[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
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
U.S. GOVERNMENT PUBLISHING OFFICE
99-805 PDF WASHINGTON : 2016
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800;
DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC,
Washington, DC 20402-0001
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)
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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.
References
Agency for Healthcare Research and Quality (June, 2011). Half of
all annual medical expenditures are for chronic diseases: Research
Activities, June 2011, No. 370. Internet citation accessed online 9/18/
2014:: http://www.ahrq.gov/news/newsletters/research-activities/jun11/
0611RA11.html
Advisory.com (April 4, 2014). Why Medicare changed its policy for
heart failure patients. Daily Briefing. Internet citation accessed
October 15, 2014: www.advisory.com/daily-briefing/2014/04/04/why-
medicare-changed-its-policy-for-heart-failure-patients
Alliance for Aging Research (2009). The Silver Book. Internet
citation accessed 8/14/2014 http://www.silverbook.org/category/
20?pageNum=1
Alston, K. (2009) Telehealth-supported innovation in home care.
Caring Magazine, Home Care Technology Association of America. Internet
citation accessed 9/12/2014 http://www.hctaa.org/cm_09July_Alston.html
American Association of Colleges of Nursing (April, 2014). Nursing
Shortage: Internet citation accessed 8/16/2014 http://
www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage
Baker, D., Gazmararian, J., Williams, M., Scott, T., Parker, Green,
D. . . . & Pell, J. (August, 2002) Functional and the risk of hospital
admission among Medicare managed care enrollees. American Journal of
Public Health. Internet citation accessed: 9/15/2014: http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC1447230/; 92(8): 1278-1283.
Berry, S.D., Quach, L., Procter-Grey, E., Kiel, D.P., Wenjun, L.
Samelson, E.J. . . . & Kelsey, L. (March 15, 2010). Poor adherence to
medications may be associated with falls. Journal of Gerontology and
Biology Science. Internet citation accessed 8/14/2014: http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC2854886
Brega, A., Schlenker, R., Hijjazi, K., Neal, S., Belansky, E.,
Talkington, S. . . . & Tennant, C. (August 2002). Study of Medicare
home health practice variations: final report. University of Colorado,
Center for Health Policy Research. Internet citation accessed 9/5/2014:
http://aspe.hhs.gov/daltcp/reports/epic.htm
Broderick, A. & Steinmetz, V. (2013). Centura Health at Home: Home
Telehealth as the Standard of Care. Internet citation accessed 8/20/
2014: http://www.commonwealthfund.org/ /media/files/publications/case-
study/
2013/jan/1655_broderick_telehealth_adoption_centura_case_study.pdf
Brown, B. (2014). A best way to manage a CMS hospital readmission
reduction program. Health Catalyst. Internet citation accessed 10/9/
2014: http://www.healthcatalyst.com/CMS-reporting-requirements-4-
changes-2014
Bureau of Labor Statistics (2013.) Internet citation accessed 9/15/
2014: http://www.bls.gov/news.release/ecopro.t08.htm
Bushy, A. (2012). Nursing in rural and frontier areas: issues,
challenges and opportunities. Harvard Health Policy Review, Vol. 7, No.
1. Internet Citation accessed 10/14/2014: http://hhpronline.org/wp-
content/uploads/2012/05/Bushy.pdf
Center for Disease Control and Prevention (2009). Chronic diseases:
the power to prevent, the call to control: at a glance. Internet
citation accessed 9/5/2014: http://www.cdc.gov/chronicdisease/
resources/publications/aag/chronic.htm
Center for Medicare Advocacy (2008) Medicare cost-Sharing for dual
eligibles: Who pays what for whom? Internet citation. Accessed 10/5/
2014: http://www.medicareadvocacy.org/InfoByTopic/
MedicareSavingsPrograms/MedSavProgs
_08_04.24.CostSharing.htm
Centers for Medicare and Medicaid. (2009). Data Compendium.
Internet citation accessed 9/15/2014: https://www.cms.gov/
DataCompendium/
Centers for Disease Control and Prevention (2011). National
diabetes fact sheet. Internet citation accessed 9/5/2014: http://
www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
Centers for Disease Control and Prevention (2011). Chronic disease
prevention and health promotion: healthy aging; Internet citation
accessed: 8/14/2014 http://www.cdc.gov/chronicdisease/resources/
publications/aag/aging.htm
Centers for Disease Control and Prevention (2014). National
diabetes fact sheet. Internet citation accessed 9/5/2014: http://
www.cdc.gov/diabetes/pubs/stats
report14/national-diabetes-report-web.pdf
Centers for Disease Control and Prevention (2014). Heart failure
fact sheet. Internet citation accessed 9/5/2014: http://www.cdc.gov/
dhdsp/data_statistics/fact
_sheets/docs/fs_heart_failure.pdf
Centers for Medicare & Medicaid Services (2012). Health Care
Financing Review. Medicare and Medicaid Statistical Supplement, Table
7.6. Internet citation accessed 9/5/2014: http://www.cms.gov/Research-
Statistics-Data-and-Systems/Statistics-Tre
nds-and-Reports/MedicareMedicaidStatSupp/index.html?redirect=/
MedicareMedi
caidStatSupp/08_2011.asp
Centers for Medicare and Medicaid Service (2011). Chronic
conditions among Medicare beneficiaries. Internet citation accessed 8/
14/2014: http://www.cms.gov/Research-Statistics-Data-and-Systems/
Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/
2011Chartbook.pdf
Centers for Medicare & Medicaid Services (2013). Memorandum of
understanding (MOU) between the centers for Medicare & Medicaid
services (CMS) and the State of New York regarding a federal-state
partnership to test a capitated financial alignment model for Medicare-
Medicaid enrollees. Internet citation accessed 8/14/2014: https://
www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-
Coordination/Medicare-Medicaid-Coordination-Office/Downloads/NYMOU.pdf
Centers for Medicare and Medicaid (2013). New data shows affordable
care act reforms are leading to lower hospital readmission rates for
Medicare beneficiaries. Internet citation accessed online 9/20/2014
http://blog.cms.gov/2013/12/06/new-data-shows-affordable-care-act-
reforms-are-leading-to-lower-hospital-readmission-rates-for-medicare-
beneficiaries/
Chan, M., Nicklason, F., Vial, J.H. (May-June, 2001). Adverse drug
events as a cause of hospital admission in the elderly. Internal
Medicine Journal. 31(4):199-205. Internet citation accessed 8/14/2014:
http://www.ncbi.nlm.nih.gov/pubmed/11456032
Chen, H., Kalish, C. & Pagan, J. (June, 2011). Telehealth and
hospitalizations for Medicare home healthcare patients. American
Journal of Managed Care. Internet citation accessed 9/12/2014: http://
carecyclesolutions.net/downloads/pdfs/ajmc-article.pdf
Chisholm-Burns, M. A. (2002). The 'cost' of medication non-
adherence: consequences we cannot afford to accept Journal of American
Pharmaceutical Association. Internet citation accessed 8/17/2014:
http://www.ncbi.nlm.nih.gov/pubmed/23229971
Congressional Budget Office (June 6, 2013). Dual-eligible
beneficiaries of Medicare and Medicaid: characteristics, health care
spending and evolving policies. Internet citation accessed: http://
www.cbo.gov/publication/44308
Coughlin, T., Waidmann, T., & O'Malley Watts, M. (2009). Where does
the burden lie? Medicaid and Medicare spending for dual eligible
beneficiaries. Henry J. Kaiser Family Foundation, Kaiser Commission on
Medicaid and the Uninsured. Internet citation accessed 9/5/2014:
kaiserfamilyfoundation.files.wordpress.com/2013/01/7895-2.pdf
Darkins, A. (2013). Telehealth services in the United States
Department of veterans affairs (VA). Department of Veterans Affairs.
Internet citation accessed 10/5/2014: http://c.ymcdn.com/sites/
www.hisa.org.au/resource/resmgr/telehealth2014/
Adam-Darkins.pdf
Darkins, A., Ryan, P. & Kobb, R. (2008). 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 TELEMEDICINE and e-HEALTH DECEMBER
2008 (Case Report, 2008) Internet citation accessed 9/23/2014 http://
senweb03.senate.ca.gov/committee/standing/health/Wilson_VA_Study.pdf
Dey, J.G., Johnson, M., Pajerowski, W., Tanamor, M. & Ward, A.
(January 11, 2011). Home health study report. L & M Policy Research.
Internet citation accessed 9/2/2014: https://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/Home
HealthPPS/downloads/hhpps_literaturereview.pdf
Dill, M. J. and Salsberg, E.S. (November 2008). The complexities of
physician supply and demand: projections through 2025, Association of
American Medical Colleges, pg. 28.
Division for Heart Disease and Stroke Prevention (DHDSP), National
Center for Chronic Disease Prevention and Health Promotion (NCCDPHP).
(March 27, 2013). Medication adherence. CDC's Noon Conference. Internet
citation accessed 8/18/2014 http://www.cdc.gov/primarycare/materials/
medication/docs/medication-adherence-01ccd.pdf
Gonzalez, J.M. (November, 2013). National health care expenses in
the U.S. civilian non-institutionalized population. Statistical Brief
#425. Medical Expenditure Panel Survey, Agency for Healthcare Research
and Quality. Internet citation accessed online 9/8/2014: http://
meps.ahrq.gov/data_files/publications/st425/stat425.pdf
Fazzi Associates (2008). National study on the future of technology
& telehealth in home care. Internet citation accessed 9/7/2014: http://
www3.medical.philips.com
/resources/hsg/docs/en-us/custom/PhilipsNationalStudyFullReport.pdf
The Federal Interagency Forum on Aging-Related Statistics
(Forum)(2012). Older Americans 2012. Key indicators of well-being.
Internet citation accessed 8/15/2014: http://www.agingstats.gov/
agingstatsdotnet/Main_Site/Data/2012_Documents/
docs/EntireChartbook.pdf
Fisher, H. M. (February 7, 2013). Preparing for the opportunity and
challenges of dual eligible integrated programs. Medicaid Innovations
Forum. Emblem Health. Internet citation accessed 9/12/2014: http://
www.medicaidinnovations.com/pdf/
2013-Speaker-Presentations/Emblem%20Health--
Holly%20Michaels%20Fisher.pdf
Gardner, B., Iliffe, S., Fox, K, Barbara, B.J. and Hamer, M.
(August, 2014). Sociodemographic, behavioural and health factors
associated with changes in older adults' television viewing over 2
years.
International Journal of Behavioral Nutrition and Physical Activity
(2014). Internet citation accessed 9/14/2014 http://www.ijbnpa.org/
content/11/1/102
Gold, J. (April 16, 2014). FAQ on ACO's: accountable care
organizations, explained. Kaiser Health News Internet citation accessed
8/14/2014: http://www
.kaiserhealthnews.org/stories/2011/january/13/aco-accountable-care-
organization-
faq.aspx
Hope, C. J., Wu, J., Tu, W., Young, J., Murray, M.D. (2004).
Association of medication adherence, knowledge and skills with
emergency department visits by adults 50 years or older with congestive
heart failure. American Journal of Health System Pharmaceuticals.
2004;61 (19) Internet citation accessed 9/12/2014: http://
www.medscape.com/viewarticle/490644
Jacobson, G., Neuman, T. & Damico, A. (April 2012). Medicare's role
for dual eligble beneficiaries. Kaiser Family Foundation. Internet
citation accessed 9/2/2014: http://dualsdemoadvocacy.org/wp-content/
uploads/2012/02/KFF-8138-02-Duals-Medicare-April-2012.pdf
Jacobson, G., Neuman, T. & Huang, J. (June 12, 2013). Projecting
Medicare advantage enrollment: expect the unexpected. Kaiser Family
Foundation. Internet citation accessed 9/2/2014: http://kff.org/
medicare/perspective/projecting-medicare
-advantage-enrollment-expect-the-unexpected/
Jayanthi, A. (June 24, 2014). Key findings on VA telehealth
services outcomes. Internet citation accessed 9/2/2014: http://
www.beckershospitalreview.com/health
care-information-technology/7-key-findings-on-va-telehealth-services-
outcomes.html
Jiang, H. J., Wier, L., Potter & D. Burgess, J. (September 2010).
Statistical Brief #96. Potentially preventable hospitalizations among
Medicare-Medicaid dual eligibles. Healthcare Cost and Utilization
Project. Agency for Healthcare Research and Quality Internet citation
accessed 8/14/2014: http://www.hcup-us.ahrq.gov/reports/statbriefs/
sb96.pdf
Institute for Healthcare Improvement (IHI). The IHI triple aim
(2013). Internet Citation accessed 8/21/2014: http://www.ihi.org/
Engage/Initiatives/TripleAim/pages/default.aspx
Kaiser commission on Medicaid and the underinsured (2012). The
diversity of dual eligible beneficiaries: an examination of services
and spending for people eligible for both Medicaid and Medicare.
Internet citation accessed 8/14/2014 http://
kaiserfamilyfoundation.files.wordpress.com/2013/01/7895-02.pdf
Kashihara, D. and Carper, K. (January 2012). National health care
expenses in the U.S. civilian non-institutionalized population, 2009.
MEPS Statistical Brief #355. Agency for Healthcare Research and
Quality. Internet citation accessed 8/18/2014: http://
www.meps.ahrq.gov/mepsweb/data_files/publications/st355/stat355
.pdf.
Kaufman, J. (September 12, 2014). Elderly New Yorker, here for the
duration. The New York Times. Internet citation accessed September 12,
2014: http://www.nytimes.com/2014/09/14/realestate/elderly-new-yorkers-
here-for-the-duration
.html?partner=rss&emc=rss&smid=fb-
nytimes&bicmst=1409232722000&bicmet=141
9773522000&smtyp=aut&bicmp=AD&bicmlukp=WT.mc_id&_r=0
Landsberg, J. (September 11, 2012). Nielsen: blacks, elderly, major
television watchers. Internet citation accessed 8/14/2014: http://
www.bottomlinecom.com/nielsen-blacks-elderly-major-tv-watchers/
Milliman, Inc. (2013). New York fully integrated duals advantage
program: perspectives of a certifying actuary. The New York State
Health Foundation. Internet citation accessed 8/15/2014: http://
nyshealthfoundation.org/resources-and-reports
/resource/ny-fully-integrated-duals-advantage-program
Mullaney, T. (March 27, 2014) House to vote on skilled nursing
facility readmissions penalties, ICD-10 extension. Internet citation
accessed 8/14/2014: http://www.mcknights.com/house-to-vote-on-skilled-
nursing-facility-readmissions-penalties-icd-10-extension/article/
339961/
Munro, D. (2/12/2014). Annual U.S. healthcare spending hits $3.8
trillion. Forbes Magazine online edition. Accessed 9/15/2014: http://
www.forbes.com/sites/danmunro/2014/02/02/annual-u-s-healthcare-
spending-hits-3-8-trillion/
Nebraska Center for Nursing (2009). Facts about the nursing
shortage. University of Nebraska Medical Center. Internet Citation
accessed 10/14/2014: http://www.unmc.edu/nursing/nursingshortage.htm
Newman, E. (September 30, 2014). Jewish Home Lifecare named
innovator of the year. McKnight's News. Internet citation accessed 9/
30/2014: http://www.mc
knights.com/jewish-home-lifecare-named-innovator-of-the-year/article/
374286/
New York State Department of Health (2014). MRT 90: Mandatory
enrollment managed long term care. Internet citation accessed 9/23/
2014: https://www.health.ny.gov/health_care/medicaid/redesign/
mrt_90.htm
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
No author (2008). Study shows home health care workers drive nearly
five billion miles to serve elderly and disabled patients. Caring
Magazine. National Association for Home Care and Hospice Internet
citation; accessed online 10/1/2014: http://caring.org/facts/
homecareStudy.html
Pfuntner, A. & Wier, L. M., Steiner, C., (January, 2010). Costs of
hospital stays in the United States. Statistical Brief #14. Internet
citation accessed 9/16/2014 http://www.hcup-us.ahrq.gov/reports/
statbriefs/sb146.jsp
Punke, H. (December 31, 2013). Top 4 ACO reimbursement models.
Becker's Hospital Review http://www.beckershospitalreview.com/
accountable-care-organizations/top-4-aco-reimbursement-models.html
Rau, J. (November 25, 2012) Hospitals face pressure to avert
readmissions. New York Times Health Section. Internet citation accessed
9/17/2014: http://
www.nytimes.com/2012/11/27/health/hospitals-face-pressure-from-
medicare-to-
avert-readmissions.html?_r=0
Samis, S., Detty, A. & Birnbaum, M. (2012). Integrating and
improving care for dual Medicare-Medicaid enrollees: New York's
proposed fully integrated duals advantage (FIDA) program. United
Hospital Fund. Internet citation accessed 8/16/2014: http://
www.uhfnyc.org/publications/880865
Stark, R. B. (August 2013 Revision). Predicting Your Hospital's
Readmission Penalty And Gauging Your ROI: A New Approach Abstract.
Reinforced Care. Internet citation accessed 9/8/2014: http://
www.reinforcedcare.com/wp-content/uploads/
2013/05/Predicting-Your-Readmission-Penalty-and-Gauging-Your-ROI-August
-2013.pdf
Trust for America's Health--Robert Wood Johnson Foundation (August,
2013). F as in fat, how obesity threatens Americans future. Issue
Brief. Internet citation accessed 8/1/2014: http://www.rwjf.org/
content/dam/farm/reports/reports/2013/
rwjf407528
United States Department of Education (2003). The health literacy
of America's adults results from the 2003national assessment of adult
literacy. Internet citation accessed 8/15/2014: http://nces.ed.gov/
pubs2006/2006483_1.pdf
United States Department of Health and Human Services, Centers for
Disease Control and Prevention (2012). Health, United States, 2012 With
Special Feature on Emergency Care. Internet citation accessed 9/12/2014
http://www.cdc.gov/nchs/data/hus/hus12.pdf
Weiss, H & Pescatello, S. (September 22, 2014) Medicare Advantage:
stars system's disproportionate impact on MA plans focusing on low-
income populations. Health Affairs Blog. Internet Citation accessed 10/
16/2014: http://healthaffairs.org/
blog/2014/09/22/medicare-advantage-stars-systems-disproportionate-
impact-on-ma-plans-focusing-on-low-income-populations/
Western New York Law Center. NY Health access (2014) New York
State's duals demonstration project: fully integrated dual advantage
(FIDA). Internet citation accessed 9/10/2014 http://www.wnylc.com/
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
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chart 2--Gateway Reductions
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chart 3--Six Month ER Visit Rate
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chart 4--Gateway Satisfaction
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chart 5--Adherence Trend in Medication
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chart 6--System Utilization
Appendix B--Stakeholders
Chart 1--Medicare Benefits Payments
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chart 2--Health Status of Duals--Comparison
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chart 3--Comparative Service Use
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
=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.
[The information referred to follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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 [email protected].
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.
[all]