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




                                                        S. Hrg. 114-235

               ADVANCING TELEHEALTH THROUGH CONNECTIVITY

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

                                HEARING

                               before the

    SUBCOMMITTEE ON COMMUNICATIONS, TECHNOLOGY, INNOVATION, AND THE 
                                INTERNET

                                 of the

                         COMMITTEE ON COMMERCE,
                      SCIENCE, AND TRANSPORTATION
                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 21, 2015

                               __________

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


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       SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

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

    SUBCOMMITTEE ON COMMUNICATIONS, TECHNOLOGY, INNOVATION, AND THE 
                                INTERNET

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
















                            C O N T E N T S

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

                               Witnesses

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

                                Appendix

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

                              ----------                              


                        TUESDAY, APRIL 21, 2015

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

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

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

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

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

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

            CHIEF TELEHEALTH AND INNOVATION OFFICER,

            UNIVERSITY OF MISSISSIPPI MEDICAL CENTER

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

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

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

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

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

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

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

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

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

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

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

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

       STATEMENT OF CHRIS GIBBONS, MD, MPH, DISTINGUISHED

 SCHOLAR-IN-RESIDENCE, CONNECT2HEALTHFCC TASK FORCE,

          FEDERAL COMMUNICATIONS COMMISSION; ASSOCIATE

        DIRECTOR, JOHNS HOPKINS URBAN HEALTH INSTITUTE;

         ASSISTANT PROFESSOR OF MEDICINE, PUBLIC HEALTH

        AND HEALTH INFORMATICS, JOHNS HOPKINS UNIVERSITY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

   Increased consumer demand for more convenient services

   Evolution of the healthcare industry including:

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

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

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

   ambulance providers and other emergency medical transport 
        providers

   health clinics of elementary, secondary and post-secondary 
        schools

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

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

   A 400 bed limit on hospitals, and

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

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

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

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

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

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

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

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

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

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

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

 Existing Clinical Studies Demonstrating the Benefits of Remote Access 
                              Technologies

Chronic Condition Management

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

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

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

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

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

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

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

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

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

  ``There was a trend toward increased prescription refill rates with 
    the use of the Pill Phone application and a decrease after the 
    application was discontinued'' [Case study titled: ``Medication 
    Adherence and mHealth: The George Washington University and 
    Wireless Reach Pill Phone Study'', Study designed, conducted and 
    analyzed by George Washington University Medical Center; Qualcomm 
    Wireless Reach Initiative was the primary funder of this study] 
    http://www.qualcomm
    .com/media/documents/files/wireless-reach-case-study-united-states-
    pill-phone-english-.pdf
                                 ______
                                 
                        Lucas, Nace, Gutierrez & Sachs, LLP
                                         McLean, VA, March 27, 2015
VIA ECFS

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

Attn: Radhika Karmarkar
Regina Brown
Wireline Competition Bureau

Re: CHRISTUS Health
CC Docket No. 02-60

Madam Secretary:

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

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

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

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

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

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

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

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

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

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

                 The Panasonic Home Gateway--10/31/2014

              Pathways to Health with Jewish Home Lifecare

                           Alexis Silver, MBA

Table of Contents

Executive Summary

Introduction

Part I

        Home Telehealth/Remote Patient Monitoring

        Making the Case for Home Telehealth

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

The Panasonic Home Gateway

        Program Rationale

        The Technology

        Program Details--Operational Design

        THE PATHWAYS TO HEALTH PROGRAM

        The Target Population

        Program Details--Implementation

        Program Challenges

Program Results

        Emergency Room Visits

        Medication Adherence

        Results: Satisfaction

Part II: Implications of the Results

Stakeholders

        Stakeholder: Medicare

        Conclusion: Medicare

        Stakeholder: Medicaid--the Dually-Eligible Population

        Conclusion: Medicaid

        Stakeholders: Medicaid State Policy and FIDA

        Conclusion: FIDA Plans

        Stakeholders: Hospitals

        Conclusion: Hospitals

        Stakeholders: ACOs--Economies of Scale

        Conclusion: ACOs

        Stakeholders: The Growing Footprint of Managed Care in Medicare

        Conclusion: Medicare Advantage

        Stakeholders: Medicare Home Health Agencies

        Conclusion: Home Care

Contributing Factors: Health Care Costs

        Cost Factor: Medication Adherence

        Cost Factor: Health Literacy

        Cost Factor: Satisfaction with the Care Experience

        Cost Factor: Labor Shortages and the Increasing Demand for Care

        Conclusion: Cost factors

Conclusion

References

APPENDIX A--Results--Pathways to Health

        Chart 1--Six month hospitalization rate

        Chart 2--Gateway Reductions

        Chart 3--Six Month ER Visit Rate

        Chart 4--Gateway Satisfaction

        Chart 5--Adherence Trend in Medication

        Chart 6--System Utilization

APPENDIX B--Stakeholders

        Chart 1- Medicare Benefits Payments

        Chart 2--Health Status of Duals--Comparison

        Chart 3--Comparative Service Use

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

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

   Hospitalizations

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

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

   Emergency room visits

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

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

   Medication adherence

     96-99 percent range

   Satisfaction

     95 percent satisfied or better

     100 percent would recommend to family or friends

     100 percent felt safer at home

   Utilization

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

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

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    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.


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

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

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

Medication Adherence
    Participants were reminded each day to take their medication and 
also were asked if they had taken their medications as prescribed. In 
contrast to studies related to overall medication adherence, 
participants generally indicated a high rate of adherence with their 
medication regimes, ranging from 96 percent at the beginning of the 
study to 99 percent in June 2014. However; each month, a significant 
percentage of those who responded ``no'' to the medication query 
additionally responded that the reason they did not was because they 
were out of their medication. This information was passed on to their 
care manager for a follow up intervention that ensured their 
prescriptions were refilled or renewed. During the course of the study, 
the percent of those that indicated they were out of their medications 
dropped, and at the same time, a slight, but noticeable trend upward 
was evidenced in medication adherence as shown in Table D. See also 
Appendix A, Chart 5.
---------------------------------------------------------------------------
    \4\ Data reported in Jacobson, (2012)
    
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                                          Table D--Medication Adherence
----------------------------------------------------------------------------------------------------------------
           Report Month               January      February      March        April         May          June
----------------------------------------------------------------------------------------------------------------
Adherent                                    97%          96%          97%          95%          98%          99%
----------------------------------------------------------------------------------------------------------------
Non Adherent                                 3%           4%           3%           5%           2%           1%
----------------------------------------------------------------------------------------------------------------

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

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

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    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).

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

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

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

   24 percent Diet non-compliance

   24 percent Prescribed medication non-compliance

   16 percent Inappropriate medication

   19 percent Failure to seek care

   17 percent other

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

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


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

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]




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

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

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

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

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

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

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

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

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]




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

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]




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

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

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

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

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

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

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

   Overall population health; and

   Per capita cost of health care.

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

   Improved access to care;

   Satisfaction with the technology;

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

   Increased patient/caregiver involvement in managing their 
        disease.

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

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

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

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

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

   Hospitalizations

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

     Medicare Advantage-44 percent reduction compared to 
            previous claims data

   Emergency room visits

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

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

   Medication adherence

     96-99 percent range, all participants

   Satisfaction

     95 percent satisfied or better

     100 percent would recommend to family or friends

     100 percent felt safer at home

   Utilization

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

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

        Chart 1--Six month hospitalization rate

        Chart 2--Gateway Reductions

        Chart 3--Six Month ER Visit Rate

        Chart 4--Gateway Satisfaction

        Chart 5--Adherence Trend in Medication

        Chart 6--System Utilization

Appendix B--Stakeholders

        Chart 1--Medicare Benefits Payments

        Chart 2--Health Status of Duals--Comparison

        Chart 3--Comparative Service Use

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


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Chart 2--Gateway Reductions

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


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

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

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

   [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.

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