[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]




 
TELEHEALTH TO DIGITAL MEDICINE: HOW 21ST CENTURY TECHNOLOGY CAN BENEFIT 
                                PATIENTS

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 1, 2014

                               __________

                           Serial No. 113-142
                           
                           
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]                          
                           


      Printed for the use of the Committee on Energy and Commerce

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                    COMMITTEE ON ENERGY AND COMMERCE

                          FRED UPTON, Michigan
                                 Chairman
RALPH M. HALL, Texas                 HENRY A. WAXMAN, California
JOE BARTON, Texas                      Ranking Member
  Chairman Emeritus                  JOHN D. DINGELL, Michigan
ED WHITFIELD, Kentucky                 Chairman Emeritus
JOHN SHIMKUS, Illinois               FRANK PALLONE, Jr., New Jersey
JOSEPH R. PITTS, Pennsylvania        BOBBY L. RUSH, Illinois
GREG WALDEN, Oregon                  ANNA G. ESHOO, California
LEE TERRY, Nebraska                  ELIOT L. ENGEL, New York
MIKE ROGERS, Michigan                GENE GREEN, Texas
TIM MURPHY, Pennsylvania             DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas            LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee          MICHAEL F. DOYLE, Pennsylvania
  Vice Chairman                      JANICE D. SCHAKOWSKY, Illinois
PHIL GINGREY, Georgia                JIM MATHESON, Utah
STEVE SCALISE, Louisiana             G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio                JOHN BARROW, Georgia
CATHY McMORRIS RODGERS, Washington   DORIS O. MATSUI, California
GREGG HARPER, Mississippi            DONNA M. CHRISTENSEN, Virgin 
LEONARD LANCE, New Jersey                Islands
BILL CASSIDY, Louisiana              KATHY CASTOR, Florida
BRETT GUTHRIE, Kentucky              JOHN P. SARBANES, Maryland
PETE OLSON, Texas                    JERRY McNERNEY, California
DAVID B. McKINLEY, West Virginia     BRUCE L. BRALEY, Iowa
CORY GARDNER, Colorado               PETER WELCH, Vermont
MIKE POMPEO, Kansas                  BEN RAY LUJAN, New Mexico
ADAM KINZINGER, Illinois             PAUL TONKO, New York
H. MORGAN GRIFFITH, Virginia         JOHN A. YARMUTH, Kentucky
GUS M. BILIRAKIS, Florida
BILL JOHNSON, Missouri
BILLY LONG, Missouri
RENEE L. ELLMERS, North Carolina



                                  (II)



                         Subcommittee on Health

                     JOSEPH R. PITTS, Pennsylvania
                                 Chairman
MICHAEL C. BURGESS, Texas            FRANK PALLONE, Jr., New Jersey
  Vice Chairman                        Ranking Member
ED WHITFIELD, Kentucky               JOHN D. DINGELL, Michigan
JOHN SHIMKUS, Illinois               ELIOT L. ENGEL, New York
MIKE ROGERS, Michigan                LOIS CAPPS, California
TIM MURPHY, Pennsylvania             JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee          JIM MATHESON, Utah
PHIL GINGREY, Georgia                GENE GREEN, Texas
CATHY McMORRIS RODGERS, Washington   G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey            JOHN BARROW, Georgia
BILL CASSIDY, Louisiana              DONNA M. CHRISTENSEN, Virgin 
BRETT GUTHRIE, Kentucky                  Islands
H. MORGAN GRIFFITH, Virginia         KATHY CASTOR, Florida
GUS M. BILIRAKIS, Florida            JOHN P. SARBANES, Maryland
RENEE L. ELLMERS, North Carolina     HENRY A. WAXMAN, California (ex 
JOE BARTON, Texas                        officio)
FRED UPTON, Michigan (ex officio)


                                   (III)



  
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Joseph R. Pitts, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     2
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     3
Hon. Fred Upton, a Representative in Congress from the State of 
  Michigan, opening statement....................................     5
    Prepared statement...........................................     6

                               Witnesses

Rashid Bashshur, Executive Director for Ehealth, University of 
  Michigan Health System, Professor Emeritus, University of 
  Michigan School of Public Health...............................     8
    Prepared statement...........................................    10
    Answers to submitted questions...............................    91
Ateev Mehrotra, Policy Analyst, Rand Corporation, Associate 
  Professor of Health Care Policy And Medicine, Harvard Medical 
  School.........................................................    24
    Prepared statement...........................................    26
    Answers to submitted questions...............................   113
Tom Beeman, President and Chief Executive Officer, Lancaster 
  General Health.................................................    35
    Prepared statement...........................................    37
    Answers to submitted questions...............................   121
Gary Chard, Delaware State Director, Parkinson's Action Network..    47
    Prepared statement...........................................    49
    Answers to submitted questions...............................   133
Kofi Jones, Vice President of Public Affairs, American Well......    56
    Prepared statement...........................................    58
    Answers to submitted questions...............................   144

                           Submitted Material

Documents submitted by Mr. Pitts.................................    76
Statement of Dr. Topol...........................................    90


TELEHEALTH TO DIGITAL MEDICINE: HOW 21ST CENTURY TECHNOLOGY CAN BENEFIT 
                                PATIENTS

                              ----------                              


                         THURSDAY, MAY 1, 2014

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:02 a.m., in 
room 2123, Longworth House Office Building, Hon. Joseph R. 
Pitts (chairman of the subcommittee) presiding.
    Present: Representatives Pitts, Burgess, Shimkus, Lance, 
Guthrie, Griffith, Bilirakis, Ellmers, Barton, Upton (ex 
officio), Pallone, Dingell, Engel, Green, Barrow, Christensen, 
and Waxman (ex officio).
    Also present: Representative Harper.
    Staff Present: Clay Alspach, Chief Counsel, Health; Sean 
Bonyun, Communications Director; Noelle Clemente, Press 
Secretary; Sydne Harwick, Legislative Clerk; Robert Horne, 
Professional Staff Member, Health; Chris Pope, Fellow, Health; 
Macey Sevcik, Press Assistant; Heidi Stirrup, Health Policy 
Coordinator; Tom Wilbur, Digital Media Advisor; Ziky Ababiya, 
Minority Staff Assistant; Kaycee Glavich, Minority GAO 
Detailee; Karen Lightfoot, Minority Communications Director and 
Senior Policy Advisor; and Matt Siegler, Minority Counsel.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Pitts. The subcommittee will come to order. The chair 
will recognize himself for an opening statement.
    Telemedicine and digital medicine in all their forms 
present a host of potential benefits to both patients and 
providers. Virtual doctor visits are one way to help address 
provider shortages, particularly in rural areas where patients 
may have to travel a great distance at their own cost to see a 
doctor in person. Telemedicine can allow in-home monitoring of 
chronically ill patients and facilitate patient education.
    Provider-to-provider virtual consultations may also lead to 
greater efficiencies in the system by providing continuity of 
care and reducing duplicative testing and services. The ability 
to Skype or use a video call can also reduce the inappropriate 
use of resources by patients. For example, a parent with a 
small child who is sick in the middle of a night could access a 
provider via web cam and potentially avoid an unnecessary trip 
to the emergency room.
    For all of its potential benefits, concerns about the 
appropriate way to support such technologies abound. If not 
done carefully, some fear the potential for good that many 
envision in this space can instead lead to waste, fraud, and 
abuse. Therefore, the purpose of today's hearing is to explore 
the types of technologies that hold great promise and hear 
ideas that allow the Federal Government to realize this 
potential to reduce cost, improve efficiencies, and ensure 
quality in our healthcare programs.
    To that end, Ranking Member Pallone and I will be releasing 
a call for ideas following the hearing. We will be looking for 
specific policy and legislative ideas on how the Federal 
Government can support technology adoption in our healthcare 
programs for the express and explicit purpose of reducing cost 
and increasing the overall quality and efficiency of the 
programs.
    We are also looking for ways in which the Federal 
Government currently inhibits the use or adoption of such 
technologies by all players in the healthcare system, be they 
insurer, provider, or patient. The more specific and targeted 
policy, the greater chance it will hold for congressional 
support down the line.
    I would like to welcome all of our witnesses to the 
subcommittee hearing today, especially Dr. Tom Beeman, 
president and CEO of Lancaster General Hospital, the largest 
hospital and one of the largest employers in my congressional 
district.
    I would like to yield the remainder of my time to the 
gentleman from Mississippi, Mr. Harper.
    [The prepared statement of Mr. Pitts follows:]

               Prepared statement of Hon. Joseph R. Pitts

    The Subcommittee will come to order.
    The Chair will recognize himself for an opening statement.
    Telemedicine and digital medicine, in all of their forms, 
present a host of potential benefits to both patients and 
providers.
    Virtual doctor visits are one way to help address provider 
shortages, particularly in rural areas, where patients may have 
to travel a great distance, at their own cost, to see a doctor 
in-person.
    Telemedicine can allow in-home monitoring of chronically 
ill patients and facilitate patient education.
    Provider-to-provider virtual consultations may also lead to 
greater efficiencies in the system by providing continuity of 
care and reducing duplicative testing and services.
    The ability to Skype or use a video call can also reduce 
the inappropriate use of resources by patients. For example, a 
parent with a small child who is sick in the middle of the 
night could access a provider via web cam and potentially avoid 
an unnecessary trip to the emergency room.
    For all its potential benefits, concerns about the 
appropriate way to support such technologies abound. If not 
done carefully, some fear the potential for good that many 
envision in this space can instead lead to waste, fraud, and 
abuse.
    Therefore, the purpose of today's hearing is to explore the 
types of technologies that hold great promise, and hear ideas 
that allow the federal government to realize this potential to 
reduce costs, improve efficiencies, and ensure quality in our 
health care programs.
    To that end, Ranking Member Pallone and I will be releasing 
a call for ideas following the hearing. We will be looking for 
specific policy and legislative ideas on how the federal 
government can support technology adoption in our health care 
programs for the express and explicit purpose of reducing costs 
and increasing the overall quality and efficiency of the 
programs.
    We are also looking for ways in which the federal 
government currently inhibits the use or adoption of such 
technologies by all players in the health care system--be they 
insurer, provider, or patient. The more specific and targeted 
the policy, the greater chance it will hold for Congressional 
support down the line.
    I would like to welcome all of our witnesses to the 
Subcommittee today, especially Dr. Tom Beeman, President and 
CEO of Lancaster General Hospital, the largest hospital and one 
of the largest employers, in my congressional district.
    Thank you, and I yield the remainder of my time to --------
------------------------------------.

    Mr. Harper. Thank you, Mr. Chairman. I appreciate your 
attention to this important subject.
    And, Ranking Member Pallone, I value your shared interest 
in telehealth.
    Over the last couple of years, I have had the privilege of 
being a part of this exciting conversation on telemedicine. My 
staff and I have engaged in a years-long discussion and 
dialogue with patients, providers, and many other industry 
stakeholders to determine the most appropriate way for Congress 
to advance telehealth.
    The bottom line is that until we can attract more 
physicians to underserved communities and tighten the access 
gap, the best and most cost-efficient alternative is to improve 
telehealth networks. That is why I have introduced the 
Telehealth Enhancement Act, a bill to strengthen Medicare and 
enhance Medicaid through expanded telemedicine coverage.
    But most importantly, it is really about fairness. Access 
to care should not be limited based on where Americans choose 
to live. My goal is to build on existing telemedicine reforms 
that States like Mississippi have advanced and pioneered. The 
University of Mississippi Medical Center, for example, has been 
a leader in advancing telemedicine. Along the way, I hope also 
that we can help States, as well as the Federal Government, to 
lower healthcare costs by encouraging people to adopt healthier 
lifestyles and reducing avoidable hospital visits.
    Just this past Monday, the State of Mississippi was 
devastated in many communities from a series of tornados. 
Yesterday, I was able to fly down with our two United States 
Senators and another Congressman to view the damage, and 
particularly hard hit were areas in Tupelo, in my home county 
of Rankin County, and the cities of Richland, Pearl, and 
Brandon, but most extensively was in the city of Louisville, 
which experienced about a 0.75 of a mile to a mile-wide tornado 
that was on the ground for some distance, with many deaths. And 
so the University of Mississippi Medical Center was able to 
utilize telemedicine to help on the ground there and continuing 
to do so. And these are things that, I think, have a great 
future.
    So thank you, Mr. Chairman. And I yield back.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the ranking member, Mr. Pallone, 5 minutes 
for an opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Chairman Pitts, for agreeing to 
hold today's important hearing on telehealth. As ranking member 
of this subcommittee and a member of the Communications and 
Internet Subcommittee, telehealth has been an interest of mine 
for some time. And I also know there are many members of the 
committee and across Congress who share this interest. So I am 
glad we are having this opportunity.
    An aging population and an expansion in healthcare coverage 
means that more Americans will be using healthcare services in 
the coming years. And as new demands are placed on our national 
healthcare system, I strongly believe as policymakers we need 
to be actively working to leverage technology to lower costs, 
increase access, and improve quality of care.
    The convergence of medical advances, health information 
technology, and a nationwide broadband network is transforming 
the delivery of care by bringing the healthcare provider and 
patient together virtually. Telemedicine has the potential to 
serve a large portion of the U.S. by expanding the reach of 
medical resources while reducing cost and increasing quality. 
And while we continue to advocate transforming our system from 
one of treating the sick to preventing people from getting 
sick, telemedicine can play a pivotal role.
    For example, persons who have difficulty leaving the home, 
the elderly and the physically disabled, could easily and 
regularly access health care from the comfort of their home. 
Telemedicine also has the ability to assist people with 
diabetes, obesity, heart failure, and mental illness, as well 
as other diseases by reducing the number of readmissions to 
hospitals.
    When Congress passed the Affordable Care Act we strongly 
felt that the status quo was not sustainable. Not only did we 
have to expand coverage in this country for the uninsured, but 
we also needed to change our system to reflect and incentivize 
both quality and efficient care. And as a part of that broader 
goal, the law includes a variety of provisions aimed at 
expanding the use of telehealth, recognizing that doing so can 
help to increase the quality of care through monitoring and 
specialization.
    For example, the Independence at Home Demonstration is 
testing whether providing chronically ill patients with a range 
of services in the home setting can reduce hospitalization and 
improve health outcomes. It also includes an option for states 
to provide health homes for Medicaid enrollees with chronic 
conditions. And of course the greater use of ACOs can play an 
important role in the expansion of telehealth services.
    Telehealth also allows patients' health to be constantly 
monitored between doctors visits and makes it easier for 
patients to connect with more specialists. Evidence shows the 
specialists utilizing telemedicine are still able to accurately 
evaluate and diagnosis patients without person-to-person 
contact. Telephone, video conferencing, computers, and Internet 
applications or apps are all employed. Hospitals and medical 
centers use telehealth to reach patients in underserved rural 
areas. The military makes use of telehealth in its health 
program, and States within their bounds are working with 
universities to practice telemedicine.
    Telemedicine can also reduce healthcare costs. It would 
enable doctors and other specialized professionals to come 
together and effectively reach more patients, which is 
important as the ACA is being implemented and more Americans 
are becoming insured. It also allows for diseases to be tracked 
so they can be treated before they become more costly. And 
telehealth proponents suggest that these technologies can 
relieve medical workforce shortages and the unequal 
distribution of clinicians in the United States.
    For patients, telehealth can mean connecting with medical 
expertise not locally available, saving time, money, and 
travel, reducing unnecessary hospital visits, and improving the 
management of chronic conditions.
    And that is why I joined with my Republican colleague, 
Representative Devin Nunes, a member of the Ways and Means 
Committee, to introduce the Telemedicine for Medicare or TELE-
MED Act, which aims to increase access to telemedicine in the 
Medicare program. Specifically, it would permit Medicare 
providers who are licensed to practice medicine physically in 
one State to treat patients electronically across State lines.
    Under that bill, the State in which the license is issued 
would have enforcement authority regardless of the patient's 
location. And by connecting the Medicare patient and provider 
virtually at the point and time of care, the TELE-MED Act gives 
Medicare patients access to the best health care anywhere at 
any time. It also directs the Secretary to report to Congress 
on how we can ensure increased use of telemedicine in the 
Medicare program.
    Now, I know there are stakeholders who remain concerned 
about the approach we have taken in this bill. I also know that 
telehealth raises operational questions and faces serious 
challenges. For example, most clinicians have not been trained 
in telehealth, and there are also security and privacy 
concerns. As a strong advocate of preserving and strengthening 
Medicare, we must ensure program integrity is preserved and 
utilization costs do not rise.
    So we have a lot of work to do, Mr. Chairman, but I hope 
that we can still find common ground. We have a great 
opportunity to come together to expand the use of telehealth in 
this country. That is why I am proud to join with you in 
calling for an exchange of ideas. And as you said, we intend to 
set up a process in which all stakeholders can share with our 
subcommittee their views on this topic. Our goal is to use this 
process to further inform the subcommittee on what public 
policies that, if adopted by Congress, might allow for improved 
delivery and access to health care.
    Thank you, Mr. Chairman.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the chairman of the full committee, Mr. 
Upton, for 5 minutes for an opening statement.

   OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF MICHIGAN

    Mr. Upton. Well, thank you, Mr. Chairman.
    We are here today to explore the opportunities 21st century 
technology presents to improve the lives of patients and 
advance our healthcare system. The introduction of digital 
forms of communication and applications, such as wireless 
technologies and smart phones, hold tremendous and great 
promise for the future of our healthcare system.
    Twenty-first century technologies can allow providers to 
monitor patients released from an inpatient hospital, help 
reduce the chances of relapse or even readmittance. They also 
can support new delivery reforms and models that were part of 
the focus of the doc fix SGR reform legislation that was 
authored by Dr. Burgess, which we passed out of this committee 
51 to nothing; help improve access for those in rural areas 
like South Haven, Michigan; reduce the overall invasiveness and 
risk related to healthcare procedures and illnesses.
    I want to commend particularly you, Chairman Pitts and 
Ranking Member Pallone, for your collaboration on today's 
hearing. As you have discussed, we will be soliciting ideas for 
how technology can be incorporated into our healthcare system 
to improve the cost, quality, and delivery of health care 
across the country.
    And in support of that effort there are a number of 
questions that need to be answered. Which technologies hold 
promise for improving the quality and delivery of health care 
in this country? What role, if any, exists for the Federal 
Government in supporting such technologies? How can Congress 
help foster and realize the promise of 21st century 
technologies to improve the lives of all Americans?
    This will be a priority of the Committee on Energy and 
Commerce over the next couple of years as we work together 
towards fostering innovation that will lead to more treatments 
and cures for issues related to personal illnesses and the 
overall delivery of health care. The topics discussed today 
will certainly be a vital part of the 21st Century Cures 
initiative that was unveiled yesterday and will continue in the 
weeks and months ahead.
    I also want to recognize the efforts of committee members 
Gregg Harper, Bill Johnson, Doris Matsui, and Peter Welch, who 
have helped author legislation that in part made today's 
hearing possible. I yield back the balance of my time to 
gentleman from Texas, Dr. Burgess.
    [The prepared statement of Mr. Upton follows:]

                 Prepared statement of Hon. Fred Upton

    We are here today to explore the opportunities 21st century 
technology presents to improve the lives of patients and 
advance our health care system.
    The introduction of digital forms of communication and 
applications, such as wireless technologies and smart phones, 
hold great promise for the future of our health care system. 
Twenty-first century technologies can allow providers to 
monitor patients released from an inpatient hospital and help 
reduce the chances of relapse and re-admittance. They also can 
support new delivery reforms and models that were part of the 
focus of SGR reform legislation authored by Dr. Burgess, help 
improve access for those in rural areas, and reduce the overall 
invasiveness and risks related to health care procedures and 
illnesses.
    I want to commend Chairman Pitts and Ranking Member Pallone 
for their collaboration on today's hearing. As they just 
discussed, they will be soliciting ideas for how technology can 
be incorporated into our health care system to improve the 
cost, quality, and delivery of health care in this country.
    In support of that effort, there are a number of questions 
that need to be answered: Which technologies hold promise for 
improving the quality and delivery of health care in this 
country? What role, if any, exists for the federal government 
in supporting such technologies? How can Congress help foster 
and realize the promise of 21st century technologies to improve 
the lives of Americans?
    This will be a priority of the Committee on Energy and 
Commerce over the next few years as we work towards fostering 
innovation that will lead to more treatments and cures for 
issues related to personal illness and the overall delivery of 
health care. The topics discussed today will certainly be a 
vital part of the 21st Century Cures initiative that was 
unveiled yesterday.
    I also would like to recognize the efforts of committee 
members Gregg Harper, Bill Johnson, Doris Matsui, and Peter 
Welch who have helped author legislation that in part made 
today's hearing possible.
    I yield the balance of my time to ------------------------
----------------------.

    Mr. Burgess. I thank the chairman for yielding and I thank 
the chairman for the recognition about the SGR bill. It is a 
landmark achievement.
    I will never forget the time in practice when I learned 
about the CPT Code 99371. It was a code that paid for a 
telephone consultation. I thought my life would be forever 
changed because now all of these hours at night I spent on the 
telephone could be reimbursed. But little did I know it fell 
into the broad category of codes with no reimbursement. All 
right.
    Medicine has changed a lot in the 21st century, and a lot 
of it has been for the good. Some of the policy has been the 
opposite of good, but many of the things that are happening on 
the technological front are certainly dramatically changing the 
practice of medicine, and telemedicine is helping to improve 
access to care and make practices more efficient. The 
convergence of medical and technological advances; everyone is 
now carrying a smart phone. The nationwide broadband network is 
transforming the delivery of care by bringing providers and 
patients together, together in a virtual world that previously 
did not exist.
    In Texas, providers from across the State can now treat 
patients in remote locations. A Texas law passed in 2013 
enables physicians to more easily collaborate with rural nurse 
practitioners via teleconference, helping to expand vitally 
needed primary care services to patients. Thus the role of the 
physician extender is finally being fulfilled.
    It is important that these services be provided in a manner 
that is safe and effective for patients. The technological 
advances before us and those just over the horizon have great 
potential to connect patients to cutting-edge care, but it must 
be practiced by those appropriately trained for the maximum 
potential benefit. For that reason, I am grateful that we have 
the panel before us today, certainly, an all-star panel of 
people who live in this world every day. I am looking forward 
to their testimony. And I will yield back, Mr. Chairman.
    Mr. Pitts. The chair thanks the gentleman.
    I now would like to ask unanimous consent to include the 
following statements for today's hearing record from the 
American Osteopathic Association, the American Academy of 
Dermatology Association, American Medical Association, and the 
American Academy of Family Physicians. Without objection, so 
ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Pitts. We have on our panel today five witnesses. I 
will introduce them in the order in which they should speak. 
First, Dr. Rashid Bashshur, executive director for eHealth, 
University of Michigan Health System. Secondly, Dr. Ateev 
Mehrotra, policy analyst, RAND Corporation; then Dr. Tom 
Beeman, president and CEO of Lancaster General Health; Mr. Gary 
Chard, Delaware State director, Parkinson's Action Network; and 
Ms. Kofi Jones, the vice president of public affairs of 
American Well.
    Thank you very much for coming. Your written testimony will 
be made a part of the record. We will give you each 5 minutes 
to summarize your testimony. There is a little system of lights 
on your table, so when you see red, that means you should wind 
up, if you please.
    And Dr. Bashshur, we will start with you. You are 
recognized for 5 minutes for your opening statement. Poke the 
button on there, please. Yes. The light should come on and then 
you are on.

   STATEMENTS OF DR. RASHID BASHSHUR, EXECUTIVE DIRECTOR FOR 
   EHEALTH, UNIVERSITY OF MICHIGAN HEALTH SYSTEM, PROFESSOR 
 EMERITUS, UNIVERSITY OF MICHIGAN SCHOOL OF PUBLIC HEALTH; DR. 
  ATEEV MEHROTRA, POLICY ANALYST, RAND CORPORATION, ASSOCIATE 
 PROFESSOR OF HEALTH CARE POLICY AND MEDICINE, HARVARD MEDICAL 
SCHOOL; DR. TOM BEEMAN, PRESIDENT AND CHIEF EXECUTIVE OFFICER, 
LANCASTER GENERAL HEALTH; GARY CHARD, DELAWARE STATE DIRECTOR, 
 PARKINSON'S ACTION NETWORK; AND KOFI JONES, VICE PRESIDENT OF 
                 PUBLIC AFFAIRS, AMERICAN WELL

                  STATEMENT OF RASHID BASHSHUR

    Mr. Bashshur. Thank you very much. I am delighted to be 
here to discuss telemedicine with you. Thank you for the 
opportunity. For convenience, I will use the term 
``telemedicine'' throughout my discussion, also referred to as 
telehealth, e-health, m-health, and connected health.
    If I may, Mr. Chairman, I would like to thank the 
distinguished Members of Congress who just spoke for making my 
job easy. They have already said it: No one has to prove that 
ready access to expert medical consultations at reasonable cost 
can save lives; that obviating travel and reducing waiting 
times for patients and their families by providing appropriate 
quality care in their local community and referrals only when 
necessary is a step in the right direction; that ready access 
to evidence-based medicine by providers is in the best interest 
of patients; that giving providers immediate access to 
electronic health records, which include patients' medical 
history, allergies, medications, would enable them to make 
better clinical decisions and to avoid errors and adverse 
events from medication contraindications; that enabling 
patients to adopt healthy lifestyles and take an active part in 
their own care is inherently good and saves money; that 
avoiding unnecessary medical visits for pre- and post-surgery 
appointments; the list goes on.
    On a more personal level, no one needs to prove that saving 
the life of a young boy presenting with cardiac arrest in a 
remote community hospital is worth the limited cost of a 
multipurpose telemedicine network. I know of one tragic event 
where such a boy died en route to a tertiary care hospital when 
a remote consultation with a pediatric intensivist could have 
saved his life.
    Telemedicine can save money by early intervention, rapid 
response, and empowered patients. It can avoid costly 
complications of chronic diseases. Its tools can be used to 
reduce human resource cost, travel cost, and wasted waiting 
times as a substitute and not an add-on service.
    The expansion of this modality of care with proper goals, 
ongoing assessment, together with attendant adjustments and 
quality controls, would save money and improve health outcomes. 
It is most effective when limited assets across State lines can 
be brought into play. Consumer feedback is necessary to avoid 
potential abuse and incompetence. National reciprocity with 
minimal paperwork and national databases are necessary.
    The technologies that can be used to promote adoption of 
healthy lifestyles with enormous implications for cost savings 
are wearable sensors, smart phones, and mobile devices, likely 
to become the dominant telemedicine technology. These 
technologies have produced efficiencies in the delivery of 
service to the point of need in entertainment, banking, 
commerce, and education. The same applies to health care.
    With continued public support for research and development 
for further deployment and refinement of these systems, there 
will be winners: patients, providers, and the public purse. 
Thank you.
    Mr. Pitts. Chair thanks the gentleman.
    [The prepared statement of Mr. Bashshur follows:]
    
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    Mr. Pitts. And I now recognize Dr. Mehrotra 5 minutes for 
an opening statement.

                  STATEMENT OF ATEEV MEHROTRA

    Dr. Mehrotra. Thank you, Chairman Pitts, Ranking Member 
Pallone, and the distinguished members of the committee, for 
inviting me to testify. My name is Ateev Mehrotra. I am a 
physician and researcher at the Beth Israel Deaconess Medical 
Center, the RAND Corporation, and Harvard Medical School.
    One of my core research interests is understanding the 
impact of delivery innovations, and I have termed the 
burgeoning number of new delivery options as the convenience 
revolution in health care. My hope is that these new care 
options can address the common complaint I hear from my own 
patients: that they often have difficulty getting care in a 
timely manner.
    My testimony today is organized around four points for the 
members of the committee to consider. First, frame telehealth 
broadly. One form of telehealth is simply replacing a face-to-
face visit with a video conference. And while this form of 
telehealth technology is important, I believe telehealth should 
be framed much more broadly. Telehealth essentially means using 
technology to deliver care in a mode other than a traditional 
face-to-face visit.
    The great diversity of telehealth technologies makes 
Congress' job very difficult. While it might be tempting to 
begin to define, regulate, or pay for telehealth on how it is 
delivered, technology changes very rapidly, and any definition 
that specifies the type of technology runs the risk of being 
outdated quickly. One reason I advocate for global payment 
methods is the payment is not specific to how the care is 
provided, and this is a point I will return to later in my 
testimony.
    My second point is do not always assume that telehealth 
improves care. As with all new technologies and delivery 
models, it is important not to assume that telehealth always 
improves care. While many studies have shown that telehealth 
can have a positive impact, others have found telehealth is 
ineffective and sometimes even harmful. For example, one recent 
study of home monitoring for older adults found that the home 
monitoring led to an increased risk of death.
    To ensure that telehealth is beneficial, we need more 
population-based quality measures instead of our current 
quality measures, which are often specific to how the care is 
delivered; for example, care in a nursing home. Also, it is 
hard to make blanket statements about whether a given 
telehealth technology is effective or ineffective. Rather, the 
impact of the telehealth technology depends on what are the 
patient and the clinical situation. And so the complexity 
emphasizes the need for more ongoing evaluation of telehealth 
and what works and what doesn't work.
    My third point is that telehealth may improve access but 
not always for the populations we expect. I believe telehealth 
can improve access for people who live in rural areas. However, 
it is important to recognize that people who live in urban 
areas and wealthier communities may be the most likely to use 
telehealth. They may preferentially turn to telehealth because 
they are equally attracted to the convenience and may have more 
access and familiarity with technology. Recognizing 
telehealth's broad appeal is essential because policies should 
not be crafted just for rural communities.
    My fourth and final point is that telehealth can be cheaper 
per clinical encounter, but could also increase utilization and 
spending. Telehealth can reduce healthcare spending. Many 
studies, including my own, have documented that telehealth can 
lead to be cheaper on a per-visit basis. However, lower costs 
per visit does not ensure that telehealth reduces spending. To 
reduce spending, the telehealth visit must replace an in-person 
visit.
    The concern is that telehealth could drive greater 
utilization and increase spending. In other words, people who 
otherwise would have not sought care use telehealth to get 
care. Now, if this increased use of care leads to better 
treatment, better health, then this new utilization is good for 
society. However, the concern is this new use could be 
overutilization, that is care that does not lead to 
improvements in health, and therefore this increased 
utilization does not have any benefit.
    The very advantage of telehealth, its ability to make care 
convenient, is also potentially its Achilles' heel. In some 
cases telehealth can be too convenient. This possibility of 
overutilization can be tempered through bundled payment. Under 
a bundled payment system, providers have more flexibility on 
deciding upon the most appropriate and cost-effective means of 
delivering care for a given patient in a clinical situation.
    To sum up, I am a firm believer in the potential for 
telehealth and other delivery innovations to improve quality, 
decrease costs, and increase access, but there are many 
complexities that require consideration to ensure that 
telehealth reaches that potential.
    Again, let me thank you for allowing me to appear before 
you today, and I would be happy to take any questions.
    Mr. Pitts. The chair thanks the gentleman.
    [The prepared statement of Dr. Mehrotra follows:]
    
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    Mr. Pitts. Now a special welcome to my constituent. I call 
him Mr. Tom Beeman, but he is listed as Dr. Beeman. He is also 
Admiral Beeman.
    But whichever title you would like, Tom, you are welcome. 
You are recognized for 5 minutes.

                    STATEMENT OF TOM BEEMAN

    Mr. Beeman. Good morning, Mr. Chairman, Ranking Member, and 
distinguished members of the House Commerce Subcommittee on 
Health. My name is Thomas Beeman, president and CEO of 
Lancaster General Health. Thank you for allowing me to 
represent our perspective and share how 21st century 
technologies can benefit patients.
    An integrated not-for-profit health system, Lancaster 
General Health, includes 690 beds, 40 outpatient sites, home 
care and infusion therapy services, a family practice residency 
program, the Pennsylvania College of Health Sciences, through 
which we educate over 1,600 future medical professionals 
annually. We employ over 7,100 employees and are aligned with a 
medical staff of over 1,000 physicians and advanced practice 
providers.
    Our leadership defines telehealth as the use of technology 
to connect the right people at the right time and place in 
order to improve the patient experience and health outcomes. 
Today, through the use of Web-based solutions, the 
affordability of mobile devices, and an increasingly tech-savvy 
population, the innovative solutions are seemingly without 
limit. These innovative solutions help us to reach our patients 
outside the walls of our system and outside the confines of a 
traditional workday.
    Our current state of technologies includes a HIMSS Level 7 
integrated platform that spans all care settings and 
incorporates our $100 million investment in Epic as our 
electronic health record. Our investment in Epic connects 
providers with clinical evidence decision support tools and 
patients via our patient portal called MyLGHealth, which gives 
patients access to their medical record anywhere Internet is 
available. Additionally, our health system participates in 
Healtheway, connecting us with the national health information 
exchange.
    With our limited time today, I would like to elaborate one 
example from the written testimony which highlights how we 
leverage our technological resources. This program is a pilot 
we call Care Connections. We know that a small percentage of 
the population accounts for most of the healthcare costs, most 
of which are generated through avoidable emergency department 
visits and inpatient stays.
    Leveraging the information gleaned from our electronic 
health records and billing department, we learned that at 
Lancaster General Health 480 patients accounted for $36 million 
in charges between 2008 and 2009. With this in mind, in 2011 we 
launched the Superutilizer Project, which incorporates a 
multidisciplinary team of a case manager, lawyer, medical care 
providers, pharmacists, psychologist, and social worker to 
manage a group of 30 patients.
    Since 2011, we have formalized the program and dubbed it 
Care Connections and expanded enrollment to 100 patients. Our 
latest results show that inpatient days in the hospital 
decreased by 84 percent and emergency department visits by 26 
percent. Limited available cost data reveals after enrollment 
per-member per-month spend decreased $670 or for 100 patients 
savings of more than $800,000 in one year.
    While this level of success requires superior clinical 
management and great effort on the part of a multidisciplinary 
team, the foundation upon which the program is built is 
telehealth. The entire Care Connections team is mobile, with 
secure iPads, iPhones, and laptops, upon which they connect in 
patient's homes using Microsoft Lync to have a visual 
connection with a provider in the office to allow for virtual 
communications, video conferencing, and patient education.
    Care Connections helps decrease our operational needs for 
physical space while achieving our optimal goal of treating the 
patient in the appropriate setting and engaging them in their 
own care. This is further supported with alerts the team 
receives whenever any of their patients enter an emergency 
department in the area so we can continue to monitor and 
intervene in their care.
    Finally, we also leverage commercial products such as Find 
My Friends mobile app to identify exact locations of our 
caregivers in the field to ensure the safety of our workforce.
    Our written testimony includes other examples of programs 
that we have instituted at Lancaster General Health that 
similarly blend technology and medicine in exciting and 
collaborative ways. As care providers, we ultimately believe 
that better informed and better engaged patients lead to better 
health, and better health is the ultimate reform, the best and 
most definitive solution to controlling the ever-spiraling 
percent of GDP that the Nation spends on healthcare.
    Mr. Chairman, it has been my honor to appear before you 
today. I would be pleased to respond to any questions that you 
or members of the subcommittee may have.
    Mr. Pitts. Chair thanks the gentleman.
    [The prepared statement of Mr. Beeman follows:]
   
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    Mr. Pitts. Mr. Chard, you are recognized for 5 minutes for 
an opening statement.

                    STATEMENT OF GARY CHARD

    Mr. Chard. Good morning, Mr. Chairman and Ranking Member 
Pallone and members of the subcommittee. My name is Gary Chard, 
and I am the Delaware State Director for the Parkinson's Action 
Network. Thank you for the opportunity to speak before you 
regarding the role telehealth technology can play in the lives 
of Parkinson's disease patients in the 21st century. As a 
person with Parkinson's, please hear me with the voice of my 
fellow persons with Parkinson's moving and shaking right along 
with me.
    I am a 62-year-old vibrant and healthy resident of the 
State of Delaware. I was diagnosed with this insidious disease 
in the spring of 2008 when I was anticipating another 10 to 15 
years of productive work life. I am a financial representative 
by practice, as well as a husband, father, grandfather, church 
and community member of whom much was expected. To say that 
many of the hopes and dreams of my family, community members, 
and clients were dashed with the progression of my PD is an 
understatement.
    I come to you today to tell you how technology can 
revolutionize the treatment and care of people living with PD 
and how it has personally helped me. Please hear me that the 
employment of telehealth technology is not limited to benefit 
only persons with Parkinson's or people in deep rural 
communities, but it is an asset that can provide safe, secure 
and in-depth diagnostic and evaluative care to the immobile and 
infirm, bringing them to experts who may otherwise be 
unaccessible.
    Parkinson's Disease is a neurological disorder that stems 
from reduced dopamine production in the substantia nigra 
portion of the brain leading to tremors in the limbs, slowness 
of movement, rigidity, and impaired balance and coordination. 
It also exhibits itself through cognitive changes such as 
confusion, forgetfulness, loss of thought pattern, and sleep 
disruptions. If my voice begins to fade this morning, please 
recognize it is a typical example of my PD.
    Parkinson's is a disease that impacts between 500,000 and 
1.5 million Americans and has an economic burden of at least 
$14.4 billion a year in the United States, and prevalence is 
estimated to more than double by the year 2040.
    With the advent of telehealth, my access to Dr. Ray Dorsey, 
my diagnosing specialist in Rochester, New York, or Dr. David 
Perlmutter, my neurological health coach in Naples, Florida, 
can be achieved with the use of existing and improving 
technology, thereby providing me with the counsel and tracking 
I rely on in a safe and comfortable environment, saving me and 
my family costs for care, travel, and productive time.
    With use of a telehealth link established between Dr. 
Dorsey and the University of Delaware's Nurse Managed Health 
Care facility, I can now safely visit with Dr. Dorsey on a 
frequent basis consistent with my diagnosis in a medically 
staffed local facility and receive his evaluation of my disease 
progression and recommendation for treatment.
    Part of the invaluable experience of telehealth is a real-
time visit with my specialists. As long as I am in a private 
environment, I feel that I can speak as candidly with my doctor 
as I can when face to face. The improvements of this technology 
serve to enhance and expedite the one-on-one interaction with a 
specialist, not detract from it. I can say that I don't feel as 
comfortable as I do with an office visit, but in lieu of 
traveling long distances, waiting to be seen in an office, and 
experiencing the other logistics of planning for an office 
visit, telehealth technology serves to provide me with a 
doctor-patient consult that surpasses searching for and 
traveling to a specialist who may be hundreds of miles away or 
more.
    In establishing the telehealth link at the University of 
Delaware, issues of patient privacy, across-state licensure, 
reimbursement, and the always looming liability immediately 
came into play. It took the interaction of several legal and 
government channels months of negotiating before allowing Dr. 
Dorsey from New York to speak with me in a doctor-patient 
relationship in Delaware, leaving me without interaction with a 
medical specialist for more than 18 months. Why? Because the 
legal, financial, and licensure channels are so convoluted that 
it took that long to sort through the terms and conditions in 
order to allow this exercise to proceed.
    For the Parkinson's community, telehealth has the potential 
to be an extremely useful tool in providing greater access to 
specialists, such as neurologists or movement disorder 
specialists. In order to provide the data needed to inform the 
needed policy changes, Dr. Dorsey, in partnership with the 
National Parkinson Foundation, is currently executing a Patient 
Centered Outcomes Research Institute-funded study on the 
quality and effectiveness of treating people with Parkinson's 
via video conferencing. Dr. Dorsey and NPF hope to build on 
previous smaller studies to prove that expert care is important 
for Parkinson's patients and that it can be delivered via 
virtual house calls.
    In conclusion, for people with Parkinson's or other complex 
diseases, I believe telehealth is a present day solution to 
address the serious issue of access to proper medical care. 
Through advocacy organizations such as the Parkinson's Action 
Network, I look forward to working with members of the 
committee to find commonsense solutions to the hurdles that 
face the utilization of telehealth in order to improve the 
quality of care for patients across the country.
    Thank you again for allowing me to testify today, and I 
would be happy to answer any questions.
    Mr. Pitts. The chair thanks the gentleman.
    [The prepared statement of Mr. Chard follows:]
    
    
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    Mr. Pitts. And now recognize Ms. Jones 5 minutes for an 
opening statement. If you will just pull the mike a little bit 
closer, that helps members hear. Thank you.

                    STATEMENT OF KOFI JONES

    Ms. Jones. Mr. Chairman, Mr. Ranking Member, and members of 
this committee, I thank you for this tremendous opportunity of 
testifying before you today. I am here today on behalf of my 
company American Well. Based in Boston, Massachusetts, American 
Well was founded in 2006 by two brothers who also happen to be 
physicians. Their goal was simple: transform healthcare 
delivery through technology and improve access to quality care 
by removing traditional barriers to healthcare delivery, such 
as distance, mobility, and time constraints.
    American Well's telehealth platform is used by health 
plans, individual providers, pharmacies, delivery networks, 
hospitals, and employers all over the country offering real-
time, synchronous, audiovisual, HIPAA-compliant, and secure on-
demand health care from any location to any location, on the 
Web or even in the palm of your hand through mobile apps. And 
health plans like WellPoint, through its LiveHealth Online 
national telehealth initiative, have made telehealth encounters 
an integrated benefit for all of their customers.
    These technologies offer the opportunity to move 
appropriate care to lower-cost settings, into the home or 
workplace, or bring care to where it is currently not 
available, like schools, prisons, or rural areas, lacking 
facilities or healthcare providers. Telehealth has been shown 
to reduce unnecessary ER utilizations, hospitalizations, or 
even general overhead, as well as support preventative care 
efforts for chronic care patients.
    I am acutely aware that I sit this morning before a panel 
of distinguished policy leaders who have already heard from a 
knowledgeable panel and know all too well that we as a Nation 
are at a critical juncture in our healthcare journey. However, 
despite the accelerating momentum for telehealth we have many 
questions left to answer as a Nation before telehealth can 
reach its full potential. That is why I applaud this committee 
for having this hearing.
    First, I would like to raise an issue that should be the 
backbone of this entire discussion: patient safety. Medical 
boards and similar boards across the Nation not only deal with 
licensure, but what is considered appropriate practice or 
clinically appropriate care to provide to patients.
    Now, currently there exists an inconsistent patchwork of 
State laws that have inhibited the deployment of telehealth in 
both the private and public sectors. There have been several 
proposed solutions to this, including the Telehealth 
Modernization Act, a bipartisan measure introduced this past 
December by Representatives Doris Matsui and Bill Johnson, 
which provides States with clear definitions and principles 
they can look to for guidance when developing new policies that 
govern telehealth. And just this past weekend the Federation of 
State Medical Boards ratified a new model national telehealth 
policy. The FSMB's new model policy marks the first time the 
medical community has unilaterally acknowledged the extremely 
beneficial impact that telehealth has had in the practice of 
medicine.
    Whatever the solution to the 50 state regulatory 
environment, we need to strike a balance between innovation and 
patient safety.
    Second, we face issues with licensure. Currently, there 
exists a home field rule: Providers must be licensed in the 
state where they provide care. These days, doctors and other 
healthcare professionals can be physically located in one state 
while their expertise is required in another.
    Licensure is a lengthy and costly process for providers and 
each state has its own set of rules. Now, there are many ways 
to address this, one of which is the bipartisan TELE-MED Act 
introduced by Representatives Frank Pallone, ranking member of 
this subcommittee, and Devin Nunes, and that would allow 
Medicare patients to be cared for by a licensed provider in any 
state.
    Ultimately, the issue of licensure will need to be 
addressed if we are to allow telehealth to reach its full 
potential, and that solution will need to both allow providers 
to provide care when and where it is needed while ensuring the 
oversight necessary to ensure patient safety.
    And finally, we should address the issue of payment: 
reimbursement. The Social Security Act defines telehealth and 
how Medicare will reimburse for telehealth services. That 
language was crafted in the year 2000, 7 years before the first 
iPhone, the iPhone you now can get real-time live health care 
on. Imagine what this language would look like if we crafted it 
today.
    This outdated language says that patients can only receive 
care if they are in a rural area presenting from a clinical 
site. That means patients still need to get into the car to 
receive care, and cities don't count. This is widely viewed as 
one of the major barriers to the full and complete deployment 
of telehealth.
    In summary, by the end of the decade, the terms online 
care, virtual care, telemedicine, and telehealth will all be 
antiquated. Telehealth will simply just become health care and 
replace a significant portion of in-person care. As these 
technologies are proven to improve outcomes, they will become 
the status quo.
    Thank you again for the opportunity for presenting before 
you today, and I am happy to answer any questions.
    Mr. Pitts. The Chair thanks the gentlelady and thanks all 
the witnesses for their opening statements.
    [The prepared statement of Ms. Jones follows:]
    
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    Mr. Pitts. We will now begin questioning, and I will 
recognize myself 5 minutes for that purpose.
    And let me start with you, Tom. How has the advancement of 
telehealth in recent years benefitted your health system? Be 
specific, if you can.
    Mr. Beeman. Let me address what the electronic health 
record has allowed us to do in our ability to leverage the new 
data that we have to deploy our resources more efficiently. 
Before we deployed the electronic health record, we could not 
tell you how many diabetics we had in our health system. We 
care for about 300,000 patients in our community. We could tell 
you we have a billion bits of data, but we could not marshal 
that data to have good information for our patients.
    Today, I can tell you that we have 280 diabetics in our 
Lincoln Family Medicine practice. We know that 270 of them are 
consistent with their regimen for insulin, 10 of them are 
noncompliant. We can deploy a nurse navigator on those 10 and 
really assist them in getting the resources that they require. 
As an example, we found one of our patients was a gambler, had 
gambled all his money, could not buy the insulin. We can help 
through resources to get him that insulin to really help 
improve his life, and that really is what, you know, health 
care is really about.
    Just the other thing I would mention on the Care 
Connections. We are talking about medical assistance patients 
that are the most difficult, most troubled patients that we 
have in our community, the most vulnerable. They use multiple 
sites for health care. By coordinating their care, leveraging 
technology, we can bring them the dignity that they need and 
want and deserve, and we can also dramatically reduce the cost 
of medical assistance care, which many of my colleagues say 
can't be done. And we actually believe that you can actually 
manage those patients' care more effectively if you really 
concentrate on marshaling those costs rather than spending more 
money on their care.
    Mr. Pitts. Just a quick follow-up. The administrative 
burden that Congress and the Federal Government has placed on 
providers also takes time away from patients. It is something 
this committee sought to partially address in Dr. Burgess' SGR 
reform bill, H.R. 4015, but much more needs to be done. In the 
meantime, are there ways in which you could imagine 
telemedicine easing the administrative burden on providers, 
thereby freeing up more time for the care patients?
    Mr. Beeman. I think it already has. We routinely use e-
visits for which we don't get paid for, but most of my 
physicians would say they would rather not have inappropriate 
visits to their office and respond through e-visits. Of course, 
they would prefer to get paid for it, which creates all sorts 
of headaches for us as far as how do you incent your physicians 
to focus on quality when they can't get paid for those. But 
most of them respond at night, early in the morning to a lot of 
their patients. So I think there are opportunities to really 
break through some of the barriers.
    I think the best thing that Congress can do is to really 
focus on things like bundled payment, the MSSP program, and 
helping us be more at risk, and then we can leverage those 
technologies. And we want to be held accountable for quality 
and cost. Let us do that and help break down those barriers, 
sir.
    Mr. Pitts. Dr. Mehrotra, in health care we have frequently 
seen new technologies promise to save money but in reality 
creating a new way for providers to bill the Medicare program. 
If Congress were to act to encourage further adoption in 
Medicare or other healthcare programs, how can we ensure that 
telemedicine actually does deliver the savings that it 
promises?
    Dr. Mehrotra. I think you raise a critical issue, and I 
would maybe echo what Dr. Beeman said, which is that it is a 
combination of having accountability through quality metrics 
that actually say this provider, what is the quality of care 
that they are providing for this patient, irregardless of how 
they are providing that care; as well as the financial 
responsibility through bundled payment and other programs that 
actually make sure that they have the flexibility with the 
single payment to decide what is best for that patient in that 
clinical encounter. And I do fear that encouraging telehealth 
through fee-for-service might be a mechanism to actually 
increase healthcare spending.
    Mr. Pitts. Dr. Bashshur, in your opinion, can the 
recognition and expanded use of telemedicine in Medicare help 
lower costs for patients and the government?
    Mr. Bashshur. The expansion of reimbursement for Medicare 
patients is not likely to increase the cost to the government, 
but it all depends how it is administered. I think there are 
good ways and bad ways of doing things. The telemedicine 
intervention itself, the modality in telemedicine does not 
inherently encourage increased use of service. We have plenty 
of evidence and programs that have been pondered where the 
patients don't pay out of pocket where the use of telemedicine 
has been extremely low.
    The point that my colleague, Dr. Mehrotra, raised regarding 
overuse of service has not been borne by any facts in the 
situation. Among all programs delivering care in the country 
none has experienced a flood of people using this modality of 
care. It has been extremely low.
    Mr. Pitts. Thank you. I have other questions, but my time 
has expired, so I recognize the ranking member, Mr. Pallone, 5 
minutes for questions.
    Mr. Pallone. Thank you, Mr. Chairman.
    I wanted to start with Mr. Chard. Thank you for being here 
today to share your experience in using telehealth to help you 
manage your Parkinson's and maintain the quality of your life. 
It is important for people like you to speak out about when the 
healthcare system works for them and when it doesn't, and 
stories like yours are why I care a lot about this issue.
    So I wondered if you could tell us a little more about your 
telehealth experience. What was it like before you had the 
ability to receive care using telehealth? Are there times when 
you had to travel to see a specialist because they weren't 
licensed in Delaware? And what you have liked about your 
telehealth experience. In what ways, if any, do you think it 
could be improved? It is a lot.
    Mr. Chard. Thank you, Mr. Pallone. To start with, when I 
moved from upstate New York to Delaware, I had already been 
diagnosed with Parkinson's disease, and I began researching 
looking for a neurologist that could help with my symptoms and 
give me continuing diagnosis and treatment. And I was unable to 
find a movement disorder specialist in the State of Delaware.
    To my pleasure, Dr. Dorsey, my diagnosing physician, moved 
down to Johns Hopkins University, which brought him into range 
at least at Baltimore, a little over an hour drive for me. But 
it was, you know, a half day, three-quarters of a day out of 
production. I would take my wife with me to make sure we got 
there safely in and out.
    So the experience in moving to Delaware was that we were 
unable to find the resources that we needed in the state. We 
had the opportunity of driving up to Pennsylvania, but it was 
one way or the other we had to travel in order to find the 
resources.
    In the interim Dr. Dorsey moved back to Rochester, New 
York, and the aspect of telehealth has been introduced through 
Dr. Dorsey and the University of Delaware, and as I mentioned 
earlier in my testimony, the licensing issues were constricting 
the ability to access Dr. Dorsey, who was my primary 
neurologist, movement disorder neurologist. So since the 
telehealth link has been established, I have been able to meet 
with Dr. Dorsey via the telehealth link in a secure setting 
with secure information privately and be able to share with him 
and he would share with me his opinion and recommendations for 
my care.
    Mr. Pallone. And just going back to the last part, in what 
ways, if any, do you think we could improve telehealth 
experience?
    Mr. Chard. Technologically, I think the improvements are 
all pretty strong right now. Legislatively, I would think that 
easing the process and making sure that there is a 
reimbursement program. It is out-of-pocket costs right now. 
Making sure there is a healthcare reimbursement program of some 
sort to ease the cost of establishing that telehealth link 
would be beneficial.
    Mr. Pallone. Well, thank you very much.
    Let me ask Dr. Mehrotra, again, thank you for sharing your 
perspective. But you noted the use of telehealth has a lot of 
potential to improve the healthcare delivery system and the 
Medicare and Medicaid programs are tremendously important. So 
as we think about expanding uses to telehealth in Medicare and 
Medicaid, we have got to make sure we are thoughtful, we go 
about it in the right way, particularly with regard to patient 
safety and cost effectiveness. So could you just speak a little 
more about the risks that my colleagues and I should consider 
as we look at expanded use of telehealth?
    Dr. Mehrotra. I think maybe an analogy would be helpful in 
this circumstance as we think about many patients who will 
benefit and many patients who may not benefit. And I might use 
the example of cardiac catheterization. Cardiac catheterization 
for many patients, either as a diagnostic or treatment for 
heart disease, is life saving.
    On the other hand, as you are well aware from some of the 
press as well as research that has been done, is in many cases 
cardiac catheterization is used inappropriately and does not 
benefit care and has been overutilized and potentially could be 
driving healthcare spending up. That is the theme of many of 
the technologies that have been introduced in health care, this 
two-edged sword, that it helps in some cases and it doesn't. 
And I think that is the real issue as we try to figure out how 
telehealth can be beneficial.
    In many cases, including Mr. Chard, telehealth is probably 
a very beneficial kind of therapy, but how do we make sure that 
it is not overused?
    Mr. Pallone. All right.
    And then, Dr. Bashshur, just briefly, if you think 
telehealth can be used effectively to treat more patients at 
lower cost, you suggested that. Can you just give us an 
example, perhaps?
    Mr. Bashshur. The example has several parts to it, if I may 
explain it. There are different elements of cost here, and our 
cost to the consumer is rarely considered by the payers because 
they are not responsible for it. That element of cost is always 
reduced because if they don't have to travel, they don't have 
to encumber the cost. There is also the convenience and the 
waiting times and sometimes time lost from work. So there are 
several aspects of cost that must be considered in their 
totality as a way to deal with the problem.
    Mr. Pallone. All right. Thanks a lot.
    Thank you, Mr. Chairman.
    Mr. Pitts. Chair thanks the gentleman.
    I now recognize chair emeritus of the full committee, Mr. 
Barton, 5 minutes for questions.
    Mr. Barton. Thank you, Mr. Chairman. And I am sincere in 
saying I appreciate this hearing. I think this is really 
important, what this subcommittee is discussing today.
    I have two general framed questions, and I will put them 
out on the table and anybody who wants to answer them. First 
question is concerning the privacy of the records that are 
generated by the telehealth or telemedicine. How secure are the 
medical records if you use this technology?
    And the second is a Medicare, Medicaid billing issue. I am 
told there are some concerns that if the doctor is in one place 
and the patient is in another and the health insurance is in 
another place, that Medicare and Medicaid sometimes are 
unwilling to or don't know quite how to cost the charges that 
result from a telehealth or telemedicine visit.
    So if anybody wants to take a crack at either of those two, 
the privacy issue or the billing issue, I am all ears.
    Mr. Bashshur. If I may, I would deal with the privacy issue 
and leave my colleague to answer the other question.
    Mr. Barton. I will come to you after him.
    No go ahead, sir, and then we will go to the young lady 
down there. Either one of you. You are both going to get to 
talk.
    Mr. Bashshur. I yield to her.
    Ms. Jones. Thank you.
    It is an excellent question. I think privacy is of the 
utmost concern. Most certainly, our technology is HIPAA 
compliant and secure. All information contained within the 
encounter is secure and kept on a server. I won't pretend to be 
able to describe the server from a technology standpoint, but 
everything is HIPAA compliant and secure.
    For the most part, you will find from a policy perspective 
that that is kind of the emerging understanding of what is 
required for a telehealth encounter to be considered secure. 
The emerging policy, including from the Federation of State 
Medical Boards that was just passed this past weekend, is that 
that should be in place within the context of any given 
telehealth encounter.
    So it most certainly is within our platform. Many of the 
telehealth programs that are out there now support HIPAA 
compliance and security to protect any PHI information. So that 
is occurring. It is the emerging standard within policy. It is 
most certainly contained within the Telehealth Modernization 
Act that just came out this past December. So it is the 
emerging standard within any telehealth technologies that you 
see out there and critically important in ensuring patient 
safety and security.
    Mr. Barton. Doctor.
    Mr. Bashshur. Yes, I agree. We have to be HIPAA compliant, 
and that really answered the question about security for the 
patient. If we violate, we will be in deep trouble, so we avoid 
trouble.
    With regards to Medicare and Medicaid billing, there are 
some differences. Typically, as you know, there is the CPT code 
that we have to submit for billing purposes and these are 
issued by CMS. Their use in the country is still extremely 
limited. For example, during the entire year of 2013 the total 
expenditures for telemedicine services for Medicare patients 
has been only $12 million for the entire country.
    Mr. Barton. So it is basically not being used for Medicare?
    Mr. Bashshur. Because of the restrictions that are placed 
on it, yes, absolutely.
    Mr. Barton. Well, if each of you will give some thought to 
that and put in writing some suggestions on how to correct that 
to the subcommittee, we would appreciate it.
    I believe we would have a bipartisan agreement that we 
shouldn't let a billing problem prevent doctors and patients 
from using this technology. We ought to be able to come up. And 
I don't think it will take legislative action so much as it 
might just take a letter from members on both sides of the 
aisle of this committee and subcommittee to Medicare and 
Medicaid and CMS to give them some guidance on what they should 
do in terms of billing.
    So with that, I yield back, Mr. Chairman. But again, thank 
you for the hearing.
    Mr. Pitts. The chair thanks the gentleman.
    We have just been called to vote. We are going to continue. 
The chair recognizes the ranking member emeritus, Mr. Dingell. 
Five minutes for questions.
    Mr. Dingell. Mr. Chairman, thank you for your courtesy and 
thank you for having this hearing.
    I would like to welcome our distinguished panel, 
particularly Dr. Bashshur, who is a constituent of mine from 
the University of Michigan and is the Executive Director of the 
health--for eHealth at the University of Michigan Health 
System.
    It is a pleasure to have the whole panel with us today, but 
especially you, Dr. Bashshur.
    Now, I have a number of questions which I hope that you 
will answer ``yes'' or ``no'' in order to save time.
    Doctor, is it correct that spending on chronic illness 
accounts for 75 percent of health expenditures in the U.S.? Yes 
or no.
    Mr. Bashshur. Yes. In approximate----
    Mr. Dingell. Now, Doctor, given your expertise in the area, 
do you believe that investing telehealth--in telehealth 
technologies to improve chronic disease management will save 
money over the long run? Yes or no.
    Mr. Bashshur. Yes.
    Mr. Dingell. Doctor, I want you to know that we would like 
to have you submit additional information as you might feel 
necessary later so that we have the benefit of your full 
judgments here.
    Now, while the Affordable Care Act has done a great job in 
making health care more accessible to the American people, I 
think most people continue to believe that much more must be 
done to improve access to care for the people in this country 
with unmet medical needs.
    Now, Dr. Bashshur, I know that you have done several 
studies about increasing access to health care.
    Do you believe that the use of telemedicine can help 
improve access to care in medically underserved communities 
like the Upper Peninsula in Michigan? Yes or no.
    Mr. Bashshur. Yes.
    Mr. Dingell. Now, Doctor, rural areas are not the only part 
of our country with citizens who have unmet medical needs, yet 
telemedicine in this country today is mostly faced--mostly 
focused on rural areas.
    Doctor, is it correct that, generally speaking, CMS has 
limited physician reimbursement for telehealth to services 
provided in rural areas? Yes----
    Mr. Bashshur. Yes.
    Mr. Dingell [continuing]. Or no?
    Mr. Bashshur. Yes.
    Mr. Dingell. Do you believe that is a good limit?
    Mr. Bashshur. No. I don't think so.
    Mr. Dingell. Now, how else has CMS restricted reimbursement 
for telemedicine in the United States today?
    This does not require a yes or no. It requires a quick 
answer to be followed by a followup in additional remarks.
    What do you have to say on this, Doctor?
    Mr. Bashshur. CMS requires synchronous live video 
conferencing with a presenting provider on one end at the 
originating site and connected to a specialist at the remote 
site.
    This happens to be the least efficient mode of telemedicine 
service. The so-called asynchronous mode is more efficient.
    Mr. Dingell. Now, Doctor, Alaska and Hawaii are exempt from 
CMS reimbursement restrictions.
    Is the use of telehealth more prevalent in those States in 
comparison to the continental 48 States? Yes or no.
    Mr. Bashshur. Yes.
    Mr. Dingell. Do you believe that telehealth technology used 
in Alaska and Hawaii are a model for the rest of the country? 
Yes or no.
    Mr. Bashshur. Yes.
    Mr. Dingell. Doctor, I want to thank you. I want to express 
my respect and high regard for you and, also, to the other 
members of the panel.
    I look forward to any additional remarks that you or any of 
the panel members might submit to any of the questions in order 
that we could have the fullest expression of your thoughts and 
views.
    Thank you, gentleman and ladies, for being here this 
morning.
    Thank you, Mr. Chairman.
    Mr. Pitts. The chair thanks the gentleman.
    I now recognize the vice chairman of the subcommittee, Dr. 
Burgess. Five minutes for questions.
    Mr. Burgess. I thank the chairman for the recognition.
    Mr. Chairman, I just wanted to point out there is an online 
medical community called medscape.com, and Dr. Eric Topol, who 
is their editor-in-chief, actually had an article addressing 
this issue.
    His conclusion to the article: ``If you fast-forward over 
the next 5 years, we will be doing a lot of office visits in a 
completely different way, and whether they are telephone 
consults or video links with transmission of the data in real 
time or in advance, it is a different look, and we should be 
getting ready for the virtual physician visit with patients in 
the years ahead.''
    I would like to ask unanimous consent that we submit Dr. 
Topol's remarks for the record.
    Mr. Pitts. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Burgess. And I think we have heard that same theme 
expressed several times this morning.
    You heard my anxiety, Dr. Beeman, along the old CPT code 
that I found one day. I thought my life was changed, my income 
will double, and, yet, that was a code that was available, but 
not reimbursed, back in the HMO days.
    What are you doing with your super-utilizer network--what 
are you doing to get around those issues?
    Mr. Beeman. Doctor, I think one of the big challenges we 
have in this is we are doing tremendous demand destruction with 
the anticipation that providing better care and services is the 
ultimate benefit.
    When Lancaster General Health decided to embark on 
population health management, we actually went through a 3-year 
process of restructuring our health care delivery system to 
take out $100 million worth of cost, and we continue to focus 
on that through Lean Six Sigma so we can afford to do the 
demand destruction.
    The problem that we have been talking about in telehealth 
is: It is a tool. It is not the end. And so, when we talk about 
paying for telehealth, what I think we need to be talking about 
is putting us health care providers at risk to care for a 
population and let us deploy the tools that we need in order to 
manage that.
    Mr. Burgess. Let me interrupt you just in the interest of 
time.
    And I don't disagree with you, but you recognize the real 
world is--there are going to be a lot of practices that will 
live in a fee-for-service world for the rest of my natural 
lifetime.
    And the SGR reform that has been mentioned several times 
this morning, it tried to acknowledge that. Sure, there are 
going to be different models of practice, bundled payment ACOs 
where just the situation you talk about may make sense.
    But I got to tell you. I practiced OB/GYN. I practiced for 
years. My greatest fear was that next-to-the-last patient on 
Friday afternoon was going to have a blood pressure--a 
diastolic blood pressure of 88 where she had always been normal 
before.
    And you know the drill. This is someone who simply could 
have an elevated blood pressure because their husband wasn't on 
time for the appointment, they couldn't find a parking place, 
or it could be the beginning of a very serious illness that 
within a very short period of time was going--she was going to 
be critically ill.
    So I am sitting in the clinic at 4:15 on a Friday 
afternoon. I got no way of knowing--some other parameters you 
can check to be sure. But even if they are all normal, you 
still have no way of knowing.
    How great would it be to have her with a blood pressure 
cuff at home and a smartphone and to be able realtime, ``Send 
me your next 10 blood pressures and, if it is over X, let's get 
together right away.''
    The old days, what was at your disposal? Put her in the 
hospital for the weekend so that someone could monitor the 
blood pressure.
    And if you didn't do that and she really was severely pre-
eclamptic, the next visit was at 3 o'clock in the morning in 
the emergency room with a seizure, with organ damage. I mean, 
it was a big deal if you guessed wrong.
    This will eliminate a lot of the guesswork out of that type 
of practice. And, you know, I would argue, too--someone brought 
up the issue of overuse.
    I mean, if we reform our liability laws in this country, 
maybe we can get around some of those problems as well. But I 
would be interested in your thoughts on that.
    Mr. Beeman. Doctor, I agree. I think right now we are 
deploying a lot of this technology in aspirational hope that it 
will pay for itself by better health care.
    And some of it is deployed because we would rather keep the 
patient out of the hospital and healthy than we would seeing 
them one more time in the emergency department.
    And, in some respects, with a medical assistant's patient 
who uses that as a primary care office rather than an office, 
it allows us to take the office to them rather than have them 
use the emergency department.
    Mr. Burgess. Let me just ask you this. And we are going to 
run out of time. But, in your opinion, are there conditions 
where the potential for misdiagnosis, the potential for harm, 
is of particular concern and it will be inappropriate to use 
telemedicine?
    Mr. Beeman. Yes. I think the----
    Mr. Burgess. Right answer. Thank you.
    Ms. Jones, I just wanted to follow up on Mr. Barton's 
questions on the issue of privacy. And I am glad you brought 
that up. I hope you will provide some thoughts to the committee 
in writing that he requested.
    Clearly this needs to be a balanced conversation. I 
remember having this discussion in 2007 with a CEO of a big 
insurance company.
    They were doing a lot of stuff with the--just financial 
data where they could perhaps predict outcomes in future 
medical issues.
    And one of things he said to me was, ``You have got to 
define privacy and stop changing your minds every 3 months.'' 
And I hope you will help us with that conversation because it 
is a critically important conversation to have.
    Ms. Jones. Certainly. We are more than eager to be partners 
in this conversation.
    I think one of the things that we have always uphold--
upheld as an organization is that there are some principles 
that uphold the highest common denominator of care, some things 
that should be in place so that providers who are providing 
care via telehealth have the ability to use the very same 
discretion that they use in person while they are providing 
care electronically.
    And the infrastructure that is required there are things 
like HIPAA compliance, documentation of care, continuity of 
care. There is some discussion around formulary and what kind 
of prescribing isn't appropriate, identity of the provider 
being affirmed, identity of the patient being affirmed.
    So I think some of these kind of principles that create the 
infrastructure for safe and secure telehealth need to be 
discussed because, when you have those in place, then, again, 
you are in a position where you are creating a safe and secure 
environment and these physicians can decide--use the very same 
discretion that they use in a face-to-face encounter to say, 
``Yes. This is appropriate for care,'' ``No. This is not 
appropriate for telehealth care,'' ``Yes. I have this 
expertise,'' ``No. I need to refer for in-person or refer to 
another expert.''
    And those are very important discussions to have and ones 
that we have on an ongoing basis.
    Mr. Burgess. Mr. Chairman, thank you very much for the 
time. I know a vote is close. So I will yield back.
    Mr. Pitts. The chair thanks the gentleman.
    Unfortunately, we have been called to the floor on the 
vote. I think we only have a couple of minutes to go to get 
there. And so we have lost our Members.
    Members will have a lot of other questions we would like to 
submit to you. We will ask that you please respond promptly in 
writing.
    This is not the end of the discussion. It is just the 
beginning. I look forward to working with my colleagues, with 
all of you, as we pursue this issue.
    I remind Members that they have 10 business days to submit 
questions for the record, and they should submit those 
questions by the close of business on Thursday, May the 15th.
    This is a very important issue. Thank you very much for 
your time, for coming, for your expertise. And we will continue 
to work with you.
    Without objection, the subcommittee is adjourned.
    [Whereupon, at 11:11 a.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
  
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