    [Senate Hearing 114-235]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 114-235

                   ADVANCING TELEHEALTH THROUGH CONNECTIVITY

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

                                    HEARING

                                   before the

        SUBCOMMITTEE ON COMMUNICATIONS, TECHNOLOGY, INNOVATION, AND THE
                                    INTERNET

                                     of the

                             COMMITTEE ON COMMERCE,
                          SCIENCE, AND TRANSPORTATION
                              UNITED STATES SENATE

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 APRIL 21, 2015

                                   __________

        Printed for the use of the Committee on Commerce, Science, and
                                 Transportation

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           SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 FIRST SESSION

                       JOHN THUNE, South Dakota, Chairman
    ROGER F. WICKER, Mississippi         BILL NELSON, Florida, Ranking
    ROY BLUNT, Missouri                  MARIA CANTWELL, Washington
    MARCO RUBIO, Florida                 CLAIRE McCASKILL, Missouri
    KELLY AYOTTE, New Hampshire          AMY KLOBUCHAR, Minnesota
    TED CRUZ, Texas                      RICHARD BLUMENTHAL, Connecticut
    DEB FISCHER, Nebraska                BRIAN SCHATZ, Hawaii
    JERRY MORAN, Kansas                  EDWARD MARKEY, Massachusetts
    DAN SULLIVAN, Alaska                 CORY BOOKER, New Jersey
    RON JOHNSON, Wisconsin               TOM UDALL, New Mexico
    DEAN HELLER, Nevada                  JOE MANCHIN III, West Virginia
    CORY GARDNER, Colorado               GARY PETERS, Michigan
    STEVE DAINES, Montana
                        David Schwietert, Staff Director
                       Nick Rossi, Deputy Staff Director
                        Rebecca Seidel, General Counsel
                     Jason Van Beek, Deputy General Counsel
                     Kim Lipsky, Democratic Staff Director
                  Chris Day, Democratic Deputy Staff Director
           Clint Odom, Democratic General Counsel and Policy Director
                                     ------

        SUBCOMMITTEE ON COMMUNICATIONS, TECHNOLOGY, INNOVATION, AND THE
                                    INTERNET

    ROGER F. WICKER, Mississippi,        BRIAN SCHATZ, Hawaii, Ranking
        Chairman                         MARIA CANTWELL, Washington
    ROY BLUNT, Missouri                  CLAIRE McCASKILL, Missouri
    MARCO RUBIO, Florida                 AMY KLOBUCHAR, Minnesota
    KELLY AYOTTE, New Hampshire          RICHARD BLUMENTHAL, Connecticut
    TED CRUZ, Texas                      EDWARD MARKEY, Massachusetts
    DEB FISCHER, Nebraska                CORY BOOKER, New Jersey
    JERRY MORAN, Kansas                  TOM UDALL, New Mexico
    DAN SULLIVAN, Alaska                 JOE MANCHIN III, West Virginia
    RON JOHNSON, Wisconsin               GARY PETERS, Michigan
    DEAN HELLER, Nevada
    CORY GARDNER, Colorado
    STEVE DAINES, Montana

                                C O N T E N T S

                                  ----------
                                                                       Page
    Hearing held on April 21, 2015...................................     1
    Statement of Senator Wicker......................................     1
    Statement of Senator Schatz......................................     2
    Statement of Senator Manchin.....................................    69
    Statement of Senator Daines......................................    72
    Statement of Senator Thune.......................................    74
    Statement of Senator Peters......................................    76
    Statement of Senator Fischer.....................................    78
    Statement of Senator Booker......................................    80
    Statement of Senator Blumenthal..................................    82
    Statement of Senator Gardner.....................................    84
    Statement of Senator Markey......................................    86
    Statement of Senator Cantwell....................................    88
    Statement of Senator Klobuchar...................................    90

                                   Witnesses

    Dr. Kristi Henderson, DNP, NP-BC, FAEN, Chief Telehealth and
      Innovation Officer, University of Mississippi Medical Center...     4
        Prepared statement...........................................     5
    Chris Gibbons, MD, MPH, Distinguished Scholar-in-Residence,
      Connect2
      HealthFCC Task Force, Federal Communications
      Commission; Associate Director, Johns Hopkins Urban Health
      Institute; Assistant Professor of Medicine, Public Health and
      Health Informatics, Johns Hopkins University...................     9
        Prepared statement...........................................    11
    Jonathan D. Linkous, Chief Executive Officer, American
      Telemedicine Association.......................................    16
        Prepared statement...........................................    17
    Todd Rytting, Chief Technology Officer, Panasonic Corporation of
      North America..................................................    20
        Prepared statement...........................................    21

                                    Appendix

    Statement of Dr. Kristi Henderson, DNP, NP-BC, FAEN, Chief
      Telehealth and Innovation Officer, University of Mississippi
      Medical Center.................................................    93
    Letter dated May 5, 2015 from Mary R. Grealy, President,
      Healthcare Leadership Council to Chairman Wicker and Ranking
      Member Schatz..................................................    96
    Statement of the American Hospital Association...................    99
    Response to written questions submitted to Dr. Kristi Henderson
      by:
        Hon. Dan Sullivan............................................   119
        Hon. Tom Udall...............................................   119
    Response to written questions submitted to Dr. Chris Gibbons by:
        Hon. John Thune..............................................   121
        Hon. Roy Blunt...............................................   121
        Hon. Dan Sullivan............................................   122
        the Hon. Tom Udall...........................................   122
    Response to written questions submitted to Jonathan D. Linkous
      by:
        Hon. Roy Blunt...............................................   123
        Hon. Dan Sullivan............................................   124
        Hon. Tom Udall...............................................   124
    Response to written question submitted to Todd Rytting by:
        Hon. John Thune..............................................   125
        Hon. Dan Sullivan............................................   126

                   ADVANCING TELEHEALTH THROUGH CONNECTIVITY

                                  ----------

                            TUESDAY, APRIL 21, 2015

                                   U.S. Senate,
           Subcommittee on Communications, Technology,
                          Innovation, and the Internet,
            Committee on Commerce, Science, and Transportation,
                                                        Washington, DC.
        The Subcommittee met, pursuant to notice, at 10 a.m. in
    room 253, Russell Senate Office Building, Hon. Roger F. Wicker,
    Chairman of the Subcommittee, presiding.
        Present: Senators Wicker [presiding], Thune, Blunt, Ayotte,
    Fischer, Johnson, Gardner, Daines, Schatz, Cantwell, Klobuchar,
    Blumenthal, Markey, Booker, Udall, Manchin, and Peters.

              OPENING STATEMENT OF HON. ROGER F. WICKER,
                     U.S. SENATOR FROM MISSISSIPPI

        Senator Wicker. Welcome. Welcome to the first hearing of
    the year for the Subcommittee on Communications, Technology,
    Innovation, and the Internet.
        I'm joined this morning by my colleague and Ranking Member,
    Brian Schatz.
        There is a lot of interest among Senators and Members of
    the Committee in this topic. They will be coming in and out
    participating in the hearing, and I expect to have a lot of
    questions and discussion as we proceed.
        Advancing telehealth through connectivity is a timely topic
    for the Committee this year as we look at ways to modernize our
    communication laws. I hope today's discussion will serve as an
    educational forum on the progress we've made, as well as an
    opportunity to identify ways we can assure all Americans have
    access to the great advancements in patient care and delivery.
        In fact, this year Senator Cochran and I plan to introduce
    the Telehealth Advancement Act, which is aimed at improving
    Medicare reimbursement and working toward payment parity. Many
    payments to telehealth exist outside the realm of
    communications. However, without broadband, telehealth is not
    possible. Ensuring all Americans, particularly those living in
    rural and remote areas, have access to high-speed broadband has
    long been a priority of mine.
        In Mississippi, for example, AT&T provides broadband
    service to the University of Mississippi Medical Center. The
    hospital's telehealth solutions include the deployment of
    portable medical carts to rural hospitals and clinics, allowing
    patients and doctors in remote locations to interact in real
    time with medical center specialists through video transmission
    of diagnostic information.
        Also, the Diabetes Telehealth Network pilot in Sunflower
    County, the first of its kind nationally, is intended to forge
    a stronger connection between clinicians and people with
    diabetes. It supports earlier clinical intervention, more
    effective use of health services, and positive health habits
    and behavior changes.
        In this instance, C SPIRE provides the high-speed mobile
    broadband communications network needed to support this
    connection between patients and clinicians in even the most
    remote parts of Mississippi.
        The state of Mississippi has made great strides in
    telehealth and in closing the digital divide, but there's still
    work to be done. Fifty-four percent of our citizens live in
    rural areas, and we have the lowest ratio of physicians to
    patients. Nationwide, more than 53 percent of Americans living
    in rural areas lack access to what the FCC now classifies as
    broadband service. Fifty-three percent of Americans in rural
    areas lack this access. Only 8 percent of Americans living in
    urban areas lack this technology.
        I would like to welcome all of our witnesses and thank them
    for testifying this morning. Our panel today represents a wide
    range of public and private stakeholders working to identify
    barriers and improve access to telehealth throughout the
    country.
        It's a special privilege for me to introduce Dr. Kristi
    Henderson from the University of Mississippi Medical Center.
    Dr. Henderson was kind enough to educate me, to the extent that
    that could be done, on all the wonderful things going on at
    UMMC to connect patients throughout the state with doctors and
    health care professionals remotely.
        I'm pleased to welcome her and other distinguished members
    of our panel: Mr. Jonathan D. Linkous, Chief Executive Officer
    of American Telemedicine Association; Dr. M. Chris Gibbons,
    Distinguished Scholar in Residence,
    Connect2HealthFCC Task Force, Federal Communications
    Commission; Mr. Todd Rytting, Chief Technology Officer,
    Panasonic Corporation of North America.
        I look forward to the testimony from this distinguished
    panel and to the opening remarks by my distinguished Ranking
    Member, Mr. Schatz.

                    STATEMENT OF HON. BRIAN SCHATZ,
                        U.S. SENATOR FROM HAWAII

        Senator Schatz. Thank you, Mr. Chairman, and good morning.
        As a strong believer in the power of telehealth to reach
    more underserved populations, address gaps in our health care
    system, and ultimately improve both physical and mental health
    care in the United States for everyone, I'm grateful for this
    opportunity to discuss telehealth in this hearing today.
        Increasing broadband and improving funding for
    telecommunications are critical. But beyond broadband, we've
    got to push providers to reimburse for telehealth services.
    Health policy is driven by what is and what is not reimbursed.
    Medicare has to lead the way. As some say, as goes Medicare, so
    goes everyone else. The United States has 49 million Medicare
    enrollees. Medicare spending occupied 14 percent of the Federal
    budget in 2013, representing $492 billion in net Federal
    Medicare outlays.
        The market share of Medicare is tremendous, and the impact
    of payment reforms in Medicare are far-reaching. Innovative
    markets, including in mobile technology, could be unleashed if
    Medicare were to step out and reimburse more extensively for
    telehealth services.
        The reimbursement policy for telehealth for Medicare is
    defined statutorily under Section 1834 of the Social Security
    Act. Under this statute, many potential episodes of telehealth
    do not occur because they're not reimbursed. For example,
    Medicare will not reimburse for telehealth services if the
    patient is not located in a rural area. If Mrs. Smith is
    elderly and homebound but lives in downtown Honolulu, her
    telehealth services would not be covered.
        Number two, Medicare will not reimburse for store and
    forward technologies, other than in demonstration projects in
    Alaska and Hawaii. Store and forward technologies allow a
    provider to store clinical information like data or images and
    then forward it to a provider at another location for clinical
    evaluation. If a primary care doctor in rural Iowa wants to
    take a picture of a suspicious arm lesion on a 68-year-old male
    patient, then send it to a dermatologist hours away, that
    episode would not be reimbursed by Medicare.
        Number three, Medicare will not reimburse for telehealth
    services if patients are located at home. If a bed-bound and
    disabled 83-year-old woman had a sinus infection in New York,
    she and her caregivers could not utilize telehealth services
    from their home. They would need to expend significant time,
    effort, and travel expenses to get to their nearest physician,
    if they could indeed get an urgent appointment.
        Number four, Medicare will not reimburse for federally
    Qualified Health Centers, or FQHCs to be sites that furnish
    providers for telehealth. As such, if a mental health provider
    at an FQHC, for instance, on Maui Island wanted to stream
    services via a telecommunications system to a patient at an
    FQHC on Lanai Island, she would not be reimbursed for those
    services.
        Number five, Medicare will not reimburse for physical,
    occupational, or speech therapists to provide telehealth
    services as they are not considered a physician or practitioner
    according to the statute. A grandfather who suffered a stroke
    in New Mexico would need to travel multiple times per week to
    his therapist to get the appropriate therapy.
        As you know, I could list many more examples, but the
    bottom line is this: Medicare needs to lead the way in payment
    methodology and thus guide the telehealth sector, and Medicare
    is lagging significantly behind not just the private sector but
    what VA is doing.
        So I look forward to this conversation and many more on a
    bipartisan basis to look at payment reform so that we can
    improve outcomes on the clinical side and reduce costs on the
    fiscal side.
        Thank you, Mr. Chairman.
        Senator Wicker. And thank you, Senator Schatz.
        We are delighted now to begin hearing testimony from our
    witnesses. Your written testimony will be submitted and
    included in its entirety in the record, and we ask each member
    to summarize using approximately 5 minutes.
        We begin at this end of the table with Dr. Henderson and
    move down the table.
        Dr. Henderson.

          STATEMENT OF DR. KRISTI HENDERSON, DNP, NP-BC, FAEN,

                CHIEF TELEHEALTH AND INNOVATION OFFICER,

                UNIVERSITY OF MISSISSIPPI MEDICAL CENTER

        Dr. Henderson. Chairman Wicker, Ranking Member Schatz, and
    members of the Committee, I thank you for the opportunity to
    appear today to discuss how we can work together to advance
    telehealth through connectivity.
        My name is Kristi Henderson, and I serve as the Chief
    Telehealth and Innovation Officer at the University of
    Mississippi Medical Center.
        Telehealth in our state is increasing access to care,
    improving health outcomes, and lowering costs. Nowhere in
    America are health care challenges greater than in Mississippi.
    Not only do we lead the Nation in prevalence of multiple
    chronic diseases, we also have the lowest number of doctors per
    capita. More than half of the state's 2.9 million citizens live
    in a rural community, and almost a quarter live at or below the
    Federal poverty line.
        Telehealth is a vital tool in delivering health care. The
    UMMC Center for Telehealth began in 2003 with the TelEmergency
    program connecting community emergency physicians to our trauma
    center. This program has resulted in a 25 percent reduction in
    rural emergency-room staffing costs and a 20 percent reduction
    in unnecessary transfers, and has produced patient outcomes in
    rural hospitals that are on par with that of the academic
    medical center.
        Twelve years later, telehealth technologies deliver over 35
    medical specialties to 166 sites across the state, including
    community hospitals and clinics, mental health facilities,
    schools and colleges, corporations, prisons, and even the
    patients' homes. The network connects to sites in 52 of the
    state's 82 counties and serves an average of 8,000 patients per
    month.
        As we work to expand telemedicine services, we continue to
    run into two primary obstacles, reimbursement parity for
    telehealth services and connectivity challenges. Prior to 2013,
    insurance companies in Mississippi did not reimburse equally
    for telehealth services. We argued that Mississippi would
    ultimately save money by providing reimbursement and undertook
    a series of pilots to prove it. We were successful.
        In 2013 and 2014, Governor Bryant signed legislation
    mandating that health insurance companies pay for telehealth
    services at the same rate as in-person services. These changes
    at the state level were the catalyst for the rapid growth of
    our state's telehealth system, and I strongly believe adoption
    of reimbursement parity at the Federal level would have a
    greater impact.
        The second obstacle we encounter is insufficient
    connectivity. Due to the largely rural nature of our state, we
    cannot take for granted that support for telehealth services
    will be available at the level we require or, frankly, at all.
    To ensure connectivity, we partner with cable, wireless, and
    broadband telecommunication companies in the state to maximize
    our existing resources and leverage the strength of incumbent
    utilities. Through these partnerships we were able to bring
    much-needed healthcare to rural Mississippi.
        Nothing tells this story better than the Diabetes
    Telehealth Network program. Last fall, we partnered with public
    and private stakeholders to launch a groundbreaking research
    pilot aimed at managing 200 uncontrolled diabetics in rural
    Sunflower County through aggressive in-home monitoring and
    intervention. The goal is to improve the health of participants
    while reducing cost of care. People in this program were sent
    home with electronic tablets that monitor glucose on a daily
    basis, provide education, information, and transmit this health
    data hundreds of miles away to specialists at our center. Many
    of our patients have never used a computer, and some can't read
    beyond a sixth grade level. But despite those challenges, our
    patients are thriving.
        Preliminary results show that the majority of patients have
    already met or exceeded the goals set for the end of the year-
    long study. With the exception of one patient, no one has been
    hospitalized or sent to the ER because of their diabetes since
    entering the program.
        But let me be clear. This connectivity between the
    providers and the patients would not exist but for the
    Universal Service Fund support that this region enjoys. This is
    true for many parts of our state where we serve, and is
    critical for our continued success. As we look to expand this
    pilot, our biggest concern is the ability to connect with
    patients in their homes and communities.
        Despite this, our needs remain the same, increased
    reimbursement parity and continued access to reliable, high-
    quality connectivity. Given the jurisdiction of this committee,
    I urge you to consider three issues: the need for continued
    support of Universal Service Funds; the need for broader
    application of the FCC E-rate program so that we can use
    telehealth services in the schools and take advantage of the E-
    rate program; and the need for a more inclusive Healthcare
    Connect Fund. As a large hospital, we don't enjoy the pleasures
    of the full benefits of that program.
        So I thank the Committee for the opportunity to testify,
    and I'm happy to answer any of the questions that you may have.
    Thank you.
        [The prepared statement of Dr. Henderson follows:]

      Prepared Statement of Dr. Kristi Henderson, DNP, NP-BC, FAEN, Chief
     Telehealth and Innovation Officer, University of Mississippi Medical
                                     Center
        Chairman Thune, Chairman Wicker, Ranking Members Nelson and Schatz
    and fellow panelists, it is a pleasure to appear before this
    subcommittee to discuss how we can work together to advance telehealth
    through connectivity. I thank the Subcommittee, and especially my
    Senator, Chairman Wicker, for the opportunity to testify and look
    forward to a robust discussion.
        Telehealth was born out of necessity. Patients living in rural
    areas have always lacked access to healthcare, and, even today, those
    who are not able to travel often receive inadequate care, or no care at
    all. Many patients are not able to see a specialist or get the
    treatment they need without traveling long distances. Long gone are the
    days when each small town had its own ``Jack of all trades'' doctor who
    could deliver babies, set broken bones and check on Grandma's aching
    back. While patients in urban areas may be located in closer proximity
    to medical services, the waiting time for appointments with specialists
    can be several weeks, resulting in increased severity of disease
    equivalent to that in the rural areas.
        Why is this?
        The physician shortage is partially to blame. The Association of
    American Medical Colleges (AAMC) predicts that by the year 2020, there
    will be a national shortage of more than 90,000 doctors, including
    45,000 primary care physicians.\1\ Rural communities rely on family
    medicine physicians because they are often the only healthcare
    providers in the area, yet in the last decade, the number of medical
    school graduates choosing to specialize in family medicine has
    declined.\2\ Of those who do elect to study family medicine, only 11
    percent choose to practice in rural areas.\3\ Chronic disease is
    another major challenge, particularly for poor, rural Americans. A
    review of data provided by the CDC reveals that approximately 117
    million people--about half of all adults in the US--have one or more
    chronic health conditions. More than 75 percent of health care costs
    are due to chronic conditions, nearly $7,900 for every American with a
    chronic disease.\4\ \5\ One in five, or 2.6 million Medicare patients
    are readmitted to the hospital within 30 days of discharge due to
    chronic conditions, which generates costs of over $26 billion each
    year. In Mississippi alone, seven of the leading causes of death in
    2011 were chronic disease-related.
    ---------------------------------------------------------------------------
        \1\ Association of American Medical Colleges, 2010.
        \2\ Rosenblatt, Roger A.; Chen, Frederick M.; Lishner, Denise M.;
    Doescher, Mark P. The Future of Family Medicine and Implications for
    Rural Primary Care Physician Supply. WWAMI Rural Health Research
    Center. Final Report, #125 (2010).
        \3\ Chen, F., Fordyce, M., Andes, S., & Hart, L. (2010). Which
    Medical Schools Produce Rural Physicians? A 15-Year Update. Academic
    Medicine, 594-598. Retrieved April 17, 2015, from http://
    www.siumed.edu/academy/jc_articles/Distlehorst_0410.pdf
        \4\ Centers for Disease Control and Prevention. 2009. Retried on
    March 27, 2014, from http://www.cdc.gov/chronicdisease/resources/
    publications/aag/chronic.htm
        \5\ Center for Disease Control and Prevention. Chronic disease
    overview: Costs of chronic disease. 2012. Available at http://
    www.cdc.gov/nccdphp/overview.htm
    ---------------------------------------------------------------------------
        Due to limited local medical services and lack of transportation,
    patients are often unable to access vital primary care health services
    that focus on prevention and management of chronic illnesses, which
    leads to inadequate continuity and coordination of care. The result is
    inflated health care costs, poor outcomes and repeated readmissions.
    Telehealth is a critical tool in addressing these challenges, one that
    Mississippi has used with great success to increase access to health
    care and reduce cost.
    The Telehealth Solution
        In its infancy, telehealth simply connected hospital sites to rural
    clinical sites, linking health providers to each other and bringing
    much needed services to remote areas. Telehealth, however, can be used
    in many different settings beyond the traditional hub and spoke model.
    From corporations to correctional facilities, telehealth is providing
    access to care and reducing costs for both providers and patients.

       In the workplace--In 2011, 11 percent of employers with at
            least 5,000 employees said that they have a telehealth program
            in place, up from 5 percent in 2010, according to a study by
            Mercer. Participating employers are seeing productivity savings
            of up to three hours and an average cost savings of $55 in
            medical costs per visit.

       In correctional facilities--From a baseline of 94,180
            transports made annually from correctional facilities to
            emergency departments at a cost of $158 million, telehealth
            technologies could avoid almost 40,000 transports with a cost
            savings of $60.3 million a year. Further, from an annual
            baseline of 691,000 physician office visits at a cost of $302
            million, telehealth could avoid 543,000 inmate transports with
            a cost savings of $210 million.\6\
    ---------------------------------------------------------------------------
        \6\ Vo, Alexander. ``The Telehealth Promise: Better Health Care and
    Cost Savings for the 21st Century.'' AT&T Center for Telehealth
    Research and Policy, no. May 2008 (2008): 10. http://
    telehealth.utmb.edu/presentations/The Telehealth Promise-Better Health
    Care and Cost Savings for the 21st Century.pdf.

       In schools--School-based telehealth provides access to
            healthcare for students to receive mental health, chronic
            disease management, and other care in schools. In an Onondaga
            County, New York, remote diabetes care program, students' A1C
            levels were lowered and urgent visits and hospitalizations
            during the course of the study were reduced.\7\ The
            availability of telehealth in schools has been shown to reduce
            students' absenteeism, enabling healthy children to become
            better students.\8\
    ---------------------------------------------------------------------------
        \7\ Daniels, Stephen R. School-centered telemedicine for type 1
    diabetes mellitus. The Journal of Pediatrics. September 2009; 155(3):
    A2.
        \8\ McConnochie KM, Wood NE, Herendeen NE, ten Hoopen CB, and
    Roghmann KJ. Telemedicine and e-Health. June 2010, 16(5): 533-542.
    doi:10.1089/tmj.2009.0138.

       In nursing homes--From a baseline of 2.7 million transports
            made annually from nursing home facilities to emergency
            departments at a cost of $3.62 billion, telehealth could avoid
            387,000 transports with a cost savings of $327 million. In
            addition, of the 10.1 million physician office visits made
            annually from nursing facilities at a cost of $1.29 billion,
            telehealth could avoid 6.87 million transports with a cost
            savings of $479 million.\9\ \10\
    ---------------------------------------------------------------------------
        \9\ Center for Information Technology Leadership Partners
    HealthCare System, Inc., 2007.
        \10\ State Health Care Spending Project, 2013. Pew Charitable
    Trusts and John D. and Catherine T. MacArthur Foundation.
    www.pewstates.org

       Into the home--Remote patient monitoring is a form of
            telehealth that is being used to address chronic disease. A
            national home telehealth program started by the Veterans
            Administration resulted in a 25 percent reduction in numbers of
            bed days of care, a 19 percent reduction in numbers of hospital
            readmissions and mean satisfaction score rating of 86 percent
            after enrollment into the program. This is just one example of
            how remote monitoring can lead to a dramatic reduction in costs
            and an equally dramatic increase in quality.\11\
    ---------------------------------------------------------------------------
        \11\ Care Coordination/Home Telehealth: The Systematic
    Implementation of Health Informatics, Home Telehealth, and Disease
    Management to Support the Care of Veteran Patients with Chronic
    Conditions. Adam Darks, Patricia Ryan, Rita Kobb, Linda Foster, Ellen
    Edmonson, Bonnie Wakefield, Anne E. Lancaster. Telemedicine and e-
    Health. December 2008, 14(10): 1118-1126.
    ---------------------------------------------------------------------------
    Telehealth in Mississippi
        Nowhere in this great nation are health care challenges greater
    than in Mississippi. Not only do we lead the Nation in prevalence of
    multiple chronic diseases, we also have the lowest number of doctors
    per capita of any state in the Nation. Add to that persistent poverty
    and low educational achievement spread throughout a rural, agrarian
    state, and you can begin to see why telehealth is our best option for
    changing health outcomes for Mississippi.
        Mississippi has a population of roughly 2.9 million people, with
    more than 1.6 million people living in a rural community and 23 percent
    living at or below the Federal poverty level.\12\ \13\ Mississippi
    ranks the worst in the country for overall health, obesity, heart
    disease, diabetes, infant mortality and preventable
    hospitalizations.\14\ We rank fifty-first in the Nation for the deaths
    before the age of 75 years resulting from conditions that could have
    been prevented with timely quality healthcare.\15\
    ---------------------------------------------------------------------------
        \12\ US Census, 2010.
        \13\ Rural Assistance Center, 2013.
        \14\ Kaiser State Health Facts, 2009.
        \15\ Commonwealth Fund State Scorecard, 2014.
    ---------------------------------------------------------------------------
        Seventy-two of Mississippi's ninety-nine hospitals are in rural
    areas and suffer from the lack of resources and corresponding access to
    care common in rural areas. The state's expenditure on healthcare
    exceeds the national average with 32 percent of the budget being spent
    on health care. Almost half of payments to health care providers in
    Mississippi were from Medicare and Medicaid.
    UMMC Center for Telehealth
        The University of Mississippi Medical Center in Jackson is home to
    Mississippi's only academic medical center, only Children's hospital,
    only transplant program and only Level One trauma center. We have the
    state's only allopathic medical school, dental school and pharmacy
    school, and are the major player in clinical and translational
    research. While these programs and services are more readily accessed
    by those living in the Jackson area, we know that, in order to make
    progress toward improved health statewide, we have to bring our health
    care experts to the patients in the communities where they live.
        The UMMC Center for Telehealth got its start over ten years ago
    with the TelEmergency program, connecting 15 emergency departments in
    rural hospitals with our Level One trauma center at UMMC. Through this
    system, UMMC's emergency medical team consults with rural providers
    using a real-time, video and audio connection, interacts with the
    patient and gives guidance to the provider regarding treatment options.
    Our TelEmergency program has resulted in a 25 percent reduction in
    rural emergency room staffing costs, a 20 percent reduction in
    unnecessary transfers and has produced patient outcomes in rural
    hospitals that are on par with that of our academic medical center.
        Twelve years later, using a similar audio/video platform, the UMMC
    Center for Telehealth is providing over 35 medical specialties in 166
    sites around the state, including community hospitals and clinics,
    mental health facilities, FQHCs, schools and colleges, mobile health
    vans, corporations, prisons and patients' homes. UMMC Center for
    Telehealth connects to sites in 52 of the state's 82 counties and
    serves an average of 8,000 patients per month.
        As we worked to expand telemedicine services, we ran into several
    laws and regulations that complicated its delivery. The first obstacle
    we encountered was the financial disincentive to practice telemedicine.
    Prior to 2013, insurance companies in Mississippi did not reimburse for
    telehealth consults in a way that made it an attractive alternative to
    a clinic visit. We argued that Mississippi would ultimately save money
    by reimbursing for telehealth and undertook a series of pilots to prove
    it. We were successful.
        In 2013, Governor Phil Bryant signed legislation mandating both
    public and private health insurance companies reimburse for Telehealth
    services at the same rates as in-person services. The following year,
    the Governor signed legislation mandating equal reimbursement coverage
    for store-and-forward and remote patient monitoring services. Thanks to
    the Governor's leadership in clearing the barriers to reimbursement
    parity, Mississippi is now recognized as a leader in telehealth. Last
    year, Mississippi was awarded an ``A'' rating by the American
    Telemedicine Association, one of only 7 states in the Nation to receive
    that distinction. These changes at the state level were the catalyst
    for the rapid growth of our state's telehealth system, and I strongly
    believe that adoption of reimbursement parity at the Federal level
    would have an even greater impact.
        Another obstacle we encountered was connectivity. Due to the
    largely rural nature of our state, we could not take for granted that
    support for telehealth services would be available at the level we
    required, or frankly, at all. In order to achieve the connectivity
    required, we partnered with many of the telecommunications companies in
    the state--cable companies, wireless and broadband providers--to
    maximize existing resources and leverage the strength of incumbent
    utilities in the areas where they serve.
        Thanks to support from the Universal Service Fund and our
    telecommunications partners across the state, we are able to bring much
    needed, life changing health care to rural Mississippi. Nothing tells
    this story better than the success of our Diabetes Telehealth Network
    pilot.
        In 2012, diabetic medical expenses in Mississippi totaled $2.74
    billion, according to the American Diabetes Association. Because
    Mississippi leads the Nation in chronic disease, we wanted to begin
    disease management where it is the worst. Ruleville, Mississippi is
    ground zero for diabetes. Sunflower County, where Ruleville is located,
    has one of the highest percentage of diabetics per capita of any county
    in the country. This means repeated visits to the ER, amputations and
    early death for too many members of this community.
        Last fall, UMMC Center for Telehealth partnered with the Governor,
    GE Care Innovation, CSpire and the North Sunflower Medical Center to
    develop a research pilot with the ambitious goal of managing 200
    uncontrolled diabetics through aggressive in home monitoring and
    intervention. The centerpiece of the partnership is a population based
    health care model that leverages telehealth technology delivered over
    state-of-the-art fixed and mobile broadband connections. Its goal is to
    improve the health of participants while reducing the total cost of
    care. Once a patient meets criteria to be admitted to the pilot, he or
    she is sent home with a tablet that monitors glucose readings daily,
    provides educational health information and transmits vital health data
    to specialists monitoring them in real time. For the first time, these
    patients have access to a team of professionals dedicated to their
    care--ophthalmologists, endocrinologists, pharmacists, nutritionists,
    diabetic educators and nurses. Many of our patients have never used a
    computer and some can't read beyond a sixth grade level. Despite these
    challenges, our patients are thriving.
        Of the 85 patients currently enrolled in the pilot, all report that
    their disease is under control for the first time and that they have
    lost weight and are feeling better. While our goal was for 75 percent
    of patients to reduce their hemoglobin A1C levels by 1 percent in the
    first year, study results show that after only six months, the average
    reduction in A1C levels among participants is almost 2 percent. In
    addition, with the exception of one patient who needed to be
    hospitalized at the time of enrollment, none of our participants have
    gone to the ER or been admitted to the hospital for their diabetes.
        It's important to recognize that the connectivity between UMMC and
    these patients would not exist but for the Universal Service Fund
    support that this region enjoys. This is true for many parts of the
    state where we serve, especially in areas like the Mississippi Delta
    where health challenges are most extreme. As we look to roll out this
    successful program beyond Ruleville and beyond diabetes, our foremost
    concern is whether we will have the ability to connect with these
    patients in their communities today and into the future.
        Given the impressive and immediate results to date of our pilot in
    Ruleville, we are not waiting for it to officially wrap up before we
    begin implementing this model in other areas. We already have plans in
    place to allow doctors and patients in Jackson, Grenada and Lexington
    to take advantage of this chronic disease management tool.
    The Future of Telehealth
        As we look to the future, we must consider opportunities and
    challenges to the growth of telehealth. Right now, the greatest
    challenges lie in winning the Federal level reimbursement parity that
    will make telehealth attractive in the marketplace and securing the
    reliable, high quality connectivity that telehealth requires. Given the
    jurisdiction of this committee, I urge you to consider these three
    issues:

      1.  The need for continued support of USF. Today, in rural
            Mississippi, there is connectivity thanks to the success of the
            Universal Service Fund's High-Cost program. A reduction in
            funding will not only impact current operations, but will
            significantly impede our efforts to grow remote patient
            monitoring and hinder connections between patients and medical
            professionals.

      2.  The need for a broader application of the FCC E-rate program. The
            sooner that children's health issues are addressed, the better,
            particularly when it comes to prevention of chronic disease. As
            such, we would like to see telehealth services into schools be
            allowed to take advantage of the E-rate program. Many children,
            particularly in rural areas, may not receive care in other
            settings, making school based evaluation and treatment even
            more important. Data shows that healthy children perform better
            in school, have less absenteeism and are more likely to reach
            higher levels of educational attainment.

      3.  The need for a more inclusive Health Care Connect Fund. Under
            today's framework, hospitals like ours are not able to receive
            the full benefit available to other participants in a network
            due to our size. However, without a large partner like an
            academic medical center, many of these smaller hospitals and
            clinics wouldn't be able to manage the paperwork and
            administrative burden of the program. We would urge a review of
            the Health Care Connect Fund, with an eye toward allowing large
            hospitals to receive a more robust reward for serving as a
            consortium lead for a network of smaller rural hospitals and
            clinics.

        The mission of the UMMC Center for Telehealth is to increase access
    to health care, improve outcomes and reduce costs. Communities that
    have limited medical services can now take advantage of health care
    services delivered to their community virtually. Providing our state
    with improved emergency medical services and specialty health care
    through telemedicine technology, UMMC Center for Telehealth is
    eliminating barriers to quality health care for Mississippians.
        I thank the Subcommittee for the opportunity to testify today and
    look forward to answering any questions you may have.

        Senator Wicker. Thank you very much, Dr. Henderson. And
    thank you for staying within the 5 minutes.
        Dr. Gibbons, we're pleased to hear your testimony.

           STATEMENT OF CHRIS GIBBONS, MD, MPH, DISTINGUISHED

     SCHOLAR-IN-RESIDENCE, CONNECT2HEALTHFCC TASK FORCE,

              FEDERAL COMMUNICATIONS COMMISSION; ASSOCIATE

            DIRECTOR, JOHNS HOPKINS URBAN HEALTH INSTITUTE;

             ASSISTANT PROFESSOR OF MEDICINE, PUBLIC HEALTH

            AND HEALTH INFORMATICS, JOHNS HOPKINS UNIVERSITY

        Dr. Gibbons. Thank you and good morning, Subcommittee
    Chairman Wicker, Ranking Member Schatz, and members of the
    Subcommittee.
        My name is Chris Gibbons. I am a Physician and Assistant
    Professor at Johns Hopkins University, and a Scholar-In-
    Residence at the Federal Communications Commission, where I
    work with its Connect2Health Task Force. I greatly appreciate
    the opportunity to appear before you today to discuss
    telehealth advancements and connectivity issues from a
    physician's perspective working at the FCC. We greatly
    appreciate your leadership in this area.
        For almost a decade-and-a-half, as the Associate Director
    of the Johns Hopkins Urban Health Institute, it has been my
    privilege to work on one of the most challenging problems in
    health care, improving population health. My work has taken me
    from the so-called ivory towers of Johns Hopkins to the homes,
    alleys, and communities of inner-city East Baltimore.
        Through these experiences, I have realized that although we
    have amazing therapies that are treating diseases and curing
    illnesses, too little was being done to prevent the problems
    from occurring in the first place. Also, there were simply too
    many people who needed medical care and not enough providers to
    meet their needs.
        I'm often asked, ``Why would a Hopkins doctor come to the
    FCC?'' My answer is simple. I can't see how we're going to
    improve our Nation's health without aggressively pursuing the
    potential that telehealth and other broadband-enabled health
    technologies have to offer.
        Let me explain what I mean. It's well-documented that
    demand for physicians is growing faster than the supply. A
    study released just last month indicated that over the next 10
    years, if nothing is done, the shortfall will be from 46,000 to
    90,000 physicians, and as high as 800,000 nurses. These
    shortfalls are expected to affect everyone, but they will be
    particularly acute in rural and underserved areas.
        So with approximately 300,000 primary care doctors, 2.6
    million nurses, and 5,800 hospitals and health clinics
    available, it is a challenge to conceive how we will provide
    face-to-face care for 320 million-plus Americans when they need
    it without broadband-enabled technologies, tools and services
    such as telehealth. The broadband imperative is clear, and from
    my perspective there is no better place to be than the FCC.
        So how is the FCC pursuing this broadband imperative? Last
    year, Chairman Wheeler created the Connect2Health Task Force to
    move the needle on broadband and advance health care
    technologies, and to serve as an umbrella for the FCC's health-
    related activities. Although broadband by itself is not a
    panacea, telehealth and other broadband-enabled health
    solutions are playing a significant role in helping us achieve
    our national health objectives.
        The Task Force is charged with making concrete
    recommendations about regulatory barriers and incentives,
    updating the health care section of the National Broadband Plan
    as needed; and raising awareness about the value proposition of
    broadband and health, and about the potential for addressing
    health care disparities in rural and underserved areas.
        To meet these goals, we are getting outside of Washington,
    D.C. to gather information and data and to explore successful
    experiences with broadband-enabled health solutions. We first
    went to the University of Virginia, their Center for
    Telehealth, in November. They have over 20 years of experience
    and have built a 126-site telehealth network across the State
    of Virginia, many of which are in rural areas.
        We also visited Jackson and Ruleville, Mississippi. We saw
    firsthand the groundbreaking and impressive work of Dr. Kristi
    Henderson and the University of Mississippi Medical Center.
    Mississippi has shown that novel public-private partnerships
    with health care providers, telecommunications carriers, IT
    specialists, software developers and government are critical in
    addressing the growing diabetes problems that affect 370,000
    adults in Mississippi and over 29 million people nationwide. In
    the coming months, the Task Force will visit other states and
    communities to learn from their experiences and to shine a
    spotlight on their work.
        Finally, in my view, the largest threat to the widespread
    advancement of telehealth lies in thinking too small. If we
    allow ourselves to believe that the value of telehealth is only
    to connect patients, doctors and hospitals, we will reap
    tangible benefits that will be substantial, but we may fail to
    achieve the transformational possibilities that broadband can
    offer our Nation.
        I commend the Committee, and Chairman Wicker in particular,
    for tackling these critical issues and for recognizing that the
    future depends on what we do today. I look forward to answering
    any questions that you may have.
        [The prepared statement of Dr. Gibbons follows:]

    Prepared Statement of Chris Gibbons, MD, MPH, Distinguished Scholar-in-
          Residence, Connect2HealthFCC Task Force, Federal
                                Communications
     Commission; Associate Director, Johns Hopkins Urban Health Institute;
    Assistant Professor of Medicine, Public Health and Health Informatics,
                            Johns Hopkins University
    Introduction
        Subcommittee Chairman Wicker, Ranking Member Schatz, and Members of
    the Subcommittee, I greatly appreciate the opportunity to appear before
    you on the critical topic of ``Advancing Telehealth through
    Connectivity.''
        For almost a decade-and-a-half, I have served as an Associate
    Director of the Johns Hopkins Urban Health Institute, and it has been
    my privilege to work on one of the most challenging problems in
    healthcare: improving population health. My work has taken me from the
    so-called ``ivory tower'' of Johns Hopkins to the homes, alleys, and
    communities of inner-city East Baltimore.
        Through these experiences and my years of training as a surgeon and
    preventive medicine doctor, I realized that too little was being done
    to reduce the endless flow of patients coming into emergency rooms and
    hospitals for care. My colleagues and I could treat many physical and
    psychological ailments, but we often felt powerless to provide the
    support patients and families needed to manage their chronic diseases
    or truly live ``well.'' While we tried to provide the best care to
    every patient, there were--and remain--too many people who need
    treatment and not enough providers to meet their needs.
        Consumers rely on many resources for their health--doctors
    certainly, but also nutritionists, pharmacies, caregivers, social
    services, and many others. Take for example older Americans. We know
    that seniors who are socially isolated are twice as likely to die
    prematurely. While the exact causes of these realities are not fully
    understood, we know that older patients are prone to depression, which
    is in turn associated with lack of medication adherence, poor diet, and
    other risk factors. To put it simply, when providers, consumers, and
    caregivers remain ``unconnected,'' it is a prescription for
    frustration, burnout, high costs, and suboptimal outcomes.
        I am sometimes asked, ``Why would a Hopkins doctor come to the
    FCC?'' My answer is simple. It's because I can't see how we are going
    to improve our Nation's health--especially in rural and underserved
    areas which have higher rates of chronic illness, poorer overall
    health, and persistent provider shortages--without aggressively
    pursuing the potential that telehealth and other broadband-enabled
    health technologies have to offer.
        Take for example, the worsening health care provider shortage and
    distribution problem we face. Demand for physicians continues to grow
    faster than supply. According to a March 2015 report by the Association
    of American Medical Colleges, the physician shortage will grow over the
    next 10 years leading to a projected shortfall of between 46,100 and
    90,400 physicians by 2025. Similarly, projections suggest a shortage of
    400,000 to 808,000 registered nurses by 2020. While the provider
    shortfall is expected to affect everyone, it will be particularly
    harmful to vulnerable and underserved consumers and patients who live
    in rural areas. And, I should emphasize that nearly 3 out of 10
    Americans live in a rural area or a small city. Thus, with
    approximately 300,000 primary care providers, 2.6 million nurses and
    5800 hospitals and clinics, it is hard to imagine how we can provide
    face-to-face care for the more than 320 million Americans when they
    need it without a greater reliance on broadband-enabled technologies,
    tools, and services, such as telehealth.
        I therefore believe the broadband imperative is clear, and many
    broadband health benefits are already on the horizon. For my work,
    there is no better place to be than the FCC, given its charge under the
    Telecommunications Act of 1996 to ``encourage the deployment on a
    reasonable and timely basis of advanced telecommunications capability
    to all Americans.''
        As detailed below, three key points are driving and shaping the
    work of the Connect2HealthFCC Task Force.
    I. Broadband is Transformative in Health
        There is one overarching reality that underscores the importance of
    this hearing, the Committee's work, and the FCC's role: future advances
    in health care increasingly are premised on the widespread availability
    and accessibility of high-speed connectivity.
        Although broadband, by itself, is not a panacea, telehealth and
    other broadband-enabled health solutions are playing (and likely will
    continue to play) a significant role in helping to achieve the national
    objective of a healthier America. Recent estimates suggest that
    broadband-enabled health information technology (health IT) can improve
    care and lower costs by hundreds of billions of dollars in the coming
    decades, yet the United States remains behind some advanced countries
    in the adoption of such technology.
        It almost goes without saying, that technology is transforming how
    we get and stay well. At the SXSW conference in mid-March, a health
    technology innovator announced a working medical tricorder, previously
    a concept relegated to Star Trek movies and other science fiction. The
    prototype was designed to diagnose 15 different medical conditions and
    monitor vital signs for 72 hours. It reportedly also conducts lab tests
    for conditions like diabetes, pneumonia, tuberculosis, and more. And,
    it includes a lipstick-sized attachment that serves as an otoscope (to
    examine ears) or spirometer (to measure breathing). On an almost daily
    basis, other broadband-enabled technologies are now being used and
    giving clinicians and consumers alike more (and often, better) tools
    for diagnosing illness and monitoring health.
        These technologies are also spawning novel partnerships and unusual
    bedfellows. Consider the new collaboration between Qualcomm
    Incorporated and Walgreens that will enable consumers to connect their
    digital health devices (like a wrist-worn blood pressure cuff) and
    automatically capture all their health data in one place, with the
    potential to share the information with their care team.
        But, as recognized by the 2010 National Broadband Plan and the 2015
    Federal National Health IT Strategic Plan, achieving the full promise
    of telehealth and other advancements rests, in large part, on adequate
    broadband health infrastructure. To put it another way, we must focus
    on the underpinnings of tomorrow's health care system today.
    II. Telehealth Can Level the Playing Field for Rural and Underserved
            Areas
        The FCC is actively engaged in proactive efforts to ensure that
    telehealth and other broadband-enabled health technologies are
    accessible in rural and remote areas, on tribal lands, and in other
    underserved sectors of the country.
        Americans living in rural areas face particularly acute shortages
    of primary care physicians and specialists, and they often must travel
    long distances to obtain medical care. The increasing cost of providing
    health care and the demands of an aging population also put pressures
    on rural health care providers, many of which struggle to keep their
    doors open.
        There is enormous potential for telehealth to help address these
    problems. In a broadband-enabled health future, access to physicians,
    specialists and high-quality health care will no longer be driven by
    geography. Three-hour drives to see a maternal-fetal medicine
    specialist, cardiologist, or diabetologist could be a thing of the
    past. Through telehealth, broadband connectivity can be a force-
    multiplier, helping to address real concerns about provider shortages.
    Telehealth can also be instrumental in meeting the health needs of our
    military veterans in rural areas where access to VA facilities is
    difficult (or distant).
        I am going to focus primarily on how the new
    Connect2HealthFCC Task Force is pursuing this broadband
    imperative.
    A. Connect2HealthFCC Task Force Mission and Goals
        In March 2014, Chairman Wheeler created the
    Connect2HealthFCC Task Force, a senior-level, multi-
    disciplinary effort to move the needle on broadband and advanced health
    care technologies. This is a deliberate attempt to get ahead of the
    curve and to think across various agency silos, with the Task Force
    serving as an umbrella for the FCC's health-related activities.
        Recognizing that technology-based innovations in clinical practice
    and care delivery are poised to fundamentally change the face of health
    care, the Task Force is charged with: making concrete recommendations
    about regulatory barriers and incentives in this area, updating the
    Health Care section of the National Broadband Plan, and raising
    awareness about the value proposition of broadband in health and the
    potential for addressing health care disparities in rural and
    underserved areas. Among other things, we will also work to highlight
    effective telehealth projects, broadband-enabled health technologies,
    and mHealth applications across the country to identify lessons
    learned, best practices, and regulatory challenges. Additionally, we
    hope to stimulate additional public-private partnerships on telehealth
    to move us forward.
        The objectives of the Task Force, working in collaboration with
    internal and external stakeholders, include the following:

       Promoting effective policy and regulatory solutions that
            encourage broadband adoption and promote health IT;

       Identifying regulatory barriers (and incentives) to the
            deployment of RF-enabled advanced health care technologies and
            devices;

       Strengthening the Nation's telehealth infrastructure through
            its Rural Health Care Program and other initiatives;

       Raising consumer awareness about the value proposition of
            broadband in the health care sector and its potential for
            addressing health care disparities;

       Encouraging the development of broadband-enabled health
            technologies that are designed to be fully accessible to people
            with disabilities;

       Highlighting effective telehealth projects, broadband-
            enabled health technologies, and mhealth applications across
            the country and abroad to identify lessons learned, best
            practices, and regulatory challenges; and

       Engaging a diverse array of traditional and non-traditional
            stakeholders to identify emerging issues and opportunities in
            the broadband health space.
    B. Connect2HealthFCC Beyond the Beltway Series
        To meet these goals, we are getting outside Washington, D.C., to
    where the action is.
        Virginia. As part of its ``Beyond the Beltway Series'' to gather
    information and data and explore and leverage on-the-ground experiences
    with broadband-enabled health solutions, particularly in rural and
    underserved areas, the Task Force held its inaugural broadband health
    roundtable at the University of Virginia (UVA) Center for Telehealth
    last November. The roundtable drew on expertise from the Secretaries of
    Health and Technology for the Commonwealth of Virginia as well as
    representatives from the senior executive ranks of the University of
    Virginia. The Task Force heard a compelling story about the UVA Center
    of Telehealth and its two decades of innovation and leadership. In part
    relying on funding from the FCC's Rural Health Care Program, UVA's
    current telehealth network comprises 126 sites across Virginia. Dr.
    Karen Rheuban, a national telehealth expert, and her team explained in
    detail how the Center has expanded in recent years and conducted
    approximately 44,551 telemedicine-based services across 45
    subspecialties, saving Virginians 15 million patient travel miles.
    Globally, the Center also supports healthcare delivery in Tanzania,
    Uganda, Rwanda, and Guatemala.
        The Task Force was fascinated to learn how UVA's telehealth program
    in high-risk obstetrics achieved a 25 percent reduction in pre-term
    deliveries. Interestingly, this teleobstetrics program currently
    provides consultation, counseling, and education services, giving high-
    risk pregnant mothers in rural Virginia access to maternal fetal
    medicine specialists at UVA. UVA's success in this area amply
    demonstrates the substantial impact of the so-called, ``non-clinical,
    social determinants of health.'' Indeed, given estimates from the
    Institute of Medicine that the cost of caring for these fragile infants
    in neonatal intensive care units exceeds $50,000 just in the first few
    weeks of life, these results are remarkable.
        In addition, in the area of telestroke, UVA is also on the cutting
    edge. We were privileged to meet one the Center's telestroke patients
    from Culpepper, Virginia, whose life and neurological function--like
    the ability to speak, move, hear and see--was saved by UVA's cutting-
    edge telestroke program. The UVA telestroke program has increased the
    use of powerful clot-busting, ``brain-saving'' medication in Virginia
    to 17 percent, 14 percentage points above the national average. We are
    watching with interest ongoing mobile broadband telestroke trials, the
    next generation of life-saving telehealth innovations that UVA is
    pursuing.
        Mississippi. In December, I and other members of the
    Connect2HealthFCC Task Force, joined by Commissioner Mignon
    Clyburn, were privileged to visit Jackson and Ruleville, Mississippi.
    The meetings, conferences, site visits, and FCC-hosted health
    technology forum at the Jackson Medical Mall reminded us of good old
    American ingenuity and creativity, which were evident throughout our
    two-day visit.
        We saw first-hand the groundbreaking work of the University of
    Mississippi Medical Center (UMMC) and its national telehealth expert
    Dr. Kristi Henderson, as well as the work of many other clinicians,
    policymakers, and technology innovators, who are all laser-focused on
    improving health in Mississippi through broadband. Mississippi has
    shown that novel public-private partnerships--with healthcare
    providers, telecommunications carriers, IT specialists, software
    developers, and government--will be instrumental in transforming the
    trajectory of broadband-enabled health and care in rural and
    underserved areas of our country. UMMC is driving telehealth beyond the
    boundaries of its health system, with more than 30 specialties, 550
    telehealth partners, and 165 non-affiliated providers. Reportedly, its
    corporate telehealth program not only improves employee health and
    morale, but also reduces absenteeism (and increases overall
    productivity) associated with time taken to make an appointment and see
    a doctor.
        During day two of our visit, Governor Phil Bryant and Commissioner
    Clyburn, along with a few members of the Connect2HealthFCC
    Task Force, visited North Sunflower Medical Center in Ruleville,
    Mississippi, 120 miles north of Jackson, Mississippi. This health
    clinic in the heart of the Mississippi Delta is a key rural partner in
    UMMC's Diabetes Telehealth Network, designed to address the growing
    diabetes crisis that affects more than 370,000 adults in the state of
    Mississippi and 29.1 million people nationwide. The centerpiece of that
    partnership is a population health care approach that leverages
    telehealth technology delivered over state-of-the-art broadband
    connections, with the goal of improving the health of uncontrolled
    diabetics while reducing the overall cost of care.
        It was personally inspiring for me to meet Ms. Collins and Ms.
    Ford, two Mississippians who are participating in the Diabetes
    Telehealth Network. Ms. Collins and Ms. Ford were enthusiastic and
    engaged in improving their health, reporting no diabetic crises or
    hospitalizations since beginning the program. They praised their
    tablets for giving them control over their disease, explaining how they
    get to share their physical, emotional, and psychological state through
    remote daily health sessions with their care team 100 miles away. In
    addition, the tablets automatically capture their health data, such as
    weight, blood pressure, and glucose levels, and transmit that
    information to clinicians daily. These women are empowered by broadband
    health technology, and are no longer captive to the more than 3,000:1
    access to care ratio in their community.
        The benefits of telehealth in Mississippi can be felt far beyond
    traditional healthcare, including in the areas of wellness, workforce
    development, research, education, and business development. The state's
    inclusive vision of broadband-enabled health care in Mississippi is to
    provide an access point in every community, whether in a hospital,
    clinic, corporate setting, school or college. Mississippi is focused on
    building out broadband infrastructure based on geography, not
    population, and striving to identify a business case that makes this
    approach sustainable for rural areas. In many ways, the Mississippi
    experience is the rural America experience.
        Virginia and Mississippi are real success stories that the FCC must
    continue to study, for what they can teach us and other rural areas.
    C. Joint FCC-FDA Workshop on Wireless Medical Device Coexistence
        Another aspect of the FCC's health-related work involves its
    statutory spectrum management role. For example, the Task Force is
    coordinating with other Federal agencies, academic and healthcare
    institutions, and industry to explore potential health risks and
    operational challenges associated with the increasing numbers of
    wireless medical devices, particularly in the unlicensed spectrum. Just
    three weeks ago, the Connect2HealthFCC Task Force and the
    FCC's Office of Engineering and Technology co-hosted a joint workshop
    with the Food and Drug Administration on the safe and seamless
    coexistence of wireless medical technologies. The workshop pulled
    together expertise from 30 nationally-recognized experts based in 15
    different states to do some focused thinking on the issues of medical
    technology innovation, wireless coexistence, and patient safety. The
    bottom line is that wireless medical devices must work as intended, and
    reliably and securely transmitting the data they collect. They also
    must play well in the sandbox with each other, and the health,
    technology and policy sectors must get ahead on this before clinical
    outcomes are negatively affected. To put this in stark terms, one's
    Fitbit, smart car, or smart appliance should not interfere with one's
    insulin pump or pacemaker.
    D. Future Task Force Activities
        In the coming months, we plan to visit a cross-section of other
    rural states and communities to learn from their experiences and to
    shine a spotlight on what's working, and where the FCC, in
    collaboration with other Federal and state stakeholders, can do more to
    help break down regulatory barriers. Thus far, we have had a wide
    variety of stakeholder meetings with a broad-cross section of
    traditional and non-traditional stakeholders: from academia, industry,
    advocacy groups, health care facilities, clinicians, and other
    government partners. The Task Force looks forward to working with, and
    hearing further from, these and other groups. As to data gathering,
    over the next several months, the Task Force plans to seek more formal
    public input and data on a variety of issues related to telehealth and
    other broadband-enabled health solutions. The Task Force also plans to
    release a Phase 1 version of its broadband health connectivity map
    using publicly available data from Virginia, in order to enlist public
    and community engagement and to refine the map's methodology.
    III. Tangible Progress on Rural Telehealth is Within Our Reach
        As demonstrated by the Task Force's Beyond the Beltway visits to
    Mississippi and Virginia, many telehealth advances are already
    underway. There is tremendous interest within and outside government in
    the power of telehealth to address seemingly intractable problems.
    Industry is beginning to innovate and collaborate, recognizing rural
    consumers as an attractive broadband health market. Technologists,
    clinicians, and rural communities are coming together. State and local
    governments are stepping up and often taking the lead. The stars are
    beginning to align, but some challenges remain.
        First, we have to get broadband done right and done right now in
    rural and underserved areas because there are real risks of
    exacerbating health and economic disparities experienced by consumers
    living in these communities, if we fail in that endeavor. For our most
    rural and remote areas, we may need to focus on particularly unique
    solutions, including neighborhood access points for telehealth or self-
    service kiosks.
        Second, there is a critical need for outreach and education, given
    the millions of Americans who remain digitally disconnected or who have
    limited computer and IT familiarity. I believe that rural consumers can
    drive the demand curve for telehealth and other broadband-enabled
    services if they--like Ms. Collins and Ms. Ford in Ruleville,
    Mississippi--better understand the value proposition of broadband in
    health. The Connect2HealthFCC Task Force's efforts in this
    area include a series of consumer tip sheets, blogposts, speeches, and
    tweets; an infographic that unpacks the broadband health imperative in
    an easily digestible way; and its Beyond the Beltway visits.
        Third, we need better tools to measure where we are now, so that we
    can gauge progress over time and identify the rural telehealth
    solutions that are providing the best return on investment. In addition
    to the Phase 1 maps mentioned above, the Task Force is considering the
    feasibility of a broadband health connectivity index to permit
    comparisons over time and across rural communities.
        Fourth, every rural community is different and every state has
    unique needs and challenges. A one-size-fits-all approach to enhancing
    broadband deployment and uptake, will not work. We need a suite of
    telehealth solutions that can be tailored as appropriate.
        Finally, the FCC cannot address all these challenges alone.
    Telehealth progress requires broad stakeholder input and collaboration.
    In particular, the Task Force hopes to work with stakeholders to
    catalyze more public-private partnerships like the one in Mississippi,
    with the goal of not only understanding and characterizing the
    problems, but also catalyzing innovations to enable rural communities
    to reach critical health goals.
    IV. Conclusion
        In my view, the greatest challenge and the largest threat to the
    widespread advancement of rural telehealth lies in thinking too small.
    If we allow ourselves to believe that the value of telehealth is only
    to connect patients, doctors, and hospitals--a critical need to be
    sure, but not the end in itself--we will certainly reap tangible
    benefits, but we could miss the transformational possibilities that
    broadband health connectivity can offer our Nation. I commend the
    Committee, and Chairman Wicker in particular, for tackling these
    critical issues and for recognizing that the future depends on what we
    do today. The Connect2HealthFCC Task Force is committed to
    doing its part.

        Senator Wicker. Thank you very much for your testimony. I
    must say that both of our witnesses so far have been right on
    the money with the 5 minutes. It's amazing.
        Mr. Linkous--have I said that correctly? Is it Linkous?
        Mr. Linkous. Yes. Yes, you have, sir. That's correct, and I
    will try to meet the expectations that have been given from the
    previous two people who were testifying.
        Senator Wicker. We're glad to have you.

      STATEMENT OF JONATHAN D. LINKOUS, CHIEF EXECUTIVE OFFICER,
                   AMERICAN TELEMEDICINE ASSOCIATION

        Mr. Linkous. Thank you, Mr. Chairman and Ranking Member
    Schatz. I appreciate the opportunity to be here.
        I am the CEO of the American Telemedicine Association. Our
    members include about 9,000 physicians and health care
    providers and administrators from around this country, actually
    around the world, and about 300 health systems and technology
    and telecommunications companies as well.
        We were formed in 1993, so over 22 years I've witnessed a
    lot of changes in telemedicine. First of all, having a hearing
    about telemedicine or telehealth is an amazing change in and of
    itself. So I thank you for the opportunity. And I also must
    tell you, I'm amazed when I hear your opening comments from
    both of you gentlemen. The things that I hear, it's a breath of
    fresh air. After 22 years, to hear this type of interest, I
    really applaud it and I thank you for that.
        One of the surprising facts about telemedicine is how much
    it's currently in use. For example, this year about 125,000
    patients who have had a stroke will be seen by a neurologist in
    an emergency room using telemedicine within that golden hour
    that makes a tremendous difference in their lives. And yet
    there are so many other thousands of stroke patients who have
    not received that and will not receive that because they don't
    get the access to telemedicine.
        Tele-ICU is used in about 11 percent of all intensive care
    beds around the country, where an ICU patient will be seen at
    some point by an intensivist or someone who is a specialist
    from a distance. That equals about 500,000 critically ill
    patients this year.
        About 1 million patients with either an implantable
    pacemaker or a cardiac arrhythmia will be monitored by a
    cardiologist or a remote monitoring center all this year, and
    yet millions and millions of patients who have a chronic
    disease cannot get monitored.
        So on the one hand, it's a great thing that's moving
    forward. On the other hand, we still have many problems to
    solve.
        Funding is the same picture. Private payers in about 25
    states now mandate that private payers reimburse for
    telemedicine. Employers are increasingly embracing the field.
    About 45 states and their Medicaid programs reimburse for
    telemedicine. The one holdout, the one laggard, the one late
    adopter of technology is Medicare, and you very well summarized
    it earlier today in your comments and the problems. We have
    fully to benefit from this potential because of such problems.
        The wonder of advanced technology to deliver telecare is
    useless if you don't have access to broadband. Access to
    broadband is no use if you don't have remote health services
    that are made available by providers. And providers aren't
    going to provide those services if Medicare and other payers
    don't pay for it, and if state and Federal regulators don't
    pave the way in easing the regulatory burden.
        Thus, the heart of the problem is regulations and
    government programs. We don't need more programs. We don't need
    more regulations. The Federal Government just needs to fix the
    programs and the regulations that we have today.
        What's frustrating is that telemedicine is not further in
    use, and it's not rocket science. Actually, I've been working
    in telemedicine and related areas for longer than the growth of
    the American Telemedicine Association. For 10 years I worked in
    the Appalachian Commission pushing the same type of technology
    many years ago, from the Southern Tier of New York down to
    Tupelo, Mississippi. And today, there has certainly been
    progress in that, but it's amazing how many problems we still
    see that I saw back 20, 30 years ago.
        And it's not rocket science. That's the really amazing
    thing. Similar problems have been facing other industries who
    have long ago resolved it. For example, in banking, without
    changes in the financial laws and the regulations, consumers
    would still have to wait in line to withdraw their money from a
    bank by taking a check to a teller, and who would do that
    today? We don't need to. Instead, we have ATM machines that are
    available around the world and Internet access to our financial
    services. Consumers can manage their money and investments over
    the Internet regardless of where they're located.
        The fact is that the 21st century solution is often
    hampered by 20th century public policies, and that's what we
    really, really want to have changed. Reform and progress is
    desperately needed in many areas, and in the written comments I
    have we offer several comments that are very specific actions
    that this committee can take, both with the Federal
    Communications Commission as well as some of the other
    programs.
        The one thing I will have to mention before I conclude is
    Chairman Wicker's Telehealth Enhancement Act, which includes a
    range of incremental, budget-sensitive improvements for
    Medicare and Medicaid. We think the CBO would find savings from
    several of these provisions, and some at no or low budget cost.
    So I would end my comments with our support and endorsement of
    this legislation, and we certainly make our offer to work with
    members of this committee and staff in any way you deem
    potentially available. Thank you very much, sir.
        [The prepared statement of Mr. Linkous follows:]

      Prepared Statement of Jonathan D. Linkous, Chief Executive Officer,
                       American Telemedicine Association
        Mr. Chairman:

        Thank you for the opportunity to speak to this Committee about the
    importance of advancing healthcare through connectivity. I am the Chief
    Executive Officer of American Telemedicine Association (ATA). ATA
    promotes telemedicine, sometimes called telehealth, telecare, mobile
    health or connected care and resolves barriers to its deployment.
    Founded in 1993, members of ATA include almost 9,000 physicians,
    administrators and other health providers as well as over 300 health
    systems and vendors of telecommunications and advanced technology.
        Telemedicine involves the use of telecommunications technology to
    provide healthcare. It is a broad term that encompasses a variety of
    health and medical services to patients located both inside and outside
    of medical facilities. Although forms of telemedicine have been in
    existence for forty years, its use has recently skyrocketed. For
    example, this year over 125,000 patients who suffer stroke symptoms
    will be diagnosed by a neurologist in an emergency room using a tele-
    stroke network. Tele-ICU is being used for 11 percent of the Nation's
    intensive care beds to help oversee almost 500,000 critically ill
    patients this year. About one-million patients with an implantable
    pacemaker or suffering from an arrhythmia will be remotely monitored.
    New technology and innovative applications to deliver healthcare using
    mobile devices are announced every day, promising even greater access
    to patients, regardless of their location.
        Driving this expansion are a number of factors including:

       Expansion of coverage and payment by private payers,
            employers and Medicaid programs in the states

       The prevalence of outcomes research showing improved
            quality, reduced cost and expanded access resulting from the
            use of telemedicine

       Increased consumer demand for more convenient services

       Evolution of the healthcare industry including:

         movement of payment mechanisms from fee-for-service to
                value-based payments which remove previous barriers in
                justifying the use of telemedicine and

         consolidation of individual hospitals and clinics into
                regional and national health systems spawning the use of
                telecommunications networks to increase efficiencies and
                expand referral patterns

        The immediate benefit of telemedicine for the patient includes
    access to care where it is not otherwise available.
        Unfortunately, despite its growth, we have yet to see its full
    benefits and its promise to transform healthcare delivery. Accessing
    healthcare continues to be a pervasive problem across America. Unmet
    demands for health services, coupled with lagging availability of
    advanced technologies continue to be a problem for a number of
    interrelated reasons. The wonder of advanced technology in the delivery
    of healthcare is useless if one does not have access to broadband
    technologies. Access to broadband is of no use without remote health
    services made available by providers. Providers can't provide such
    services if it is not allowed by payers and regulators.
        Solutions to this problem do not require rocket science. In fact
    similar problems facing other industries have long ago been resolved.
    Without changes in financial laws and regulations consumers would still
    have to wait in line to withdraw their money from a bank by writing a
    check and presenting it to a teller. Instead ATM machines are available
    across the world and consumers can manage their money and investments
    over the Internet regardless of when or where they are located. The
    fact is telemedicine is a 21st century solution hampered by 20th
    century public policies.
        Reform and progress is desperately needed in several areas. I would
    like to focus on some very specific actions you can take as a
    Subcommittee as well as in your broader roles as members of other
    Committees.
        Most germane to this Subcommittee are opportunities to improve the
    Federal Communications Commission (FCC) programs for health provider
    broadband connection rates and infrastructure.
    Infrastructure to physically enable telehealth services
        Shortly after the Nation passed the 1996 Telecommunications Reform
    Act the Federal Communications Commission began to develop regulations
    to implement provisions expanding broadband access for rural healthcare
    facilities. The estimate at that time was that the program would
    provide upward of $400 million annually to support broadband
    connectivity for rural healthcare. Almost twenty years later, and after
    numerous ``fixes,'' the Commission still fails to provide even half
    that amount. Rural health facilities, crushed under increasing demands
    and shortages of funding, have yet to take full advantage of the
    opportunities afforded by telemedicine to overcome these problems.
    Suffering the most are the patients and their families that have yet to
    fully benefit from the promise that Congress held out in 1996.
        The latest iteration of the FCC's solution to this issue is the
    Healthcare Connect program, which, although designed with high hopes,
    is still falling short of obligating its relatively small allocation of
    universal service funds. Congress needs to step in and help the
    Commission finally turn their program into a shining example from the
    embarrassment it is today.
        We urge approval of two small, but important legislative
    Telecommunications Act changes included in the Telehealth Enhancement
    Act (S. 2662 in the last Congress) from Chairman Wicker and his senior
    Senator.
        For the rural health care provider discounted broadband rates, the
    bill would update the almost 20 year old list of eligible providers
    under section 254(h)(7) to also include--

       ambulance providers and other emergency medical transport
            providers

       health clinics of elementary, secondary and post-secondary
            schools

       other sites where telehealth services are provided for
            Medicare or Medicaid patients

        The other improvement would specify that health care provider
    access to advanced telecommunications and information services under
    254(h)(2)(A) be considered based on need rather than geographic
    location--similar to schools and libraries.
        Second, we urge you to work with the FCC to suspend some of the
    program requirements, at least until the annual allocation is reached.
    We highlight two requirements that seem the most significant barriers:

       A 400 bed limit on hospitals, and

       No funding for administrative costs, even a modest
            percentage directly attributable to the costs of recordkeeping,
            data reporting and other administrative requirements of the FCC
            program.
    Benefit coverage to financially enable telehealth networks
        Many state governments have been very active assuring health
    benefit coverage for telehealth-provided services, at least on par with
    in-person services, for privately insured, Medicaid recipients, and
    state employees. Several state legislatures have made or on the verge
    of major progress for telehealth coverage in recent months. Beyond the
    obvious value for such people, since much of telehealth provision
    functions as network, the larger number of participants makes the
    networks better, stronger, and cheaper.
        While the Departments of Defense and Veterans Affairs are among the
    leaders in taking advantage of the benefits of telehealth and advancing
    telehealth applications and quality, other Federal health benefit
    programs, such as Medicare, FEHBP, and TRICARE, are laggards.
        We greatly appreciate the leadership of Chairman Thune for
    enactment as part of the new Medicare physician payment reforms to not
    have the major restrictions on Medicare telehealth coverage apply to a
    new program for ``alternative payment methods'' program to begin in the
    fall of 2016.
        Chairman Wicker's Telehealth Enhancement Act includes a range of
    incremental, budget-sensitive improvements for Medicare and Medicaid.
    We think the Congressional Budget Office would find scorable savings
    from several of the provisions and some others at no or low budget
    cost. I will highlight two specific provisions:

       Create a Medicaid option for high-risk pregnancies using a
            telehealth network. Independent CBO-style analysis estimated
            savings of $186 million over 10 years. This provision is
            largely based on a very successful statewide program in
            Arkansas.

       Cover remote diagnosis of ischemic strokes so that clot
            busting therapies greatly reduce the need and cost of stroke
            rehabilitation.

        Other Federal health benefit programs, such as the Federal
    Employees Health Benefits Program, should not deny claims for covered
    services when an interactive video or other telehealth means is used.
    Federal collaboration to nurture telehealth networks
        I will close by highlighting the need and opportunity for Congress
    to direct or facilitate the development of new telehealth networks, in
    addition to continued support for the relatively small Federal grant
    program for telehealth networks.
        Just as there are numerous federally-funded networks for medical
    research by centers of excellence, there should be networks for medical
    treatment. Two specific recommendations are the following:

       Autism CARES Act (section 399BB of the Public Health Service
            Act) activities should be amended to include promoting the
            creation of a network of autism care centers to improve care
            quality and accessibility.

       Medicare should be amended to allow community health center
            professionals to be the telehealth providers for Medicare
            services, not just a site where the patient needs to be served
            by non-CHC professionals, thus fostering CHC telehealth
            networks of diverse and scarce services.

        Thank you for the opportunity to present these comments. I and the
    members of ATA stand ready to help you and the other members of the
    Committee to make advances and reform the health and technology
    policies in order to help the residents of your states take advantage
    of the promise of telemedicine.

        Senator Wicker. Thank you, Mr. Linkous, for that testimony
    and for that kind offer.
        Mr. Rytting, what do you have to add to this discussion?

    STATEMENT OF TODD RYTTING, CHIEF TECHNOLOGY OFFICER, PANASONIC
                      CORPORATION OF NORTH AMERICA

        Mr. Rytting. Well, hopefully it's less than 5 minutes.
        [Laughter.]
        Mr. Rytting. Good morning, Chairman Wicker and Ranking
    Member Schatz and the other members of the Subcommittee. My
    name is Todd Rytting. I am Chief Technology Officer from
    Panasonic North America, and I am deeply grateful to have the
    chance to tell you about some of the things that Panasonic is
    doing.
        Before telling you about the telehealth part, I need to
    probably educate a little bit about what Panasonic is in the
    United States. Most of the time we think it's cameras and TVs
    and the occasional microwave. But in the United States, most of
    our revenue, 85 percent, comes from the business-to-business
    sales we have. We deal with the transportation industry, where
    we sell batteries and control systems for electric and hybrid
    vehicles, and we are a major supplier of multimedia systems in
    cars. We're the number-one global provider of in-flight
    entertainment and communications for aviation. And then we have
    other professional businesses that sell audio/visual equipment,
    computing equipment and communications.
        But the reason I'm here is to talk about our interest in
    telehealth. Our vision from our CEO, Joe Taylor, is that we
    need to take the technology that Panasonic has and apply it to
    our senior population because they are a group of people that
    we believe are underserved by technology.
        So with that interest, we are doing several things in the
    health care industry specifically pointed at the senior citizen
    population. One of the projects called SmartCare was started a
    couple of years ago. It is targeted at people who have just
    come out of the hospital; chronic heart failure patients that
    are healing. The challenge is to help the maintenance providers
    to be able to help them stay out of the hospital for health
    reasons.
        We used the television as the primary interface because
    these people know how to use the television. It's familiar
    technology, and it's accessible. On the screen once a day pops
    up a reminder from a recorded nurse that reminds them to take
    their measurements. They stand on the scale, which is
    wirelessly transmitted to the system. They also take their
    blood pressure and other measurements, all of which are
    gathered and sent to a health care professional.
        They are also interviewed. On the screen they have several
    text-based questions that they respond yes or no to, with a
    simplified remote control, like this. And the questions are:
    Are you feeling better than you did yesterday? Are your feet
    swelling? Did you take your medication? And other things that,
    once they get to the health care professionals, they're
    analyzed, they're flagged, and if there might be a concern,
    then a nurse is alerted, and it's their responsibility to
    contact the person and find out what's going on.
        The results were extremely pleasing. We experienced a
    reduction in hospital visits, re-hospitalization, and visits to
    the emergency room by more than two-thirds.
        The second thing we noticed is that they stayed on their
    medication longer, which is obviously something that's
    important to health.
        And the third thing that we were surprised about is the
    very high level of patient acceptance and participation in the
    study. We attribute that to the use of the television, which is
    very familiar to them.
        So after the study we looked at the results and, no
    surprise to the people in this room and this committee, the
    biggest problem we faced was the lack of broadband to some of
    our citizens. Chairman Wicker, you mentioned 8 percent. We
    found some of them in downtown New York City. That difficulty
    with being able to contact them is why we're here.
        We have enough encouragement that we're going ahead with
    more studies. One of them will be in Newark, New Jersey,
    serving the urban members of that population. But what we'd
    like to do is recommend and urge you to action with the
    industry in three areas.
        The first is to encourage ubiquitous, robust, and reliable
    broadband service to everybody. As you know, this is a very
    dynamic and rapid-moving industry, and if we couple good
    national policies with the efforts of industry, we hope that we
    can expand that reach. We appreciate the strong focus in this
    area from your committee and also from the FCC.
        Second, we urge the government to be careful not to over-
    regulate this emerging service. It needs national, not state-
    by-state rules, in order to flourish, and we need to, of
    course, pay attention to security, and pay attention to
    privacy.
        Third and finally, we urge this committee to continue to
    ensure that Federal agencies work together. We do know, as
    we've heard from the witnesses, that there are positive
    outcomes from this technology, even while lowering the costs,
    as Dr. Henderson testified.
        I appreciate being here, and we appreciate the opportunity
    to speak to you.
        [The prepared statement of Mr. Rytting follows:]

         Prepared Statement of Todd Rytting, Chief Technology Officer,
                     Panasonic Corporation of North America
    Summary
        Panasonic Corporation of North America (``Panasonic'') has
    conducted remote patient monitoring pilot studies, and plans to invest
    in larger, longer-duration ones, in the belief that telehealth
    technologies that are reliable and accessible to those needing chronic
    care can help advance American healthcare delivery, improve care
    outcomes, engage patients in self-care, and contain care costs.
        Panasonic will share its experience in this field to date,
    including the challenges and opportunities of delivering successful
    telehealth care, and provide some recommendations for Federal policy
    and practice to encourage private sector investment in this field.
        Good morning, Chairman Wicker, Ranking Member Schatz, and Members
    of the Subcommittee. My name is Todd Rytting, and I serve as the Chief
    Technology Officer of Panasonic Corporation of North America. I am
    honored to have been invited to participate in today's hearing to
    examine the progress that has been made by the private sector and
    government entities in bringing the benefits of telehealth to all parts
    of the U.S.--including rural and remote areas. And I would like to
    explore with you some of the challenges facing the advancement of
    telehealth, so our country can meet the objective of ensuring
    healthcare providers and patients have access to the connectivity
    required to take advantage of innovative telehealth solutions.
        Panasonic strongly supports the effort to transform America's
    healthcare system through the power of information technology--
    supported by robust broadband connectivity--and I will describe how our
    company is actively investing in innovation to help realize this goal.
    By way of background, Panasonic Corporation of North America
    (``Panasonic''), based in Newark, NJ, is the principal North American
    subsidiary of Osaka, Japan-based Panasonic Corporation and the hub of
    its branding, marketing, sales, service, product development and R&D
    operations in the U.S. and Canada. Panasonic operations in North
    America include R&D centers, manufacturing bases, the award-winning
    Panasonic Customer Call Center in Chesapeake, VA, business-to-business
    and industrial solutions companies, and consumer products with sales
    and service networks throughout the U.S., Canada and Mexico. Panasonic
    Corporation of North America and its subsidiaries and affiliates employ
    some 12,000 people in the region.
        Panasonic believes that a fully-connected and interoperable health
    information and communications technology (``ICT'') ecosystem will
    provide the foundation to improve the coordination and quality of care,
    better health outcomes, and reduced overall costs. We believe such an
    ecosystem can be designed and operate safely and securely to capture
    and share patient-generated health data (``PGHD'') and electronic
    health records (``EHRs''), support informed clinical decision-making,
    and facilitate personal health self-management. Such a secure,
    interoperable healthcare infrastructure can help improve all aspects of
    care delivery along the continuum of care--from enabling healthcare
    providers to make improved diagnostic and treatment decisions, to
    empowering patients to make healthy lifestyle choices.
        One key component of this connected and interoperable system--
    perhaps the leading edge and one of the biggest opportunities for
    innovation in healthcare delivery--is the adoption and utilization of
    telehealth and remote patient monitoring services.\1\ Recent advances
    in technology and modes of healthcare delivery allow patients and
    providers to connect whenever and wherever care is needed, and enable
    patients increasingly to engage in management of their own care. Many
    examples exist to illustrate how remote monitoring is utilized in the
    medical home setting for the most chronically ill, for example, by
    monitoring intravenous infusions, measuring blood glucose levels,
    tracking blood pressure, heart rate, and fluid volume in dialysis
    patients, and even medical-grade weight scale readings from the non-
    hospital setting to health-care workers, among many other applications.
    These and other critical information datasets can be sent automatically
    to medical professionals who can analyze trends and alert physicians or
    care providers, in order to identify the onset of problems quickly.
    Today's technologies can also determine the location of ambulances and
    deploy them efficiently to reduce the time it takes to respond.\2\ I
    should also note that the FCC, who I am pleased to be here with today,
    has recognized the benefits of remote monitoring for rural and
    underserved communities in a number of different contexts,\3\ most
    recently through its Connect2Health Task Force.\4\
    ---------------------------------------------------------------------------
        \1\ For example, remote patient monitoring--just one aspect of
    telehealth services--is expected to save $36 billion globally by 2018.
    See Juniper Research, Mobile Health & Fitness: Monitoring, App-enabled
    Devices & Cost Savings 2013-2018 (rel. Jul. 17, 2013), available at
    http://www.juniperresearch.com/reports/mobile_health_fitness.
        \2\ For example, George Washington University's Heart and Vascular
    Institute, The Wireless Foundation, D.C.-area Hospitals and D.C. Fire &
    EMS have partnered to reduce time from onset of chest pain to treatment
    by equipping D.C.-area ambulances with technology that enables rapid,
    wireless transmissions of EKGs to both the on-call physician's wireless
    device and tertiary care hospitals. See http://www.newswise.com/
    articles/view/596059/.
        \3\ Technology Transitions, et al., GN Docket No. 13-5 et al.,
    Order, Report and Order and Further Notice of Proposed Rulemaking,
    Report and Order, Order and Further Notice of Proposed Rulemaking,
    Proposal for Ongoing Data Initiative, 29 FCC Rcd 1433, 1504,  225
    (2014).
        \4\ Just Around the Broadband Bend, Posting of P. Michele Ellison,
    Chair, Connect2HealthFCC Task Force, Official FCC Blog, http://
    www.fcc.gov/blog/just-around-broadband-bend (Feb. 23, 2015).
    ---------------------------------------------------------------------------
        When enabled by reliable connectivity, telehealth and remote
    patient monitoring solutions hold great promise. Clinical evidence has
    demonstrated that interoperable remote monitoring, enabled by
    connectivity, improves care, reducing the frequency of potentially-
    preventable visits to medical institutions, in-patient care and re-
    admissions (thus averting Medicare penalties for hospitals, for
    example), and helping to avoid complications while improving patient
    satisfaction, particularly for the chronically ill.\5\ Therefore,
    attention to PGHD through remote monitoring solutions can enhance
    patient care and raise accountability by healthcare providers while
    containing costs through preventing the deterioration of chronic health
    conditions, such as congestive heart failure and diabetes,\6\ as well
    as engage patients in their own care, leading to improved lifestyle
    choices and improve overall health.\7\ There are extensive clinical
    studies that demonstrate the benefits of utilizing advanced ICT,
    enabled by connectivity, in such areas as chronic condition management,
    heart failure, diabetes management, and medication adherence.\8\
    ---------------------------------------------------------------------------
        \5\ See, e.g., U.S. Agency for Healthcare Research and Quality
    (``AHRQ'') Service Delivery Innovation Profile, Care Coordinators
    Remotely Monitor Chronically Ill Veterans via Messaging Device, Leading
    to Lower Inpatient Utilization and Costs (last updated Feb. 6, 2013),
    available at http://www.innovations.ahrq.gov/content.aspx?id=3006.
        \6\ See, e.g., National eHealth Collaborative (NeHC), Patient
    Generated Health Data Introduction and Current Practices: Report to the
    HIT Policy Committee Consumer Empowerment Workgroup by the Technical
    Expert Panel Convened by National eHealth Collaborative on behalf of
    the Office of the National Coordinatorfor Health Information Technology
    (Jul. 18, 2013), available at http://www.nationalehealth.org/blog/
    patient-generated-health-data-technical-expert-panel-presents-initial-
    findings. Note that the NeHC has since merged with HIMSS.
        \7\ See, e.g., Sanjena Sathian, ``The New 21st Century House
    Call,'' Boston Globe (July 29, 2013), available at http://
    www.bostonglobe.com/lifestyle/health-wellness/2013/07/28/century-house-
    call/tdupWvOQI6b3dKdKcEgdGM/story.html.
        \8\ Please see a list of these studies appended to this testimony.
    ---------------------------------------------------------------------------
        Therefore, Panasonic would urge that national policy should reflect
    the dynamic and transformative nature of advanced ICT solutions, and
    not inhibit the innovation that holds the promise to continually
    improve the care delivery system even as it can contain costs. A
    flexible, supportive approach to such innovation is particularly
    important within rural--as well as many urban--healthcare settings
    which face unique population health challenges based on economic,
    demographic, and other factors that directly affect access to care and
    the quality of outcomes. For example, telemedicine consultations with
    specialists, such as pediatric critical-care physicians, have been
    shown to significantly improve the quality of care for seriously ill
    and injured children treated in rural emergency rooms.\9\
    ---------------------------------------------------------------------------
        \9\ See, e.g., Dharmar, et al, Impact of Critical Care Telemedicine
    Consulations on Children in Rural Emergency Departments, Journal of
    Critical Care Medicine (Aug, 7, 2013), doi: 10.1097/CCM.0b013e31828e98.
    ---------------------------------------------------------------------------
        These positions are not just rhetoric for Panasonic, but reflect
    our own experiences. In partnership with Jewish Home Lifecare
    (``JHL''), a New York City sub-acute eldercare network serving the
    greater New York City area, and HealthFirst, a major NY-based Medicare
    and Medicaid provider, Panasonic recently conducted a formal telehealth
    pilot study we called ``Pathways to Health.'' The objective of this
    pilot was to test the efficacy of Panasonic's ``SmartCare'' Remote
    Patient Monitoring technology in the chronic care management of elderly
    patients at high-risk for congestive heart failure re-hospitalization.
        Our study--whose results are reported in the attached Panasonic
    `white paper'--showed impressive results in the reduction of hospital
    readmissions (69 percent reduction for CMS Dual-Eligibles) and
    Emergency Department visits (74 percent for CMS Dual-Eligibles).
    Equally exciting were extremely positive outcomes around medication
    adherence, and, frankly, glowing patient satisfaction reports. Our
    Pathways to Health pilot, however, revealed significant challenges as
    well. The most significant technical challenge, by far, was the lack of
    reliable Internet connectivity within the patient's home.
        While it is easy to state the goal, i.e. a connected healthcare
    continuum of care that fully utilizes innovative telehealth and remote
    patient monitoring products and services, it may not be easy to
    successfully navigate the path towards that goal. At Panasonic we are
    striving to navigate this path, in the realms of technology, business,
    and public policy, through strategic partnerships and with the aid of
    numerous industry associations and multi-stakeholder coalitions that
    serve as key fora for collaboration.
        Based on Panasonic's experience, we would like to offer a number of
    recommendations: some cross-cutting, and others perhaps more agency-
    specific.
    Cross-Cutting Recommendations
        Congress and Federal agencies should ensure that their approaches
    in this space utilize a technology-neutral approach, so as not to
    ``lock in'' a limited set of solutions that, while deemed adequate for
    today, may fall preclude or impede innovations that are not yet
    predicted. For certain no industry better illustrates the need for
    flexibility and technology neutrality than the incredibly dynamic ICT
    industry. For this reason, the FCC should maintain a technology-neutral
    approach in its work, particularly in the critical context of
    healthcare connectivity.
        Furthermore, Panasonic believes that the Federal Government should
    recognize that over-regulation can act as a disincentive to investment
    in new technology, particularly in the healthcare space where well-
    intentioned regulations can inadvertently inhibit innovation, even
    potentially short-change or harm the American patient. We would urge
    that through analysis, oversight and periodic review of rules and
    guidelines, duplicative or conflicting and unnecessary elements can be
    removed, and that the government act to evolve continually with the
    industry, of course, appropriately balancing potential the risk of
    patient harm with the broad and far-reaching benefits of investment and
    innovation. Existing program mechanisms that incent innovation should
    be maintained, while at the same time the means to improve and modify
    existing frameworks should be explored. The importance of this concept
    is highlighted in the accelerating convergence of sectors and
    industries, now giving rise to the forthcoming ``Internet of Things.''
        Finally, we believe there is a need for continued, cross-agency
    coordinated inquiries into opportunities for wireless broadband
    allocations that can be utilized by healthcare applications. A great
    recent example I might note is the FCC's hosting of a March 31, 2015,
    workshop with the Food and Drug Administration (``FDA'') on wireless
    health test beds, which featured experts from industry, medicine,
    academia, and government focusing on the role of wireless medical test
    beds and their influence on the development of converged medical
    technology for clinical and non-clinical settings.\10\
    ---------------------------------------------------------------------------
        \10\ FCC and FDA Joint Workshop, Promoting Medical Technology
    Innovation--The Role of Wireless Test Beds (Mar. 31, 2015). Video and
    materials from this workshop are publicly accessible at http://
    www.fcc.gov/events/fcc-and-fda-joint-workshop-promoting-medical-
    technology-innovation-role-wireless-test-beds.
    ---------------------------------------------------------------------------
    Federal Communications Commission
        Clearly the FCC has and will continue to play a central role in the
    connectivity needed to provide advanced eCare. And as I noted earlier,
    Panasonic fully supports advancing a national communications
    infrastructure that supports health, safety, and care delivery, and we
    are committed to working with a wide range of policymakers to promote
    this concept.
        In the Universal Service context, we believe that the FCC's
    policies should constantly be re-examined for ways to foster innovation
    in order to ``enhance. . .access to advanced telecommunications and
    information services'' for eligible health care providers.\11\ The FCC
    has been consistent in examining ways to evolve its support of rural
    healthcare (such as the Healthcare Connect Fund, capped at $400m,
    created to expand health care provider access, or ``telehealth,'' to
    broadband, especially in rural areas, and encourage the creation of
    state and regional broadband health care networks); but, its existing
    relevant programs only permit funding to service providers to offer
    discounted wire-line telecommunication services to eligible healthcare
    providers. This funding does not, but we believe should, extend to
    services, such as remote patient monitoring, that are provided to
    patients in their homes.
    ---------------------------------------------------------------------------
        \11\ 47 U.S.C. Sec. 254(h)(2)(A).
    ---------------------------------------------------------------------------
        Some intriguing proposals which contemplate the intent of Congress
    in the creation of Universal Service have been submitted by key
    stakeholders that merit careful consideration, such as Christus Health,
    who has urged the FCC to consider subsidizing under the RHC program the
    wireless broadband contracts between the healthcare providers and
    wireless carriers' healthcare providers use for remote monitoring.\12\
    We stand ready to work with the FCC in efforts to improve how it
    supports rural--and even urban--healthcare moving forward.
    ---------------------------------------------------------------------------
        \12\ See Ex Parte of CHRISTUS Health, CC Docket No. 02-60 (filed
    Mar. 30, 2015), attached.
    ---------------------------------------------------------------------------
        Further, the FCC's Rural Health Care (RHC) program, now some 15
    years old, remains undersubscribed. Panasonic believes there is a need
    for heightened efforts to increase awareness of the RHC through a
    public-private partnership model, such as the approach reflected in the
    FCC's Connect2Health Initiative. We look forward to exploring ways to
    ensure that Universal Service funds dedicated to rural healthcare are
    maximized.
        Since 1985, the Lifeline program has provided basic phone service
    connectivity at a discount to qualified low-income consumers. Recently,
    the Commission has taken significant steps to modernize Universal
    Service across its programs, while improving accountability. We believe
    that the FCC should also give appropriate consideration to the
    opportunities to integrate broadband telecommunications costs with the
    delivery of public services, such as eHealth, to low-income consumers.
    Building on the ongoing work of the Commission within the Universal
    Service context, we believe there is a significant opportunity to
    utilize the Lifeline fund to support these services for low-income
    consumers by adding support for broadband connections--both wired and
    wireless--that are specifically used for providing eHealth and remote
    patient monitoring.
        Finally, in order to advance a national communications
    infrastructure, close and constant coordination will be needed between
    the FCC and other Federal agencies as it continues to make frequency
    management decisions that directly impact opportunities for mobile
    broadband allocations that can be utilized by healthcare applications.
    The solutions needed for a fully connected healthcare system must be
    able to utilize both licensed as well as unlicensed spectrum, as be
    permitted to operate with appropriate sharing arrangements.
        Mr. Chairman and Members of the Subcommittee, thank you again for
    inviting me to participate today; and I would be pleased to answer any
    questions you may have about Panasonic's healthcare activities and
    issues which can affect the implementation of a robust and affordable
    connected telehealth system.
                                     ______

                        Telecommunications Industry Association
                                              Arlington, VA, April 2015

     Existing Clinical Studies Demonstrating the Benefits of Remote Access
                                  Technologies

    Chronic Condition Management

      Veterans Administration: Study Size: Over 17,000 patients.
      ``Routine analysis of data obtained for quality and performance
        purposes from a cohort of 17,025 CCHT patients shows the benefits
        of a 25 percent reduction in numbers of bed days of care, 19
        percent reduction in numbers of hospital admissions, and mean
        satisfaction score rating of 86 percent after enrolment into the
        program. The cost of CCHT is $1,600 per patient per annum,
        substantially less than other NIC programs and nursing home care.
        VHA's experience is that an enterprise-wide home telehealth
        implementation is an appropriate and cost-effective way of managing
        chronic care patients in both urban and rural settings.'' ``Care
        Coordination/Home Telehealth: the systematic implementation of
        health informatics, home telehealth, and disease management to
        support the care of veteran patients with chronic condition''
        [Darkins A, Ryan P, Kobb R, Foster L, Edmonson E, Wakefield B,
        Lancaster AEs, Telemed J E Health. 2008 Dec; 14(10):1118-26. doi:
        10.1089/tmj.2008.0021.] http://online.liebertpub.com/doi/pdf/
        10.1089/tmj.2008.0021

      Primary Care E-Visit v. Physician Office Visit: Study Size 8,000
        Office
      and E-Visits
      From The Washington Post, 1/21/2013: ``A new study suggests that ``e-
        visits'' to health-care providers for sinus infections and urinary
        tract infections (UTIs) may be cheaper than in-person office visits
        and similarly effective.'' [Ateev Mehrotra, MD; Suzanne Paone, DHA;
        G. Daniel Martich, MD; Steven M. Albert, PhD; Grant J. Shevchik,
        MD, JAMA Intern Med. 2013; 173(1):72-74. doi: 10.1001/2013. jama
        internmed.305] http://archinte.jamanetwork.com/
        article.aspx?articleid=1392490

      Randomized Control Trial of Telehealth and Telecare: Study Size 6,191
        patients, 238 GP practices
      ``The early indications show that if used correctly telehealth can
        deliver a 15 percent reduction in A&E visits, a 20 percent
        reduction in emergency admissions, a 14 percent reduction in
        elective admissions, a 14 percent reduction in bed days and an 8
        percent reduction in tariff costs. More strikingly they also
        demonstrate a 45 percent reduction in mortality rates.'' [Source:
        ``Whole System Demonstrator Programme, Headline Findings--December
        2011'', Department of Health, United Kingdom] http://
        www.telecare.org.uk/sites/default/files/file-directory/secure_an
        nual_reports/Publications/
        Effect%20of%20Telehealth%20on%20use%20of%20seco
        ndary%20care%20and%20mortality%20findings%20from%20the%20WSD%20clus
        ter%20randomised%20trial.pdf
    Heart Failure Managagement

      Remote Patient Monitoring of Heart Failure Patients, Meta analysis:
        Study Size 4,264 patients
      ``Remote monitoring programmes reduced rates of admission to hospital
        for chronic heart failure by 21 percent (95 percent confidence
        interval 11 percent to 31 percent) and all cause mortality by 20
        percent (8 percent to 31 percent); of the six trials evaluating
        health related quality of life three reported significant benefits
        with remote monitoring.'' [Telemonitoring or structured telephone
        support programmes for patients with chronic heart failure:
        systematic review and meta-analysis, Robyn Clark, Sally Inglis,
        Finlay McAlister, John Cleland, Simon Stewart, MJ (British Medical
        Journal), doi:10.1136/bmj.39156.536968.55 (published 10 April
        2007)] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1865411/

      Remote Patient Monitoring of Heart Failure Patients, Meta analysis:
        Study Size 6,258/2,354 Patients
      ``RPM convers a significant protective clinical effect in patients
        with chronic HF compared with usual care.'' [J Am Coll Cardio:
        2009;54:1683-94] http://content.onlinejacc.org/
        article.aspx?articleid=1140154

      Telehome Monitoring Program: 1,000 Patients Enrolled
      ``Research at the Heart Institute has shown telehome monitoring at
        the Heart Institute has cut hospital readmission for heart failure
        by 54 percent with savings up to $20,000 for each patient safey
        diverted from an emergency department visit, readmission and
        hospital stay.'' [University of Ottawa Heart Institute, Feburary
        24, 2011, Press Release] http://www.heartandlung.org/article/S0147-
        9563(07)
        00084-2/fulltext

      Remote Patient Monitoring at St. Vincent's Hospital
      ``Impact: In less than two years, preliminary results show that the
        care management program implemented by St. Vincent Health and
        facilitated by the Guide platform reduced hospital readmissions to
        5 percent for patients participating in the program--a 75 percent
        reduction compared to the control group (20 percent), and to the
        national average (20 percent).''[St. Vincent's Hospital Reduces
        Readmissions by 75 percent with a Remote Patient Monitoring-Enabled
        Program, Case Study by Care Innovations, an Intel GE Company]
        http://www.careinno
        vations.com/data/sites/1/downloads/Guide_product/
        guide_stvincent_profile
        .pdf
    Diabetes Management

      Mobile Phone Personalized Behavior Coaching for Diabetes: Study Size
        163 patients over 26 Practices
      ``Conclusions--The combination of behavioral mobile coaching with
        blood glucose data, lifestyle behaviors, and patient self-
        management individually analyzed and presented with evidence-based
        guidelines to providers substantially reduced glycated hemoglobin
        level over 1 year.'' [Cluster-Randomized Trial of a Mobile Phone
        Personalized Behavioral Intervention for Blood Glucose Control,
        Charlene Quinn, Michelle Shardelll, Michael Terrin, Eric Barr,
        Soshana Ballew, Ann Gruber-Baldini, Diabetes Care. Published Online
        July 25, 2011] http://care.diabetesjournals.org/content/34/9/
        1934.long

      Mobile Phone Diabetes Management: Study Size 30 patients from 3 group
        practices
      ``Conclusions: Adults with type 2 diabetes using WellDoc's software
        achieved statistically significant improvements in A1c. HCP and
        patient satisfaction with the system was clinically and
        statistically significant.'' [WellDocTM Mobile Diabetes
        Management Randomized Controlled Trial: Change in Clinical and
        Behavioral Outcomes and Patient and Physician Satisfaction,
        Charlene Quinn, Suzanne Sysko Clough, James Minor, Dan Lender,
        Maria Okafor, Ann Gruber-Baldini, Diabetes Technology &
        Therapeutics, Vol 10, Number 3, 2008, pps 160-168] http://
        online.liebertpub.com/doi/pdf/10.1089/dia.2008.0283
    Medication Adherence for Chronic Conditions: 50 patients

      ``There was a trend toward increased prescription refill rates with
        the use of the Pill Phone application and a decrease after the
        application was discontinued'' [Case study titled: ``Medication
        Adherence and mHealth: The George Washington University and
        Wireless Reach Pill Phone Study'', Study designed, conducted and
        analyzed by George Washington University Medical Center; Qualcomm
        Wireless Reach Initiative was the primary funder of this study]
        http://www.qualcomm
        .com/media/documents/files/wireless-reach-case-study-united-states-
        pill-phone-english-.pdf
                                     ______

                            Lucas, Nace, Gutierrez & Sachs, LLP
                                             McLean, VA, March 27, 2015
    VIA ECFS

    Marlene H. Dortch, Secretary
    Federal Communications Commission
    Washington, DC.

    Attn: Radhika Karmarkar
    Regina Brown
    Wireline Competition Bureau

    Re: CHRISTUS Health
    CC Docket No. 02-60

    Madam Secretary:

        We write regarding the increasing importance of remote home health
    monitoring to the delivery of health care, particularly in rural
    settings. The experience of CHRISTUS Health aligns with the
    Commission's recognition that remote monitoring improves the quality of
    care while reducing costs to patients and providers. We urge the
    Commission to consider supporting the deployment of remote monitoring
    by providing limited universal service support to eligible health care
    providers through the Rural Health Care (``RHC'') program. A
    streamlined RHC application mechanism that supports remote monitoring--
    if only on a limited pilot basis--will help rural hospitals who are
    facing a crisis that is undermining healthcare delivery in rural
    America.
        CHRISTUS Health is an international Catholic, faith-based, not-for-
    profit health system comprised of almost 350 services and facilities,
    including more than 60 hospitals and long-term care facilities, 175
    clinics and outpatient centers, and dozens of other health ministries
    and ventures.\1\ Jointly sponsored by the two religious congregations
    of the Sisters of Charity of the Incarnate Word in Houston and San
    Antonio, the mission of CHRISTUS Health is to extend the healing
    ministry of Jesus Christ. To support its health care ministry, CHRISTUS
    Health employs approximately 30,000 associates and has more than 9,000
    physicians.
    ---------------------------------------------------------------------------
        \1\ See http://www.christushealth.org/workfiles/
    2015SystemProfile.pdf (last visited Mar. 11, 2015). CHRISTUS Health is
    the lead entity and member of the Texas Health Information Network
    Collaborative (``TxHINC''), a RHC pilot program awardee. However, with
    this letter, CHRISTUS Health and Mr. Conklin, who is the Chief
    Information Officer for CHRISTUS Health and Project Manager of TxHINC,
    are representing CHRISTUS Health and not TxHINC.
    ---------------------------------------------------------------------------
        CHRISTUS Health has facilities in Texas, Louisiana, Arkansas,
    Georgia, Iowa, and New Mexico (as well as facilities in Mexico and
    Chile). Many sites in the CHRISTUS Health system are either designated
    ``rural'' for purposes of the RHC program, or serve patients who live
    in areas that are rural, remote, and medically underserved.
    Growing Importance of Remote Patient Monitoring
        Remote monitoring helps doctors manage post-operative care and
    patients with chronic conditions such as heart disease and diabetes.\2\
    Devices attached to patients use wireless broadband to transmit
    measurements back to the hospital where they can be monitored and
    medications or other treatments adjusted. Detecting problems early
    improves the quality of patient care, avoids unnecessary visits to a
    doctor or emergency room, and reduces costs to patients, hospitals, and
    insurers. As a result of Medicare penalties based on patient
    readmission rates, it also improves the bottom-line for hospitals. This
    opportunity to improve care and lower costs makes remote monitoring an
    increasingly important sector of our health care system.
    ---------------------------------------------------------------------------
        \2\ See generally, e.g., Jonathan D. Rockoff, Remote Patient
    Monitoring Lets Doctors Spot Trouble Early, Wall St. J., Feb. 16, 2015.
    ---------------------------------------------------------------------------
        CHRISTUS Health has long been an innovator and, in 2012,
    implemented its own remote monitoring pilot in partnership with a
    carrier (AT&T) and remote monitoring vendor (Vivify Health), both based
    in Texas.\3\ Working with a care transition team focused on post-
    hospitalization treatment of patients with chronic heart conditions and
    diabetes, the CHRISTUS Health remote monitoring project sought to
    increase quality of care, while reducing the burdens on the certified
    care transition nurses responsible for monitoring remote patients. The
    project successfully reduced readmission rates, all with very high
    patient satisfaction.\4\
    ---------------------------------------------------------------------------
        \3\ See Rajiv Leventhal, Innovator Semifinalist Team: Improving
    Home Health at CHRISTUS Health With RPMS, Healthcare Informatics, Feb
    18, 2014, available at http://www.healthcare-informatics.com/article/
    innovator-semifinalist-team-improving-home-health-christus-health-rpms.
        \4\ Id. at 2.
    ---------------------------------------------------------------------------
    Crisis Facing Small Rural Healthcare Providers
        Many small rural hospitals in America are in crisis, facing a
    ``perfect storm'' of demographic, regulatory, and economic challenges
    that threaten their continued viability.\5\ Since 2010, there has been
    a dramatic increase in the number of rural hospital closures.\6\ Rural
    hospitals serve ``some of the sickest and poorest'' patient populations
    in the Nation and these closings are reducing the availability of
    emergency and other care to these populations, resulting in avoidable
    deaths and medical complications.\7\ Managing care for these ``sickest
    and poorest'' is a particular challenge for rural hospitals, and
    readmission penalties associated with their care are one factor in the
    perfect storm these hospitals are facing.\8\
    ---------------------------------------------------------------------------
        \5\ See Jayne O'Donnell and Laura Ungar, Rural Hospitals in
    Critical Condition, USA Today, Nov. 12, 2014, available at http://
    www.usatoday.com/story/news/nation/2014/11/12/rural-hospital-closings-
    federal-reimbursement-medicaid-aca/18532471/; see also Guy Gugliotta,
    Rural hospitals, beset by financial problems, struggle to survive,
    Wash. Post, Mar. 15, 2015, available at http://wapo.st/1BHy5re
    (``[R]ural hospitals. . .suffer from multiple endemic disadvantages
    that drive down profit margins and make it virtually impossible to
    achieve economies of scale. These include declining populations;
    disproportionate numbers of elderly and uninsured patients; the
    frequent need to pay doctors better than top dollar to get them to work
    in the hinterlands; the cost of expensive equipment that is necessary
    but frequently underused; the inability to provide lucrative specialty
    services and treatments; and an emphasis on emergency and urgent care,
    chronic money-losers.'').
        \6\ See O'Donnell and Unger, supra note 5, at 1 (``Since the
    beginning of 2010, 43 rural hospitals--with a total of more than 1,500
    beds--have closed, according to data from the North Carolina Rural
    Health Research Program. The pace of closures has quickened: from 3 in
    2010 to 13 in 2013, and 12 already this year. Georgia alone has lost
    five rural hospitals since 2012, and at least six more are teetering on
    the brink of collapse''); see also Coshandra Dillard, Dying rural
    hospitals affect most vulnerable, Tyler Morning Herald, Feb. 14, 2015,
    available at http://www.tylerpaper.com/TP-News+Local/213794/dying-
    rural-hospitals-affect-most-vulnerable (profiling closing of East Texas
    Medical Center in Gilmer, TX); Alex Smith, Facing Layoffs And Closures,
    Rural Hospitals Push For Medicaid Expansion, KCUR Kansas City Public
    Radio, Feb 11, 2015, available at http://hereandnow.wbur.org/2015/02/
    24/rural-hospitals-medicaid (profiling closing of Sac-Osage Hospital in
    Osceola, Missouri).
        \7\ See O'Donnell and Unger, supra note 5, at 1.
        \8\ See Dillard, supra note 6 (``The Affordable Care Act was
    designed to provide more access to health care, helping rural hospitals
    stay afloat. However, new penalties for performance-based measures,
    such as re-admission rates, stifled already strapped hospitals.'').
    ---------------------------------------------------------------------------
        The FCC has an opportunity to help these hospitals, all of which
    are intended beneficiaries of the RHC program--a program, which fifteen
    years after being established, remains undersubscribed.\9\ Indeed, this
    crisis among rural hospitals demonstrates that undersubscription of the
    RHC program is not due to a lack of need for RHC support among targeted
    beneficiaries.
    ---------------------------------------------------------------------------
        \9\ The RHC has not shown dramatic growth since the Healthcare
    Connect Fund (``HCF'') was launched in January 2013. See USAC Rural
    Health Care Funding Information, http://usac.org/rhc/healthcare-
    connect/funding-information/default.aspx (showing less than $200
    million in total funding requests for funding year 2013) (last visited
    Mar. 25, 2015).
    ---------------------------------------------------------------------------
    How the FCC Could Help
        Allowing rural hospitals to obtain a discount on wireless broadband
    costs associated with providing remote monitoring to patients is one
    way the Commission could help. The remote monitoring kits employed by
    health care providers (``HCPs'') consist of different kinds of remote
    monitoring equipment such as blood pressure cuffs and fingertip blood-
    oxygen meters that are integrated with a wireless broadband service
    provided by a wireless carrier. These can also include tablet
    computers, however the equipment supplied by the HCP is locked down and
    can only be used for healthcare related purposes. (No streaming movies
    on an HCP-provided tablet computer, for example.) The kits are sent
    home with patients on a temporary basis, maintained by the hospital,
    and reusable (after being sterilized).
        Patients in rural areas may have difficulty obtaining reliable
    broadband for remote monitoring. At a minimum, such patients often do
    not have multiple wireless broadband providers to choose from. However,
    the area served by an HCP may span a wide region with no single carrier
    able to serve all of the patients served by the HCP. As a result, HCPs
    may need different remote monitoring kits that work with different
    wireless broadband providers.\10\ The kits and associated wireless
    broadband contract costs are paid for by the HCP, not the patient.
    ---------------------------------------------------------------------------
        \10\ This is similar to a consumer selecting a smartphone from a
    carrier that has the best coverage where they live or work. Note, if
    particular patients are unable to obtain wireless broadband service
    capable of supporting remote monitoring from any provider, HCPs are in
    a position to report this information to the Commission for use in
    other universal service proceedings.
    ---------------------------------------------------------------------------
        The Commission should consider subsidizing under the RHC program
    the wireless broadband contracts between the HCP and wireless carriers
    HCPs use for remote monitoring. This could be done in some cases under
    the existing $10,000 competitive bidding exemption \11\ or perhaps by
    establishing a new exemption (on a pilot basis) for rural HCPs
    purchasing services at publicly-available commercial mobile broadband
    rates. A simple reimbursement mechanism that is administratively easy
    to implement and easy to apply for could directly and immediately
    benefit rural hospitals. Enhancing access to advanced services in this
    way would encourage the deployment of technologies that benefit rural
    health care providers and the patients they serve.
    ---------------------------------------------------------------------------
        \11\ 47 C.F.R. Sec. 642(h)(1). This exemption could be sufficient
    for many rural hospitals. Assuming a monthly mobile broadband data rate
    of $50 per month per active connection, this would equal $600 per year
    per connection. In this example, sixteen connections active for every
    month of the year would equal $9600 per year--potentially eligible for
    $6240 in HCF subsidy.
    ---------------------------------------------------------------------------
        The legal basis for funding mobile broadband connectivity between
    eligible HCPs and patients under the RHC program is addressed below.
    The Rural Health Care Program Should Continue to Foster Innovation
        The Commission has in the past used the Rural Health Care Program
    to explore innovative ways to ``enhance . . . access to advanced
    telecommunications and information services'' for eligible health care
    providers.\12\ For example, in 2007 the RHC pilot program allocated
    $417 million spread over several years to fund network projects across
    the country ``designed to bring the benefits of innovative telehealth
    and telemedicine services to areas of the country where the need for
    those benefits is most acute.'' \13\ While individual pilot projects
    saw varying degrees of success, the overall effort proved hugely
    beneficial and provided Commission policy-makers with the practical
    basis for establishing the Healthcare Connect Fund in 2012 (as a
    component of the overall RHC program).
    ---------------------------------------------------------------------------
        \12\ 47 U.S.C. Sec. 254(h)(2)(A).
        \13\ See Rural Health Care Support Mechanism, WC Docket No. 02 60,
    Report and Order, 27 FCC Rcd 16678, 16684-85,  13 (2012) (HCF Order)
    (describing RHC pilot program).
    ---------------------------------------------------------------------------
        More recently, the Commission has twice considered RHC program
    initiatives that would have continued to explore and support innovation
    in healthcare delivery. In 2012, the Commission announced a $50 million
    pilot program to consider the benefits of funding connections from
    eligible health care providers to skilled nursing facilities
    (``SNFs'').\14\ The Commission recognized the important goal of using
    advanced services to improve patient outcomes and saw SNFs as a
    critical part of the care continuum for patients.\15\
    ---------------------------------------------------------------------------
        \14\ See generally HCF Order, 27 FCC Rcd at 16815-18,  345-350.
        \15\ See id. at 16816,  346.
    ---------------------------------------------------------------------------
        While the Commission ultimately did not implement the SNF pilot, in
    2014, it sought comment on a proposal to use the $50 million in unused
    SNF funding for a series rural healthcare broadband experiments that
    would be ``consumer oriented'' and could ``improve patient access to
    health care.'' \16\ The Technology Transitions Order specifically
    highlighted the benefits of remote monitoring, explaining:
    ---------------------------------------------------------------------------
        \16\ Technology Transitions, et al., GN Docket No. 13-5 et al.,
    Order, Report and Order and Further Notice of Proposed Rulemaking,
    Report and Order, Order and Further Notice of Proposed Rulemaking,
    Proposal for Ongoing Data Initiative, 29 FCC Rcd 1433, 1504,  224
    (2014) (Technology Transitions Order).

            [T]echnological advances hold great promise to enable the
            elderly to age in place, in their home, with remote monitoring
            of key health statistics through a broadband-enabled device.
            Likewise, the Department of Veteran Affairs has implemented a
            telehealth initiative which has reduced the number of days
            spent in the hospital by 59 percent, and hospital admissions by
            35 percent for veterans across the country, saving over $2000
            per year per patient, including even when factoring in the
            costs of the program. These programs are critical to achieving
            savings in healthcare costs, and reducing the amount of time
            patients are away from home, but a critical gap remains in
            ensuring that patients, such as the elderly and veterans, have
            access to sufficient connectivity at home to transmit the
            necessary data for telemedicine applications such as remote
            health care monitoring, to enable patients to access the health
            care provider's patient portal, and for other broadband-enabled
            health care applications.\17\
    ---------------------------------------------------------------------------
        \17\ See id. at 1504,  225 (footnotes omitted).

        The FCC's Connect2Health Task Force has also recognized the clear
    benefits of remote monitoring for rural and underserved communities.
    The Task Force described first-hand encounters with these benefits
    ---------------------------------------------------------------------------
    while on a recent visit to Ruleville, Mississippi (pop. 3,007):

            While at North Sunflower [County Medical Center], two diabetes
            patients, ``Ms. Annie'' and ``Ms. Jackie,'' shared moving
            firsthand accounts of how wireless broadband and remote
            monitoring have helped them control their diabetes and avoid
            the debilitating consequences of the disease experienced by
            other family members.

            We also learned that, as a direct result of the broadband-
            enabled remote monitoring effort in Ruleville, hospital
            admissions for diabetes-related illness are plummeting.\18\
    ---------------------------------------------------------------------------
        \18\ Just Around the Broadband Bend, Posting of P. Michele Ellison,
    Chair, Connect2HealthFCC Task Force, Official FCC Blog, http://
    www.fcc.gov/blog/just-around-broadband-bend (Feb. 23, 2015).

        The Technology Transitions Order also asked whether Section 254
    provides the legal authority to fund broadband experiments focusing on
    ``providing advanced telecommunications and information services to
    consumers in rural areas, with a particular focus deploying broadband
    that is sufficient to meet consumers' healthcare needs'' and sought
    comments ``on experiments that would provide support to health care
    providers.'' \19\ (The existing RHC programs provide funding to service
    providers, who then provide discounted services to eligible health care
    providers.)
    ---------------------------------------------------------------------------
        \19\ See id. at 1506,  230.
    ---------------------------------------------------------------------------
    Can Universal Service Support Broadband Connectivity Underlying
            Remote Monitoring?
        The broadband connectivity that makes remote monitoring possible
    easily fits within the definition of ``advanced services'' eligible for
    universal service support in the Healthcare Connect Fund.\20\ The
    current rule, Section 54.634(a) provides:
    ---------------------------------------------------------------------------
        \20\ See HCF Order, 27 FCC Rcd at 16720-30,  110-111; see also
    id. at 16732-34,  116-119 (declining to impose minimum bandwidth
    requirements on HCF support).

            Eligible health care providers may request support from the
            Healthcare Connect Fund for any advanced telecommunications or
            information service that enables health care providers to post
            their own data, interact with stored data, generate new data,
            or communicate, by providing connectivity over private
            dedicated networks or the public Internet for the provision of
    ---------------------------------------------------------------------------
            health information technology.

        What is new would be allowing HCPs to obtain support for the cost
    of connectivity to individual patients rather than to other HCPs.
    Review of the statutory language authorizing the RHC programs, however,
    show the challenge is more practical than legal.
        Although RHC has traditionally supported connectivity between
    entities, there is nothing in the statute limiting support to entity-
    to-entity connections. Section 254(h)(1)(A) provides support to rural
    HCPs for ``telecommunications services which are necessary for the
    provision of health care services''; while Section 254(h)(2)(A)
    authorizes the FCC to create rules that enhance HCP access to
    ``advanced telecommunications and information services for all public
    and non-profit. . .health care providers. . . .'' \21\ These two
    statutory provisions are intended to assist both patients and HCPs in
    obtaining basic health care services that now include remote
    monitoring.
    ---------------------------------------------------------------------------
        \21\ See 47 U.S.C. Sec. 254(h).
    ---------------------------------------------------------------------------
        From a funding standpoint, the practical obstacle involves how
    these services are procured. It is at best impractical for a small
    rural hospital to conduct a competitive bidding process for the
    commodity mobile broadband service that underpins remote monitoring
    kits. In selecting service providers, hospitals will consider foremost
    the availability of adequate mobile broadband service at the location
    (or locations) where the patient will be monitored (typically but not
    necessarily their private residence). In cases where more than one
    service provider could be selected, other factors such as price can be
    expected to come into play.
        Even in cases where multiple broadband providers could provide the
    needed service, a competitive bidding exemption makes sense. First,
    services are needed for a limited period of time that will vary and be
    uncertain in duration: it could be weeks, months, or years, depending
    on the patient and the medical conditions being monitored. Conducting a
    traditional RHC competitive bidding process annually for each situation
    would make no sense. Even if services were procured in bulk for a range
    of patients in a particular region for a set period of time (one year
    for example), because mobile broadband pricing is a commodity in most
    cases, program savings would be minimal and the complexity of the RHC
    procurement process and requirements would discourage participation by
    the small rural hospitals that urgently need this support.
        Instead, the Commission should consider a competitive bidding
    exemption that allows rural hospitals to request funding for the costs
    of mobile broadband supporting remote monitoring purchased at publicly
    available commercial rates, and to submit invoices for reimbursement at
    the 65 percent HCF flat discount rate. Because the number of rural
    hospitals is limited \22\ and the amount of these costs will be
    relatively low, there is little risk this would be a dramatic drain on
    limited RHC funding. Moreover, proceeding on a limited time pilot
    basis--three years, for example--would allow the Commission to assess
    the demand, impact, and benefits of such an approach.
    ---------------------------------------------------------------------------
        \22\ In 2012, the Commission estimated there were 1,674 rural
    hospitals eligible for RHC support. See HCF Order, 27 FCC Rcd at 16723-
    24,  98, n.266.
    ---------------------------------------------------------------------------
        We appreciate any attention you can give to this important matter
    and look forward to discussing this issue further.
                Respectfully submitted,
                                             George S. Conklin,
                                         Senior Vice President and CIO,
                                                           CHRISTUS Health.

                                           Jeffrey A. Mitchell,
                                       Lukas, Nace, Gutierrez & Sachs, LLP.
                                                            Its Counsel
        cc Connect2HealthFCC Task Force

        Senator Wicker. Well, thank you. Thank you to all of you.
        Mr. Rytting, in addition to your testimony, you've
    submitted a white paper, I believe.
        Mr. Rytting. That's correct.
        Senator Wicker. Without objection, that will be included in
    the record also.
        [The information referred to follows:]

                     The Panasonic Home Gateway--10/31/2014

                  Pathways to Health with Jewish Home Lifecare

                               Alexis Silver, MBA

    Table of Contents

    Executive Summary

    Introduction

    Part I

            Home Telehealth/Remote Patient Monitoring

            Making the Case for Home Telehealth

            Estimated Annual Savings from the use of Home Telehealth
            (Litan, 2008)

    The Panasonic Home Gateway

            Program Rationale

            The Technology

            Program Details--Operational Design

            THE PATHWAYS TO HEALTH PROGRAM

            The Target Population

            Program Details--Implementation

            Program Challenges

    Program Results

            Emergency Room Visits

            Medication Adherence

            Results: Satisfaction

    Part II: Implications of the Results

    Stakeholders

            Stakeholder: Medicare

            Conclusion: Medicare

            Stakeholder: Medicaid--the Dually-Eligible Population

            Conclusion: Medicaid

            Stakeholders: Medicaid State Policy and FIDA

            Conclusion: FIDA Plans

            Stakeholders: Hospitals

            Conclusion: Hospitals

            Stakeholders: ACOs--Economies of Scale

            Conclusion: ACOs

            Stakeholders: The Growing Footprint of Managed Care in Medicare

            Conclusion: Medicare Advantage

            Stakeholders: Medicare Home Health Agencies

            Conclusion: Home Care

    Contributing Factors: Health Care Costs

            Cost Factor: Medication Adherence

            Cost Factor: Health Literacy

            Cost Factor: Satisfaction with the Care Experience

            Cost Factor: Labor Shortages and the Increasing Demand for Care

            Conclusion: Cost factors

    Conclusion

    References

    APPENDIX A--Results--Pathways to Health

            Chart 1--Six month hospitalization rate

            Chart 2--Gateway Reductions

            Chart 3--Six Month ER Visit Rate

            Chart 4--Gateway Satisfaction

            Chart 5--Adherence Trend in Medication

            Chart 6--System Utilization

    APPENDIX B--Stakeholders

            Chart 1- Medicare Benefits Payments

            Chart 2--Health Status of Duals--Comparison

            Chart 3--Comparative Service Use

            Table 1--MLTC Covered Services vs. Medicare Covered Services

    APPENDIX C--the Panasonic Home Gateway System
                                     ______

    Executive Summary
        In the last ten years, much has been written about the utilization,
    evolution and future of home telehealth or what is often referred to as
    remote patient monitoring. Many studies and research projects--some
    large, some small--have been conducted in the hope of validating the
    efficacy of the technology in the home as a valuable component of case
    management. With a few exceptions, it can be said that the studies
    confirm what is intuitive--home telehealth saves clinicians time, saves
    money through reduced utilization of health services and improves the
    quality of patient life through education, self-empowerment and
    improved self-management of disease.
        This paper reviews the current health ecosystem, its dramatically
    changing landscape and illustrates how case management programs
    utilizing home telehealth technology, and specifically, the Panasonic
    Home Gateway, can impact the cost of health care in multiple
    stakeholder-settings by reducing costs associated with health services
    utilization while supporting high levels of quality outcomes,
    medication adherence and patient satisfaction.
        Panasonic partnered with Jewish Home Lifecare, a New York City-
    based health care system with many years' experience in using multiple
    modalities of home telehealth products, to pilot their innovative
    introduction in the home telehealth arena. The joint venture--Pathways
    to Health--resulted in significantly lower rates of hospitalizations
    and emergency room visits while supporting high levels of medication
    adherence, patient satisfaction and system utilization. Pilot outcomes
    included:

       Hospitalizations

         JHL cohort (dually eligible)--69 percent less than the
                dually eligible average

         Medicare Advantage cohort--44 percent less compared to
                previous claims data

       Emergency room visits

         JHL cohort (dually eligible)--74 percent less than
                dually eligible average

         Medicare Advantage--43 percent less compared to
                previous claims data

       Medication adherence

         96-99 percent range

       Satisfaction

         95 percent satisfied or better

         100 percent would recommend to family or friends

         100 percent felt safer at home

       Utilization

         90.3 percent patients used the tablet at least three
                times per week.

        McKnight's Excellence in Technology Awards competition named Jewish
    Home Lifecare the 2014 Innovator of the Year for the Pathways to Health
    program use of the Panasonic Home Gateway (McKnight's, 2014).
        These remarkable program results confirm and improve on those found
    in many other studies; however, from a fiscal perspective, there is a
    persistent concern with how home telehealth should be financed. This
    paper reviews some of the major stakeholders that could benefit from
    the use of home telehealth and addresses the financial implications of
    implementing home telehealth programs to each stakeholder--Medicare,
    Medicaid, hospitals, Managed Care, ACO's and home health agencies. Each
    has a unique opportunity to benefit from incorporating home telehealth
    as part of their program operational design.
    Introduction
        The American health ecosystem is struggling to improve access to
    timely, quality care in the face of the growing demands of an aging
    population, an increasing number of people with chronic illnesses,
    fewer clinicians, and a healthcare system primarily focused on treating
    acute conditions. These pressures combined with consumer preference for
    ``aging in place'' are providing the stimulus for the adoption of new
    community based care models that will allow a patient to stay in their
    home and still receive quality care.
        These pressures come at a time when the Affordable Care Act (ACA)
    reforms are changing the financial face of healthcare through payment
    reform and rebasing. These reforms are expected to increase
    consolidation among hospitals and downstream providers as they strive
    to provide higher quality, more efficient care.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Home telehealth, sometimes called remote patient monitoring, will
    play an increasingly critical role with the current evolution in health
    care delivery and reimbursement models. And while telehealth is widely
    known for its impact on improving quality and access to care, there is
    ongoing dispute over its value in economic terms. Who pays for it?
    There is no simple answer as the payer (or cost saver) in each health
    care setting may be different. As our health care settings and payers
    align, there will be shared savings; capitated payments will lead to
    economies of service; readmissions penalties and losses will
    incentivize methods to prevent readmissions. All these roads lead to
    home telehealth as a valuable patient management technology.
        This paper will explore the current healthcare marketplace and its
    major stakeholders: Medicare and Medicaid; hospitals; managed care and
    home care agencies. In addition, it will discuss the savings
    telehealth, and in specific, the Panasonic Home Gateway, can bring to
    those different care settings.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
                                     Part I
    Home Telehealth/Remote Patient Monitoring
        The benefits of the many forms of telemedicine \1\, and in
    particular home telehealth or remote patient monitoring (RPM), are well
    known. As part of a comprehensive, evidence-based care management
    process, early interventions based on changes in reported via a
    telehealth unit placed in an individual's home result in a reduction in
    hospitalizations and emergency room visits.
    ---------------------------------------------------------------------------
        \1\ This paper will discuss home telehealth, as opposed to
    telemedicine, which is a broader term usually used in the context of
    physician's offices, clinics and hospitals.
    ---------------------------------------------------------------------------
        Home telehealth is expected to continue to transform and improve
    current practices in chronic disease care management. Daily reporting
    of vital signs reveals trends in patient biometrics. Prompts,
    reminders, and queries can assist patients in medication adherence.
    Educational features help patients learn to self-manage their disease
    through increased awareness of healthy diet and exercise. Improvement
    in self-management, knowledge and skills reduces health system
    utilization, keeping costs down. According to the Centers for Disease
    Control and Prevention (CDC, 2013), improved self-management of chronic
    disease results in an approximate cost-to-savings ratio of 1:10.
        To capture data, monitoring technologies use a variety of wired or
    wireless peripheral measurement devices such as blood pressure cuffs,
    scales, and pulse oximetry. Some also permit video interaction/chat
    between the patient and health care professional. Some systems can
    prompt users to enter answers to targeted questions, and then use this
    information for data interpretation, provision of educational
    materials, as well as instructions such as scheduling an office visit
    or going to the nearest emergency room. Similarly, telehealth software
    systems can transmit user-entered data; store the data in secure
    records systems accessible to clinicians; flag abnormal readings or
    responses; and alert clinicians to abnormalities via web dashboard, e-
    mail or text messages. In response to these alerts, clinicians can
    review data, follow up with patients, or take other appropriate
    actions. Although applications of the monitoring technologies are most
    often used in the home setting, a variation called a kiosk (multiple
    users) is used in congregate settings such as community-based senior
    centers, adult day care centers and nursing homes.
    Making the Case for Home Telehealth
        The estimated savings Litan (2008) projects from the use of home
    telehealth are encompassing and aggressive. He reports that up to $10.1
    billion could be saved for all payers annually through the use of home
    telehealth with heart failure alone (Table A). Countless telehealth
    papers have attested to the savings their specific programs have
    incurred. The question at point; however, is to whom do these savings
    accrue? Who, beyond the Federal payers, have an interest and a
    potential role in achieving some of these savings? The second section
    of this paper will explore those questions.

                            Table A--Estimated Annual Savings from the Use of Home Telehealth
                                                      (Litan, 2008)
    ----------------------------------------------------------------------------------------------------------------
                                              Heart Failure               Diabetes                    COPD
    ----------------------------------------------------------------------------------------------------------------
    Emergency Care                                  $50 million              $0.1 billion               $.2 billion
    (avoidance) Expense
    Hospitalization                                $7.4 billion              $3.5 billion              $2.9 billion
    (avoidance) Expense
    Nursing Home                                   $2.7 billion              $2.5 billion              $1.8 billion
    (avoidance) Expenses
    Total                                         $10.1 billion              $6.1 billion              $4.9 billion
    ----------------------------------------------------------------------------------------------------------------

                           The Panasonic Home Gateway
    Program Rationale
        According to the International Journal of Behavioral Nutrition and
    Physical Activity (2014), cross-sectional comparisons across age groups
    suggest that as people get older, they tend to watch more television
    and become less active. Nielson (2014) reported that people over the
    age of 65 spend nearly 48 hours a week, about 7 hours a day watching
    television. This makes the television an ideal medium to reach an
    elderly population. The television is a critical part of most older
    person's lives, and thus makes an ideal medium to reach that
    population.
        There are many models of home telehealth that offer different
    features and capabilities. Beyond the basic functions of vital sign
    monitoring and self-assessment queries, the Panasonic Home Gateway
    system was designed to address many of the issues inherent to the
    geriatric population: medication adherence, health literacy, self-
    engagement in health, poor eyesight and hearing, television use and
    sedentary lifestyle. Panasonic's television-based technical
    capabilities were embedded with the clinical evidence-based best
    practices of the Jewish Home Lifecare Telehealth Program.
        Could a television-based product, coupled with a proven telehealth
    care management program, reduce hospitalizations while maintaining high
    levels of customer satisfaction, medication adherence and system
    utilization? The answer, as shown in the following pages, is a
    resounding ``yes.''
    The Technology
        The Panasonic Home Gateway is a small box, similar to a DVD player,
    which connects to and utilizes patients' televisions as a medium to
    provide biometric monitoring, health self-assessment surveys and
    educational videos to support disease self-management. The Gateway is
    accompanied by a specially designed remote control (Appendix C) that
    allows users to choose specific answers and options, such as health
    videos that can be displayed on the television. Data received is
    transmitted to a remote website via the internet, where it can be
    reviewed by a nurse. Data that is outside normal parameters is flagged
    to alert the nurse. The gateway software is customizable to allow for
    specific reports such as patient health and satisfaction surveys and
    aggregate as well as individual and aggregate responses.
    Program Details--Operational Design
        Each morning at an individualized, preset time, participants
    receive a friendly video prompt on their television in (English or
    Spanish), reminding them to take their vital signs. Weight and blood
    pressure readings are then transmitted via Bluetooth to the television,
    and then to the Panasonic software portal via the internet. Heart
    failure patients with an additional diagnosis of diabetes are prompted
    to take their blood sugar readings using their own glucometer, and then
    asked to manually put the readings into the system. Patients may be
    reminded up to three times to take their vital signs if they don't
    respond to the first prompt, thus improving patient utilization of the
    technology.
        In acknowledgement of the lower levels of health literacy as will
    be discussed in Part II, health videos were made available on demand.
    Patients can be encouraged to watch videos appropriate to their disease
    at least once as can their families.
        Following the taking of the daily vital signs, patients were asked
    to answer a number of self-assessment questions related to their health
    status and symptoms. They were asked if they remembered to take their
    medication, and if not, why they didn't. They were regularly queried
    about their satisfaction with the program, or asked questions related
    to their diet or lifestyle, such as smoking habits or doctor's
    appointments.
    The Pathways to Health Program
        Panasonic's partnership with Jewish Home Lifecare (JHL) enabled
    them to benefit from JHL's many years' experience with home telehealth.
    As part of their ``Nursing Homes without Walls'' program for dually
    eligible beneficiaries, JHL has long used a number of home telehealth
    product lines as successful interventions to keep fragile patients in
    their homes with the belief that home technologies not only prolong,
    but dramatically improve the quality of life through disease
    management, improved patient safety and confidence, reduced numbers of
    hospitalizations and emergency room visits. JHL was a key part of the
    Pathways to Health pilot development process, overseeing the pairing of
    the Panasonic technology with their proven telehealth processes.
    The Target Population
        The Pathways to Health Beta project targeted two population
    cohorts:

      1.  Dually eligible patients that were current enrollees in JHL's
            Lombardi, or Long Term Home Health Care Program (LTHHCP), also
            known as the ``Nursing Homes without Walls'' program; and

      2.  Medicare patients referred to JHL from Healthfirst, a major
            Medicare Advantage provider in the Metropolitan New York City
            area.

        During the program, the LTHHCP patients, who were dually eligible,
    were transferred to the oversight of Managed Long Term Care Programs
    per New York State mandate (MRT 90, 2014).
        Patients were all diagnosed with Stage III or Stage IV Heart
    Failure. Many patients had additional diagnoses, with diabetes being
    the most common. Several patients within the program also had a
    diagnosis of end stage renal disease, which made them extremely high
    risk for hospitalization.
        The average age of the pilot participants was 75 years old with the
    JHL patients being, on average five years older. In addition, the JHL
    patients were predominantly female (80 percent), Hispanic or African
    American (80 percent) and Spanish speaking (65 percent). The
    Healthfirst population was approximately 65 percent female and 75
    percent Caucasian, with almost all speaking English, with one patient
    speaking Creole. The participants from both cohorts were heavily
    concentrated in Bronx and Manhattan, with a few residing in Brooklyn.
        These demographics are consistent with the differences between the
    dually eligible population and Medicare-only.
    Program Details--Implementation
        To be eligible, patients needed to be diagnosed with Stage III or
    IV Heart Failure and at high risk for hospitalization. Both English and
    Spanish speaking patients were accepted.
        Once a patient was screened as eligible and agreed to participate,
    Panasonic installers visited their home, installed the equipment and
    provided instruction on how to use the technology. Each patient then
    was visited once by a JHL nurse to assess the clinical appropriateness
    of the patient for the program, sign consents, reinforce the training
    and outline the patient responsibilities during the monitoring period.
        Patients were subdivided into four cohorts:

       Heart Failure, English Speaking

       Heart Failure, Spanish Speaking

       Heart Failure with Diabetes, English Speaking

       Heart Failure with Diabetes, Spanish Speaking

        Each cohort received daily prompting on the television to take
    their vital signs, followed by self -assessment health queries in their
    preferred language. Participants responded using the Panasonic remote
    control to choose selected answers. Questions were asked in large bold
    text shown on the television, easy for elderly eyes to see. The
    system's branching logic identified additional critical information
    related to pain status, medication adherence and supply and
    exacerbation of symptoms.
        JHL nurses monitored and educated patients appropriate to their
    individual diagnosis and further reinforced education throughout the
    monitoring period. In addition, JHL nurses communicated with patients'
    case managers, keeping them appraised of the patient status. As it was
    a pilot with new technology, careful track was kept of patients' use,
    satisfaction and problems incurred with the equipment.
    Program Challenges
        As with any pilot program, there were challenges that provided a
    learning experience for both organizations. The Panasonic-JHL
    implementation team met regularly to discuss and collectively solve
    clinical, technical, and any program operational issues as they
    appeared.
        As many of the patients selected were dually eligible participants,
    introducing the program and maintaining the Gateway technology
    presented a number of challenges related to their age, tech
    ``savviness'' and in many cases, their socioeconomic status. The
    targeted population was generally a very febrile group--uptake during
    recruitment was slow at first and often required multiple phone calls
    to explain the project, speak with family members and arrange for
    installation. Once scripts were provided for staff, uptake improved.
        As the project matured and showed clinical successes, case managers
    directly referred a number of suitable candidates to JHL's telehealth
    department and in some cases asked for special consideration for high
    risk patients to be admitted as soon as possible.
        The most significant technical challenge, once patients were
    recruited was the lack of Internet connectivity. Some patients that did
    have Internet did not know their password. As an intervention, mifi's
    or hotspots were installed to provide connectivity where needed, but a
    system-wide upgrade from one major provider resulted in a system wide
    failure of mifi's--all had to be replaced. In order to provide the best
    service and connectivity possible, the operations team began to use
    different service providers determined by patient location. Although
    the mifi's were overall a very successful intervention, some
    participants lived in ``dead zones'' or in high rises that did not
    receive adequate service and could not be admitted into the program.
        Patients and their families sometimes interfered with the Gateway
    once installed, unplugging it to use outlets or television ports for
    games, VCRs or DVD. Mifi's were unplugged, television inputs were
    changed. Some patients with behavioral health issues were nervous about
    the LED lights embedded in the box; others were concerned about the
    cost of additional electricity usage.
        Some fixes were easy. Power strips were provided. Aides and family
    members were trained to troubleshoot the simple problems, such as
    changing the television input. Lights were taped over; the cost of
    electricity was explained, mifi's were hidden behind the television,
    out of sight.
        There was some attrition during the course of the study as a few
    participants proved to be unreliable, disinterested or in some cases,
    cognitively unable to participate. One participant advised she was
    going on vacation for a few weeks, but did not return until the study
    was nearly over.
        Although there were multiple service calls for connectivity
    issues--most of which were caused by the participants or their
    families--no Gateways malfunctioned or had to be replaced during the
    course of the study.
        The pilot results--gathered throughout the program as well as from
    formal exit interviews--provided valuable feedback that enabled
    Panasonic and JHL to institute technical and program refinements that
    overcame the majority of those challenges that surfaced during the
    program.
                                Program Results
        Thirty four patients met completion requirements for the program--
    being enrolled a minimum of 90 days within a six month period beginning
    January, 2014 and ending in July, 2014.
        Throughout the program time frame, hospitalization and emergency
    room visits were analyzed on a monthly basis, as were medication
    adherence, and satisfaction related to technology ease of use, program
    in general and quality of life. Additional aggregate and individual
    trends were available for reporting as well and were used for clinical
    care management by the telehealth team.
        Claims data was available for twelve Medicare Advantage (MA)
    patients from a managed care company and those patients were compared
    against their previous year with no adjustments made for exacerbation
    of disease over the course of one year. The remaining 22 patients were
    compared against the standard for dually eligible patients as
    determined by data published by the Kaiser Family Foundation (2012).
        According to a brief on Medicare Policy from the Kaiser Family
    Foundation (Jacobson, et al., 2012), the dually eligible had higher
    hospitalization rates than Medicare (26 percent vs. 18 percent) and
    were more likely to have two or more hospitalizations (11 percent vs. 6
    percent). They were also more likely to use the emergency room--17
    percent versus 12 percent for Medicare patients.
        Both cohorts showed remarkable reductions in hospitalizations as
    shown in Figure B. The Medicare Advantage group had 44 percent fewer
    hospitalizations than they had the year before,\2\ despite the normal
    progression of disease over the course of a year. JHL's dually eligible
    population had an average hospitalization rate of 8 percent--69 percent
    less than the average rate of 26 percent for dual eligible
    beneficiaries.
    ---------------------------------------------------------------------------
        \2\ As this was a six month study, data was compared seasonally--
    the data from the first six months of 2013 was compared to the first
    six months of 2014 for Medicare Advantage patients.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                       Table B--Hospitalization Rates--Comparison
    ----------------------------------------------------------------------------------------------------------------

    ----------------------------------------------------------------------------------------------------------------
    Cohort                        Medicare             Medicare             Dually               Dually
                                  Advantage            Advantage            Eligible             eligible JHL
                                  Before               With                 Average              Patients with
                                  Gateway--2013        Gateway--2014        2012 \3\             Gateway 2014
    Six month                             18%                  10%                  26%                   8%
    Hospitalization Rate
    % Reduction/difference                                     44%                                       69%
    ----------------------------------------------------------------------------------------------------------------
    See Appendix A, Chart 1 ``Six Month Hospitalization Rate''

    Emergency Room Visits
        Emergency room visit rates were reduced in a manner similar to
    hospitalizations, as shown in Table C. Medicare Advantage rates were 43
    percent lower; JHL patients 74 percent lower. Also see Appendix A,
    Chart 3.
    ---------------------------------------------------------------------------
        \3\ Data reported in Jacobson, (2012)

                                       Table C--Emergency Room Visits--Comparison
    ----------------------------------------------------------------------------------------------------------------

    ----------------------------------------------------------------------------------------------------------------
    Cohort                    Medicare              Medicare              Dually                JHL patients
                              Advantage Pre         Advantage             Eligible              with
                              Gateway--2013         With                  Average               Gateway 2014
                                                    Gateway--2014         (2012)\4\
    Six Month ER visit rate           9.70%                 5.50%                  17%                  4.50%
    Percent Reduction                                        43%                                         74%
    ----------------------------------------------------------------------------------------------------------------

    Medication Adherence
        Participants were reminded each day to take their medication and
    also were asked if they had taken their medications as prescribed. In
    contrast to studies related to overall medication adherence,
    participants generally indicated a high rate of adherence with their
    medication regimes, ranging from 96 percent at the beginning of the
    study to 99 percent in June 2014. However; each month, a significant
    percentage of those who responded ``no'' to the medication query
    additionally responded that the reason they did not was because they
    were out of their medication. This information was passed on to their
    care manager for a follow up intervention that ensured their
    prescriptions were refilled or renewed. During the course of the study,
    the percent of those that indicated they were out of their medications
    dropped, and at the same time, a slight, but noticeable trend upward
    was evidenced in medication adherence as shown in Table D. See also
    Appendix A, Chart 5.
    ---------------------------------------------------------------------------
        \4\ Data reported in Jacobson, (2012)

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                                              Table D--Medication Adherence
    ----------------------------------------------------------------------------------------------------------------
               Report Month               January      February      March        April         May          June
    ----------------------------------------------------------------------------------------------------------------
    Adherent                                    97%          96%          97%          95%          98%          99%
    ----------------------------------------------------------------------------------------------------------------
    Non Adherent                                 3%           4%           3%           5%           2%           1%
    ----------------------------------------------------------------------------------------------------------------

    Results: Satisfaction
        A monthly satisfaction survey was administered to all patients on
    the system using the dialogue feature of the Gateway. In addition, as
    the program reached the first phase of its completion, in-person exit
    interviews were conducted during equipment removal. The exit interviews
    were used to validate the electronically gathered data and to solicit
    additional feedback.
        Overall, patients reported high rates of satisfaction with the
    program. During the program operation, 94 percent were either very
    satisfied or satisfied; exit interviews confirmed this level of
    satisfaction with a 95 percent satisfied or better report. One hundred
    percent of participants responded they would recommend the Panasonic
    Home Gateway to family or friends. One hundred percent said using the
    Gateway generally helped them manage their disease and feel safer at
    home. This was validated by the exit interviews.

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        Slightly more than half the participants had used other home
    telehealth systems; 85 percent said the Gateway was easier to use than
    others. Participants especially liked the service embedded in the
    television as it was easy for them to see and read. All but one
    participant liked the reminders. There were a few negative comments
    related to connectivity issues, many of which were caused by those
    participants themselves. A small sample did not like the repetitive
    nature of the health self-assessment questions, which is a common
    complaint amongst users of home telehealth.
        Those who watched the embedded videos said they were helpful (83
    percent) or somewhat helpful (13 percent). Those that did not watch the
    videos reported that they didn't know about them (25 percent), didn't
    think they needed them (18 percent), they were in the wrong language
    (18 percent) or ``other'' (42 percent). Only English videos were
    available for this pilot, which was a disadvantage as a significant
    proportion of the target population was Spanish speaking.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        The exit interview confirmed what is commonly believed about home
    telehealth technology--the interaction with the telehealth nurse made
    the participants feel more connected to their health care providers,
    not less (86 percent said they always felt more connected, 10 percent
    responded frequently). 100 percent of the responses indicated the nurse
    was always or frequently helpful in teaching them about their disease
    (See Appendix A, Chart 4).
                      Part II Implications of the Results
        The Panasonic Home Gateway concept of utilizing interactive
    television capability to monitor biometrics and patient symptoms has,
    in its Beta form, shown remarkable promise in its stated goal of
    minimizing hospitalizations while maintaining high rates of patient
    engagement and satisfaction. Coupled with the clinical oversight and
    friendly guidance and support provided by JHL Telehealth nurses, it
    extends the eyes, ears and touch of healthcare.
        The Panasonic Home Gateway Beta Project showed significant
    reductions in hospitalizations and emergency room visits. The ultimate
    question; however, in today's healthcare environment is: is home
    telehealth financially sustainable? In the next sections, this paper
    will lay out the burden different payers bear related to the ever
    increasing health issues related to chronic illness.
        Medicare and Medicaid, as Federal and State payers have a huge
    stake in corralling the spiraling cost of health care, and while there
    are many cost containment strategies--some incorporating technology,
    some not, it is evident that home telehealth/remote patient monitoring
    is a strategy to be taken seriously as a tool to be incorporated into
    the evolving practices of health care. The Panasonic Home Gateway, with
    its demonstrated reduction in hospitalizations and emergency room
    visits, coupled with patient engagement and satisfaction scores, has
    shown to be a serious contender in the battle to combat many of the
    concerns circling the provision of telehealth-based case management.
        Managed care companies, especially Medicare Advantage or the soon
    to be developed FIDA plans have comparable stakes in the reduction of
    health system utilization. These fully capitated plans are responsible
    for providing the full panel of services to elderly patients, including
    hospitalizations and will be developing strategies to subsequently
    minimize their risk. Home telehealth will fit well into these
    strategies.
        Hospitals, with newly implemented readmissions penalties, must
    continue to develop strategies to reduce readmissions while partnering
    with community service providers to manage care across settings. These
    collaborative efforts are a prime opportunity for home telehealth
    technologies to bridge the potential gaps in care that occur during the
    discharge processes.
        Medicare home care agencies have been a bed of growth and
    development for home telehealth and remote patient monitoring since the
    1990s. First used in early video visit form to substitute for in
    person-nurse visits, home telehealth's monitoring of vital signs has
    shown to be an invaluable care support, allowing nurses to make
    clinically-driven visits and provide care interventions before they
    reach a crises point. These technologies will continue to evolve and
    target their audiences in a more sophisticated and diverse manner. The
    Panasonic Home Gateway was tested in this environment, receiving
    excellent outcomes and high satisfaction rates.
        The second section of this paper discusses prominent stakeholders
    in the health care environment, including Medicare, Medicaid,
    hospitals, managed care and Medicare home health agencies, and how
    effective home telehealth systems, such as the Panasonic Home Gateway,
    can accrue savings for each of those stakeholders.
                                  Stakeholders
    Stakeholder: Medicare
        Health care is expensive. In 2013, Medicare was responsible for 14
    percent of the Federal Budget ($492 Billion). These payments were
    allocated per Figure E (See Appendix B, Chart 1).

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Medicare beneficiaries with multiple chronic conditions (non-
    communicable illnesses that are prolonged in duration, do not resolve
    spontaneously, and are rarely cured completely) are the heaviest users
    of health care services. As the number of chronic conditions increases,
    so do utilization of health care services and health care costs (CDC,
    2009).

                                    Table E--Medicare Benefit Payments--$492 Billion
    ----------------------------------------------------------------------------------------------------------------
                       Other        Medicare      Hospital      Physician    Outpatient     Hospital       Skilled
     Home  Health     Services      Advantage     Inpatient     Payments      Rx Drugs     Outpatient      Nursing
    ----------------------------------------------------------------------------------------------------------------
              3%            14%           25%           24%           12%           11%            6%            5%
    ----------------------------------------------------------------------------------------------------------------

        Among all Americans, the most likely to have chronic conditions are
    Medicare beneficiaries age 65 and older as about four out of five are
    affected by a chronic condition, such as heart disease and cancer,
    hypertension, stroke and diabetes (CDC, Health Aging, 2011). Research
    indicates that in 2008, two-thirds of all Medicare beneficiaries had at
    least two or more chronic conditions (CMS, 2011). Because the risk for
    multiple chronic diseases rises with age, the prevalence of multiple
    chronic conditions is expected to grow even more as the Medicare
    population ages. Additional, post-acute care costs for the 14 percent
    of those who received them totaled $54.7 billion dollars (Rau, November
    26, 2012).
        The 30 day all cause readmission rate for all FFS beneficiaries was
    19 percent compared to a rate of 25 percent for beneficiaries with 6 or
    more chronic conditions.
        Medicare beneficiaries with multiple chronic conditions are the
    heaviest users of health care services. As the number of chronic
    conditions increases, in addition to the hospitalizations, there is a
    corresponding increase in overall health system utilization such as
    post-acute services and home health care. Likewise, as the number of
    chronic conditions increases, so do readmission rates. Compared to
    beneficiaries with 0 or 1 chronic condition, Medicare spending overall
    was 3 times greater for beneficiaries with 2 or 3 chronic conditions
    and 15 times greater for those with 6 or more chronic conditions (CMS--
    Chronic Conditions, 2011).
        Emergency room visits follow the same trend, with a strong
    correlation between the number of chronic conditions and number of
    visits to the emergency room, with 70 percent of beneficiaries with 6
    or more chronic conditions having at least one ER visit and over 25
    percent having three or more visits.
        An estimated 17 percent of Medicare beneficiaries have heart
    failure, accounting for 800,000 admissions annually (Advisory.com,
    April 4, 2014). Nearly one in four patients hospitalized with HF is re-
    hospitalized within 30 days of discharge. The American Heart
    Association (AHA) lists the major causes of hospital readmission as:

       24 percent Diet non-compliance

       24 percent Prescribed medication non-compliance

       16 percent Inappropriate medication

       19 percent Failure to seek care

       17 percent other

        According to Brown (2014) data shows that readmissions more than
    double the cost of providing care to a patient. On average, Medicare
    pays $15,000 in overall health system costs for an episode with no
    readmission and $33,000 for an episode with one readmit. The use of
    home telehealth to educate patients with low health literacy, support
    medication adherence and provide an additional layer of case management
    can result in exponential savings as seen in the inset text box.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Conclusion: Medicare
        There is general consensus that many hospitalizations and
    subsequent re-hospitalizations can be avoided for the Medicare
    population. The Panasonic Home Gateway resulted in dramatic reductions
    in admissions and readmissions, similar to those in the rough analysis.
    To avoid the continual and potentially catastrophic increase in the
    cost of Medicare, effective strategies such as home telehealth, that
    promote disease self-management and reduction in utilization must be
    implemented.
    Stakeholder: Medicaid--the Dually-Eligible Population
        Many of the highest cost, chronically ill patients are eligible for
    both Medicare and Medicaid and are called dually eligible
    beneficiaries, or what commonly called ``dual eligibles'' or sometimes
    simply as ``duals.'' Policymakers are interested in finding ways to
    improve the delivery of care and reduce spending for beneficiaries
    because they are among the frailest and highest cost segments of the
    Medicare and Medicaid programs.
        The dually eligible are low-income seniors and individuals with
    disabilities who rely on Medicare for coverage of acute care medical
    services and on Medicaid for financial assistance with Medicare's
    premiums and cost sharing. Most also rely on Medicaid to provide
    coverage for services not included in Medicare, particularly long-term
    care. They are among the poorest and sickest beneficiaries covered by
    either program and consequently account for a disproportionate share of
    spending in both programs. More than half have incomes less than
    $10,000, compared to only 8.3 percent of Medicare beneficiaries. They
    are less likely to be married and to be non-White. The dually eligible
    are much more likely to be living in an institution: one of six
    compared to only one out of 50 other Medicare beneficiaries reside in
    an institution (Kaiser Commission, 2012). This high rate of
    institutionalization has a critical impact on health care spending. In
    2009, the Federal and state governments spent a total of more than $250
    billion on health care benefits for the nine million dually eligible
    population (CBO, 2013). The difference in health system utilization and
    associated costs is shown in the following charts.
    Charts A & B (Kaiser, 2012)

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        The dually eligible beneficiaries comprise 21 percent of the
    Medicare population, but 31 percent of total Medicare costs, and 15
    percent of the Medicaid population, accounting for 39 percent of total
    Medicaid costs (Jacobson et al., 2012; Young et al., 2012). As a group,
    they are similar in the sense that they tend to have low incomes and
    modest assets, but otherwise, they are quite heterogeneous, with a wide
    range of health problems and needs, requiring care from multiple types
    of providers in a wide range of settings.
        According to Jiang et al, in a report for the Healthcare Cost and
    Utilization Project (2008), the dually eligible are more likely to be
    hospitalized than Medicare patients--7.2 percent for heart failure,
    101.2 percent for Diabetes, with heart failure being the leading cause
    of hospitalization among the chronically ill. The dually eligible are
    also in poorer health as seen in Table F.

                                  Table F--Health Status of Duals vs Other Medicare \5\
    ----------------------------------------------------------------------------------------------------------------
                                             Heart                              Mental                     Mental
                                            Disease    Diabetes      COPD       Illness    Alzheimer's   Retardation
    ----------------------------------------------------------------------------------------------------------------
    Duals                                     29.3%        5.2%       25.1%         34%          5.7%          6.3%
    Other Medicare                            25.6%        0.5%       16.3%       16.8%           25%          0.6%
    ----------------------------------------------------------------------------------------------------------------

        (See also Appendix B, Chart 2). As a result of their lower health
    status, the dually eligible have a higher level of health system
    utilization than other Medicare beneficiaries as shown in Table G.

                                          Table G--Comparative Service Use \5\
    ----------------------------------------------------------------------------------------------------------------
                                                                 Skilled
                                             Institutional       Nursing      Inpatient    Outpatient     Physician
                                            Long Term  Care     Facility      Hospital      Hospital        Visit
    ----------------------------------------------------------------------------------------------------------------
    Duals                                               16%          9.2%         26.1%         66.9%         65.8%
    Other Medicare                                       0%          3.5%         15.1%         51.2%         62.8%
    ----------------------------------------------------------------------------------------------------------------

        (See also Appendix B, Chart 2).
        According to Wilding (2014), about 25 percent and Segal (2011); 26
    percent of hospitalizations for dually eligible beneficiaries are
    preventable. Heart failure was the leading condition associated with a
    potentially avoidable hospitalization.
    ---------------------------------------------------------------------------
        \5\ Data from Urban Institute analysis of MSIS-MCBS 2007 as quoted
    in the Kaiser Commission Report on Medicaid and the Uninsured
    ---------------------------------------------------------------------------
    Conclusion: Medicaid
        In addition to the cost to federally funded Medicare, dually
    eligible patients add an additional burden to states that are
    responsible for those health expenses not paid for by Medicare. They
    have poorer health, lower socioeconomic status and higher rates of
    health system utilization, including high rates of expensive
    institutionalization. They are more likely to be hospitalized, and thus
    re-hospitalized. Home telehealth coupled with effective case management
    can delay nursing home placement, allowing individuals to stay safely
    in their homes. Dually eligible participants who participated in the
    Panasonic Gateway project, for example, had 69 percent less
    hospitalizations than the normal rate (as reported by Kaiser, 2010) of
    26 percent.
    Stakeholders: Medicaid State Policy and FIDA
        State Medicaid agencies must pay Medicare cost-sharing for most
    ``dual eligibles.'' Further, most of the dually eligible are excused,
    by law, from paying Medicare cost-sharing, and providers are prohibited
    from charging them (Center for Medicare Advocacy, 2008), but the
    particulars are complex in traditional Medicare and become even more
    complex when a dually eligible beneficiary is enrolled in a Medicare
    Advantage (MA) plan.
        Many states are looking to FIDA, or Fully Integrated Dual Advantage
    plans, a new type of managed care plan for certain dual eligible
    beneficiaries to reduce the growing cost burden to the state, of the
    dually eligible population, 73 percent of which is incurred in the long
    term care setting as shown in Chart A.
        New York is a good example. The dually eligible are among New York
    State's costliest and most complex Medicaid beneficiaries. On average,
    each dual eligible costs the State $30,384 per year--the highest rate
    in the Nation and twice as much as the national average of $15,459 (New
    York State Health Foundation, 2013). According to a presentation by
    Emblem Health (2013), New York State spends about $35 billion on an
    estimated 820,000 dually eligible beneficiaries. Because of New York's
    comprehensive Medicaid long-term care benefit, the majority of Medicaid
    spending on the dually eligible in New York is for long-term care, and
    the majority of Medicaid's long-term care spending is for that specific
    population (Samis, 2012).
        Under ACA, the Federal Government has funded 15 states, including
    New York, to develop FIDA demonstration programs. FIDA plans will care
    for dually enrolled beneficiaries through a full-capitation model in
    which a single managed care plan delivers all Medicare and Medicaid
    services. Meeting participant needs, including the ability to self-
    direct care, be involved in one's care, and live independently in the
    community, are central goals of this initiative (CMS 2013).
        This shift in reimbursement model is important in that the FIDA
    plan will assume full responsibility for all healthcare costs incurred
    by the member. In other words, a FIDA member will essentially trade in
    all of their insurance cards--Medicare (Original or Medicare
    Advantage), Medicaid, MLTC, Medigap, and Medicare Part D--and only have
    one health plan--their FIDA plan. When fully implemented, the FIDA
    demonstration program could affect approximately 150,000 New Yorkers in
    the metropolitan New York City and surrounding areas (United Fund,
    2012).
        According to NY Health Access (2014), the New York State
    demonstration area includes dually eligible patients in New York City,
    Long Island, and Westchester County who:

       Receive or need managed long term care services--those
            adults age 21+ who receive or need community-based long term
            care services; and

       The dually eligible living in nursing homes or who come to
            be permanently placed in nursing homes.

        The FIDA plan model is significantly different from the current
    partially capitated managed long term care plan (MLTC) currently
    serving the dually eligible population in New York in that is
    responsible for all the patient's incurred healthcare costs. MLTC's are
    currently not responsible for the cost of hospitalizations, doctors'
    visits, medications (See Appendix B, Table 1) and therefore, have less
    incentive to provide clinically indicated preventive/avoidance
    services--Medicare picks up many of those costs. As the MLTC plans in
    the affected area migrate into FIDA plans, they will have increased
    incentives to implement telehealth as a cost savings case management
    tool, especially for those patients in the over 75, whose costs are
    more than twice as high for those 65-74 (Samis, 2012).
    Conclusion: FIDA Plans
        Fully capitated FIDA plans will strongly benefit from home
    telehealth's proven record of chronic disease management success in
    reducing hospitalizations and emergency room visits.
    Stakeholders: Hospitals
        Hospitals, like hotels and other brick and mortar facilities, need
    to be fully occupied to economically self-sustain; however, new
    policies created under ACA result in hospitals having a significant
    stake in reducing readmissions.
        As health care costs continue to rise and the population ages,
    policymakers are increasingly concerned about the growing burden of
    hospital-based medical care expenses on payers--the government,
    insurers, patients, and employers. Inpatient hospital services account
    for a small share of health care utilization (7 percent) but constitute
    the largest share of total health care spending in the United States
    (29 percent in 2009) (Kashihara and Carper 2009).
        According to Brown (2014), data shows that readmissions more than
    double the cost of providing care to a patient. On average, Medicare
    pays $15,000 for an episode with no readmission and $33,000 for an
    episode with one readmit. Hospitals themselves have a significant stake
    in preventing readmissions. A simulation run by Reinforced Care
    (August, 2013), using CMS data, found that, for each of three
    diagnostic-related groups (acute myocardial infarction, heart failure
    and pneumonia) on which penalties depend, the prevention of a single
    readmission for heart failure saved the average hospital $8,200 (per
    each prevented admission) for FY 2013 and FY 2014. The loss included
    the CMS penalty and the net cost of care.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        THE HHRP. Section 3025 of the Affordable Care Act (ACA) added
    section 1886(q) to the Social Security Act establishing the Hospital
    Readmissions Reduction Program (HRRP), which requires the Centers for
    Medicare and Medicaid (CMS) to reduce payments to hospitals with excess
    readmissions, effective for discharges beginning on October 1, 2012.
    Initially, the program targeted Medicare patients who were hospitalized
    for heart attack, heart failure, or pneumonia. In the Federal Fiscal
    Year 2015, CMS will expand the list of conditions to include elective
    total hip arthroplasty, total knee arthroplasty, and acute exacerbation
    of chronic obstructive pulmonary disease.
        In December of 2013, CMS announced that hospital readmission rates
    were slowly declining (from a steady 19 percent between 2007 and 2011
    to 18.5 percent in 2012) and attributed that decline to the HRRP.
    Preliminary claims data shows the Medicare readmission rate averaged
    less than 18 percent over the first eight months of 2013 (CMS, 2013).
    This reduction; however, means that the pressure will continue to
    reduce readmissions as each hospital is measured against a collective
    benchmark.
        Based on the perceived success of the HRPP, it is not unreasonable
    to expect that it is only a matter of time before the similar payment
    reduction/financial incentive programs already under consideration
    related to other modalities of care such as nursing homes (Mullaney,
    2014) and home care (Blockberger-Miller, 2014) are implemented. This
    broad focus on reducing readmissions plus a payer focus on reducing
    hospitalizations in general will enhance the value of disease
    management models that show documented reductions in health system
    utilization.
    Conclusion: Hospitals
        The pressure on hospitals to reduce their readmissions rates will
    continue, most likely past 60 days and on to 90. As the penalty
    benchmarks inch downward, the pressure will accelerate, making chronic
    disease programs incorporating home telehealth invaluable--especially
    for those frequently readmitted patients.
    Stakeholders: ACOs--Economies of Scale
        As a result of the financial and quality outcome pressures created
    by ACA, consolidation has intensified across healthcare, encouraging
    mergers and acquisitions between hospitals, health systems, health
    plans, medical groups and post-acute providers. Some industry experts
    say the consolidations allow for greater coordination to reduce
    unnecessary services and improve outcomes, as well as creating
    sufficient scale to manage the financial risks of new payment models,
    such as accountable care organizations (ACOs).
        ACOs are legally formed collectives of doctors, hospitals, and
    other health care providers who work together to provide care to their
    Medicare patients. While there are several basic reimbursement models
    or payment arrangements, most center on shared savings (Punke, 2013),
    i.e., when an ACO succeeds both in both delivering high-quality care
    and spending health care dollars efficiently (by reducing unnecessary
    services and cost), it will share in the savings it achieves for the
    Medicare program. In Medicare's traditional fee-for-service payment
    (FFS) system, doctors and hospitals generally are reimbursed for each
    test and procedure. ACOs do not eliminate FFS, but do create an
    incentive to be more efficient by offering bonuses when providers keep
    costs down while achieving better health outcomes--thus encouraging a
    balance between high quality care and cost control. Bonuses are based
    on meeting specific quality benchmarks, focusing on prevention and
    carefully managing patients with chronic disease (Kaiser 2014).
    Conclusion: ACOs
        While the structures of ACO's vary--both legally and financially,
    home telehealth is an ideal tool to be used within the ACO framework as
    a central telehealth office oversight is invaluable during those
    transitions between collaborating partners, reducing costly and
    punitive readmissions.
    Stakeholders: The Growing Footprint of Managed Care in Medicare
        Managed care has become a major player in the health reimbursement
    ``payer'' market for the elderly with Medicare Advantage now managing
    care for 15.7 million (Kaiser, 2014) or 30 percent of the Medicare-
    eligible market, with Medicaid managed care providing benefits to over
    74 percent of Medicaid recipients (Kaiser, 2011) or 50 million people
    (Medicaid.gov, 2014).
        Managed care, which had its roots in the early 20th Century, played
    only a modest role in the financing and delivery of health care until
    the 1970s, when the Health Maintenance Act of 1973 was enacted as a way
    to curb medical inflation through the encouragement of managed care
    plans (Fox and Kongstvedt, 2007). The Medicare Modernization Act (MMA)
    of 2003 created Medicare Advantage plans, which include an entitlement
    benefit for prescription drugs known as Medicare Part D. This coverage
    became effective on January 1, 2006 (CMS, February 2009). It should be
    noted that currently (and thus underlying the importance of medication
    adherence), prescription drugs account for 11 percent of the Medicare
    budget (Kaiser 2014).
        Medicare Payment Policy Reversals Have Impact Medicare pays
    Medicare Advantage plans a capitated amount per enrollee accounting for
    between 25 percent and 30 percent of total Medicare spending (Appendix
    B, Chart 1). As Medicare Advantage plans matured, Medicare payment
    policy shifted gradually from one that produced savings to one that
    focused more on expanding access to private plans and providing extra
    benefits to Medicare private plan enrollees. These policy changes
    resulted in Medicare paying private plans more per enrollee than the
    cost of care for beneficiaries in traditional Medicare (MedPAC, 2010).
        Subsequently, ACA reversed the payment policy by reducing Federal
    payments to Medicare Advantage plans over time, bringing them closer to
    the average costs of care under the traditional Medicare program. It
    also provided for new bonus payments to plans based on quality, or 5-
    Star ratings (Weiss and Pescatello, 2014) beginning in 2012, and
    required plans beginning in 2014 to maintain a medical loss ratio of at
    least 85 percent, restricting the share of premiums that Medicare
    Advantage plans can use for administrative expenses and profits (Kaiser
    Foundation, May 1, 2014). There is currently concern that the 5-Star
    rating system unfairly penalizes those Medicare Advantage plans serving
    primarily low-income and dually eligible individuals (who require more
    services), thus increasing the pressure on those plans to seek ways to
    provide less expensive oversight without sacrificing quality.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     Table H
    ------------------------------------------------------------------------

    ------------------------------------------------------------------------
    Total cost of Medicare Advantage Heart Failure         $3,150,000,000.00
     Admissions
    ------------------------------------------------------------------------
    Savings with 19.7 percent reduction (VA--Darkins,        $620,550,000.00
     2008)
    ------------------------------------------------------------------------
    Savings with 39.7 percent reduction (Chen et al,       $1,250,550,000.00
     2011)
    ------------------------------------------------------------------------
    Savings with 44 percent reduction (Panasonic Gateway)  $1,386,000,000.00
    ------------------------------------------------------------------------

    Conclusion: Medicare Advantage
        Although projections for the growth of Medicare Advantage plans
    vary (Kaiser, 2013), enrollment has grown by 30 percent since 2010, and
    there is no doubt that it will play a significant role in the health
    care arena for the foreseeable future. As payment reductions, quality
    outcome bonuses and star ratings continue to pressure Medicare
    Advantage plans to provide more services while controlling costs, home
    telehealth coupled with effective case management will be a lucrative
    option.
    Stakeholders: Medicare Home Health Agencies
        Home health agencies provide nursing services, home health aides
    and services such as physical therapy, occupational therapy and social
    services. Medicare pays for home health services when they are
    medically reasonable and necessary and when an individual is confined
    to his or her home (homebound) and needs skilled nursing care on a
    part-time or intermittent basis, or physical or speech therapy, and in
    certain circumstances, occupational therapy. Roughly 9.6 percent of
    Medicare fee-for-service (FFS) beneficiaries (or 3.4 million
    individuals) used home health services in 2010. According to an article
    in Caring (2008), home care nurses, aides and therapists drive more
    than 5 billion miles per year--many of those miles could be eliminated
    through the use of home telehealth/remote patient monitoring.
        Medicare pays home health agencies under the Medicare Home Health
    Prospective Payment System (HH PPS) based on a standard sixty-day
    episode rate, adjusted for patient acuity and local labor costs.
        Currently, reforms stemming from provisions of ACA will result in
    rebasing of reimbursement rates, which will most likely lead to cuts in
    payments to home care providers. The MedPAC Commission recommends
    further cuts, despite concerns over the fiscal health of home care
    providers, especially those rural and public agencies which show high
    losses. These fiscal pressures will heighten the need for agencies to
    find ways to provide higher quality services while reducing costs.
        The major source of loss for providers is for the care of
    ``outliers,'' or high cost cases (NAHC, 2011). Recent changes under ACA
    have reduced the rate for outlier payments and instituted a per agency
    cap for outlier payments. This negatively impacts those agencies that
    routinely serve high need patients, creating an additional strain on
    the financial health of home care agencies.
        Home telehealth offers the opportunity to save home care agencies
    precious dollars by reducing staff utilization and improving quality of
    care. Typically, home visits are made on a formal, calendar-driven
    schedule. By incorporating telehealth monitoring into patient care,
    nurses are driven by clinical need rather than by calendar, generally
    saving needless visits.
        According to CMS's Health Care financing Review (2012) Medicare
    Home Health agencies were paid an average of $3618 per episode for a
    patient with heart failure. According to the Medicare Cost report
    (2010, page 19), skilled nursing is responsible for 55 percent of the
    costs incurred by home health agencies during an episode. Centura
    (2008) reported a dramatic reduction in nurse visits resulting from the
    installation of telehealth--from 2-3 visits per week to 3 visits per 60
    day episode. For the purpose of this paper, we will estimate a 50
    percent reduction in Centura's nursing visits as an example of cost
    savings.

    =======================================================================
    ROUGH ANALYSIS: TWO COST SAVINGS EXAMPLES \6\
    ---------------------------------------------------------------------------
        \6\ Agencies will of course, have varying reimbursements and costs
    associated with this rough analysis, but it demonstrates the value of
    considering home telehealth as a viable care management tool within
    each patient's ``budget'' or estimated payment.

    (1) VNA of Western Pennsylvania documented a reduction--14 visits for
    Heart Failure patients without telehealth and 11 for patients with
    telehealth within approximately the same episode length (Alston, 2009.
    This is a 21.4 percent reduction in nursing visit cost--or: $3618
    Medicare payment x 55 percent = $1990 cost of skilled nursing. Minus a
    21.4 percent reduction in visit cost = $1564.01 cost of nursing or a
    ---------------------------------------------------------------------------
    $426 savings per patient per episode, minus the cost of technology.

    (2) If Centura had a 50 percent reduction in nursing visits, their
    savings would be equal to $995 per patient per episode, minus
    technology cost.
    =======================================================================

        With the understanding that not every patient is appropriate for
    home telehealth technology, in light of the current and more severe
    projected shortage in nurses and the pressure on agencies to reduce re-
    hospitalizations (including proposed readmissions penalties) while
    maintaining efficiencies and quality outcomes this savings is a
    compelling argument for home telehealth on its own merit. Based on
    these assumptions, reducing the number of visits per episode by even
    three would have critical impact on home care profitability.
    Conclusion: Home Care
        Additional financial pressures created by Medicare cuts to home
    care combined with labor shortages, potential readmissions penalties,
    competition for managed care contracts and increased focus on quality
    outcomes (such as home care compare star ratings proposed for 2016)
    create additional incentives for Medicare Certified Agencies to begin
    or expand the incorporation of home telehealth as a best practice.
                    Contributing Factors: Health Care Costs
        Beyond the socioeconomic issues detailed previously in the
    differences between Medicare and dually eligible beneficiaries, there
    are additional contributing factors to the current cost of health care.
    These factors are universal across all healthcare settings and include
    the interface of human capital, human factors, regulatory and economic
    factors. The most important of these are medication adherence, health
    literacy, patient engagement/satisfaction and labor force.
    Cost Factor: Medication Adherence
        Drugs are the primary treatment for heart failure but have limited
    effectiveness if patients are non-adherent to their medication regime
    (Hope et. al, 2004). According to the World Health Organization's (WHO)
    World Health Report 2003, quoted in (Wood 2012) the degree of
    medication non-adherence is so great and the consequences are of such
    concern that more people worldwide would benefit from efforts to
    improve medication adherence than from the development of new medical
    treatments. WHO also reports, according to Chisholm-Burns (2012), that
    the average non-adherence rate is 50 percent among those with chronic
    illnesses. The AHA (2010) reports that collectively, non-adherence to
    medication and inappropriate medications are responsible for 40 percent
    of hospital readmissions. Consequences of non-adherence include
    worsening condition, increased comorbid diseases, increased health care
    system utilization and potentially, death.
        Chan, Nicklasan and Vial (2001) write that low medication adherence
    is increasingly being recognized as a dominant feature in elderly
    patients. In older adults, medication non-adherence accounts for
    between 25 percent (CHAMP, undated) and 40 percent (McKesson, 2012,
    ESRD Network, undated) of nursing home admissions. Medication non-
    adherence results in an estimated 125,000 deaths annually, and costs
    between $100 billion (CHAMP, undated) and $289 billion (CDC, 2013) a
    year, depending on source, including approximately $47 billion for
    drug-related hospitalizations (CHAMP, undated).
        In a study of elderly patients greater than 75 years of age Chan,
    Nicklason and Vial (2001), found that non-adherence, omission and
    cessation of drug therapy collectively accounted for 26 percent of
    hospital admissions. The most common causative drugs were
    cardiovascular drugs (48.4 percent) and the most common manifestations
    were falls, heart failure and delirium.
        After adjusting for age, sex, race/ethnicity, education, alcohol
    use, cognitive measures, functional status, depression, and number of
    medications, (Berry et al, 2010) found that low medication adherence
    was associated with a 50 percent increased rate of falls compared with
    high medication adherence. According to HCUP (2010) data, among persons
    aged 65 and over, falls were the most common cause of injuries,
    accounting for 13 percent of all emergency department visits in 2008-
    2010 (U.S. Department of Health and Human Services, 2013). Average cost
    for ED expenditures, not including admissions to hospital, was $1062
    for patients over the age of 65.
        In an article in the American Journal of Health System Pharmacy,
    Hope et al., (2004) reported that medication non-adherence may be
    caused by patient's lack of health literacy and diminished skills and
    abilities. The article concluded that greater medication knowledge,
    skills, and adherence were associated with fewer ED visits in a study
    among patients 50 years of age or older with congestive heart failure
    in an urban, teaching medical center.
        Reminder prompts and adherence queries, with optional dispensers
    embedded in home telehealth programs have shown to dramatically improve
    medication adherence. As noted earlier, the Panasonic Home Gateway
    system had a patient-reported medication adherence rate of between 96-
    99 percent.
    Cost Factor: Health Literacy
        Inadequate literacy is especially prevalent among the elderly, the
    population with the largest burden of chronic disease and the greatest
    health-related reading demands. According to the National Adult
    Literacy Survey (2003) 38 percent of adults over 65 had intermediate
    health literacy, with 30 percent having basic and 29 percent having
    below basic health literacy. Only 3 percent had proficient levels of
    health literacy. This lower reading ability among older adults is most
    likely the result of age-related declines in information processing,
    and it is not explained by their having less education, a higher
    prevalence of chronic diseases, worse physical or mental health, or
    dementia.
        A study of 3260 Medicare managed care enrollees that correlated the
    rates of hospitalizations with levels of literacy (Baker et al., 2002)
    found that the risk of hospitalizations was higher for individuals with
    inadequate literacy.
    Cost Factor: Satisfaction with the Care Experience
        Simply put: health care is about the patient. Patient-driven care
    facilitates patient engagement, patient--provider communication and is
    instrumental to engaging the patient in their own health. Engaged
    patients have better outcomes; engagement is measured through patient
    satisfaction scores. According to an article in Health Affairs
    (February 13, 2014), a growing body of evidence demonstrates that
    patients who are more actively involved in their health care experience
    better health outcomes and incur lower costs. As a result, many public
    and private health care organizations are employing strategies to
    better engage patients, such as educating them about their conditions
    and involving them more fully in making decisions about their care.
    Patient engagement is one strategy to achieve the ``triple aim'' of
    improved health outcomes, better patient care, and lower costs.
        The Institute for Healthcare Improvement (IHI) has developed a
    framework that describes an approach to optimizing health system
    performance (IHI, 2013), defining three global dimensions of care as
    overall areas for needed improvements in healthcare settings. This
    framework for improvement includes:

       The patient experience of care (including quality and
            satisfaction);

       Overall population health; and

       Per capita cost of health care.

        Although much of the focus on telehealth has been dedicated to cost
    savings achievable through the use of home telehealth, its use has been
    widely documented as a tool that supports and enhances both quality of,
    and satisfaction with care.
        A paper written by Fazzi Associates (2008) on the future of
    technology and home telehealth concluded that using technology to
    connect the patient to the healthcare system in a tangible, visible
    manner generally accomplishes the following:

       Improved access to care;

       Satisfaction with the technology;

       Satisfaction with the related communication which may occur
            as a result of the telehealth monitoring; and

       Increased patient/caregiver involvement in managing their
            disease.

        The VA provided various forms of telehealth and telemedicine care
    to 608,900 patients in 2013, according to a Department of Veterans
    Affairs report (Darkins, 2013). Overall, outcomes for patients
    receiving home telehealth services were positive with the average
    patient satisfaction being 84 percent. Similarly, a poll of 200 Centura
    Health at Home patients indicated that approximately 86 percent (4.3/5)
    ``completely agreed'' that they would recommend telehealth. The Home
    Gateway system had extremely high rates of participant satisfaction as
    reported in Section 1.
    Cost Factor: Labor Shortages and the Increasing Demand for Care
        The shortage of health care personnel as a global concern,
    especially in rural areas, is well documented (Bushy, 2006, Nebraska,
    2009) and is expected to exacerbate due to the growth of chronic
    illnesses coupled with an aging population.
        The U.S. Census Bureau projects the overall general population to
    increase by 13 percent between now and 2025. In 1900, the elderly
    (defined as persons 65 years or older) constituted just 4 percent of
    the U.S. population, according to the Federal Interagency Forum on
    Aging-Related Statistics (2012). By 2010, they represented 13 percent,
    growing in number from a population of 3 million to 40 million.
    Currently, there are close to 11 million elders who need assistance
    with at least one aspect of independent living (FORUM, 2012). A
    significant impact of this trend is that those 65 or older use twice as
    many physician resources as those less than 65 (Dill and Salsberg,
    2008).
        According to the Bureau of Labor Statistics' Employment Projections
    2012-2022 released in December 2013, Registered Nursing is listed among
    the top occupations in terms of job growth through 2022. The RN
    workforce is expected to grow from 2.71 million in 2012 to 3.24 million
    in 2022, an increase of 526,800 or 19 percent. The Bureau also projects
    the need for 525,000 replacements nurses in the workforce bringing the
    total number of job openings for nurses due to growth and replacements
    to 1.05 million by 2022 (BLS, 2013).

       According to the Paraprofessional Healthcare Institute
            (PHI), by 2020, the Nation will need 1.1 million additional
            direct-care workers.

       The Association of Schools of Public Health (ASPH) projects
            a shortage of 250,000 public health workers by 2020.

       The American Geriatrics Society reports that the
            geriatrician supply in the United States is declining (down
            one-quarter to 7,000 since 2000), and predicts that demand will
            skyrocket as the population ages to 36,000 by 2030 (Zywiak, no
            date).

        These collective shortages will undoubtedly impact the quality of
    patient care in the next ten years, while increasing competition for a
    shrinking labor pool. Health care organizations will subsequently have
    to increase wages and benefits to be competitive employers, thus
    increasing overall labor cost.
    Conclusion: Cost factors
        The causes of the rise in health care system utilization and the
    resulting costs are many and complex. Each factor has, in turn, its own
    complexities which further complicate both understanding the problem at
    large and the solution or solutions. The previously discussed cost
    factors are four of the most prominent contributing factors that affect
    the future of health care costs. All could be mitigated, to some
    extent, with the use of home telehealth devices.
                                   Conclusion
        Home telehealth is coming of age. Within the current health care
    arena, a number of political, social and economic forces are aligning
    that will require changes in the way our health care is provided--
    changes that save nurse and physician time, improve quality of care,
    maintain high rates of patient satisfaction and save money.
        Against this broader landscape of stakeholders and contributing
    cost factors, the Panasonic Home Gateway System was designed and tested
    as an technology that could, when coupled with evidence based best
    practices embedded in case management, provide cost savings through
    reduced hospitalizations and emergency room visits while maintaining
    high rates of patient satisfaction.
        The joint project between Panasonic and Jewish Home Lifecare--
    Pathways to Health--produced excellent outcomes. A summary of outcomes
    includes (unless noted, data is for all patients):

       Hospitalizations

         JHL cohort(dually eligible)--69 percent less than the
                dually eligible average

         Medicare Advantage-44 percent reduction compared to
                previous claims data

       Emergency room visits

         JHL cohort (dually eligible)- 74 percent less than
                dually eligible average

         Medicare Advantage--43 percent less compared to
                previous claims data

       Medication adherence

         96-99 percent range, all participants

       Satisfaction

         95 percent satisfied or better

         100 percent would recommend to family or friends

         100 percent felt safer at home

       Utilization

         90.3 percent patients used the tablet at least three
                times per week.

        These outcomes, when viewed through the lens of the current health
    care economic environment, clearly substantiate the overall value of
    using home telehealth as a critical tool in the care management
    process. Coupled with the many advantages a television-based product
    brings to an elderly health care cohort, the outcomes validate the
    Panasonic Home Gateway as a viable and effective product in the
    American home telehealth marketplace.
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    www.nytimes.com/2012/11/27/health/hospitals-face-pressure-from-
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    health/entry/166/
    Table of Contents--Appendix
    Appendix A--Results--Pathways to Health

            Chart 1--Six month hospitalization rate

            Chart 2--Gateway Reductions

            Chart 3--Six Month ER Visit Rate

            Chart 4--Gateway Satisfaction

            Chart 5--Adherence Trend in Medication

            Chart 6--System Utilization

    Appendix B--Stakeholders

            Chart 1--Medicare Benefits Payments

            Chart 2--Health Status of Duals--Comparison

            Chart 3--Comparative Service Use

            Table 1--MLTC Covered Services vs. Medicare Covered Services
                    Appendix A--Results--Pathways to Health
    Chart 1--Six Month Hospitalization Rate

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    Chart 2--Gateway Reductions

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    Chart 3--Six Month ER Visit Rate
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    Chart 4--Gateway Satisfaction
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    Chart 5--Adherence Trend in Medication
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    Chart 6--System Utilization

                            Appendix B--Stakeholders
    Chart 1--Medicare Benefits Payments
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    Chart 2--Health Status of Duals--Comparison
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    Chart 3--Comparative Service Use
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    Table 1--MLTC Covered Services vs. Medicare Covered Services

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        New York State Department of Health (2014). Managed Long term Care
    Covered Services. Internet citation accessed 8/10/2014 https://
    www.health.ny.gov/health--care/managed--care/mltc/coverservices.htm
                 Appendix C--the Panasonic Home Gateway System

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        Senator Wicker. Let's begin.
        Mr. Rytting, in your testimony and white paper, you discuss
    several successful clinical trials focused on the management of
    chronic conditions. I think it was Mr. Linkous who said all
    this is useless without broadband.
        So how does high bandwidth connectivity enable telehealth
    organizations to deploy these innovation solutions?
        Mr. Rytting. In our experience with the pilots, these
    people, most of them did not have broadband connectivity. We
    used other methods to get the connection into the home, like a
    Wi-Fi hot spot or something like that. We even had problems
    with that because sometimes the Wi-Fi signals don't go above
    the 10th to 15th floor in high-rise buildings, and these
    buildings were not necessarily flourishing with Wi-Fi
    repeaters.
        So we were stuck in several of the instances where we
    couldn't get broadband, either cellular or Wi-Fi, up to the
    patient to successfully serve them. So that's one indication of
    how having broadband, farther range, more repeaters, more
    access points to wired connections, would have really helped
    us.
        Senator Wicker. Thank you.
        Let me then shift to Dr. Henderson and again thank you for
    my tutorial that you have conducted in Jackson and other places
    in Mississippi.
        In your testimony, Dr. Henderson, you expressed concern
    regarding future availability of universal service support. So
    what would happen to programs like the one in Sunflower County
    which Mr. Gibbons has visited if competitive wireless coverage
    is reduced in that community, and are you able to do what
    you're doing today without robust wireless coverage there?
        Dr. Henderson. So, simply put, we wouldn't be able to do
    it, bottom line. That program depends on a robust
    telecommunications network and is dependent upon the wireless
    connectivity. As we advance that and scale it up across our
    state, we've got to have that infrastructure or it simply will
    not happen. We won't be able to reach people where they are.
    They'll have to drive to go get health care.
        So, just a quick visual. Every green and red dot on this
    map is taking advantage of USF funding in Mississippi. Without
    it, we would not have a robust telehealth program.
        Senator Wicker. OK. So, we'll put that in the record.
        Dr. Henderson. Perfect.
        [The information referred to follows:]

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        =Green dot (Green dots are the light gray)
        =Red dot (Red dots are the darker gray)

        Senator Wicker. Dr. Gibbons, would you care to comment on
    what we've discussed so far with Dr. Henderson and Mr. Rytting?
        Dr. Gibbons. Sure. I think Dr. Henderson articulated it
    very well. There are many people who, without infrastructure,
    broadband infrastructure, simply would not be able to take
    advantage of what health care has to offer, as well as other
    services that they need in order to improve their health. So
    these are absolutely critical. I would agree with her.
        Senator Wicker. And, Mr. Linkous?
        Mr. Linkous. Well, when you ask the question of somebody
    who has been around as long as I have, you've got to be
    prepared. So I absolutely would agree with the previous two
    comments about how important it is. It is critically important
    for rural areas to have access, and this program has been
    really helpful.
        However, having been around in the Senate and working in
    these offices and these hallways, when Senators Snowe and
    Rockefeller first worked on the Telecommunications Reform Act
    and implemented the program for rural health care, and working
    with the Commission staff for all these 20 years since then, I
    am constantly disappointed that the Federal Communications
    Commission has not done more on this program.
        I certainly think there is great good that has been done.
    When it was first started, the estimate was that it would spend
    $400 million to support rural hospitals getting access to
    broadband. Over the years there have been many, many fixes,
    many changes, new names for the programs, new chairmen, new
    members of the Commission and new staff, and yet we still have
    the same problems of it not being used enough. The program is
    too engineered and needs a lot of fixes.
        Frankly, I would encourage this committee to really talk to
    the Commission about how it can improve this program. Schools
    and libraries are hugely successful in the way they've been
    able to get access to the program. The health care program has
    been successful where it is available, but the problem is all
    the potential it could do that it just hasn't met yet.
        Senator Wicker. So, in your testimony and your answer, we
    need action from the Commission. And also there are serious
    problems with Medicare and what you've described as being a
    laggard in this field.
        Mr. Linkous. I believe you summed it up. That's probably a
    full agenda right there.
        Senator Wicker. Thank you very much.
        Senator Schatz?
        Senator Schatz. Thank you.
        Mr. Linkous, what is VA and DOD doing right that Medicare
    needs to learn from?
        Mr. Linkous. They're supporting telehealth, to put it very
    bluntly. The Veterans Administration is a closed health care
    system. So some would criticize that they're not like everyone
    else because they can go ahead and implement these programs,
    but they've done it because it makes sense. They've done it
    because veterans benefit. They've done it because they have
    actually documented cost savings.
        Millions of veterans are getting this help. The last count
    that I saw, it was around 80,000 veterans are getting remote
    chronic care monitoring in the home, and I know that's
    expanding every year, and I know that the VA is planning on
    expanding that in the years to come.
        They've had a dedicated effort to integrate telemedicine,
    telehealth services into the practice of care. It isn't a
    sidelong demonstration. It isn't just funded by the project.
    They've taken it seriously and they've integrated it into the
    health care services.
        Senator Schatz. How much of this is a matter of will and
    execution, and how much is a matter of the statutory
    constraints that Medicare may be operating under?
        Mr. Linkous. To be fair, it's a little bit of both. There
    are certainly areas that Congress can take that will open up
    some additional resources that will allow Medicare
    beneficiaries access to services that they can't have today.
    However, there are a number of things that Medicare can do
    today. For example, the Secretary of HHS can waive some
    provisions of Section 1834 so that some of the accountable care
    organizations and some of the others that are in the program
    right now can use telemedicine where they cannot otherwise.
    That authority has been there since the program began. We have
    asked on numerous occasions to have those restrictions waived,
    and yet they have not done it.
        Senator Schatz. Thank you for that. We'll follow up on
    that.
        Mr. Linkous. Thank you.
        Senator Schatz. I have another question. It seems to me
    that on the broadband side and on the health care policy side,
    we'll be moving forward on sort of parallel tracks. What
    worries me a little bit is that if we make policy changes that
    are based on the facilities-based VTC model of telehealth,
    which I'm sure you're intimately familiar with based on your
    leadership on this issue since the 1990s, that we're now
    evolving into probably an app-based kind of individual home-
    based model, and obviously if they're going to be in the NICU
    or wherever else, you've got to be facilities-based for sure.
        But in the prevention space and diabetes and mental health,
    I can think of opportunities where you can really get health
    care services, prevention services, some oversight from an app
    on your phone and dealing with all the encryption and HIPAA
    issues.
        How do we make sure that as we move forward in the policy
    space that we're not solving last decade's problem and ending
    up basically having to catch up again 15 years from now?
        Mr. Linkous. Well, you really put it well. I thank you for
    that. You're absolutely right. The Commission, the FCC--and I
    don't mean to completely wipe away all the tremendous things
    the FCC has done. But a lot of their broadband policy is
    focused on bringing broadband to the home. Broadband doesn't
    belong in the home. It belongs to the person. Everyone around
    this table probably has a digital phone where you have
    broadband services where you are, but that's not true for a lot
    of people in rural areas.
        When you mentioned the NICU, which is an interesting
    example, actually a very important application for pediatric
    intensivists is the use of an application on their cell phone
    where they will be able to monitor a child in a NICU no matter
    where they are and get their vital signs. So even though they
    are facilities-based individuals, the applications go to
    wireless broadband there as well.
        So, you're absolutely right, we do need to start looking at
    this issue as broadband to the person, what I like to call it,
    rather than broadband to the home, and some of the policies
    need to take that into consideration.
        Senator Schatz. Thank you very much.
        I just want to thank the Chairman for convening this first
    hearing. I think this is a real opportunity for us to work
    together on a bipartisan basis. This is exciting stuff, and
    this is a space where I think we can make some pretty good
    progress relatively quickly, and I can't always say that from
    this side of the dais. Thank you.
        Senator Wicker. Thank you, Senator Schatz. I think the
    participation by senators is a testimony to the interest that
    we have in this issue. Twelve members have checked in already,
    and I have on the list Daines, who has stepped out; Manchin,
    Peters, Johnson, Fischer, Booker, Blumenthal, Blunt, and Udall.
        Senator Manchin?

                    STATEMENT OF HON. JOE MANCHIN,
                    U.S. SENATOR FROM WEST VIRGINIA

        Senator Manchin. Thank you, Mr. Chairman.
        Thank you all, too.
        I would like to start off with something about substance
    abuse treatment to see what you think about this. Two million
    Americans are addicted to prescription opiates. An estimated
    6.5 million Americans currently abuse some sort of prescription
    drug. In my state of West Virginia, it's the number one killer.
    It comes out of the medicine cabinet.
        No one seems to be talking about it. It almost seems like
    everybody in this room right now knows someone in their family,
    immediate family or extended family, that's been affected. It's
    an epidemic proportion. We're not talking about it. It's almost
    as if we've accepted it. It is what it is; what are we going to
    do? I think we have to do something because it's destroying a
    whole generation and the family structure as we know it.
        Do you believe prescription drug abuse is one of the
    biggest medical threats we face today? And what role do you
    think telehealth can play in leveraging our limited resources
    to combat it? Anybody on the panel, if you want to speak up on
    this.
        Dr. Henderson?
        Dr. Henderson. I'll take that. I think it's interesting. I
    absolutely agree with you, it's a huge epidemic in our country,
    and the technology allows us to use the services that we have
    and scale them up and reach people where they are. That's in
    home. That's virtual support groups. That's counseling. That's
    day in and day out support. It's almost AA in a mobile
    platform.
        But there are so many things that we can do, from
    counseling and support groups, that the technology allows us to
    do more often and more frequently where the patient wants it
    and can support people through that transition off of the
    drugs, not to mention help with oversight to be able to see and
    monitor who is prescribing what through shared electronic
    medical records.
        Senator Manchin. There are two things, I think. I mean,
    basically, you have to produce the drug first, and the FDA is
    letting stuff come on the market that shouldn't be on the
    market. I think we're going to rein that in. Second is how
    they're prescribing it.
        Dr. Henderson. Right.
        Senator Manchin. Doctors are handing it out like candy, and
    we've changed that from Schedule 3 to Schedule 2 and opiates.
    There's so much more that needs to be done as far as them, and
    also following up on them to make sure they have continuing
    education, what they're doing to people.
        Dr. Henderson. Absolutely. I think that what's interesting
    now is before, we didn't know what the other health systems or
    other providers were prescribing. You took care of a patient
    right then in that instance. Now, with the shared electronic
    medical record, we can know more and are able to make smarter
    decisions.
        Senator Manchin. Let me say this. In 2007, West Virginia,
    our state, became part of the rural health care pilot program.
    There were 90 sites throughout the state that have been
    involved over the past 7 years, and right now sustainability is
    the key factor for us to continue. In your testimony you
    mentioned--and this is for you, Mr. Linkous--you mentioned that
    the mere $65 million fell short of the $400 million that was
    set aside.
        Let me show you this in my little state, a rural state.
    Everything you see in green is an underserved area that
    qualifies. We're getting no services in those areas. That's
    what we're saying.
        Senator Wicker. Why don't we put that in the record?
        Senator Manchin. If we could, I would love that, because
    I'm sure every state has the same concerns we're having.
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        Senator Manchin. Everything in that green there shows over
    half of our state qualifies for underserved, and we're not
    getting services. Tell us what we can do and how we would be
    able to change that to get the service to the areas of need.
        Mr. Linkous. Senator, thank you very much for this. It is
    right on the mark. I'm very familiar with West Virginia, having
    worked on the Appalachian Commission, having two parents who
    are from there.
        Senator Manchin. Absolutely. Thank you.
        Mr. Linkous. So, strong in my heart is West Virginia.
        The problems that you point out of accessibility are
    problems that, when I was at the Appalachian Commission, we
    worked that by building highway systems. We now have the
    problems of building telecommunication systems that essentially
    do the same things, that open up the hollows to allow people to
    get access to the services that they need. Unfortunately, we
    really failed in some of that, whether that's providing
    incentives or whether it has been changing the Medicare program
    to reimburse, which is what we talked about earlier.
        We have a dual problem here. We have to work on the
    infrastructure to allow broadband to get to where people need
    it, and we talked about so much of the broadband needs to be
    wireless. You very well know that in many parts of West
    Virginia you might be able to get wireless access at the top of
    the mountain but you can't get it down at the bottom. So that's
    a significant problem.
        Certainly at the same time, Medicare, when it does not
    reimburse for some of the basic services you can get for
    telemedicine and doesn't provide those incentives, the doctor
    is not going to get paid for those services, they're just not
    going to provide it.
        Senator Manchin. And one final thing, if I may. When I was
    Governor, I always felt that if we could connect, if we were
    providing for Medicaid and also Medicare, should be connected,
    real time. We have people shopping, and especially for the
    opiates, on Friday nights they start to shop, because that way
    they have limited staff. They'll say back pain, six pills, back
    pain, six pills, four or five hospitals a night, and before you
    know it, the weekend, they've got a pretty good stash. They're
    ready to go start selling on Monday. We followed it all the way
    through, but we didn't have any doctors with real time.
        Dr. Gibbons, you just were down the road here this morning,
    but every time I pushed on that, they would say, well, first of
    all, they can't afford it. There was no mandate from the
    Federal Government to say if you're going to participate in
    Medicare and Medicaid, which is the largest part of
    reimbursement, this is what you have to do. Then they said
    privacy. Then I had the privacy thing, then I had the cost.
        Are we making any ground at all on getting people
    connected?
        Anybody want to take that one?
        Dr. Henderson. I will. We are in Mississippi, and it's
    working, and we're saving money. We're addressing it. We're
    reaching the most----
        Senator Manchin. You're connecting real time.
        Dr. Henderson. Yes.
        Senator Manchin. So if I walk in with my card and I'm a
    Medicaid recipient, you can check and say, hey Joe----
        Dr. Henderson. In 166 locations we're doing that. Now it's
    more of a plug and play. It's not UMMC's network. Now it's
    anybody that is a provider in our state can get on the network
    and take care of patients.
        Senator Manchin. Because you do have some say in Medicaid.
    You don't have any say in Medicare, but in Medicaid you're
    doing this.
        Dr. Henderson. That's correct, and third-party payers.
    That's right.
        Senator Manchin. OK. I like to check on them. Thank you.
        Mr. Linkous. Just to add, there are some shining examples
    in West Virginia. The West Virginia University has a doctor
    program, which I'm sure you're familiar with, and they've made
    a lot of progress. But certainly I'm sure if they were here
    today, they would say they need additional assistance and
    additional support from both the Federal Government and other
    areas as well.
        Senator Manchin. Thank you all.
        Senator Wicker. Senator Daines?

                    STATEMENT OF HON. STEVE DAINES,
                       U.S. SENATOR FROM MONTANA

        Senator Daines. Thank you, Mr. Chairman.
        I represent the great state of Montana, and we have a very
    rural character to our state. Thankfully, technology is
    starting to move geography as a constraint where we now can
    have both the quality of life of hiking, of hunting, of skiing,
    of fly fishing, as well as access to the world and competing
    globally, building companies there.
        I'm curious about your thoughts. Perhaps I'll start with
    Dr. Gibbons. What are the current interstate barriers, and how
    can we remove them so rural Montanans can have access to the
    same specialty health care providers as we see in the urban
    areas?
        Dr. Gibbons. Senator, thank you for your question. Let me
    just start by clarifying. The Connect2Health Task Force is
    focused on showing the benefits of the program. We don't focus
    on those kinds of issues, and I personally have not worked on
    those kinds of issues at the Task Force during my stay there.
    But I'm happy to take your question and forward it to the
    appropriate people at the Commission and supply you with an
    appropriate answer.
        Senator Daines. OK, thank you.
        Mr. Linkous, do you have any thought on that?
        Mr. Linkous. I'd be more than happy to respond to that. One
    of the big problems that we have in telemedicine right now is
    state barriers because every state has their own way of
    regulating and their own way of licensing physicians.
        In Montana, that is very certainly the problem. One of our
    past presidents, Thelma McClosky Armstrong, runs the Eastern
    Montana Telemedicine Network in Billings, and I'm sure she
    would tell you it's very much the same problem they have when
    they work between areas, for example between Montana and
    Wyoming. There are a number of programs there, but if you
    happen to be a physician in Billings and see a patient in
    Wyoming, you have to be licensed in Wyoming as well as in
    Montana. If you're over there providing health care in those
    areas, you have to follow the peculiar laws of the state of
    Wyoming as well as the laws that might be in the state of
    Montana as well.
        So we have 50 different ways of regulating health care, 50
    different ways of licensing health care. What we have talked
    about for a long time is the need for reciprocity, for states
    to work together, not to replace it necessarily with a Federal
    program, but at least to push the states into doing something
    that makes sense so that patients, no matter where they're
    located, can get access to health care services. Certainly
    there are people in both eastern and western Montana and in
    southern Montana that are close to the borders of other states
    who would benefit from that.
        Senator Daines. We don't have an in-state medical school.
    We have the WWAMI program. The University of Washington is our
    partner there, so you might have a rancher out in eastern
    Montana that might need to have a telehealth discussion with a
    doctor in Seattle, a specialty doc, and I'd appreciate your
    help as we look at that. How do we break down those barriers
    and that reciprocity? That would be helpful. Thank you.
        Dr. Gibbons, I just met, in fact, last week with the winner
    of the Principal of the Year in Montana, and we chatted, and I
    asked what are some of your challenges as a principal? Do you
    know the first thing she said to me was? Some of the mental
    health issues that our children face today. We need more mental
    health services for the kids in our schools.
        Even though schools currently have access to broadband
    services, why do you believe the deployment of telehealth
    services like mental health counseling in schools have been
    slow to develop?
        Dr. Gibbons. I'm sorry, I didn't hear the last part of your
    question.
        Senator Daines. Why do you believe the deployment of
    telehealth services like mental health counseling in schools
    have been slow to develop?
        Dr. Gibbons. Senator, thank you for this question. I must
    be honest with you. I trained as a surgeon in preventive
    medicine, so that's really beyond my area of expertise, and I'd
    hesitate to give you an answer that's not as accurate as it
    could be, but I'd be happy to get with the right people and
    give you the appropriate help there.
        Senator Daines. All right. Thank you.
        I want to shift gears to HIPAA and PII. How can we ensure
    that patients----
        Senator Wicker. Senator Daines, let me give you an extra
    bit of time. I think there are other members of the panel that
    might want to jump in and help you answer that question.
        Dr. Henderson, were you eager to----
        Dr. Henderson. On the mental health piece?
        Senator Wicker. Yes.
        Dr. Henderson. Absolutely. The challenge is that that's not
    a site of service that can be reimbursed, and we can't take
    advantage of the E-rate connectivity there. So if we can change
    that so that we can use that same connectivity to deliver
    health care and that the school becomes a site of service where
    we can be reimbursed for that care, then you'll see that jump
    up.
        Senator Daines. OK, thank you. I appreciate that.
        Mr. Linkous, any thoughts on that as well?
        Mr. Linkous. I would absolutely agree with that.
        Senator Daines. OK, that's helpful.
        I want to shift to HIPAA and PII. How can we ensure that
    patients' PII is kept private as required by HIPAA? I'll open
    it up to anybody who wants to look over here and take that
    question. Everybody's looking down at their notes.
        [Laughter.]
        Mr. Linkous. Well, I'm always one to jump in. I call HIPAA
    the Lawyer Full Employment Act.
        [Laughter.]
        Mr. Linkous. I apologize, but I couldn't help it.
        Those are problems that are real, but also problems that
    can be seriously handled. We have encryption that can and
    should be done, and I'm sure Dr. Henderson uses it throughout
    her program, and it should be gone through in every program.
        The problems with privacy are often not with the
    telemedicine programs themselves but with what happens at the
    other end when a doctor is looking at the monitor with the
    patient and he happens to be doing it in an open area where any
    patient can walk by and look over his shoulder. There are some
    very practical issues.
        But certainly encryption of the data and managing the data
    the same as we do with our banking systems, we don't seem to
    have the same issues on that level with a lot of the other
    systems that use electronic communications. I'm not saying it's
    not a problem, but I do say that that is a problem that's
    smaller than any of the other issues that we've seen in
    telemedicine.
        Senator Daines. Great, thank you.
        Senator Wicker. The Chairman has arrived, and I'll
    recognize Chairman Thune, and then Mr. Peters following the
    Chairman.

                     STATEMENT OF HON. JOHN THUNE,
                     U.S. SENATOR FROM SOUTH DAKOTA

        The Chairman. Thank you, Mr. Chairman. I want to thank you
    and Senator Schatz for having this hearing. This is an issue of
    great importance to me and to many members of this panel. There
    are a lot of folks on this panel who represent large and
    sparsely populated areas of the country for whom technology has
    become an increasingly important answer when it comes to health
    care delivery and health care solutions.
        So, Dr. Gibbons, I just want to mention that I've seen
    firsthand in South Dakota the important role that skilled
    nursing facilities play in the delivery of care, particularly
    in rural areas. For example, the Evangelical Lutheran Good
    Samaritan Society operates hundreds of skilled nursing
    facilities, mostly in rural locations, many in states that are
    represented on the Commerce Committee, which connect with Good
    Samaritan's national headquarters in Sioux Falls, South Dakota.
        Good Samaritan has designed and implemented technology that
    allows rural patients, who might otherwise have to travel up to
    100 miles to see a physician, to remotely connect with
    hospitals and their doctors. In June 2014, I wrote a letter to
    the FCC urging the agency to resume its skilled nursing
    facilities pilot. I understand the FCC has since completed its
    consideration of proposals submitted in response to its related
    technology transitions order. As such, does the FCC now have a
    plan to support skilled nursing facilities as part of the rural
    health care program?
        Dr. Gibbons. Thank you, Senator. In February 2014, the
    Commission deferred the Skilled Nursing Facility Pilot Program
    pending its consideration of the health care-related proposals
    at the agency's Technology Transition and Rural Broadband
    Experiments proceeding. In that proceeding, the Commission
    solicited comment on, among other things, conducting consumer-
    oriented rural broadband experiments that would improve patient
    access to health care. The Commission sought comment on using
    funds from either the Connect America Fund or the Rural Health
    Care Program for the rural health care broadband experiments,
    including whether to use part of the $50 million set aside by
    the Commission for the SNF pilot program.
        Accordingly, until all the awards are decided in the
    Technology Transitions and Rural Broadband Experiments
    proceeding, the SNF pilot is still deferred. And although the
    SNFs currently are ineligible for health care funding support,
    they may partner with eligible health care provider consortia
    members in networks to reap the benefits that the others are
    gaining.
        The Chairman. So the answer to the question is that they
    have not completed consideration of these proposals that have
    been submitted? You said it was deferred.
        Dr. Gibbons. The action was deferred in 2014, sir, and it
    is still deferred at this time.
        The Chairman. OK. We're well into 2015 now. That's a year
    ago. The letter I wrote was a year ago. I'm just wondering why
    the FCC won't support these facilities that are so critical to
    rural America.
        Dr. Gibbons. Well, again, these facilities can get some
    support from available funds by being part of a consortia. But
    I'm happy to, again, take your question to the FCC and get any
    additional response that may be helpful.
        The Chairman. I would appreciate if you can do that. This
    thing seems to be dragging on, and these deferrals and delays--
    these are facilities that could benefit enormously from the use
    of telehealth, telemedicine and the delivery of health care to
    these areas of the country. It strikes me at least that we
    ought to be doing everything we can to promote that. If, in
    fact, there's a process that's been put in place to consider
    these proposals and ways in which to do this, I would certainly
    hope that the FCC would move that process along.
        Dr. Gibbons. I'll do that.
        The Chairman. Thank you, appreciate that.
        Mr. Chairman, One other question, very quickly. This is for
    Mr. Rytting, and that has to do with spectrum management and
    the way in which licensed and unlicensed spectrum can be used.
        In light of the ongoing work that's being done by NTIA and
    the FCC to deal with the country's spectrum resource issues, I
    was wondering if maybe you could talk a little bit about how
    the spectrum needs for mobile broadband-based health care
    applications can be addressed, the things you believe we ought
    to be doing as policymakers to ensure that M-health, as some
    are calling it, can continue to develop and thrive.
        Mr. Rytting. At Panasonic we believe, like many of the
    people in our industry, including the people that we have here
    from TIA, that being able to have access to more of the
    spectrum would help us. The limitations that are there right
    now are fairly old. We would also welcome the opportunity to
    have prioritized access for certain critical resources. We
    believe health care would be one of those.
        But the spectrum issues and how to get the information from
    Point A to Point B is something we rely heavily on the
    telecommunications industry to do for us. We don't operate any
    of the carriers, but we license and use their bandwidth to get
    our work done. So we would welcome the participation of that
    industry with the FCC and with this body to have access to more
    of the spectrum, be able to get signals farther, be able to get
    more bandwidth through it. That would greatly help the
    situation.
        The Chairman. Thank you.
        Thanks, Mr. Chairman.
        Senator Wicker. Thank you, Senator Thune.
        Dr. Gibbons, when do you think you might be able to get an
    answer back to Chairman Thune from the Commission?
        Dr. Gibbons. Sir, I'll take all concerns to the Commission
    today and work to get those to you as soon as possible. It's
    not possible for me to put a date on it right now, but I assure
    you I'll work as expeditiously as possible.
        Senator Wicker. Very much appreciate that.
        Senator Peters?

                    STATEMENT OF HON. GARY PETERS,
                       U.S. SENATOR FROM MICHIGAN

        Senator Peters. Thank you, Mr. Chairman, and thank you to
    our panelists for today's fascinating discussion and certainly
    one that we have to continue to work on, for those of us, all
    of us, who represent rural areas in our states. Even though we
    have urban areas, we also have vast rural tracks, as I do in
    Michigan in the northern part of the state, particularly the
    Upper Peninsula.
        Mr. Rytting, I appreciate your comments that telemedicine
    also helps our urban populations as well, to make sure that
    folks have access to quality care. I can say that I'm committed
    to the notion that in this great country of ours, no matter who
    you are, no matter where you live, you should have access to
    quality, first-class health care. That's what you do when you
    live in the greatest country on earth, and telemedicine is
    going to be a key part of that.
        So I appreciate the discussion that we've had today, but
    I'd like to have the panelists react a little bit to some of
    the critics that have been pushing back on telemedicine,
    particularly from a cost perspective. Obviously, access is
    critically important. We want to have everybody have access to
    it, but we also have constraints as to the amount of money that
    we have available to pay for health care across the country.
        There are folks at the CBO, as well as other health care
    analysts, that are concerned that if you have telemedicine, you
    actually open up the floodgates--this is their words, not
    mine--open up the floodgates to cost and we'll see a rapid
    escalation of costs that will be difficult to handle. I think
    the CBO has always had very high cost estimates. They haven't
    realized those estimates that they put forward, some might
    argue because there isn't the reimbursement that is going
    forward.
        But I'd like you to respond to the critics out there who
    believe that this will open up the floodgates and perhaps
    address how you see it not doing that and how it actually
    brings more efficiency to the system, or however you'd like to
    respond.
        Dr. Henderson, if you'd like to start with that, that would
    be great.
        Dr. Henderson. Yes, I'd love to. Thank you.
        So, no better way to answer that than with the facts in our
    story in Mississippi. Once we cleared all the barriers to
    reimbursement and regulations in our state, that was the fear.
    The floodgates were going to open and, oh my gosh, it's going
    to cost us more. But, in fact, we've seen quite the opposite.
        So now, over 12 years of experience in this, and we're
    seeing lower costs and improved health outcomes. There's
    nothing better than to show those facts and find other states
    that have had the same type of outcomes and be able to provide
    that forward for examples. So we think that if you advance the
    legislation at a national level, that we'll see the same
    benefits and cost savings.
        Senator Peters. Great. Thank you.
        Dr. Gibbons?
        Dr. Gibbons. Yes, I would agree. The science and the
    evidence simply don't support that contention. What can happen
    sometimes, particularly when you're providing services to
    people who didn't previously have them, because you're finding
    new things, you might see a small blip up because you're
    finding things that would have been ignored. But inevitably, if
    it's the right thing to do, costs come down in the long run.
    It's very beneficial. So that's just an uninformed perspective.
        Senator Peters. Great.
        Mr. Linkous. So I would agree with the previous two
    comments. Certainly, the evidence is mounting that it's just
    the opposite. There's the tremendous experience that we
    mentioned earlier with the Veterans Administration. They have
    documented substantial cost savings. The National Library of
    Medicine has something like 15,000 studies now dealing with
    telemedicine, many of them showing the cost-effectiveness, and
    a very quick story.
        When we worked with the Congressional Budget Office many
    years ago on the issue of telestroke, we looked at the idea of
    what happens when you have a patient come in who has suffered a
    stroke within the first 60 minutes and they can see a
    neurologist. They issue, for example, directions for a blood
    clot-busting drug, and many times these people can walk out of
    the hospital completely cured or completely well again, or
    certainly significantly better. They don't have to go to a
    nursing home. They don't have to go through substantial rehab.
    They can go out.
        The Congressional Budget Office says, well, cost savings
    for nursing homes or rehabilitation, that's not our department.
    We're just looking at the cost in the hospital. The cost in the
    hospital, all of a sudden you're administering tPA, which is a
    very costly drug to take care of that blood clot. So we think
    there are actually more costs in that.
        Those are some of the problems we're looking at. There's
    long-term savings that are very real and very measureable, and
    yet we've got to get some of the folks who are involved in this
    area, the Congressional Budget Office, to understand where
    these cost savings are.
        Senator Peters. Great. Thank you.
        Mr. Rytting?
        Mr. Rytting. I can look at it from a slightly different
    perspective, as a supplier of possible solutions and hardware
    and electronics. We engaged in the pilot. One of the reasons
    was to validate our business model and working with insurance
    companies and managed care organizations. Based on what we
    learned from this pilot, that's what encouraged us to move
    forward with the two or three other pilots and expand the work.
        We do have a culture at Panasonic of contributing to
    society. We have some values that are stamped on the back of
    our business cards that are 80 years old. But that contribution
    to society doesn't answer the stockholders. Profits do. And we
    believe that this is a profitable industry, at the same time
    giving back benefits to society. So we're all for it.
        Senator Peters. I appreciate your comments, and it's an
    example where we can expand access while doing it efficiently
    and reducing overall costs. So, thank you for your response.
    Appreciate it.
        Senator Wicker. Thank you, Senator Peters.
        I might just emphasize part of Dr. Henderson's testimony
    where she says our telemergency program has resulted in a 25
    percent reduction in rural emergency room staffing costs, and a
    20 percent reduction in unnecessary transfers. So thank you
    very much for exploring that line of questioning.
        Senator Fischer?

                    STATEMENT OF HON. DEB FISCHER,
                       U.S. SENATOR FROM NEBRASKA

        Senator Fischer. Thank you, Mr. Chairman.
        Telehealth is a relatively new industry, but I believe it's
    one with great potential, as we're hearing today on all the
    questions and all your answers. So, thank you.
        This is new technology, but we already see a number of
    agencies that have their own programs and their own regulations
    and their own grants. It's the FCC, the FTA, the USDA, HHS, any
    alphabet soup there that you can think of.
        So I would ask this of any of the witnesses who would like
    to answer. Is there an argument, do you believe, for one agency
    to cover these connected health issues that are out there, as
    opposed to the multiple agencies? And do you have any
    recommendations on how to streamline the Federal Government's
    role?
        Mr. Rytting. Let me just give a real brief answer, echoing
    some of the earlier statements that I made. Being part of the
    technology industry, this is moving incredibly fast, and trying
    to keep up with our competition not only in developing products
    and software and technology and networking, this is basically
    an Internet of things discussion, because remote telehealth is
    a ``thing'' in that paradigm.
        If it's difficult for the industry to keep up with each
    other and to continue to evolve and accelerate, it's probably
    just as if not more, difficult for the legislative agencies and
    the governmental agencies to also keep up.
        Our recommendation is to, number one, work together with
    industry to share knowledge and to share experience so that we
    can make the best decisions possible. At the same time, we
    would like to deal with fewer, not more, agencies.
        Mr. Linkous. Senator, thank you for that question. Over 10
    years ago, ATA recommended to Congress and to the
    Administration that there be a high-level coordinating
    committee that looks at all the different agencies that are
    providing money, that are regulating, the Federal agencies that
    are involved in either funding for telemedicine programs,
    providing reimbursement for programs, doing their own programs,
    like the Veterans Administration or the Department of Defense,
    or regulating in some way, like the FTC or FCC.
        There are various groups that are together that are more
    brown-bag lunch groups, but there are no high-level,
    authoritative groups that can look at unifying regulations. I
    don't think we can do something where we're consolidating them
    into one department. But nevertheless, there's a huge amount of
    opportunity there to have the people at a high level, maybe
    even managed out of the White House, that says this is a
    problem that we have in coordinating the regulations,
    coordinating the funding. We see all the time programs that are
    funded in a state or in a community, two or three different
    programs that are funded by different agencies to do the same
    thing, but entirely different regulatory mechanisms where it
    really should be coordinated.
        So that's one of the things that we would really strongly
    recommend that either Congress can push the Administration,
    some form of a high-level coordinating committee that has the
    ability, the technical and, frankly, the administrative
    authority to do some coordination among these programs.
        Senator Fischer. It would be nice to have coordination, but
    not just to establish another committee also at the government
    level. I think you also have to look at the regulations that
    are currently out there, one dealing with medical devices. It
    was there in 1976, and I introduced a bill last year with
    Senators King and Rubio on it, the Protect Act, with medical
    devices, how do you define that. And we have the FDA that is
    using a 1976 definition on health IT apps that are out there
    that, by the time they get around to looking at them, it's
    already moved on. So we faced outdated definitions besides just
    the coordination on it.
        So I guess I would ask you, Dr. Gibbons, how do you then
    try to streamline that? Because my experience here is it's very
    difficult to do.
        Dr. Gibbons. Senator, thank you for the question. As you
    know, the FCC manages both wireless and wireline spectrum, and
    to that extent, as health care becomes more wireless, the FCC
    footprint will inevitably grow. You know the FCC also has an
    historic role in that it has a part in certification of all
    FDA-approved medical devices that have a wireless component. So
    the FCC's role in health care is not new.
        Senator Fischer. But hopefully you'll streamline those
    regulations as well, then.
        Dr. Gibbons. That's actually what I was just about to say.
    To the Chairman's credit, last year when he established this
    Connect2Health Task Force, one of the things that he charged us
    with doing is looking at regulations of the FCC and making
    recommendations regarding barriers as well as incentives.
        Senator Fischer. Thank you.
        I've run out of time. Thank you, Mr. Chairman.
        Senator Wicker. Senator Booker.

                    STATEMENT OF HON. CORY BOOKER,
                      U.S. SENATOR FROM NEW JERSEY

        Senator Booker. First of all, I really want to thank
    Senator Schatz and Senator Wicker for holding this hearing.
    It's a really important issue and, obviously, as you said, the
    Chairman, with so many Senators attending, it's obviously
    something of interest to all of us. But it's something of
    urgency for the Nation as a whole.
        What's impressive to me is that telehealth, if you add that
    into the sophistication of the devices that are measuring
    biometrics these days, if you add that on top of the advances
    we've already made in science where you can actually implant
    chips in people that can release medicine at certain specific
    needed times, the advances in the way they build upon each
    other is really opening up an extraordinary opportunity to
    achieve what has already been said in this hearing, many of the
    objectives that we have, from lowering costs to increasing
    quality of health.
        I'm just glad that we have such a great panel here, but I
    really want to focus in on the guy from Newark. No bias
    whatsoever there.
        [Laughter.]
        Senator Booker. But I just, first of all, want to welcome
    you. Panasonic has been a partner of mine for years now, and
    it's an industry leader, an important player in this space, and
    their company's North American headquarters I hear is in an
    extraordinary city.
        I just want to jump in because you have now mentioned it a
    number of times, Mr. Rytting. There's no bias here. If there
    was bias, I'd be giving Dr. Gibbons a lot more love because of
    his great haircut.
        [Laughter.]
        Senator Booker. Just real quick, Mr. Rytting, because
    you've mentioned this a number of times, the issues of
    spectrum, and it's something that I have a lot of concern about
    because, in many ways, government has a tremendous amount of
    authority and control over how we use spectrum. So from new
    apps, wireless devices, telehealth, all these issues come down
    to the availability of spectrum, and we have an obligation and
    responsibility to ensure this scarce resource is being utilized
    as efficiently and effectively as possible in order to reap
    these vast benefits that we're talking about.
        Senator Rubio and I joined together to introduce the Wi-Fi
    Innovation Act, which aims to make more spectrum available for
    unlicensed and Wi-Fi purposes.
        So, Mr. Rytting, how important is spectrum in the
    telehealth equation? Can you just sort of give a little bit
    more of the urgency that you've already sort of tangentially
    touched upon?
        Mr. Rytting. I'm going to quote Chairman Wicker, that if
    you don't have broadband, you don't have telehealth, right?
    Cellular and Wi-Fi is a crucial part of that because it's part
    of the equation of getting the information from one point to
    the other.
        Right now what we see, it's very difficult to get access to
    some of the available spectrum that might be sitting there just
    waiting to be used, but we can't. So that's a problem.
        It's also a problem of trying to figure out how to allow
    better access to spectrum, but at the same time--and this is a
    juggling challenge--at the same time preserve some of the
    protected parts of the spectrum that may have bearing on
    international agreements or reciprocity with other agencies in
    other lands.
        We deeply endorse the idea of being able to apply for and
    access commercially more of the spectrum, because it will open
    up more opportunities for range, for bandwidth, and that is the
    key to the whole equation, unless we come up with other ways of
    communicating. There are other ways, but not quite as prevalent
    or as inexpensive as Cellular and Wi-Fi technology is.
        Senator Booker. So, in short, would you agree with me that
    you cannot have an effective and innovative national telehealth
    care system without equally effective national spectrum policy
    that supports and serves that system?
        Mr. Rytting. We absolutely agree with both of those
    initiatives.
        Senator Booker. And so the urgency for us to reexamine the
    allocations that are already made to make sure we're using it
    efficiently, would you say to reexamine it, especially in terms
    of our emphasis on health and safety, it's something that
    really Congress should be doing?
        Mr. Rytting. I believe that.
        Senator Booker. OK. Just shifting in the last seconds that
    I have, you're doing incredible work in Newark, and I just want
    to know what are some of the unique needs. We've heard a lot
    about the rural challenges, but what are some of the unique
    needs to urban communities as they face accessing the benefits
    of telehealth?
        Mr. Rytting. What we discovered was not an expected finding
    in that we can understand rural availability of broadband and
    why it's not there. What I did not dream of running into at the
    time was the unavailability of broadband in urban settings. To
    be a heartbeat away from New York City and not be able to get a
    signal in a structure that had thousands of tenants in it just
    boggled my mind.
        So I believe they share some of the same concerns.
        Senator Booker. And we therefore have an urgency for
    broadband penetration to really focus on rural and urban
    together.
        Mr. Rytting. Sure.
        Senator Booker. Thank you very much.
        Mr. Chairman, how did I do on time, sir?
        Senator Wicker. You did very well, and I appreciate your
    mentioning parochial matters.
        Let me just ask you this, Senator Booker. If someone missed
    the peak of the cherry blossom season here in Washington, D.C.,
    is there any place within a 3-hour drive where people might be
    able to see cherry blossoms?
        Senator Booker. Sir, you have just earned so much love from
    me.
        [Laughter.]
        Senator Booker. Forget Schatz. I used to have a bromance
    with him. It's over.
        [Laughter.]
        Senator Booker. The number one city in America, in fact,
    for cherry blossoms is Newark, New Jersey. And, yes, the peak
    has just passed this weekend, but you still can catch some
    beautiful pictures. Or, sir, you can go on my Instagram account
    and see some of it right now.
        [Laughter.]
        Senator Wicker. Thank you, and I'm glad that's part of the
    record for someone 10 years from now to wonder about.
        [Laughter.]
        Senator Wicker. Senator Blumenthal?
        Senator Gardner. Mr. Chairman, we have some buds in
    Colorado, too.
        [Laughter.]
        Senator Wicker. The many layers. A lot of things growing
    out there in Colorado.
        [Laughter.]
        Senator Wicker. Mr. Blumenthal, could you bring us back to
    earth?
        [Laughter.]

                 STATEMENT OF HON. RICHARD BLUMENTHAL,
                     U.S. SENATOR FROM CONNECTICUT

        Senator Blumenthal. That will be very difficult, Mr.
    Chairman.
        [Laughter.]
        Senator Blumenthal. But I'll try.
        Let me bring together a number of important conceptual and
    practical threads to the testimony that has been offered so
    far, and I agree with all my colleagues that telemedicine holds
    great promise for treating patients who may be reluctant or
    reticent or unable to seek treatment in other ways. That's
    particularly true, I think, for people who are suffering from
    mental health issues, because they really want the anonymity
    and the confidentiality that comes with consulting a mental
    health professional, and they may find access also difficult to
    mental health care.
        That goes for young people who may be in school and may be
    in dormitories where going to the college health center for
    mental health treatment makes them an object of attention, or
    perhaps even ridicule. It goes for veterans who are effectively
    now denied effective mental health care in many parts of the
    country because our VA facilities simply lack sufficient
    resources. And that's one of the reasons why, as Ranking Member
    of the Veterans Affairs Committee, I introduced successfully
    the Clay Hunt Veteran Suicide Prevention bill, to provide more
    mental health services to our veterans and prevent a fact that
    is absolutely staggering, 22 veterans every day in the United
    States of America commit suicide.
        So there are emotional barriers, practical barriers to
    seeking effective mental health care for them and for many
    other parts of our population. So I wonder if I could ask maybe
    Dr. Henderson, beginning with you, whether your feeling is that
    telemedicine can be beneficial in treating mental health issues
    based on your practical experience, and the ways that Congress
    can support and expand access to mental health care generally,
    and particularly for those groups that I mentioned and others
    who may not have the access and availability that they really
    need.
        Dr. Henderson. Yes, absolutely. Thank you for that
    question. So let me give you another example that we started
    this year. In one of our 4-year colleges in Mississippi, we
    offer now tele-psychiatry services to every single student so
    they can have that anonymity and go to the regular clinic on
    campus that they would go for their cough or cold and will
    connect to one of our psychiatrists at our facility hundreds of
    miles away, and it's making a huge difference.
        It's about access, and it's about access where they want it
    because, you're right, people don't want to be labeled or have
    to go into public and have it obvious that they're going to a
    mental health clinic. So I think we can transform the mental
    health delivery system and offer it in unique ways.
        One of the challenges and ways that we can be supportive is
    to be able to do this in all levels of schools, going much
    younger into the elementary schools and start to deliver mental
    health services and counseling services and bring in the
    parents, as well as teachers and students. So we can do it in
    some transformative ways that our traditional model would never
    be able to financially support and wouldn't be successful at.
    So that's one way we could enhance that.
        Senator Blumenthal. And are people secure in the
    confidentiality and anonymity of the service that's provided?
        Dr. Henderson. Yes, absolutely. I think a good way to look
    at it is this is really no different than in-person care,
    except that you're stepping into an exam room and getting it
    through connectivity in that room. So the same challenges of
    privacy and security in an electronic medical record in my
    clinic if you physically came there is no different than if we
    did telemedicine. So they feel comfortable.
        Senator Blumenthal. And the more people Skype with
    relatives, the more comfortable they are with this kind of
    communication.
        Dr. Henderson. That's right. All ages have been open arms
    with this because it's about access, and it's convenient access
    that they can take advantage of.
        Senator Blumenthal. I'd invite any of the other members of
    the panel to comment.
        Dr. Gibbons. Senator, thank you for your question. I
    appreciate you broadening out and thinking about other types of
    technologies and ways to use them. I did one of the first
    studies looking at is there any evidence that any of these non-
    traditional telemedicine technologies, broadband-enabled
    technologies, is there any evidence that they can be effective,
    and what we found at that time is that, in fact, yes, there
    were some preliminary effects.
        But in the area of mental health, that was where some of
    the strongest evidence was, particularly providing cognitive
    and behavioral therapy remotely to patients not only by
    psychiatrists but by psychologists and sometimes behavioral
    therapists, behavioral specialists, right directly into the
    home.
        So there are a variety of ways this can be done. There is
    evidence that it is effective and saving in costs as well.
        Senator Blumenthal. Thank you.
        Mr. Linkous. Senator, if I could just add a couple of
    moments on that. When ATA was founded in 1993, one of my first
    conversations with a gentleman outside of Washington, D.C., who
    was agoraphobic, who was involved at that point with a bulletin
    board system--it was before the Internet really took off, and
    they used that as a very obvious way of helping folks who were
    afraid to get out of their house to connect with each other.
        So it's not surprising today that telemental health, as we
    call it, is one of the most advanced and important parts of
    telemedicine. Both the American Psychiatric, the American
    Psychological Association, and the National Association of
    Social Workers have endorsed this. We estimate somewhere around
    400,000 patients this year will have seen a therapist using
    telemedicine.
        Incidentally, in Colorado there's an interesting program
    that combines both the Indian Health Service and the Veterans
    Administration reaching out to returning veterans. So there are
    a number of examples of this. There is tremendous opportunities
    to expand that program.
        Senator Blumenthal. My time has expired, but if you could
    provide in greater detail, perhaps in written form, to our
    committee, any of you, specific, concrete examples of how this
    system can really enable greater access, greater availability
    of telemental health services, I would appreciate it.
        Thank you, Mr. Chairman.
        Senator Wicker. Thank you, Senator Blumenthal.
        Senator Gardner?

                    STATEMENT OF HON. CORY GARDNER,
                       U.S. SENATOR FROM COLORADO

        Senator Gardner. Thank you, Mr. Chairman, and thank you to
    the witnesses for your time and testimony today.
        We've heard a lot of impressive statistics and figures when
    it comes to telemedicine this morning, so I thought that I
    would add Colorado's numbers to it as well. It was about 9
    years ago when I was in the state legislature in Colorado that
    we passed one of the first telemedicine bills addressing COPD
    issues, cardiovascular issues.
        But one of the things that I think was stunning to learn
    during that time-frame was a study done on the Western Slope of
    Colorado--I think it was at the time Centura Health that did
    the study--showing, similar to the statements made by others,
    that a test group, a patient test group of I can't remember how
    many people were in it, but basically the results came back
    showing that the hospital spent around $150,000 to set up the
    telemedicine pilot study. Over the course of this multi-year
    study, they were able to reduce hospital visits amongst this
    patient test group between 70 and 90 percent, and they were
    able to reduce the emergency room visits by 100 percent, and
    the hospital saved about $900,000. They spent $150,000 and
    saved about $900,000, and reduced emergency room visits by 100
    percent.
        So here we are nine years later and we're still talking
    about how we can get involved in telemedicine, what needs to be
    done, and we've made some advancements and steps. But I'm
    really curious about how we jump-start this into the mainstream
    instead of just talking about how this could effect on the
    edges.
        A couple of my questions have been asked by various members
    of the panel, so I want to ask just a few things that may not
    have been asked.
        Do we have a medical licensing issue that we need to
    address?
        Mr. Linkous. Oh, yes, we do. It has been an issue since the
    beginning of ATA 22 years ago, but it was largely ignored
    because many of the telemedicine programs were within the
    state. Now health care has gone regional and national. Health
    care services are national. People in Colorado can now access a
    doctor if they're at the Mayo Clinic in Rochester, Minnesota.
    People who are in rural Nevada can access a doctor in Denver,
    Colorado.
        However, they can't do that unless that doctor gets a
    license in the other state. I don't know how many of the
    members of this committee have a doctor at home that treats
    you, but if they treat you for a condition in Washington and
    they're not licensed in the District of Columbia, they're
    violating the law.
        Senator Gardner. And are you familiar with legislation by
    Congressman Devin Nunes and others that has been introduced?
    Would that solve the problem?
        Mr. Linkous. I'm not familiar with all the details of that.
    There have been several pieces of legislation which I think
    would help. We are looking for reciprocity among the states so
    that you have a state that has a law that requires a doctor to
    pass an exam, another state which is using the exact same exam
    for that doctor should be able to accept the license of that
    doctor so that a physician in Colorado could practice in other
    parts of the country as long as they're duly licensed in their
    own state.
        Senator Gardner. Is this something that you would prefer be
    done at the state level versus the Federal level?
        Mr. Linkous. We think the Federal Government can help the
    states solve this problem on a national level. We have not
    endorsed national licensure, but we do think you don't need to.
    I think the states can provide an area of reciprocity, but they
    will not do it without the Federal Government helping them.
        Senator Gardner. And we've talked a little bit about the
    HCF a little bit here, talking about how HCF doesn't allocate
    any money for administrative and operational costs but it's
    very costly to administer. I guess, Dr. Henderson, maybe this
    is best for you. How do telehealth providers get funding for
    operational and administrative support?
        Dr. Gibbons. How do you tell what? I'm sorry, I missed it.
        Senator Gardner. How do telehealth providers get funding
    for operational and administrative support when they can't use
    HCF allocations?
        Dr. Gibbons. Senator, thank you for your question. While
    the Commission has considered supporting administrative costs
    in the Health Care Fund program, it ultimately decided against
    doing so for several reasons. First, exclusion of
    administrative costs from the program support obviates the need
    for additional complex application requirements which would be
    necessary to protect the support from waste, fraud, and abuse.
    Accordingly, both USAC and applicants are spared from such
    additional requirements.
        Second, lack of support for administrative expense has not
    seemed to hinder the program participation. Thousands of health
    care providers participate annually in the program.
        And finally, the Commission has designed the Health Care
    Fund program to minimize, to the extent possible,
    administrative burden on the applicants. And to this end and
    among other things in the program, these are the reasons they
    have decided not to support administrative costs.
        Senator Gardner. Dr. Henderson, would you like to add
    anything to that?
        Dr. Henderson. I would just add that in our state, we have
    the challenge of being a consortium leader but having a cap on
    that. For any large hospital over 400 beds, there's a cap on
    the funding that you can receive. The challenge with that is
    we're the anchor institution that everybody wants to lead the
    consortium. So we have challenges with covering our costs with
    that. I would love to have a review of that as a consortium
    leader in a rural state, leading all these rural institutions,
    that funding being opened up.
        Senator Wicker. Senator Markey?

                   STATEMENT OF HON. EDWARD MARKEY,
                    U.S. SENATOR FROM MASSACHUSETTS

        Senator Markey. Thank you, Mr. Chairman, very much.
        So we're moving from the old era where you went into the
    doctor's office and the nurse would open up her cabinet and
    pull out your file and hand it to the doctor, and after the
    doctor was finished with you the nurse would put it back in the
    file and lock it. The nurse knew, the doctor knew, and you knew
    the doctor wasn't going to tell anybody anything. It was a very
    private world, totally secure for the most part.
        Now, because of these new technologies, we are entering an
    era where these records through telemedicine can just be out
    there. So concomitant with the efficiency which these new
    technologies make possible, you also need a discussion about
    what the privacy rights are, because there was always total
    privacy. You kind of trusted your home doctor.
        They're not under lock and key, and the records can now be
    up in the cloud. The medical providers can be using the least
    costly way of storing this information, using pretty much the
    same connection that we watch YouTube videos on.
        Those that would crack into our privacy don't need crowbars
    anymore, breaking into the doctor's office. They just need a
    smartphone. It's our privacy, our security, our safety which is
    at stake. The stakes are as high as they can get because it can
    wind up in thousands in unpaid charges, loss of insurance
    coverage, potentially dangerous details in your medical records
    that become known to others that should not have access to that
    information. They can sell your medical data. They can disrupt
    actual life-giving benefits of telemedicine.
        So what I'd like is, if we could, Dr. Gibbons and Ms.
    Henderson, how do we ensure that our laws and regulations are
    flexible and yet robust enough to ensure that telemedicine and
    our health information being protected are compatible concepts?
    So what new laws would you like to see put on the books in
    order to ensure the protection of the information as it's being
    transmitted?
        Dr. Henderson?
        Dr. Henderson. That's an excellent point, and I think that
    it's a concern that many have, and I think while it's a
    concern, with the program that's set up right to deliver
    telehealth and secure and encrypt that pathway and that
    network, we can ensure that privacy and security.
        But one of the challenges is that every program is a little
    different. And so while I know my program and I know end-to-end
    what's happening and who is touching it and how it's secured,
    I'm not sure that everyone is following those same standards.
        Senator Markey. What is the standard? Do we need a law? Do
    we need a regulation? What do we need? Because we can't trust
    everybody to do the right thing, so you need some standard.
        Dr. Henderson. Yes. I think this goes to that earlier point
    of do we need a higher Federal entity that determines minimum
    standards around that. There are some from different
    organizations, and state by state we all are coming up with our
    own model. But I think that would be helpful, to have a
    consistent minimum standard.
        Senator Markey. Do you agree with that, Dr. Gibbons? Do we
    need a national standard so that everyone knows whose health
    information is being transmitted across the country or across
    the planet, that there are laws on the books to protect that?
        Dr. Gibbons. Thank you again for the question. One of the
    things that the Task Force is doing is coordinating and
    partnering with other Federal partners in multiple areas. One
    area where we've begun to work is working with our counterparts
    at the National Institutes of Standards and Technology. They
    have a very significant cybersecurity infrastructure for just
    this purpose, developing the standards.
        So we've just begun to collaborate with them, but that's
    the reason that we're doing that.
        Senator Markey. So do you think we're going to need a
    national law that's binding that guarantees that there is
    protection of the privacy of individuals? Do we need that?
        Dr. Gibbons. Well, Senator, I'm not a cybersecurity expert
    myself personally. I can say everybody wants their information
    to be secure. Whether we need a law or not, I'm not at liberty
    to say. I mean, I'm not an expert. We need to continue our
    consultation with the cybersecurity experts to determine that
    more fully.
        Senator Markey. Well, my sense is that you need a law. You
    need something that the bad guys know is going to get them in
    trouble if they do it. Otherwise, bad guys are going to do it.
    So that's just the bottom line. You need some standard that
    good guys are going to meet every time, because they're going
    to want to protect the privacy. But the bad guys are going to
    know they're going to pay a price if they crack into the
    medical records of tens of thousands of people, or somehow
    they're cracking into a video or a teleconference where
    somebody is being given medical advice and a stranger is
    watching this that would have never been possible otherwise.
    There has to be penalties which are put on the books.
        Senator Wicker. Let me just ask, Dr. Henderson, has this
    been a problem in your experience with the program in
    Mississippi?
        Dr. Henderson. We have not had any breach of security with
    our program.
        Senator Wicker. And, Mr. Linkous, in your association, do
    you see examples of this type of problem that Senator Markey
    outlined?
        Mr. Linkous. We have not seen any examples of broad breach
    of security for electronic medical records. There are,
    obviously, HIPAA laws and requirements, and there are certain
    uses of encryption technologies that absolutely must be used.
    But as far as I know, I'm not aware of any broad leak of
    medical information.
        Senator Wicker. OK. Well, thank you.
        And thank you, Senator Markey.
        Senator Cantwell?

                   STATEMENT OF HON. MARIA CANTWELL,
                      U.S. SENATOR FROM WASHINGTON

        Senator Cantwell. Thank you, Mr. Chairman, and thank you
    for having this important hearing.
        The state of Washington is very excited about telemedicine
    and I would just say health care innovation overall, everything
    from delivery system reform to advances in technology. So my
    questions are about what more areas of flexibility do we need
    and how we cover. I know this is the Commerce Committee and not
    the Finance Committee, which I also serve on, but the issues of
    covering reimbursements and costs and technology. I mean, we
    have so many people working on what they think will be the
    health care delivery into the home where so many of the vital
    statistics of a patient can be then transported to their
    physicians and monitored.
        So what do we need to do to make sure that we're getting
    flexibility in what's being covered in telemedicine?
        Dr. Henderson. So I think that any restriction based on
    geographic location is limiting the vision and impact that we
    could have for telehealth. I think we are still just scratching
    the surface on the possibilities here. When you think of what
    the health care team is going to be ultimately made of, right
    now it's physicians and nurses in a traditional model and a
    clinic, but when you start thinking about community health
    advocates and paramedics and all the other people that are part
    of the team that are working in a different area, now we're
    going to be able to connect all those.
        So I think we've got to think really big and try to be as
    forward-thinking as possible when we're writing the
    reimbursement legislation to be able to have the full impact.
        Senator Cantwell. Anybody else?
        Dr. Gibbons. Yes, I would agree. I think it's clear, as Dr.
    Henderson has said, as we move forward that things are changing
    precipitously. Patients rely on many things to achieve their
    health goals, certainly doctors and hospitals, but also
    pharmacists, caregivers, and health workers of a variety of
    kinds. And as we go forward, we need to also think about
    connecting patients to those things. As I tell my medical
    students, ``How effective is the best medication in the world
    if the patient can't take it?''
        So I think it's absolutely imperative that we work on the
    things that we've talked about today, but not to stop there, to
    think about, as Wayne Gretzky, the great hockey player said,
    the key to succeeding is skating to where the puck is going,
    not where it is. So thinking about what health care is going to
    look like tomorrow and producing legislation today that will
    enable that innovation to flourish.
        Senator Cantwell. And what about broadband deployment,
    then, and Lifeline, things of that nature that help us get
    there? Because the central part of my state is a big part of
    our agricultural economy, and yet it's very spread out. It
    would take you many hours to drive from one end to the other,
    just in the central part. So our health care providers there
    have done, more or less, satellite health care facilities
    throughout that region, and so they need telemedicine to
    continue to provide that care, as opposed to building a
    hospital in every single community.
        Dr. Gibbons. Well, we found already in our outreach efforts
    that you're absolutely right. In addition, multiple options are
    available. A one-size-fits-all for providers or for patients is
    not likely to work for everybody. There are kiosk-based
    approaches where you can go into a thing, the door closes
    behind you, you have a telemedicine visit there. Some of them
    are very advanced. They even give you your medicines right
    there. So there's no physical person. It could be located, some
    of them, even outside. They don't even have to be in a
    building.
        So there's a whole variety of tools. But you're absolutely
    right in the central problem.
        Senator Cantwell. Well, we've had great success with the
    prescription drug model of having--since we've had pharmacy
    shortages and pharmacist shortages, so basically having a
    provider then work with telemedicine to actually prescribe when
    the dispensary could be more regionally located, and then
    people can get access to that medicine.
        So that's worked very well in the Pacific Northwest, and we
    want to continue the model. We think there's a lot more to do
    here. But that basis of the rural delivery system, which is
    what is needed now, as you were saying, Dr. Gibbons, is a
    precursor to what you can get done with what we're going to see
    with Baby Boomer retirees who we don't really want to go on
    Medicaid. We want them to stay in their homes, and we want to
    get as much health care delivered that way, and information, so
    that all of that is reducing cost in the long run. So I think
    we're going to have to look at the reimbursement model on this.
        Thank you, Mr. Chairman.
        Senator Wicker. Thank you, Senator Cantwell.
        Senator Klobuchar, you are recognized, and because Senator
    Schatz and I have other appointments that we must attend, I'm
    going to allow you to close out the hearing.
        Senator Klobuchar. OK. You're so kind, Senator Wicker.
        Senator Wicker. I want to thank the panelists for a very,
    very fine discussion.
        Senator Klobuchar?

                   STATEMENT OF HON. AMY KLOBUCHAR,
                      U.S. SENATOR FROM MINNESOTA

        Senator Klobuchar [presiding]. Well, thank you so much, and
    I apologize for being late. I was at the Agriculture Committee
    on Cuba, and I'm carrying that bill to lift the embargo, so I
    had to be there, and we had a successful negotiation today on
    the sex trafficking bill that we were working on. But I really
    did want to stop by because of the importance of this issue,
    and I'm going to get right to the work that Senator Thune and I
    have done together.
        We've introduced legislation in the past and incentivized
    home health agencies to use remote patient monitoring
    technologies, and I am encouraged that the sustainable growth
    rate repeal bill that was signed into law last week includes a
    study on the potential benefits of this kind of remote patient
    monitoring, and I look forward to continuing to work with
    Senator Thune on the issue.
        Mr. Rytting, Panasonic recently conducted a study on the
    efficacy of your SmartCare Remote Patient Monitoring
    technology. You mentioned that the study found an impressive
    reduction in hospital admissions and in ER visits. What was the
    reaction of patients and providers to this kind of home
    monitoring system? I mean, it's kind of something new for
    people to get used to. Talk to me about that, because we just
    see a lot of potential with this.
        Mr. Rytting. We think there's tremendous potential with it.
    We approached this project with the health care providers as
    partners and as co-participants in this study, and that's the
    model we want to use as we expand it into other areas that,
    before you came, we were talking about, starting larger pilots
    in other cities, including Senator Booker's Newark, which he
    was happy with.
        Senator Klobuchar. He's always happy when you bring up
    Newark.
        Mr. Rytting. Of course.
        Senator Klobuchar. Like you didn't plan that.
        [Laughter.]
        Mr. Rytting. Well, our headquarters is there.
        Senator Klobuchar. Oh, OK.
        Mr. Rytting. So it worked out.
        We worked in conjunction with the care providers. In fact,
    as I explained, we used the TV as the primary interface to the
    people because that's what they know and what they're familiar
    with, and it's an accessible technology. The questions that
    came on the screen to give an indicator to the remote health
    care professional on what's happening with this person--are
    they feeling better, are they taking their medication--that
    they responded to were composed by the health care
    professionals, not us. We're engineers and they're the experts
    on that. We are using some of their intellectual property,
    which is their experience and know-how and what kinds of
    questions they would ask if they were sitting there, and they
    were able to cast that into a remote setting.
        It was surprising that the patients didn't really feel much
    of a disruption because, again, the primary interface was the
    television. We brought some additional equipment into their
    homes: a bathroom scale, a blood pressure monitor, showed them
    how to use them, but they were not responsible for sending
    information. We did that all automatically.
        One of the findings of the study, besides the reduction in
    ER revisits and hospital readmissions, was a surprising high
    rate of participation. Usually in studies like this, I was told
    that you can expect maybe--you can correct me if I'm wrong, but
    in the 60, 70, 80 percent range. I don't know if that's about
    the average. But we were in the 95 percent range.
        Senator Klobuchar. Wow. OK.
        Mr. Rytting. Again, we credit that toward--I don't think we
    fully understood how good of a selection we made going into it.
        Senator Klobuchar. Exactly.
        Mr. Rytting. But casting the technology behind something
    that they were familiar with.
        The last comment I would make is we have other senior care
    initiatives as part of our portfolio that we're working on. One
    of them is this tablet I have in front of me that's for early
    onset Alzheimer's. Again, we're trying to make things very
    simple, very easy to use for that population, because they get
    scared off pretty easily. In this case, it worked out really
    well.
        Senator Klobuchar. Well, thank you. I hope we continue
    working on that, so thank you very much.
        Dr. Henderson, the Minnesota state legislature is currently
    debating a bill that would require health insurance to pay for
    remote consultations, the same way they do for in-person
    visits, and the bill would greatly expand telemedicine and
    allow for patients in rural and underserved areas to better
    manage their health. As you can imagine, in Minnesota we have
    the Mayo system. They do a lot of that, going back into their
    own system, but this would also allow to have insurance
    companies pay.
        As you mentioned in your testimony, Mississippi already has
    a law like this, again a rural state. Could you talk about what
    you see as some of the benefits of a law like this?
        Dr. Henderson. It will be the catalyst to open up your
    telehealth program so that you can have the full impact to
    access and improving health care to lower cost. When we did
    that, the concern was, of course, there's going to be fraud and
    abuse and overuse and not going to have any improved health
    outcomes, but we saw quite the contrary. We saw improvements in
    health, we didn't see an increase in cost, and access has
    improved all over our state.
        Senator Klobuchar. Very good. Thank you.
        The last thing I'd ask is that one of the most exciting
    areas in health care right now is the field of precision
    medicine. We have already seen the extraordinary results of
    precision medicine, health care tailored to a person's genes,
    environment, lifestyle can have, for example, in a breakthrough
    drug to treat cystic fibrosis.
        Mr. Linkous, how can telemedicine and other health
    technologies help improve and personalize care?
        Mr. Linkous. Well, as I said earlier, having a technology
    available out there in something like precision medicine is a
    wonderful invention, but it will do no good unless you can get
    it to the patient. I think the one thing that telemedicine
    offers is connectivity to where the people are, to where the
    patient is, because all too often, when you get into something,
    particularly somebody with multiple morbidities, often
    transportation is an issue, and often access to a specialist or
    access to information in this case with personalized medicine
    is a real barrier. It's only through telecommunication networks
    that we can actually use the ideas behind personalized medicine
    or some of the other innovations with automation, for example,
    to actually make a difference in people's lives.
        To do that, we have to change some of the regulatory
    structures that we have both at the Federal level and at the
    state level to enable that technology to move forward.
        Senator Klobuchar. OK. Well, thank you.
        Thank you all.
        Dr. Gibbons, I will ask your question on the record to
    spare you here, about broadband and speeds and things like
    that, because I know it's been a long day for all of you, and
    I've heard you've done a great job, and I want to thank you.
        This is really exciting, and as you can see, there's
    bipartisan support for moving forward in these areas, and
    that's always a good thing. So, thank you.
        The hearing is adjourned and the record is going to stay
    open for two weeks. I thought I could play a joke on Senator
    Thune and say two months or something like that, but no.
        [Laughter.]
        Senator Klobuchar. Even though I'm holding the gavel, I
    will keep with the rules and say 2 weeks.
        Thank you, everyone.
        [Whereupon, at 11:48 a.m., the hearing was adjourned.]

                                A P P E N D I X

     Statement of Dr. Kristi Henderson, DNP, NP-BC, FAEN, Chief Telehealth
        and Innovation Officer, University of Mississippi Medical Center
        Chairman Thune, Chairman Wicker, Ranking Members Nelson and Schatz,
    thank you for the opportunity to testify at the recent hearing,
    ``Advancing Telehealth Through Connectivity.'' It was an honor to speak
    about our program at the University of Mississippi Medical Center
    (UMMC) Center for Telehealth and participate in the important dialogue
    about how telehealth can increase access to care, decrease costs and
    improve the quality of care.c
        To address several questions raised during the hearing, I am
    providing the following submission for the record. In this document, I
    outline the need for the telehealth solution for mental health, share
    relevant telehealth cost savings and patient satisfaction reports and
    reinforce that none of our progress and success would be possible
    without the necessary connectivity.
    Mental Health
    The Situation
        Mental health in America suffers from high demand without the
    available providers to meet the demand. According to the National
    Institute of Mental Health, 18.6 percent of all adults in the U.S. have
    been diagnosed with Any Mental Illness (AMI),\1\ and 4.1 percent of
    U.S. adults suffer from Serious Mental Illness (SMI).\2\ Children also
    need access to mental health care, as over 46 percent of children in
    America ages 13-to 18-years-old have a lifetime prevalence of mental
    illness. Even more concerning is that more than 20 percent of children
    suffer from a severe mental disorder.\3\
    ---------------------------------------------------------------------------
        \1\ Any Mental Illness (AMI) Among Adults. (2012). National
    Institute of Mental Health. Retrieved May 2, 2015, from http://
    www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-
    among-adults.shtml
        \2\ Serious Mental Illness (SMI) Among U.S. Adults. (2012).
    National Institute of Mental Health. Retrieved May 2, 2015, from http:/
    /www.nimh.nih.gov/health/statistics/prevalence/serious-mental-illness-
    smi-among-us-adults.shtml
        \3\ Any Disorder Among Children. (2012). National Institute of
    Mental Health. Retrieved May 2, 2015, from http://www.nimh.nih.gov/
    health/statistics/prevalence/any-disorder-among-children.shtml
    ---------------------------------------------------------------------------
        The situation is the same in Mississippi, as well. According to
    data from Mental Health America, the Nation's leading association for
    mental health advocacy, 20.27 percent of Mississippians suffer from
    AMI.\4\ Additionally, Mississippi ranks among the five worst states
    overall for ``highest prevalence of mental illness and lowest rates of
    access to care.'' \5\ This statistic holds true when individually
    assessing adult and youth mental health care in the state--Mississippi
    ranks 42 in the Nation for high rates of youth mental illness with low
    access to services and 51 in the country for the same indicator in
    adult care.\6\
    ---------------------------------------------------------------------------
        \4\ Parity or Disparity: The State of Mental Health in America
    2015. (2015). Mental Health America. Retrieved May 2, 2015, from http:/
    /www.mentalhealthamerica.net/sites/default/files/Parity or Disparity
    2015 Report.pdf
        \5\ Ibid.
        \6\ Ibid.
    ---------------------------------------------------------------------------
        This data reinforces the great need for mental health care to treat
    these patients. However, according to a September 2014 report from the
    Health Resources and Services Administration (HRSA), nearly 96.5
    million Americans live in areas that are underserved by mental health
    providers.\7\ Likewise, Mississippians lack access to mental health
    care, as the state ranks 50 nationally for access to mental health care
    and 46 for mental health workforce availability.\8\
    ---------------------------------------------------------------------------
        \7\ Radnofsky, L. (2015, February 16). Where Are the Mental-Health
    Providers? The Wall Street Journal. Retrieved May 2, 2015, from http://
    www.wsj.com/articles/where-are-the-mental-health-providers-1424145646
        \8\ Parity or Disparity: The State of Mental Health in America
    2015. (2015). Mental Health America. Retrieved May 2, 2015, from http:/
    /www.mentalhealthamerica.net/sites/default/files/Parity or Disparity
    2015 Report.pdf
    ---------------------------------------------------------------------------
    The Telehealth Solution
        With this pervasiveness of mental health care need and poor access
    to care, hospitals, community mental health clinics and others are
    seeking innovative solutions to meet the demands they have for mental
    health care services. At the UMMC Center for Telehealth, the request
    that we receive most frequently across the state is for TelePsychiatry
    services. To this end, the Center for Telehealth has established
    strategic partnerships to help cover gaps in care. An example of one of
    our groundbreaking telehealth partnerships is with one of Mississippi's
    leading universities.
        This university needed a way to connect its students with mental
    health services outside of the university counseling center. Therefore,
    we established a TelePsychiatry clinic in the Student Health Center--a
    location on campus where students receive their primary healthcare
    services. Therefore, students who need mental health care can obtain it
    in a location where no one has to know the type of care they are
    receiving--there is no stigma for these students to have an appointment
    at the Student Health Center, whereas students might be concerned about
    the stigma of walking into the university counseling center. A UMMC
    psychiatrist connects to the university's Student Health Center via a
    simple technology solution and provides the consults using telehealth.
        The initial agreement with the university was for two half-days of
    coverage per week for TelePsychiatry. However, after the program proved
    to be valuable in meeting the students' needs and covering gaps in
    care, the university increased its utilization of the program to three
    half-days each week. The program has been successful at treating
    students and providing interventional care when and where students need
    it most.
    Opportunities for the Future
        As we continue to grow our telehealth program and are able to reach
    all corners of Mississippi, access to mental health will be available
    to all Mississippians locally--in their hometowns--when and where they
    need it. Students, not only in college, but also in grades K-12 will
    receive needed primary and mental health services, including ADD and
    ADHD diagnoses and treatment, at their schools via school-based
    telehealth. Every hospital and community mental health clinic in the
    state will have access to a mental health provider using the telehealth
    solution.
        This vision could become reality in the short term, as I have been
    approached recently about assisting the Mississippi Psychiatric
    Association with establishing a true statewide solution to the mental
    health crisis in the state. Through this program, the UMMC Center for
    Telehealth would partner with the Mississippi Psychiatric Association
    and use the Association's physicians to create a mental health network
    statewide. As this mental health network continues to be developed and
    implemented, it could become a model that is scaled and replicated in
    states across the country to help meet demands for care.
        These opportunities are within our grasp, but this access to care
    will not be available without the needed connectivity, particularly in
    rural parts of our state. As you consider the programs under your
    purview, including the Universal Service Fund (USF) and other funding
    programs, please know how valuable they are to the work we are doing to
    cover gaps in healthcare, including much-needed mental health services.
    Cost Savings and Patient Satisfaction
    Veterans Health Administration
        The Veterans Health Administration (VHA) has implemented a
    comprehensive telehealth program for its patients and has established
    the Office of Telehealth Services (OTS) to coordinate this care. Within
    OTS, the VHA has focused on providing treatment for chronic diseases
    utilizing a home telehealth and remote patient monitoring program;
    enabled access to 45 medical specialties via video telehealth
    connections; and provided store-and-forward telehealth services for
    review of medical imaging. In Fiscal Year 2013, the VHA connected
    608,900 of its patients to healthcare services via telehealth.\9\
    Additionally, 45 percent of these patients were located in rural areas
    \10\ and would not have had access to these services or advanced care
    without the telehealth solution.
    ---------------------------------------------------------------------------
        \9\ Darkins, A. (2013). Telehealth Services in the United States
    Department of Veterans Affairs. Retrieved May 2, 2015, from http://
    c.ymcdn.com/sites/www.hisa.org.au/resource/resmgr/telehealth2014/Adam-
    Darkins.pdf
        \10\ Ibid.
    ---------------------------------------------------------------------------
        The cost savings and improved outcomes achieved by the VHA's
    telehealth program have been dramatic. In FY 2013, the home telehealth
    program reduced bed days of care by 59 percent and decreased hospital
    admissions by 35 percent. The clinical video telehealth program reduced
    mental health patients' bed days of care by 38 percent.\11\
    ---------------------------------------------------------------------------
        \11\ Ibid.
    ---------------------------------------------------------------------------
        Cost savings also were achieved through VHA telehealth by avoiding
    travel expenses for medical consultations. The clinical video
    telehealth program saved $34.45 per consultation, and store and forward
    telehealth saved $38.81 per consultation. The VHA's home telehealth
    program also saved $1,999 per patient per year.\12\
    ---------------------------------------------------------------------------
        \12\ Ibid.
    ---------------------------------------------------------------------------
        VHA patients indicated significant levels of satisfaction with the
    telehealth program. This includes mean satisfaction rates of 84 percent
    for the home telehealth program, 95 percent for store-and-forward
    telehealth, and 94 percent for clinical video telehealth.\13\
    ---------------------------------------------------------------------------
        \13\ Ibid.
    ---------------------------------------------------------------------------
    The UMMC Center for Telehealth
        Like the VHA, programs at the UMMC Center for Telehealth have shown
    improved health outcomes and cost savings in Mississippi. To date, the
    UMMC TelEmergency program, which connects the emergency department of
    the academic medical center to 15 emergency departments throughout
    Mississippi, has increased local hospital admissions by 20 percent,
    avoiding unnecessary emergency department transfers. Additionally, in a
    study of the first 9 TelEmergency sites, the program reduced emergency
    department staffing costs by 25 percent. Patients have expressed high
    levels of satisfaction with the TelEmergency program, as health
    outcomes are on par with those of patients who receive in-person care
    at the academic medical center.
        The Center for Telehealth's corporate telehealth program provides
    access to primary care in the workplace for a company's employees. A
    UMMC nurse practitioner connects to patients via video in the workplace
    clinic or designated space. Companies utilizing telehealth for their
    employees are saving, on average, $324 per employee per year--this
    savings encompasses the cost of care, as well as the expenses of
    employee absenteeism. Within the first seven months of implementation
    of the corporate telehealth program, results showed $14,100 in total
    savings. Additionally, patients have been pleased with the quality of
    care and the technology solution that enables their treatment in the
    corporate telehealth program. Recent reports indicate that greater than
    86 percent of patients strongly agree that they were satisfied with
    their telemedicine encounters via corporate telehealth, and
    approximately 50 percent said they would have missed work that day had
    it not been for the workplace telehealth program.
        As chronic diseases in Mississippi cost the state approximately $4
    billion in 2010, remote patient monitoring of patients with chronic
    diseases offers a valuable opportunity to improve health outcomes and,
    thus, reduce healthcare costs. Projections indicate that the state will
    save approximately $125 million each year with the use of remote
    patient monitoring. UMMC currently is ramping up this program to
    include monitoring for patients across the state. Already in UMMC's
    remote patient monitoring program of uncontrolled diabetics in the
    Mississippi Delta, patients have reduced their A1C levels by an average
    of nearly 2 percent. Additionally, patients are being empowered to
    improve their health and indicate that they are being educated on how
    to handle their diabetes unlike ever before.
    The Importance of the Connectivity
        Without the necessary connectivity, none of this access to care via
    telemedicine would be possible. Most of the UMMC Center for
    Telehealth's sites across the state are located in rural areas. USF has
    been crucial to enabling these communities to have the appropriate
    connectivity for telehealth, and we appreciate the subcommittee's
    commitment to supporting rural broadband development for healthcare and
    other requests.
        Once this needed broadband infrastructure is in place, the network
    can be used to enable even greater coordination of care via the Health
    Information Exchange (HIE), Electronic Medical Records (EMR) and other
    applications. Ultimately, the more we are connected with the needed
    Internet access, the more we will be able to use the network to improve
    health outcomes.
        I hope that the subcommittee will continue this important dialogue
    about enabling telehealth through sustained support of the necessary
    connectivity. I welcome the opportunity to answer any questions about
    the connectivity, UMMC's telehealth program, and its value in
    Mississippi.
                                     ______

                                  Healthcare Leadership Council
                                                            May 5, 2015

    Senate Commerce, Science, and Transportation Committee,
    Subcommittee on Communications, Technology, Innovation, and the
                Internet
    Washington, DC.

       Re: Statement for the Record for ``Advancing Telehealth
                                 Through Connectivity'' Hearing

    Dear Chairman Wicker and Ranking Member Schatz:

        Thank you for your leadership on the advancement of telehealth. We
    appreciate your recent hearing on the topic as well as the opportunity
    to submit a statement for the record.
        HLC is a not-for-profit membership organization comprised of chief
    executives of the Nation's leading healthcare companies and
    organizations. HLC's membership has seen firsthand that telehealth is
    an important tool to make the workforce as efficient, effective and
    patient-centric as possible. Telehealth acts as a force-multiplier,
    extending the ability of the current healthcare workforce to meet
    patient needs (e.g., in underserved areas); and can elevate quality by
    reaching individuals more effectively (e.g., improving patient
    adherence, providing interpretation services for those with language
    barriers), all at a lower cost than services performed in traditional
    settings. HLC strongly supports the timely advancement of policies
    designed to create a firm foundation for telehealth technology, which
    includes expanding access to broadband.
        Attached for your reference are HLC's Workforce Principles, which
    outline our multisector, consensus principles to strengthen the
    healthcare workforce in order to meet the demands of an innovative
    healthcare system, dramatically changing patient demographics, and an
    increased focus on the prevention and management of chronic diseases.
    These principles identify telehealth as a top priority to equip
    healthcare providers with the tools needed to ensure they can meet
    these challenges.
        HLC believes that telehealth legislation and regulation should be
    flexible enough so that new and innovative technologies do not face
    barriers from outdated frameworks. Additionally, HLC supports
    reexamining restrictive reimbursement and regulatory provisions that
    make it challenging to use telehealth across state lines and for
    qualified nonphysicians to be paid for care provided in a telehealth
    setting.
        We were pleased to hear the Committee express bipartisan support
    for the need to address reimbursement and licensure to enable
    telehealth expansion. Our comments below are specific to those areas of
    focus and concern of members of the Committee and witnesses.
    Expanded Reimbursement and Licensure
        As you know, changes to the current telehealth payment structures
    and requirements are urgently needed to increase access to these
    services. We support waiving current ``1834(m) restrictions'' on
    originating site, geography, and type of eligible provider. By opening
    up telehealth services beyond the current narrowly-drawn boundaries,
    more patients will be able to access important, quality health
    services. We also advocate expanding the list of qualifying telehealth
    services to address patient needs that are unmet because of geography
    or other access barriers, reduce readmissions or other costly services,
    substitute for an in-person visit, or allow patients to be moved to a
    lower level of care (including home care). Further, HLC supports
    expanding reimbursement to ensure that the appropriate providers can be
    reimbursed for those services (consistent with state scope of practice
    laws). Finally, HLC supports setting payment rates based not on the way
    the service is delivered (i.e., in person or via telehealth
    technology), but the quality of the service. This echoes the consistent
    focus of Congress and the Administration to focus increasingly on
    outcomes rather than on process. Payment should support and allow for
    constantly changing and improving technologies.
        HLC members have seen significant cost savings from telehealth
    implementation, and these savings are cited in many rigorous studies.
    The Centers for Medicare and Medicaid Services (CMS) has acknowledged
    the value and increased usage of telehealth. We fully understand
    Congress' need to protect the taxpayer dollar, but the evidence shows
    telehealth can be seen as a cost saver instead of a cost driver.
        Finally, HLC members support changing licensure requirements in a
    way that allow practitioners (including nonphysician providers) to
    practice across state lines. This change will support the way care is
    increasingly delivered and will promote better quality and efficiency.
        Thank you again for your leadership in convening this hearing and
    for advocating an increased use of telehealth technology. We look
    forward to working with you further. If you have any questions, please
    do not hesitate to contact Debbie Witchey at dwitchey@hlc.org.
                Sincerely,
                                                Mary R. Grealy,
                                                             President.
    Cc:
    Senate Commerce, Science, and Transportation Committee Chairman Thune
    Senate Commerce, Science, and Transportation Committee Ranking Member
    Nelson
    Enclosure
                                     ______

                            HLC Workforce Principles
    Overview
        Innovation in healthcare is not limited to medicines or devices; it
    includes the way in which care is delivered. With the implementation of
    the Patient Protection and Affordable Care Act (PPACA) and the changing
    demographics in this country, the way healthcare is delivered and the
    workforce required to do so will need to change in response. The
    Healthcare Leadership Council (HLC) views the healthcare workforce from
    a unique, multisectoral perspective that reinforces HLC member efforts
    to promote value and quality and highlights the changing healthcare
    delivery system.
        HLC developed these Workforce Principles to guide HLC's activity
    and strategy in addressing healthcare workforce challenges. These
    principles may also guide Federal and state policymakers as they draft
    legislation and regulations that affect the healthcare workforce.
    Overarching Goals
        HLC members believe that any steps taken to address existing and
    future healthcare workforce challenges should (1) look to the future
    needs and structures of the healthcare system; and (2) support a
    healthcare system based on quality and value.
        Build the Future Healthcare System. As the healthcare system
    changes, so too must the healthcare workforce. Public and private
    efforts to develop and strengthen the healthcare workforce must be
    constructed in a way that encourages the healthcare delivery system to
    lower costs and improve outcomes. HLC believes that workforce policies
    geared toward the goals of the future rather than the current system
    will produce a shift toward improved quality in healthcare and create a
    workforce ready to address critical needs.
        Promote Quality and Value. The existing workforce must also
    transform to reflect the changing healthcare landscape. Efforts to
    improve and strengthen the healthcare workforce must move the system
    from volume-based, episodic care to value-driven, team-based, quality
    care that incorporates prevention and other important health
    determinants. HLC believes that we must realign the current workforce
    to better promote quality and value.
    Key Strategies
    1. Ensure a Sufficient Healthcare Workforce

       All sectors of American healthcare are or will be affected
            by a shortage of specialists, physicians, nurses, skilled
            scientists, pharmacists, and/or allied health workers that
            provide the expertise and personnel to treat an increasingly
            diverse, aging, and chronic disease-ridden population. This has
            an effect throughout the healthcare system, including
            healthcare coverage and the ability to treat patients, as well
            as the cost of healthcare.

       In particular, the physician workforce is hampered by
            policies and payment systems that have resulted in a shortage
            of physicians in certain disciplines and geographic areas, and
            at financially strained academic medical centers serving the
            sickest and most vulnerable patients. Graduate Medical
            Education (GME), funded under the Medicare program, has not
            been updated for more than 15 years, and misaligned payment
            systems discourage individuals from pursuing careers in key
            specialties or geographic areas, while an aging population
            combined with increased access to insurance coverage through
            healthcare reform has and will continue to strain the system.

       The healthcare workforce pipeline for all sectors of
            healthcare begins with STEM (science, technology, engineering,
            and math) education. Increased STEM education is needed at all
            levels of education to train and retain the workers needed to
            fill more traditional healthcare jobs, as well as geneticists,
            engineers, and people who are able to interpret the large
            amounts of data produced in healthcare. A shortage in graduates
            with a STEM educational background has made it difficult for
            some healthcare companies to hire qualified workers for high-
            paying positions in the U.S. A well-educated, qualified
            workforce is essential to research, innovation, and patient
            care.

       HLC believes that an emphasis on STEM education should be
            integrated into Federal policies. The Federal Government has
            many areas of influence that should be used to promote STEM
            skills, including immigration policies, policies to drive
            innovation, Federal and state spending priorities, and
            education policies affecting elementary, secondary, and
            postsecondary students.

       HLC believes we need dramatic reform of how physicians are
            trained and paid. Payment policies should be sufficient to
            cover the full cost of direct and indirect medical education in
            the clinical setting, be better aligned to meet geographic
            needs, and be more efficiently allocated to meet evolving
            patient demand. Payment should be sufficient enough to support
            education and bring enough workers into the system.
    2. Support Nonphysician Providers

       Nonphysician providers such as nurse practitioners, nurse
            assistants, community-based providers, pharmacists, and trained
            health educators are an integral part of the healthcare
            delivery system. Health services provided by nonphysician
            providers are an important way for the current healthcare
            system to be more productive and efficient because the services
            they provide are often lower cost to the patient and supplement
            the care given in a traditional healthcare setting.
            Additionally, providers of this type are critical to the
            development of team-based care.

       HLC believes that, in order to meet the needs of a growing
            and aging population, we need dramatic reform of how the
            healthcare workforce incorporates nonphysician providers.
            Nonphysician providers should be allowed to deliver the care
            that they are trained to provide in collaboration with health
            teams. Reimbursement and regulatory gaps or barriers should be
            addressed so this type of care is accessible by more patients.
    3. Promote and Enhance Tools That Support a More Efficient Healthcare
            Workforce

       In order to make the workforce as efficient, effective, and
            patient-centric as possible, providers from all sectors must
            utilize tools to reach, treat, and engage patients. Telehealth
            is an important component of these tools. Telehealth:

         Acts as a force-multiplier, extending the ability of
                the current healthcare workforce to meet patient needs
                (e.g., in underserved areas);

         Can elevate quality by reaching individuals more
                effectively (e.g., locating noncompliant patients or
                providing interpretation services for those with language
                barriers); and

         Supports improved workforce training and development
                (e.g., using telehealth to train or retrain workers and
                allowing workers to interact with each other via
                telehealth).

       HLC believes that telehealth legislation and regulation
            should be flexible enough so that new and innovative
            technologies do not face disincentives from outdated
            frameworks. Additionally, HLC supports reexamining restrictive
            reimbursement and regulatory barriers that make it challenging
            to use telehealth across state lines and for qualified
            nonphysicians to be paid for care provided in a telehealth
            setting.
                                     ______

                 Statement of the American Hospital Association
        On behalf of our nearly 5,000 member hospitals, health systems and
    other health care organizations, and our 43,000 individual members, the
    American Hospital Association (AHA) appreciates the opportunity to
    comment for the record in support of advancing the use of telehealth to
    improve access to health care services.
        Telehealth increasingly is vital to our health care delivery
    system, enabling health care providers to connect with patients and
    consulting practitioners across vast distances. Hospitals are embracing
    the use of telehealth technologies because they offer benefits such as
    virtual consultations with distant specialists, the ability to perform
    high-tech monitoring without requiring patients to leave their homes,
    and less expensive and more convenient care options for patients.
    According to AHA survey data, in 2013, 52 percent of hospitals used
    telehealth and another 10 percent were beginning the process of
    implementing telehealth services.\1\
    ---------------------------------------------------------------------------
        \1\ AHA Annual Survey, Health Information Technology Supplement
    (2013).
    ---------------------------------------------------------------------------
        Telehealth offers significant promise for health care patients and
    providers, yet significant barriers to expansion remain, greatly
    limiting health care access for many patients. The AHA applauds the
    Committee for its interest in advancing the use of telemedicine, and we
    look forward to working with its members to achieve that goal. Below we
    outline the different types of telehealth modalities, examples of how
    telehealth is used to provide care and, finally, current obstacles and
    proposed solutions for the Committee to consider as it develops
    legislation. We specifically urge the Committee to consider the
    limitations of Medicare payment on services delivered via telehealth
    and expand support for broadband access for health care providers under
    the Health Care Connect Fund administered by the Federal Communications
    Commission (FCC).
    The Three Traditional Modalities of Telehealth
        Telehealth traditionally encompasses three main modalities, each
    with distinct applications within the broader telehealth industry.
        One telehealth modality is ``real-time,'' a live, two-way
    interaction between a patient (or the patient's caregiver) and a health
    care provider using audiovisual technology. Real-time telehealth
    services can be used to consult, diagnose and treat patients.
        Another telehealth modality is ``store-and-forward,'' which
    involves the transmission of a patient's recorded health history (e.g.,
    pre-recorded videos or digital images such as X-rays and photos)
    through a secure electronic communications system to a health care
    provider, usually a specialist. The information is used to evaluate a
    patient's case or, in some cases, render a service outside of a real-
    time interaction. Store-and-forward technologies have the advantage of
    providing access to patient data after it has been collected, and are
    particularly beneficial to patients requiring specialty care when
    providers are not otherwise available locally.
        A third telehealth modality, ``remote patient monitoring,''
    involves collection of a patient's personal health and medical data via
    electronic communication technologies. Once collected, the data is
    transmitted to a health care provider at a different location, allowing
    the provider to continue tracking the patient's data once the patient
    has been released to his or her home or another care facility.
        In addition to these traditional telehealth modalities, a growing
    number of mobile health, or ``mHealth'' technologies, applications and
    online services are being sold directly to patients, such as wearable
    devices to track health and wellness. The market for wearable devices
    is expected to increase from $1.5 billion in 2014 to $6 billion by
    2016. \2\ Patients will be able to benefit from tools such as wearable
    electrocardiogram (EKG) monitors, which deliver readings to a treating
    physician.\3\
    ---------------------------------------------------------------------------
        \2\ NTT Data, Trends in Telehealth (2014), available at: http://
    americas.nttdata.com/Industries/Industries/Healthcare//media/
    Documents/White-Papers/Trends-in-Telehealth-White-Paper.pdf.
        \3\ NTT Data, Trends in Telehealth (2014), available at: http://
    americas.nttdata.com/Industries/Industries/Healthcare//media/
    Documents/White-Papers/Trends-in-Telehealth-White-Paper.pdf.
    ---------------------------------------------------------------------------
        Increasingly, information from these devices and applications will
    become linked to the health information managed by providers. For
    example, Apple is marketing its Health app to patients, allowing them
    to aggregate personal health information on their Apple devices and
    link those data to mobile health applications that work with the Apple
    platform through HealthKit. At the same time, Apple is partnering with
    providers and electronic health record (EHR) companies to determine how
    the tool can be used in health care settings.
        Similarly, mobile platforms, such as smartphones, will likely
    become a more significant part of the telehealth platform over time.\4\
    Easy access to smartphones, tablets and other devices is a critical
    component enabling patients to more fully embrace mHealth applications.
    Between 2011 and 2016, the number of Americans with smartphones is
    expected to grow two-fold from 93.1 million to 192.4 million.\5\
    ---------------------------------------------------------------------------
        \4\ Akanksha Jayanthi. The Rise of mHealth: 10 Trends. Becker's
    Health IT and CIO Review (June 27, 2014), available at: http://
    www.beckershospitalreview.com/healthcareinformation-technology/the-
    rise-of-mhealth-10-trends.html.
        \5\ NTT Data, Trends in Telehealth (2014), available at: http://
    americas.nttdata.com/Industries/Industries/Healthcare//media/
    Documents/White-Papers/Trends-in-Telehealth-White-Paper.pdf.
    ---------------------------------------------------------------------------
    Applications of Telehealth by Hospitals and Health Systems
        Hospitals can provide the base from which telehealth services are
    offered, thereby expanding access to care for a wider population. Some
    examples of hospital-based platforms include telestroke, tele-ICU,
    cybersurgery and remote monitoring.
    Improving Access to Health Care and Convenience for Patients
        Approximately 20 percent of Americans live in rural areas where
    many do not have easy access to primary care or specialist services.
    Patients in urban areas also face challenges due to physician
    shortages. The availability of telehealth services to these areas
    facilitates greater access to care by eliminating the need to travel
    long distances to see a qualified health care provider. Telehealth also
    can fill gaps in subspecialist care. Telepharmacy is another way to
    offer patients the convenience of remote drug therapy monitoring,
    authorization for prescriptions, patient counseling and monitoring
    patients' compliance with prescriptions. With a nationwide shortage of
    psychiatrists, telepsychiatry allows psychiatrists to use
    videoconferencing to speak to and evaluate patients in need of mental
    health services, who may otherwise have to drive hours to see mental
    health providers.
        Rural and critical access hospitals (CAHs) often are in need of
    critical care clinicians to diagnose, manage, stabilize and make
    transfer decisions concerning their most complex patients, and can use
    telehealth to connect to those services. Telestroke programs can
    expedite delivery of time-sensitive treatments to patients who present
    to emergency rooms that lack needed specialists, saving lives and
    reducing the adverse consequences of stroke. Tele-ICU programs can help
    hospitals supplement clinician staffing of their ICU beds.
        In addition to improving access, patients are increasingly
    expecting levels of convenience in health care similar to what is
    available in the retail and banking sectors.\6\ Telehealth, regardless
    of geographic location, can foster a patient's ability to connect with
    a primary care physician or health system on a more flexible basis and
    often without an in-person visit. Patients are able to receive services
    at a distance by using secure online video services or through secure
    e-mail, often with the added benefit of reducing travel to health care
    facilities.
    ---------------------------------------------------------------------------
        \6\ PricewaterhouseCoopers Health Research Institute. New Health
    Economy (2014).
    ---------------------------------------------------------------------------
    Improving Quality of Care and Patient Satisfaction
        There is a growing body of research illustrating that the use of
    telehealth can significantly improve the quality of patient care.
    Research conducted in 2013 on nearly 120,000 adult patients from 56
    ICUs in 32 hospitals belonging to 19 U.S. health-care systems concluded
    that ICU telehealth interventions, especially those that increase early
    intensivist case involvement, improve adherence to ICU best practices,
    reduce response times to alarms and encourage the use of performance
    data. In addition, the overall effects of ICU telemedicine programs
    were associated with better survival rates for patients and reduced
    hospital lengths of stay. \7\ Significant improvements in the quality
    of care for seriously ill and injured children treated in remote rural
    EDs also were achieved by using telehealth consultations with pediatric
    critical care medicine physicians at the University of California,
    Davis Children's Hospital. \8\
    ---------------------------------------------------------------------------
        \7\ Craig M. Lilly, M.D., FCCP et al., A Multicenter Study of ICU
    Telemedicine Reengineering of Adult Critical Care, CHEST 145(3): 500-
    507 (2014), article abstract available at: http://
    journal.publications.chestnet.org/article.aspx?articleID=1788059.
        \8\ Madan Dhamar, et al, Impact of Critical Care Telemedicine
    Consultations on Children in Rural Emergency Departments, CRITICAL CARE
    MEDICINE (2013).
    ---------------------------------------------------------------------------
        For several years, the Veterans Health Administration (VHA) has
    used telehealth for home health monitoring to track vital signs and
    conditions for patients with chronic diseases or who have been released
    recently from the hospital. Adam Darkins, former chief consultant for
    telehealth services for the VHA, reported that telehealth services in
    its post-cardiac arrest care program resulted in a 51 percent reduction
    in hospital readmissions for heart failure and a 44 percent reduction
    in readmission for other illnesses. In addition to improved patient
    care, veterans reported patient satisfaction levels of 84 percent for
    the home telehealth services provided through the program. VHA's
    Clinical Video services with real-time video conferencing between VA
    medical centers and VA Community Based Outpatient Clinics also were
    rated highly, with a 94 percent patient satisfaction rate. \9\
    ---------------------------------------------------------------------------
        \9\ Adam Darkins, ``Telehealth Services in the United States
    Department of Veterans Affairs (2014), available at: http://
    c.ymcdn.com/sites/www.hisa.org.au/resource/resmgr/telehealth2014
    /Adam-Darkins.pdf.
    ---------------------------------------------------------------------------
    Barriers to Expanding Telehealth Services
    Coverage and Payment for Telehealth Services
        Few obstacles present greater challenges for providers seeking to
    improve patient care through telehealth technologies than coverage and
    payment for telehealth services. Whether providers are adequately
    reimbursed for telehealth services is a complex and evolving issue and,
    as a result, a possible barrier to adopting such services.
        A baseline question with respect to provider payment for telehealth
    services is whether the payer covers telehealth services at all. On the
    public payer front, inconsistencies exist. For example, Medicare's
    policies for coverage and payment for telehealth services lag far
    behind other payers due to its restrictive statutes and regulations.
    Many state Medicaid programs cover telehealth services to some extent,
    although the criteria for coverage vary widely from state to state. On
    the private payer side, by contrast, there has been significant
    expansion with many states passing laws requiring private payers to
    provide coverage for telehealth services.
    Private Payers
        According to the American Telemedicine Association (ATA), 20 states
    and the District of Columbia have enacted ``parity'' laws, which
    generally require health insurers to cover and pay for services
    provided via telehealth the same way they would for services provided
    in-person. Virginia and New Mexico are two states that have created a
    regulatory environment that encourages the availability and provision
    of telehealth services, including providing telehealth coverage for
    their state employee health plans. Two additional states--Arizona and
    Colorado--have enacted partial parity laws that require coverage of and
    reimbursement for telehealth services. However, coverage is limited to
    a certain geographic area or a predefined list of qualified
    services.\10\
    ---------------------------------------------------------------------------
        \10\ American Telemedicine Association, STATE TELEMEDICINE GAPS
    ANALYSIS: COVERAGE & REIMBURSEMENT, available at: http://
    www.americantelemed.org/docs/default-source/policy/50-state-
    telemedicine-gaps-analysis--coverage-and-reimbursement.pdf?sfvrsn=6.
    ---------------------------------------------------------------------------
    Medicaid
        A 2014 report by the Center for Connected Health Policy noted that
    46 state Medicaid programs, both fee-for-service (FFS) and Medicaid
    managed care, have some form of coverage for telehealth services, such
    as for remote patient monitoring (13 states). Live video is the most
    frequently covered telehealth service, while store-and forward services
    are defined and reimbursed by only a handful of state Medicaid
    programs. State Medicaid programs rarely cover e-mail, telephone and
    fax consultations, unless they are used in conjunction with some other
    type of communication. Twenty-four states pay providers either a
    transmission or a facility fee, or both. A few states have adopted the
    Medicare policy that restricts coverage to only telehealth services
    that are provided in rural or underserved areas.\11\
    ---------------------------------------------------------------------------
        \11\ Center for Connected Health Policy, STATE LAWS AND
    REIMBURSEMENT POLICIES, available at: http://cchpca.org/sites/default/
    files/uploader/50%20STATE%20MEDICAID%20
    REPORT%20SEPT%202014.pdf.
    ---------------------------------------------------------------------------
    Medicare
        Despite recent expansions in covered services, Medicare lags behind
    the private sector and many state Medicaid programs in promoting
    telehealth. For example, at least 20 states across the Nation require
    private payers to pay the same amount for all medical services, whether
    delivered via telehealth or through an in-person encounter. In
    addition, many state Medicaid programs have more progressive policies
    than the Medicare program. Even within Medicare, some Medicare
    Advantage plans are beginning to provide telehealth benefits that are
    not covered under Medicare FFS rules, leaving the 70 percent of those
    utilizing FFS with limited access to these technological advances. In
    order to modernize Medicare coverage and payment for telehealth,
    several statutory restrictions must be addressed, including:

       Eliminating geographic and setting location requirements;

       Expanding the types of covered services (today, Medicare
            pays for only 75 services);

       Simplifying the process to expand the list of covered
            services by type instead of CPT codes; and

       Including store-and-forward and remote patient monitoring as
            covered services.

        The committee can help address some of these issues by expanding
    our Nation's telecommunications infrastructure. This would help
    specifically with:

       Expanding eligible patient location (originating site).
            Telehealth services will be covered only if the beneficiary is
            seen at an originating site listed in law, such as a hospital,
            skilled nursing facility or physician office. As our Nation's
            telecommunications systems continue to improve, it will become
            increasingly possible to safely provide care to patients in
            other settings, including, potentially, the office, school or
            home.

       Expanding approved technologies. Medicare may only cover
            telehealth services that are furnished via a real-time, video-
            and-voice telecommunications system. Outside of Hawaii and
            Alaska, Medicare may not pay for telehealth services provided
            via store-and-forward technologies. And, despite growing
            evidence of the benefits of remote monitoring technologies for
            quality of care and cost savings, they are not included in
            Medicare's telehealth policy.
    Rural Health Care Program and Health Care Connect Fund Limitations
        Subsidy and Usage. The FCC created the Health Care Connect Fund
    (HCCF) as a part of the Rural Health Care Program (RHCP) in 2012 with
    the goal of expanding broadband access for health care providers. The
    AHA urges the Committee to look at these underutilized programs for
    ways to provide a greater benefit to health care providers. The pilot
    program that served as a precursor to the HCCF allowed providers an 85
    percent subsidy level. The HCCF reduced the subsidy amount to 65
    percent. According to a 2010 Government Accountability Office report,
    the RHCP program disbursed $327 million while in operation--well below
    the $400 million yearly cap.\12\ Funds are going unused, while
    providers still struggle to expand their networks. The AHA recommends
    the Committee consider expanding the subsidy to offer reduced cost
    sharing for participating health care providers and to more
    appropriately utilize the HCCF. Reducing the administrative burden of
    participation also would likely increase involvement by providers.
    ---------------------------------------------------------------------------
        \12\ FCC's Performance Management Weaknesses Could Jeopardize
    Proposed Reforms of the Rural Health Care Program, available at: http:/
    /www.gao.gov/new.items/d1127.pdf
    ---------------------------------------------------------------------------
        Limits on Hospitals--Provider Status and Capacity Limits. Current
    program requirements restrict access for certain types of providers.
    For-profit entities are an integral part of the rural health care
    system. For example, 12 percent of rural hospitals are for-profit. The
    program can clearly support additional providers, and we urge the
    Committee to consider ways to expand participation for those for-profit
    entities serving vulnerable populations. The AHA also would support
    lifting the cap on funding for non-rural hospitals with more than 400
    beds that are part of a consortium that is predominantly rural.
    Conclusion
        The AHA and the hospital field appreciate your recognition of
    telehealth as a vital component of the health care system of the
    future. However, implementation has been hampered by operational
    challenges. The implementation and effective use of Internet, mobile
    and video technologies offer hospitals, physician groups and health
    plans ways to improve performance and provide greater convenience and
    value to patients. The Rural Health Care Program, including the Health
    Care Connect Fund, is a critical source of support for health care
    providers. We appreciate the Committee's consideration of proposed
    changes, which would greatly strengthen the program and support the
    advancement of telehealth. These programs need to continue to evolve to
    encourage provider participation through lower administrative burden,
    reduced cost sharing, and better compensation for program
    administration. We urge the Committee to work toward creating a policy
    environment that supports these efforts and accelerates the transition
    to the health care system of the future.
                    Panasonic--A Better Line, A Better World

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

        Response to Written Question Submitted by Hon. Dan Sullivan to
                              Dr. Kristi Henderson
        Question. In Alaska, telehealth is hugely important, as it is the
    primary way many people in rural areas are able to receive healthcare.
    Some of our health facilities have reported interoperability problems
    with telehealth software and electronic health records (EHR) software.
    In addition to the problems caused by this lack of integration, we are
    also missing out on potential benefits of having fully integrated
    systems. Have you seen this interoperability problem in other areas of
    the country? If so, are there possible solutions to the problem?
        Answer. Thank you, Senator Sullivan. You are correct. Healthcare
    providers across the country experience problems with EHR integration,
    and ensuring interoperability of the EHR platforms costs time and
    money. This inability for various EHR systems to interface is
    concerning, as providing the patient's data when and where it is needed
    is crucial for enabling better care coordination and improved health
    outcomes.
        In Mississippi, the state developed the Mississippi Health
    Information Network (MS-HIN) to deliver the interfacing solution across
    multiple EHR programs throughout the state. A public-private
    partnership established by House Bill 941 in the 2010 state legislature
    and funded by an American Recovery and Reinvestment Act (ARRA) grant,
    the mission of MS-HIN is ``to provide sustainable, trusted exchange of
    health information to improve the quality, safety, and efficiency of
    health care for all Mississippians.'' Its vision is to be ``the trusted
    source for secure, quality health care information--anywhere, anytime
    for a healthier Mississippi.''
        MS-HIN integrates various EHR platforms among providers in the
    state, allowing for a secure and reliable exchange of health
    information. Statewide EHR interoperability is especially important for
    our work at the University of Mississippi Medical Center (UMMC)--Center
    for Telehealth. Of our 166 distant telehealth sites across the state,
    the majority of these locations do not use the same EHR as UMMC.
    Consequently, we work with MS-HIN to help integrate the different
    medical record platforms for us, enabling this important data exchange
    to occur.
        MS-HIN provides a streamlined and efficient approach and cost-
    effective strategy for EHR interoperability. As you explore the
    possibility of a national medical record system, Mississippi's exchange
    could be a model worth replicating. Please contact me with further
    questions or for additional information.
                                     ______

         Response to Written Questions Submitted by Hon. Tom Udall to
                              Dr. Kristi Henderson
        Question 1. As you know, Congress recently replaced the SGR with an
    alternative payment model. The bill includes a new Medicare program of
    alternative payment methods free from longstanding telehealth
    restrictions. How does this provide a model for Congress and the Center
    for Medicare and Medicaid Innovation to remove the current restrictions
    by identifying ``better incentives of value-based payments''?
        Answer. The Medicare Access and CHIP Reauthorization Act of 2015
    (MACRA), through which the SGR was repealed, provides for the GAO to
    conduct a study on the use of telehealth in Federal programs, as well
    as on remote patient monitoring services in Medicare and private payor
    settings. The study is to address ``issues that can facilitate or
    inhibit the use of telehealth under the Medicare program under such
    title, including oversight and professional licensure, changing
    technology, privacy and security, infrastructure requirements, and
    varying needs across urban and rural areas.'' \1\ It also includes an
    evaluation of payment and delivery models for telehealth and the
    monitoring of those payments in the Medicare program. The study,
    therefore, provides an opportunity to test these models of care,
    including the benefits of telehealth in urban settings, and provide
    valuable data and outcomes for evaluation.
    ---------------------------------------------------------------------------
        \1\ Medicare Access and CHIP Reauthorization Act of 2015, H.R. 2,
    114th Cong. (2015). Retrieved from https://www.congress.gov/bill/114th-
    congress/house-bill/2/text
    ---------------------------------------------------------------------------
        Additionally, MACRA's Merit-Based Incentive Payment System (MIPS)
    encourages incentivized payments to physicians based on various
    metrics. One of the subcategories that affect a physician's MIPS score
    is the implementation of care coordination, including remote patient
    monitoring and telehealth. The telehealth and remote patient monitoring
    solution is ideal for these incentivized payments, as telehealth
    enables improved health outcomes and, thus, lower costs. For example,
    at the University of Mississippi Medical Center (UMMC) Center for
    Telehealth, we are providing remote patient monitoring to high-risk
    diabetic patients in rural Sunflower County for ongoing assessment and,
    if needed, intervention.
        While costs may be higher at the onset of the program from
    equipment, training and other expenses, significant costs savings will
    result from improvement in the chronic condition and related health
    issues, decreased medication expenses and other outcomes. Chronic
    diseases in Mississippi cost the state approximately $4 billion in
    2010, but projections indicate that the state will save nearly $125
    million each year with the use of remote patient monitoring.
        Already in UMMC's remote patient monitoring program, patients have
    reduced their A1C levels by an average of nearly 2 percent. Because of
    the success of this program and its outcomes, UMMC currently is ramping
    up this program to include monitoring for patients across multiple
    chronic disease states throughout Mississippi.

        Question 2. In your opinion given our mobile society, should
    providers have the ability to treat their patients anywhere using
    technology as long as they have an established patient-provider
    relationship in the state of licensure?
        Answer. The issue of location is determined by the location of the
    patient at the time of the encounter. If the patient is located in a
    state where the provider is licensed, providers should be able to treat
    patients using telehealth. In many states, including Mississippi, the
    patient-provider relationship can be established over the telehealth
    connection.

        Question 2a. Would you support Federal legislation directing the
    states to allow this for all Federal health programs?
        Answer. I would most certainly support Federal legislation that
    enables greater access to telehealth services for patients utilizing
    Federal health programs.

        Question 2b. What are some Federal licensing options that may also
    work for non-federal plans?
        Answer. I am not aware of Federal licensing options for health care
    providers. However, the Federation of State Medical Boards (FSMB),
    which represents all medical boards in the country, is promoting an
    Interstate Medical Licensure Compact to help streamline the licensure
    process for physicians practicing across state lines. This compact now
    has taken effect, as the required number of states has passed
    legislation adopting this process. These states include Idaho, Montana,
    Wyoming, Utah, South Dakota, Minnesota, West Virginia and Alabama.
        The process is the following: a physician would designate a member
    state in the Interstate Compact as his or her state of principal
    license and would apply for the Interstate Commission's expedited
    license with the board in his state of principal practice. The state
    board would evaluate if the physician is eligible for expedited
    licensure and would submit a letter confirming the physician's
    eligibility and credentialing to the Interstate Commission. The
    physician would then complete the registration process established by
    the Interstate Commission for licensure in another compact member
    state; and the Interstate Commission would receive all fees and
    registration information and transmit these documents to the additional
    states requested.

        Question 3. Today, adult children may be the caregivers for their
    parents, even if they live in another state. What role could telehealth
    have to assure that family members and caregivers can be included,
    virtually, at patient visits or in communication with the provider
    (with patient permission)?
        Answer. Family members are an important part of our health care
    system. Twenty-nine percent of the U.S. population (65.7 million)
    provides care to someone who is ill, disabled or aged.\2\ Additionally,
    43.5 million adult family caregivers care for someone 50 years of age
    or older, and 14.9 million care for someone who has Alzheimer's disease
    or other dementia.\3\ Therefore, the use of technology to connect the
    family member to the health care team can enhance the care of the
    patient and improve care coordination.
    ---------------------------------------------------------------------------
        \2\ Selected Caregiver Statistics. Family Caregiver Alliance:
    National Center on Caregiving. (2012 November). Retrieved May 27, 2015,
    from https://caregiver.org/selected-caregiver-statistics
        \3\ Ibid.
    ---------------------------------------------------------------------------
        Telehealth truly provides a comprehensive approach to health care,
    enabling greater information sharing and care coordination. Remote
    monitoring devices in the home setting allow family members and the
    health care team to be more engaged with patients and provide the right
    level of care when and where it is needed. By monitoring aging
    patients--who often suffer from chronic diseases and dementia--in their
    home, deviations in their normal health status and behavior can be
    identified earlier, allowing for earlier intervention. Aging people
    often need reinforcement of medication and treatment plans that can be
    done through telehealth in an easy, cost effective manner that is
    customized to the individual's needs.
        Data sharing through the Electronic Medical Record (EMR), Health
    Information Exchange (HIE), remote patient monitoring devices and other
    platforms establishes meaningful use of the information in ways that
    can improve the quality of health care by preventing duplication,
    reducing variations in care and allowing for earlier disease detection.
                                     ______

         Response to Written Question Submitted by Hon. John Thune to
                               Dr. Chris Gibbons
        Question. When the FCC created the Healthcare Connect Fund in 2012,
    the agency said that it expected to consider in the future whether the
    [Rural Health Care] Telecommunications Program should be reformed or
    eliminated. The FCC recognized that the Telecommunications Program,
    which generally pays for older ``legacy services,'' may be heavily
    relied upon in very remote communities but thought that many health
    care providers would migrate to the new Healthcare Connect Fund because
    they could purchase higher bandwidth services at a lower out-of-pocket
    cost. Has the FCC begun the assessment of the Rural Health Care
    Telecommunications Program that it talked about in 2012 and, if not,
    does it plan to do so in the near future?
        Answer. At this time, the Healthcare Connect Fund is still in its
    infancy, with funding only having been made available to new applicants
    starting on January 1, 2014. The FCC does not have any near-term plans
    to reform the Telecommunications Program, as some more time will be
    needed to assess how the Healthcare Connect Fund is progressing.
    Thereafter, a decision can be made about any possible reforms to the
    Telecommunications Program.
                                     ______

          Response to Written Question Submitted by Hon. Roy Blunt to
                               Dr. Chris Gibbons
        Question. What are some of the barriers that telehealth programs
    have in expanding services, and what are you doing to alleviate these
    issues?
        Answer. Barriers to telehealth programs vary widely depending on
    the nature and scope of the services at issue. For example,
    telemedicine involves using telecommunications technologies to support
    the delivery of medical, diagnostic and treatment-related services
    usually by doctors. Telehealth includes a wider variety of remote
    healthcare services beyond the doctor-patient relationship, including
    services provided by nurses, pharmacists, paramedics or social workers,
    for example, who may leverage technology to assist with patient health
    education, social support and medication adherence, and to promote
    preventive approaches that obviate acute or chronic illness.
        The Commission, through the Connect2HealthFCC Task
    Force, is working to engage a broad cross-section of stakeholders to
    better understand both the barriers and opportunities related to the
    deployment and/or utilization of broadband-enabled health tools and
    services. Thus far, several perceived barriers have been reported: (i)
    lack of availability and affordability of broadband in rural and
    underserved areas; (ii) lack of consumer awareness of the potential
    value of broadband-enabled tools and devices in health; (iii) lack of
    technical expertise to deploy and maintain advanced technology
    solutions; (iv) inadequate healthcare provider reimbursement for
    telehealth services; and (v) lack of interoperability of telehealth
    tools across vendors and healthcare systems.
        The Commission remains committed to addressing potential
    connectivity barriers through its universal service programs, including
    the Rural Health Care support mechanism which provides funding to
    eligible health care providers for telecommunications and broadband
    services necessary for the provision of health care. In addition, a
    critical part of the Connect2HealthFCC Task Force
    stakeholder engagement strategy includes not only an assessment of
    potential barriers to telehealth services, but also a solicitation of
    actionable strategies and solutions to any identified barriers. We
    believe that innovative approaches are underway across the country and
    that bringing those solutions to light, including lessons learned and
    best practices, could help advance telehealth nationwide. The
    Commission is also working closely with other relevant Federal agencies
    in this effort. Most recently, the Commission and Food and Drug
    Administration co-sponsored a well-attended workshop on promoting the
    safe co-existence of wireless medical devices, which are often part of
    telehealth strategies and services. Finally, the Commission is aware
    that other government agencies and stakeholders at both the Federal and
    state levels are pursuing the reimbursement and interoperability
    issues.
                                     ______

        Response to Written Questions Submitted by Hon. Dan Sullivan to
                               Dr. Chris Gibbons
        Question 1. As Senator Wicker announced, there are plans to
    introduce a new version of the Telehealth Enhancement Act. How can we
    improve the Rural Healthcare program of the Universal Service Fund
    through legislation?
        Are you familiar with the Telehealth Enhancement Act introduced
    last Congress? If so, what are your thoughts on it, and how do you
    think we can improve upon it?
        Answer. While the FCC typically does not endorse or take official
    positions about specific pieces of legislation, to the extent it is
    useful, my colleagues in the Wireline Competition Bureau are happy to
    work with your staff and provide any technical assistance you may
    request as the bill moves forward in the legislative process.

        Question 2. In Alaska, telehealth is hugely important, as it is the
    primary way many people in rural areas are able to receive healthcare.
    Some of our health facilities have reported interoperability problems
    with telehealth software and electronic health records (EHR) software.
    In addition to the problems caused by this lack of integration, we are
    also missing out on potential benefits of having fully integrated
    systems. Have you seen this interoperability problem in other areas of
    the country? If so, are there possible solutions to the problem?
        Answer. The Commission defers to the Office of the National
    Coordinator for Health IT, which is the principal federal entity
    charged with coordination of nationwide efforts to implement and use
    the most advanced health information technology and the electronic
    exchange of health information. As a clinician, I am aware that
    software interoperability problems involving Electronic Medical Record
    systems have been reported across the country. My understanding is that
    the problem is caused, in part, by EMR and telehealth vendors who each
    develop their products using proprietary processes and standards.
    Industry-wide health IT development standards or protocols would help
    to substantially reduce and or totally eliminate this problem.
                                     ______

       Response to Written Questions Submitted by the Hon. Tom Udall to
                               Dr. Chris Gibbons
        Question 1. With so many Federal agencies having some
    responsibility for and interest in telehealth, why isn't there some
    formal coordinating mechanism to communicate and collaborate, making
    more consistent and effective the standards, industry expectations,
    goals and even funding parameters across Federal agencies?
        Answer. The Office of the National Coordinator for Health
    Information Technology (ONC) in the Office of the Secretary at the U.S.
    Department of Health and Human Services (HHS) lead ongoing, formal
    coordination and collaboration efforts on health IT policies and
    strategies across Federal agencies. The FCC coordinates with ONC and
    other Federal entities on issues within its purview. For example, the
    FCC routinely participates in various cross-government meetings and
    discussions with ONC and other Federal agencies on telehealth policies
    and strategies, and it most recently provided input on the draft
    Federal Health IT Strategic Plan 2015-2020, which proposes a whole
    government approach to reaching defined health IT strategic goals. (The
    draft Plan is available at http://healthit.gov/sites/default/files/
    federal-healthIT-strategic-plan-2014.pdf.) We look forward to
    continuing to coordinate closely with our colleagues at HHS, the Food
    and Drug Administration, and other agencies.

        Question 2. Today, adult children may be the caregivers for their
    parents, even if they live in another state. What role could telehealth
    have to assure that family members and caregivers can be included,
    virtually, at patient visits or in communication with the provider
    (with patient permission)?
        Answer. Research confirms the significant role of caregivers in
    promoting, assuring and maintaining the health of family members and
    friends. According to a June 2013 report from the Pew Research Center,
    39 percent of adults said that they had ``provided unpaid care to an
    adult relative or friend to help them take care of themselves'' over
    the previous 12 months. According to a 2012 report by the AARP Public
    Policy Institute, Home Alone: Family Caregivers Providing Complex
    Chronic Care:

       46 percent of family caregivers performed medical/nursing
            tasks for care recipients with multiple chronic physical and
            cognitive conditions. These tasks include managing multiple
            medications, helping with assistive devices for mobility,
            preparing food for special diets, providing wound care, using
            monitors, managing incontinence, and operating specialized
            medical equipment.

       78 percent of family caregivers who performed medical/
            nursing tasks were managing medications, including
            administering intravenous fluids and injections.

       Despite frequent emergency department visits and overnight
            hospital stays, few family caregivers reported receiving
            assistance and training from health care professionals.

       More than half of family caregivers performing medical/
            nursing tasks said they did not feel they had a choice because
            there was no one else to do it, or insurance would not cover a
            professional's help. They also reported very few home visits by
            health care professionals. A total of 69 percent of the care
            recipients did not have any home visits by health care
            professionals. Of those who did have home visits, roughly seven
            in 10 were visited by a nurse.

        Technology-based solutions have the potential to reduce the
    substantial burden of caregiving reported in these studies, enhance the
    quality of care provided by caregivers, and facilitate aging in place.
        For example, ``smart'' pill bottles and medication dispensers can
    help increase medication adherence and reduce harmful errors. Digital
    diet and nutrition aids could lessen the burden of special meal
    planning and preparation. Social networking tools for the elderly could
    address social isolation (a known exacerbating and contributing factor
    to certain chronic health conditions) and help relieve caregiver
    stress, providing real-time social support and remote trouble-shooting
    assistance.
        Similarly, broadband-enabled health applications could offer more
    tailored and interactive training and education to improve caregiver
    skill and proficiency with critical caregiving tasks. Life-like robots
    (e.g., ``carebots'') with wireless capabilities could enable remote
    ``check-ins'' by health care providers. ``Smart home'' and other
    wireless sensor solutions that automatically adjust lights and
    appliances for consumers could help those with vision, musculoskeletal
    or cognitive impairments. Finally, point-and-click digital translation
    tools could distill doctors' orders and discharge instructions in near-
    real time for seniors with low literacy levels and for consumers who
    speak English as a second language, ultimately enhancing patient
    engagement, self-care, and health outcomes.
                                     ______

         Response to Written Questions Submitted by Hon. Roy Blunt to
                              Jonathan D. Linkous
        Question 1. Many States are wrestling with what constitutes a
    ``patient-provider relationship'' when telehealth medicine is involved
    and these rules vary greatly from State-to-State. How should patients,
    providers, and States balance the convenience and access of telehealth
    options with the importance of engaging patients in a dialogue about
    their health with a physician who can manage their ongoing needs?
        Answer. In general, a state's patient-provider relationship
    requirements should be comparable between in-person and telehealth
    care. For example, urgent care services have no requirement for a pre-
    existing provider-patient relationship. It should be noted that most
    states accommodate the requirements for a relationship by the type of
    health service rendered and other circumstances such as emergencies.

        Question 2. The Office of Rural Health at the Department of Health
    and Human Services administers several grant programs to provide
    funding for projects that demonstrate telehealth networks and improve
    healthcare services for medically underserved populations. This program
    can be a particularly important tool in allowing access to medical
    specialists for rural populations. How do we adequately expand this
    program to ensure patients in underserved communities receive access to
    specialty care?
        Answer. Without Congress providing additional appropriations for
    such, one approach would be to consolidate the more categorical grant
    funding for the Office for the Advancement of Telehealth and possibly
    other HHS programs into one program specifically focusing on the
    delivery of services to underserved areas.
                                     ______

        Response to Written Question Submitted by Hon. Dan Sullivan to
                              Jonathan D. Linkous
        Question. In Alaska, telehealth is hugely important, as it is the
    primary way many people in rural areas are able to receive healthcare.
    Some of our health facilities have reported interoperability problems
    with telehealth software and electronic health records (EHR) software.
    In addition to the problems caused by this lack of integration, we are
    also missing out on potential benefits of having fully integrated
    systems. Have you seen this interoperability problem in other areas of
    the country? If so, are there possible solutions to the problem?
        Answer. The lack of interoperability for sharing patient data is
    almost nationwide and comparable between in-person and telehealth
    services. As the major payor of health care services and the major
    payor for electronic health records, the Federal Government seems to
    have significant opportunities for requiring interoperability.
                                     ______

         Response to Written Questions Submitted by Hon. Tom Udall to
                              Jonathan D. Linkous
        Question 1. We were pleased to see that the ATA recognized New
    Mexico with an ``A'' grade for our state's telehealth coverage and
    reimbursement policies. What is happening in states presently to create
    parity with in-person coverage?
        Answer. Currently, 24 states and the District of Columbia have
    adopted parity legislation for private insurance. Arkansas and
    Washington, enacted parity for private insurance plans this year and
    several others are close.
        It is important to broaden the parity concept in states for
    Medicaid and state employee health benefit plans.
        It is also important that states foster other opportunities beyond
    mere parity with in-person coverage, such as foster open access state
    telehealth networks and shifting reimbursement from fee-for-service to
    value-based methods.

        Question 2. As you know, Congress recently replaced the SGR with an
    alternative payment model. The bill includes a new Medicare program of
    alternative payment methods free from longstanding telehealth
    restrictions. How does this provide a model for Congress and the Center
    for Medicare and Medicaid Innovation to remove the current restrictions
    by identifying ``better incentives of value-based payments''?
        Answer. We hope that the actual experience of alternative payment
    methods with telehealth will give Congress, the Congressional Budget
    Office, the Centers for Medicare and Medicaid Services the data and
    knowledge for greater coverage under other payment methods.

        Question 3. Currently, a provider must be licensed in the state
    where the patient is located at the time of care, despite being a
    mobile society that emphasizes coordinated care. The Department of
    Defense, IHS and VA providers treat patients in any of the agencies'
    provider sites without obtaining separate state licenses. Why doesn't
    this exemption apply to Medicare and other Federal health programs?
        Answer. We support its extension for Federal agencies to all
    Federal programs and federally-funded health care sites.

        Question 3a. Could that happen with a change in regulation, or does
    it require a statutory change?
        Answer. As a practical matter, this may require Congressional
    action, like the STEP Act that passed Congress without one vote of
    opposition.

        Question 4. In your opinion, should providers have the ability to
    treat their patients anywhere using technology as long as they have an
    established patient-provider relationship in the state of licensure?
        Answer. Yes

        Question 4a. Would you support Federal legislation directing the
    states to allow this for all Federal health programs?
        Answer. Medicare and other payors reimburse for a telehealth
    encounter based only on the provider's location--with the implication
    that the provider's location is where the health service is rendered.
    It seems that under either Federal sovereignty (just as each state has
    sovereignty for its own operations) or the interstate commerce clause
    of the U.S. Constitution that Congress can take such action--and
    without the step of directing the states.

        Question 4b. What are some Federal licensing options that may also
    work for non-federal plans?
        Answer. The goal is to allow patients to receive medical care from
    any qualified health provider regardless of location, to reduce the
    extensive time delay and the cost of the existing licensing structure.
        For a variety of reasons, the most probable option is for Congress
    to enact an interstate compact based on a-one-state-license-with-
    reciprocity or mutual recognition among the states. This maintains
    state sovereignty to issue a license but allows patients to see and be
    seen by their physician regardless of their location.
        A reciprocal approach would save healthcare millions of dollars in
    duplicative licensing fees and remove the delays inherent in gaining
    state medical boards approval. Since the requirements to be licensed in
    any state are very consistent nationwide, a common concern of an
    ``easy'' state would seem diminished. Such a compact should also allow
    for multi-state provider databases investigations and enforcement. A
    rough parallel to this would be the Nurse Licensure Compact or
    interstate Driver License Compact and the National Driver Register.
        It should be noted that the new interstate compact proposed by the
    Federation of State Medical Boards (FSMB) that is being considered by
    state medical boards establishes up a unified application process but
    may fail to achieve any of the three goals listed above. Such approach
    still requires state-by-state actions to process and approve each
    license before a physician can practice in the state, still requires
    the payment of a duplicative licensing fee to each state board and will
    probably require the payment of additional fees to the FSMB itself for
    administering the process.
                                     ______

         Response to Written Question Submitted by Hon. John Thune to
                                  Todd Rytting
        Question. Thank you for your testimony highlighting the innovative
    work that Panasonic has done to study the effects of remote patient
    monitoring. I'd like to ask about the proposal you raised that would
    use the FCC's Universal Service Fund to subsidize the connectivity
    costs of remote patient monitoring for rural health care providers.
        Based on your own remote patient monitoring pilot, do you have a
    sense of what the costs and benefits would be of this proposal--for
    example, how much money would need to come from the universal service
    fund to support remote patient monitoring as compared to the potential
    cost savings for providers and patients resulting from such
    technologies?
        Answer. In 2014, Panasonic conducted a Home Telehealth performance
    study in partnership with a New York-based provider of long term, sub-
    acute eldercare services and a major Medicare Advantage provider in
    Metropolitan New York.
        The study was centered on Panasonic ``SmartCare,'' a television-
    based remote patient monitoring technology designed to be user-friendly
    for seniors--who may not be comfortable with contemporary consumer
    technologies, such as smartphones. SmartCare utilizes a small set-top
    box that interacts with a patient's television to deliver remote
    biometric monitoring, interactive health-assessment surveys, and
    condition-specific educational health videos to facilitate patient
    self-management. The study's background, objectives, design parameters,
    and outcomes are documented in the White Paper submitted to this
    Committee under separate cover.
        The general objective of our study was to determine the impact of
    Panasonic's television-based remote patient monitoring technology on
    the chronic care management of seniors with congestive heart failure
    and having a high-risk for re-hospitalization.
        Using baselines established from Medicare Advantage claims data,
    and historic data for dual-eligible patients drawn from studies
    published by the Kaiser Family Foundation, SmartCare reduced six month
    hospital readmission rates by an average of 44 percent for Medicare
    Advantage Patients and 69 percent for dual-eligible patients,
    respectively. Strikingly positive results were also attained in the
    reduction of Emergency Department visits, increased Medication
    Adherence, and positive measures of patient engagement.
        As demonstrated by our study, and the potential for savings is
    real, and significant.
        An estimated 17 percent of Medicare beneficiaries have Congestive
    Heart Failure (CHF), which account for 800,000 hospital admissions
    annually. And, approximately 25 percent of Medicare patients
    hospitalized for CHF are re-hospitalized within 30 days of discharge.
    On average, Medicare pays $15,000 in overall costs for heart failure
    admission without a readmission, and $33,000 for an episode with a
    single readmission.
        Therefore, if 800,000 patients are admitted for heart failure at a
    cost of $15,000 for each admission, and, subsequently, 25 percent, or
    about 200,000 patients, are readmitted to the hospital at a cost of
    $33,000, the total Medicare spend is $18,600,000,000 per year.
        However, assuming that home telehealth technology, like Panasonic
    SmartCare, can reduce both admissions and readmissions for CHF by a
    conservative 20 percent, the total Medicare spend would be reduced to
    $13,824,000,000. Furthermore, a more ambitious 40 percent reduction in
    hospitalizations and readmissions would reduce readmissions to 72,000,
    resulting in an aggregate Medicare cost of $2,376,000,000 per year.
    These are meaningful potential savings.
        Notably, the most significant challenge uncovered by the Panasonic
    study was the lack of broadband Internet connectivity. In some cases,
    broadband was simply not available. But the most common reason for the
    lack of Internet was affordability. Our test subjects were
    predominantly elderly, poor, and urban; with all suffering from
    multiple chronic health conditions. Chronic conditions are common among
    those over the age of 65--whether urban, or rural. Furthermore, low
    income and poverty are highly correlated to poor lifestyle choices that
    lead to the early onset of chronic conditions, well below retirement
    age.
        These demographic cohorts--the elderly; the urban and rural poor,
    and others lacking the social capital to inform healthy lifestyle
    choices--are the very groups least likely to have broadband
    connectivity in the home. They simply can't afford it. And broadband
    can also help ensure that the 1,326 rural Critical Access hospitals in
    the U.S. can remotely tap into a variety of dearly needed specialty
    healthcare services currently only available in more densely-populated
    urban centers.
        As detailed in the Panasonic White Paper, Home Telehealth solutions
    can have a significant positive impact by improving health outcomes and
    reducing costs. Excluding the cost of enabling hardware and service
    initiation, preliminary estimates indicate that as little as $15 to $20
    per patient per month could potentially have a profoundly positive
    impact on the adoption and utilization of home Telehealth by low-income
    seniors. Use of the FCC Universal Service Fund to subsidize the
    connectivity costs of remote patient monitoring for society's most
    needy and deserving citizens, in both urban and rural populations,
    would be money well-invested.
                                     ______

        Response to Written Question Submitted by Hon. Dan Sullivan to
                                  Todd Rytting
        Question. In Alaska, telehealth is hugely important, as it is the
    primary way many people in rural areas are able to receive healthcare.
        Some of our health facilities have reported interoperability
    problems with telehealth software and electronic health records (EHR)
    software. In addition to the problems caused by this lack of
    integration, we are also missing out on potential benefits of having
    fully integrated systems. Have you seen this interoperability problem
    in other areas of the country? If so, are there possible solutions to
    the problem?
        Answer. The interoperability of Telehealth Solutions with provider
    systems--such as Electronic Medical Records (EMR) and Health
    Information Management (HIM) systems--is essential to unlocking the
    potential of these innovative new technologies. However, the attainment
    of these objectives involves technical challenges, including standards
    for data aggregation, normalization, analysis, and exchange; the
    evolution of business policies, which may require the sharing of data
    sets held by competing stakeholders; complex workflow challenges; and
    regulatory issues, such as the issues surrounding the storage and
    management of Protected Health Information (PHI). For these reasons,
    and others, true interoperability represents a significant challenge.
        But healthcare information technology challenges of similar
    magnitude have been faced before -and overcome. For instance, it was
    reported just this week that over 67 percent of the prescriptions
    written in the United States in 2014 were transmitted electronically
    over the Surescripts network. That's over 6.5 billon electronic
    prescriptions--more than the number of financial transactions processed
    by American Express. Surescripts was created in 2001 to connect
    physicians with pharmacies. But it wasn't until 2008 when the
    Surescripts electronic prescribing network was merged with a benefits
    network called RxHub--thus aligning the major stakeholder interests--
    did electronic prescribing really take off. So these things take time,
    but the benefits are tremendous.
        Analogously, the growth and expansion of a emerging ``connected
    health ecosystem'' will begin to resolve the vexing challenge of
    Telehealth system interoperability. Like Surescripts, companies now
    creating large, technology-agnostic, analytics-driven Telehealth
    networks can support the standards and workflow processes required to
    facilitate system-wide interoperability, while innovators can rapidly
    create the edge devices, such as the wearable monitors & communications
    devices that optimize the user experience, and algorithms the power the
    analytic engines that support risk management & clinical decision
    support.
        With reimbursement policy rapidly moving in the direction of
    Accountable Care--which requires care coordination across many
    settings, bound to outcome-based reimbursement--connected,
    interoperable technology becomes an absolute imperative.

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