projects to study the impact of telehealth on
health care access, quality, and cost. These projects have proven the
feasibility of using technology to provide primary and specialty care
for patients in rural and medically underserved areas.
The Health Care Financing Administration (HCFA) however has created
reimbursement policies that have had the effect of excluding services
to those patients who would derive the most benefit from access to
telehealth; seniors who are often unable to travel long distances for
direct health care. In 1999, Medicare covered only 6 percent of all
telehealth visits. That was about $11,000 in claims. Clearly, Congress
intended that HCFA would provide more reimbursement for these critical
services.
With these facts in mind, I introduced H.R. 4841, the Medicare
Access to Telehealth Services Act of 2000, a measure aimed at
eliminating some of the reimbursement barriers to telehealth services.
H.R. 4841 looks at Medicare reimbursement for telehealth services and
addresses the significant barriers in the Balanced Budget Act of 1997
(BBA) to the continued use and expansion of this technology.
Some of the most onerous barriers will be discussed during today's
hearing. They include requiring a telepresenter to be with the patient,
forcing providers to share their fees, limiting reimbursement areas and
billing codes, and neglecting facility costs.
As the discussions continue on further refinements of the BBA, I
strongly urge the members of this subcommittee to include provisions to
address these funding barriers. Congress has worked to ensure that
technology is available to our constituents, now it's time for this
technology to work for us.
______
Prepared Statement of Children's National Medical Center
Background on CNMC
On behalf of the hundreds of thousands of children treated at our
facilities over the years, coming from every state in the country, we
appreciate the opportunity to offer testimony regarding our experiences
in providing telehealth services in medically underserved urban areas
for a large Medicaid population.
Children's National Medical Center (CNMC) has provided
comprehensive quality medical care and health services since 1870, and
is the only integrated healthcare system in the Washington D.C. area
dedicated exclusively to the care of infants, children, adolescents and
young adults. In addition to our main campus, Children's network of
care includes four inner-city pediatric health centers, six regional
outpatient centers, several suburban ambulatory surgical locations, and
a hearing and speech center. CNMC consistently ranks among the nation's
top pediatric hospitals.
Above all, CNMC seeks to provide unparalleled pediatric healthcare
services that enhance the health and well-being of children regionally,
nationally, and internationally. We are creating solutions to pediatric
healthcare problems. To meet the unique healthcare needs of children,
adolescents, and their families, CNMC strives to excel at the core
components of our mission--Care, Advocacy, Research, and Education.
A Model for Medically Underserved Urban Areas
Currently, much of our community outreach and our efforts to
improve healthcare access occur through our four Community Pediatric
Health Centers (CPHC) located throughout medically underserved urban
areas in the District of Columbia. Since the first opening in 1967, the
CPHCs have provided three generations of District of Columbia families
with high quality primary, specialty and preventive healthcare
services.
After a decade of preliminary work, CNMC established a formal
Pediatric Telemedicine Program in 1997 in an effort to provide leading
edge technological support for clinical care and research. CNMC has
actively pursued telemedicine in an effort to define opportunities
where technology can be leveraged to improve patient care for the
children of the region. The telemedicine team is dedicated to planning,
implementing, and analyzing telemedicine activities in order to improve
access to primary and specialty care, to increase convenience for
patients and physicians, and to improve education for physicians,
healthcare professionals, families and patients.
Despite dramatic advances in our knowledge of how to treat the
medical conditions of our population, children of urban underserved
communities encounter many obstacles when attempting to access quality
healthcare--including socioeconomic isolation, maldistributed health
services, lack of health insurance, and poverty. Fragmented access,
inconsistent quality, excess costs, loss of continuity, and ineffective
continuing medical education characterize the deficiencies of our
existing health care system.
Meeting the healthcare challenges of our inner city children and
families with the help of telemedicine requires a collaborative network
of community partners. These partnerships provide the foundation for a
new technology-enabled delivery model, the Pediatric Community Health
Network (PCHN). Our proposed approach will be a major step toward
achieving our long-term goal of providing a means to improve pediatric
health indicators at the local and national level.
This technology-enhanced telemedicine model strives to achieve the
following goals:
1) increase access to primary and specialty healthcare for the child
and family;
2) increase the convenience of healthcare delivery by bringing the
specialists and healthcare professionals to the child and the
family;
3) decrease cost and time lost while seeking primary and specialty care
(lost school days, lost work days);
4) decrease delays in diagnosis by allowing earlier access to
specialists, which in turn will reduce costs and treatment
time;
5) improve communication and provide a means to support the continuum
of care for the patient, family and healthcare provider(s);
6) improve healthcare education by providing patients and their
families with better resources and educational healthcare;
7) improve quality and effectiveness of medical follow-up appointments.
Through the use of telemedicine at our primary care clinics and
outlying rural sites, patients can have instant access to the myriad of
specialists at our main campus. Oftentimes access to health care in
large urban areas can be just as difficult and time consuming as in
rural areas. For many of our patients, travelling across a large
metropolitan area to reach another health care facility would require
time off from their jobs, time lost from school, and hours spent on
public transportation lines before reaching the facility. For the
families that have access to this technology, this instant access to
specialists reduces the need for follow-up appointments that often must
be canceled, and assists with earlier diagnosis that helps children
heal faster.
Children's telemedicine program for the underserved urban pediatric
community is the first initiative of its kind. Our goal is to build a
sustainable model that will be replicated across the country. By
deploying telemedicine in the urban setting, the impact on the
underserved community could be extensive. This technology that supports
our telemedicine program empowers families and communities to improve
the health status of their most valuable asset--the children.
Barriers to Effective Use of Telemedicine
As promising as this technology and its applications may sound,
significant reimbursement barriers prevent us from deploying this
technology solution to a great extent in medically underserved urban
communities and the surrounding area. The significant challenges we
face include:
Funding for technology: Although the Office for the
Advancement of Telehealth in the Health Resources and Services
Administration has provided support for the development of
telehealth services, their funding has been limited to rural
projects only. But children in medically underserved urban
areas face many of the same barriers to health care as rural
patients, and could benefit substantially from telemedicine
projects. We strongly urge Congress to support funding for
telemedicine projects in urban settings.
Reimbursement for telehealth services for Medicaid patients:
As Congress considers improvement of the reimbursement
mechanisms for telehealth services, we strongly urge you to
remember the children and families that receive their health
care from Medicaid. Telehealth services should not be
restricted to Medicare beneficiaries. The Medicaid population
is often overlooked or forgotten during consideration, but the
children who benefit from Medicaid services are equally
deserving.
Summary
Children's National Medical Center is dedicated to improving the
health status of our community. We can not do this alone. The
advancement of new technologies coupled with a highly competitive and
challenging healthcare environment requires innovative patient care. It
is critical that telemedicine be permitted to enter the mainstream
delivery system.
According to the Children's Defense Report in 1998,
Every 43 minutes a child was reported abused or neglected . . .
Every 6 hours a baby was born to a teenage mother . . .
Every 7 hours a baby was born at low birth weight . . .
Every 3 days a baby died during the first year of life . . .
These ``moments'' represent reality in the lives of many District
of Columbia infants, children and adolescents, and are reflective of a
growing trend in our region and our nation. The region's children face
a long list of challenges that impact their ability to receive quality
health care so that they may lead healthy and productive lives. While
we understand the significance of bringing telemedicine to rural
Medicare beneficiaries, we strongly urge Congress not to forget the
medically underserved urban children who are Medicaid beneficiaries.
They are important constituents, too.
We look forward to working with you to advance the use of
telemedicine to help build healthy communities. If you need further
information regarding CNMC, please do not hesitate to contact Greta
Todd, CNMC Director of Legislative Affairs, at 202-884-2340. Thank you
again for your consideration of our concerns.