[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
21st CENTURY MEDICINE: HOW TELEHEALTH CAN HELP RURAL COMMUNITIES
=======================================================================
HEARING
before the
SUBCOMMITTEES ON AGRICULTURE, ENERGY, AND TRADE AND HEALTH AND
TECHNOLOGY
OF THE
COMMITTEE ON SMALL BUSINESS
UNITED STATES
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
HEARING HELD
JULY 20, 2017
__________
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Small Business Committee Document Number 115-031
Available via the GPO Website: www.fdsys.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
26-251 WASHINGTON : 2017
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HOUSE COMMITTEE ON SMALL BUSINESS
STEVE CHABOT, Ohio, Chairman
STEVE KING, Iowa
BLAINE LUETKEMEYER, Missouri
DAVE BRAT, Virginia
AUMUA AMATA COLEMAN RADEWAGEN, American Samoa
STEVE KNIGHT, California
TRENT KELLY, Mississippi
ROD BLUM, Iowa
JAMES COMER, Kentucky
JENNIFFER GONZALEZ-COLON, Puerto Rico
DON BACON, Nebraska
BRIAN FITZPATRICK, Pennsylvania
ROGER MARSHALL, Kansas
RALPH NORMAN, South Carolina
NYDIA VELAZQUEZ, New York, Ranking Member
DWIGHT EVANS, Pennsylvania
STEPHANIE MURPHY, Florida
AL LAWSON, JR., Florida
YVETTE CLARK, New York
JUDY CHU, California
ALMA ADAMS, North Carolina
ADRIANO ESPAILLAT, New York
BRAD SCHNEIDER, Illinois
VACANT
Kevin Fitzpatrick, Majority Staff Director
Jan Oliver, Majority Deputy Staff Director and Chief Counsel
Adam Minehardt, Staff Director
C O N T E N T S
OPENING STATEMENTS
Page
Hon. Rod Blum.................................................... 1
Hon. Brad Schneider.............................................. 2
Hon. Al Lawson................................................... 3
Hon. Trent Kelly................................................. 4
WITNESSES
Ms. A. Nicole Clowers, Managing Director, Health Care Team,
United States Government Accountability Office, Washington, DC. 5
Ms. Barb Johnston, Chief Executive Officer and Co-Founder,
HealthLinkNow, Sacramento, CA.................................. 6
Mr. Michael Adcock, Administrator, Center for Telehealth,
University of Mississippi Medical Center, Jackson, MS.......... 8
David Schmitz, M.D., President, National Rural Health
Association, Washington, DC.................................... 10
APPENDIX
Prepared Statements:
Ms. A. Nicole Clowers, Managing Director, Health Care Team,
United States Government Accountability Office, Washington,
DC......................................................... 32
Ms. Barb Johnston, Chief Executive Officer and Co-Founder,
HealthLinkNow, Sacramento, CA.............................. 43
Mr. Michael Adcock, Administrator, Center for Telehealth,
University of Mississippi Medical Center, Jackson, MS...... 49
David Schmitz, M.D., President, National Rural Health
Association, Washington, DC................................ 53
Questions for the Record:
None.
Answers for the Record:
None.
Additional Material for the Record:
CCA - Competitive Carriers Association....................... 62
GAO Report................................................... 65
The National Congress of American Indians and The National
Indian Health Board........................................ 137
21st CENTURY MEDICINE: HOW TELEHEALTH CAN HELP RURAL COMMUNITIES
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THURSDAY, JULY 20, 2017
House of Representatives,
Committee on Small Business,
Subcommittee on Agriculture, Energy and Trade,
joint with the
Subcommittee on Health and Technology,
Washington, DC.
The Subcommittees met, pursuant to call, at 10:00 a.m., in
Room 2360, Rayburn House Office Building, Hon. Rod Blum
[chairman of the Subcommittee] presiding.
Present: Representatives Chabot, Luetkemeyer, Radewagen,
Kelly, Blum, Comer, Gonzalez-Colon, Bacon, Fitzpatrick,
Marshall, Lawson, Espaillat, and Schneider.
Chairman BLUM. Good morning. I call this hearing to order.
The Subcommittees are here today to examine how the expansion
of telehealth services may benefit small businesses and rural
communities. Telehealth or telemedicine refers to the use of
online video or telephone communication to deliver healthcare
services that are to replace or supplement existing healthcare
services.
Telehealth is becoming a vital component of medical
treatment, particularly in areas where there are provider
shortages, such as rural areas where I am from, or for
conditions that require regular monitoring.
While 20 percent of Americans live in rural areas, only 9
percent of physicians practice there. Rural communities often
struggle with provider shortages, requiring patients and their
families to travel long distances to access medical care.
Telehealth may allow rural physicians to expand their
patient base and to keep dollars in the community, benefitting
other local small businesses, such as retail establishments and
restaurants, contributing to a sense of community that American
small towns pride themselves on. Expanding use of telehealth
services may even attract physicians to open or relocate
practices in rural areas without worrying about having enough
local patients to stay in business. Those of us from rural
areas would not want to live anywhere else, yet new physicians
often have concerns about opening a viable practice in a rural
community.
Our witnesses today will discuss the current use of
telehealth and the barriers that are providing wider use. I
want to thank all of them for being here today. We look forward
to hearing your testimony. And I now yield to the ranking
member of the Subcommittee on Agriculture, Energy, and Trade,
Mr. Schneider, right on cue, for his opening statement.
Mr. SCHNEIDER. Thank you, and I am sorry I am late.
Elevators. Anyway, I want to thank the panelists for being here
and taking the time to share your thoughts with us about
healthcare coverage for rural America.
Today, rural populations are more likely to be poorer,
sicker, older, and have higher rates of uninsured compared with
urban populations. Exacerbating these issues, rural Americans
experience many difficulties in accessing healthcare services
which leads to higher morbidity and mortality rates compared to
those of their urban counterparts.
Among the primary challenges rural communities face is a
lack of adequate insurance coverage or even getting coverage at
all. Nearly one-quarter of all adults in rural communities are
uninsured, and nearly 60 percent of the rural uninsured are
low-income families.
Rural populations are less likely to have employer-
sponsored health insurance. Consequently, Medicaid is a
critical lifeline for rural and underserved communities. This
is why efforts to repeal the progress the Affordable Care Act
has made to provide coverage to underserved and rural
communities is so misguided.
In addition, there is a shortage of doctors and hospitals
in rural areas, and institutional barriers can make providing
care in these areas especially challenging. These challenges
not only result in poor health outcomes for people in rural
communities but have significant implications for the local
economy.
I look forward to hearing testimony today about policies
that can increase the number of physicians in underserved
communities and leverage technological innovation to improve
health access and quality. Policies that increase insurance
coverage not only benefit patients but also create jobs in the
healthcare sector, a sector that is overwhelmingly comprised of
small businesses.
In fact, it is estimated that, since 2012, 50,000 jobs were
added to the healthcare sector as a direct result of the
expansion of coverage under the Affordable Care Act. Despite
this growth, there still remains a significant provider
shortage in rural areas. Even with insurance coverage, many
patients in rural areas struggle to find care, especially when
it comes time to visit a specialist.
The fact is made abundantly clear by the ongoing opioid
epidemic currently plaguing our Nation. It's estimated that as
many as 3 million people in the U.S. are suffering from opioid
addiction related to prescription drugs and heroin. As opioid-
related deaths have gone up across the Nation, the largest
increases are reported in heavily rural States. Our
constituents and their families need help, but they often have
no place to go. For example, 13 percent of rural communities
have no behavioral health providers. Telehealth has the
potential to bring high quality behavioral health services to
these suffering communities.
Indeed, studies have shown that video telehealth users have
satisfaction levels and outcomes similar to those clients
receiving in-person therapy. Although it is still in its early
stages, telehealth is expanding at a rapid rate, and has
potential to dramatically improve access to quality care in a
number of areas. Telehealth also has the potential to draw more
doctors into practice in rural settings, who would otherwise
feel isolated, and can be used to connect specialists with
community providers, allowing practitioners to join a virtual
community where they can receive mentoring and grow
professionally.
Improving access to care in rural areas also benefits the
local small business economy. There are over 1,500 rural
hospitals nationwide that support nearly 2 million jobs. Every
dollar spent by a rural hospital produces $2.29 of economic
activities. When patients can receive care in their community,
they do not need to travel to urban centers. They are able to
keep their dollars within their own community and help to drive
the success of local small firms. I look forward to hearing
testimony today about how we can advance policies and leverage
telehealth to improve access to quality healthcare for rural
and underserved communities.
With that, I say thank you, and I yield back.
Chairman BLUM. Thank you, Mr. Schneider.
I would now like to yield to the ranking member of the
Subcommittee on Health and Technology, Mr. Lawson, for his
opening statement.
Mr. LAWSON. Thank you, Mr. Chairman, and welcome to the
Committee.
Nineteen percent of the U.S. population live in rural
areas, as most of you know, yet only about 9 or 10 percent of
physicians practice in rural areas. Rural populations have
fewer hospitals and healthcare providers, particularly
specialists, than any other urban counterparts. And patients
often must travel long distances, as we heard earlier, to
access care while primary care providers struggle to coordinate
care with specialists.
This not only has implications for doctors, clinics, and
small hospitals, but for the local small business economy.
However, innovations in technology are helping to alleviate the
strain on small providers. Today's hearing will offer an
opportunity to examine ways that we can improve access to
healthcare in rural areas.
Telehealth has the potential to advance healthcare quality
by reducing costs. It can save patients time and money in
traveling to see their doctors while also allowing small
practices to broaden their scope. This also indirectly benefits
local small business economy by keeping dollars in the
community to make rural areas more attractive.
I myself grew up in a rural area. And in recent years,
innovations have made telehealth technology more accessible to
rural providers than ever before. However, obstacles to its
adoption remain. Some barriers are easy to overcome, such as
educating doctors and patients about its utility. Other
obstacles, such as a lack of broadband connectivity, are more
challenging.
I am pleased this hearing will provide the opportunity for
us to examine not only the barriers to health faced by rural
communities but how innovations in technology can improve them.
I hope that this hearing will help us identify ways we can
encourage greater adoption of telehealth and how improved
access to care benefits small business economy. I want to thank
our witnesses again who traveled here today for both their
participation and insight into this important topic.
With that, Mr. Chairman, I yield back.
Chairman BLUM. Thank you, Mr. Lawson.
If Committee members have an opening statement prepared, I
ask that it be submitted for the record.
I would like to take a moment to explain the timing lights
to our panelists. You will each have 5 minutes to deliver your
testimony. The light will start out as green. When you have 1
minute remaining, the light will turn yellow. And, finally, at
the end of your 5 minutes, it will turn red, and we ask that
you try to adhere to that time limit to the extent possible.
I would now like to formally introduce our witnesses today.
Our first witness is Ms. Nikki Clowers, the managing director
of the healthcare team at the U.S. Government Accountability
Office, or better known as GAO. The healthcare team at GAO
recently released a report entitled ``Telehealth and Remote
Patient Monitoring Use in Medicare and Selected Federal
Programs'' and surveyed a wide variety of stakeholders on the
state of telehealth use in Federal health programs. Thank you
for being here with us today.
Our next witness is Ms. Barb Johnston, the chief executive
officer and cofounder of HealthLinkNow in Sacramento,
California. Ms. Johnston's company helps mental health
providers incorporate telehealth services into their practices.
Additionally, through a Centers for Medicare and Medicaid
Services grant, her company integrated telehealth services into
more than 80 primary care clinics in three rural States,
Montana, Wyoming, and Washington. We appreciate your testimony
and being here today.
And I now yield to Mr. Kelly, a member of the full
Committee, for the introduction of our next witness.
Mr. KELLY. Thank you, Mr. Chairman.
I would also like to just acknowledge that the chairman of
the full Committee, Chairman Chabot, has joined us, and we
thank him for being here on this important event.
Thank you. I am proud to introduce Mr. Michael Adcock, the
administrator of the Center for Telehealth at the University of
Mississippi Medical Center, or UMMC. As executive director for
UMMC Center for Telehealth, Michael is on the front lines of
combating the severe doctor shortage that Mississippi faces.
The UMCC Center for Telehealth is, in my opinion, the best in
the country and leverages location within Mississippi's only
teaching hospital to deliver high-quality care to rural
patients that often lack access.
Mr. Adcock, I am excited to have a great Mississippian here
today, and I look forward to hearing your opening statement.
Thank you, Mr. Chairman. I yield back.
Chairman BLUM. Thank you, Mr. Kelly.
I now yield to our ranking member, Mr. Schneider, for the
introduction of our next witness.
Mr. SCHNEIDER. I am going the yield to my colleague Mr.
Lawson.
Mr. LAWSON. Thank you, sir. Okay. I have the pleasure of
introducing Dr. Schmitz, president of the National Rural Health
Association, professor and chair in the Department of Family
and Community Medicine at University of North Dakota School of
Medicine and Health Sciences.
Dr. Schmitz has spent nearly 20 years in rural practice and
teaching residents and students in the area of medical
education, rural health, and workforce research. He is an
active in both the American Academy of Family Physicians,
serving on the Commission on Quality and Practice, the Global
Association of Family Physicians serving as the North American
representative to the executive of the Group of Rural
Practices. I welcome Dr. Schmitz.
Chairman BLUM. Thank you, Mr. Lawson.
I would like to now recognize Ms. Clowers for her 5-minute
testimony.
STATEMENTS OF A. NICOLE CLOWERS, MANAGING DIRECTOR, HEALTH CARE
TEAM, UNITED STATES GOVERNMENT ACCOUNTABILITY OFFICE,
WASHINGTON, D.C.; BARB JOHNSTON, CHIEF EXECUTIVE OFFICER AND
COFOUNDER, HEALTHLINKNOW, SACRAMENTO, CALIFORNIA; MICHAEL
ADCOCK, ADMINISTRATOR, CENTER FOR TELEHEALTH, UNIVERSITY OF
MISSISSIPPI MEDICAL CENTER, JACKSON, MISSISSIPPI; AND DAVID
SCHMITZ, M.D., PRESIDENT, NATIONAL RURAL HEALTH ASSOCIATION,
WASHINGTON, D.C.
STATEMENT OF A. NICOLE CLOWERS
Ms. CLOWERS. Chairman Blum, Ranking Members Schneider and
Lawson, Chairman Chabot, and members of the Subcommittee, thank
you for inviting me here today to discuss our April 2017 report
on telehealth.
Access to healthcare services can be challenging for some
people, such as those who live in remote areas. Telehealth can
provide an alternative to healthcare provided in person or at a
doctor's office--for example, by providing clinical care
remotely through two-way video.
In my comments today, I will cover three topics from our
April report. One, the extent to which telehealth is used in
Medicare and Medicaid; two, factors that affect the use of
telehealth in Medicare; and, three, the different payment and
delivery models that could affect the potential use of
telehealth in Medicare.
First, we found that Medicare providers used telehealth
services for a small proportion of beneficiaries and relatively
few services. For example, an analysis of Medicare claims data
by the Medicare Payment Advisory Commission, or MedPAC, shows
that less than 1 percent of all Medicare Part B fee-for-service
beneficiaries accessed services using telehealth in 2014.
According to MedPAC, beneficiaries using telehealth
averaged about three telehealth visits in 2014, and Medicare
spent about $14 million in total in telehealth services in that
year. The most common telehealth visits were for evaluation and
management services, followed by behavioral health services.
MedPAC's analysis shows that 10 States accounted for almost
half of all Medicare telehealth visits.
For Medicaid, the use of telehealth varies by State, as
individual States have the option to determine whether to cover
telehealth and what types of telehealth services to cover,
among other things. We reviewed six States to gauge the extent
to which telehealth is used by Medicaid. We found that
officials from States that were generally more rural than urban
said they used telehealth more frequently than officials from
more urban States.
For example, Montana officials told us that they have used
telehealth as a tool to help patients see both in-state and
out-of-state specialists remotely, as there is a limited access
to specialists in the State.
In contrast, officials from Illinois, which contains more
urban areas, told us that telehealth represented a very small
portion of their Medicaid budget and was used primarily to
provide behavioral health services.
Second, stakeholders that we interviewed identified factors
that encouraged the use of telehealth in Medicare, including
the potential to improve or maintain quality of care, address
provider shortages, and increase convenience to patients.
For example, telehealth can increase convenience by
shortening or eliminating travel times, which may lead to
better adherence to recommended treatment and to patient
satisfaction. However, these stakeholders also identified
several potential barriers to the use of telehealth in
Medicare, including payment and coverage restrictions.
For example, officials from one provider association
reported that Medicare's telehealth policies for payment and
coverage, such as those restrictions that limit the geographic
and practice settings in which beneficiaries may receive
telehealth services, are more restrictive than the policies of
other healthcare payers.
Finally, as of April 2017, CMS was supporting eight models
and demonstrations that have the potential to expand the use of
telehealth in Medicare. For example, one demonstration aims to
develop and test new models of integrated healthcare in
sparsely populated rural areas. Under the demonstration, CMS
allows participating providers to receive cost-based payment
for telehealth when their location serves as the originating
site, rather than the approximately $25 fixed fee that CMS
otherwise pays originating sites.
In summary, while the use of telehealth in select Federal
programs is low, it remains an important alternative to
providing healthcare services in person, especially for
patients who cannot easily drive long distances for care.
Chairman, ranking members, and members of the Subcommittee,
this concludes my prepared remarks. I would be pleased to
answer questions at the appropriate time.
Chairman BLUM. Thank you Ms. Clowers.
I now recognize Ms. Johnston for 5 minutes.
STATEMENT OF BARB JOHNSTON
Ms. JOHNSTON. Thank you. Honorable Steve Chabot, Chairman
Blum, and other members of the Subcommittee, my name is Barb
Johnston as announced----
Chairman BLUM. Can you move closer to the microphone or
move it closer to you? Thank you.
Ms. JOHNSTON. Does that work better? Okay. So sorry. I have
been working in telemedicine for so long now I am thinking of
lying. It has been over 20 years. It has been a labor of love.
I have learned so much along the way. Today, I am here as a
private citizen. I am doing that because I have been working in
so many different areas, I wanted to cover lessons learned from
so many of the opportunities I have had to work primarily
serving people in rural areas.
As mentioned before, the core problem for rural medicine is
15 percent of the Americans who live there are only served by
10 percent of the Nation's doctors. Telemedicine has been
around for a long time. Some of you may not know that
psychiatry, telepsychiatry has been practiced for 50 years,
half a century.
So far, there are some key things I wanted to share with
you that have been demonstrated and that people have already
mentioned, but I want to bring it up again. Telemedicine has
shown and has massive capacity to keep rural dollars in rural
communities. It supports rural primary care providers and
clinics. It helps keep hospitals and clinics open. Without the
support of specialists through these modalities that are so
commonly used in our everyday life, such as using our cell
phone, which is just a minicomputer or banking or education--
people in this country expect to be able to use technology to
receive appropriate and high-quality care using telemedicine,
and it is happening. It is happening all over the country. It
is growing.
It encourages recruitment and retention of the local
doctors and providers who do serve physically in person in
rural communities. Many, many studies, work that I have done,
continues to show it does lower the overall cost of care. It
can actually avoid small businesses closing. A person who owns
a small business or a worker in a rural community who has to
travel 3, 4 hours out site has to shut down that business that
day. It costs them so much money and is so unnecessary. They
lose wages, and the community may lose the barber shop, the
only restaurant in town.
It also helps support health IT workforces. Every program I
have ever started has included people in rural communities
learning to use these technologies, and one thing you all
should know: Rural people are very smart. They catch on very
quickly. They are brilliant at putting these things together.
I think we all know that the cost of healthcare in this
country is significant. It is growing. Telemedicine has the
capacity to help resolve some of that financial burden. There
are laws and regulations that could help significantly. I am
identifying three that are crucial.
Number one is the problem we have with the DEA rule related
to a 2008 bit of legislation called the Ryan Haight Act that
inadvertently prevents our doctors providing the medication
that they need so that when a telemedicine service is provided,
specifically it affects three groups: Opiate addicts who need
the medication, the doctors are not allowed to do the
prescription online. All the doctors that we work with use
electronic health records. They can't provide the drugs that
these opiate addicts need. Our veterans, and I have seen a lot
of them, they cannot receive the basic medications they need
for PTSD, traumatic brain syndrome, just because of an
inadvertent inclusion in that DEA rule. That could and should
be changed and corrected. Children with ADDH, they lose school
days. They can't pass because they can't get the medication
they need.
One of the biggest problems we have had since Medicare
instituted the rural requirement, this limits patients with
Medicare who live in geographic locations that are defined by,
in my opinion, very narrow rural designation; they can't
receive Medicare services. Those constituents are getting more
and more upset. They are seeing these things on TV. They know
telemedicine exists. Medicaid doesn't have these rules, but
Medicare does.
And the last one is the complicated credentialing licensing
problems.
I see my time has run out. So I will leave where I am
because I hit the key elements, and I am grateful, very honored
to be allowed to present to you, and thank you so much for your
consideration on this important topic.
Chairman BLUM. Thank you, Ms. Johnston. We are grateful
that you are here, as well.
Mr. Adcock, you are recognized for 5 minutes for your
testimony.
STATEMENT OF MICHAEL ADCOCK
Mr. ADCOCK. Thank you. Chairman Chabot, Chairman Blum,
Ranking Members Schneider and Lawson, and members of the Small
Business Committee, thank you for the opportunity to appear
today. I am Michael Adcock, Executive Director for the Center
for Telehealth at the University of Mississippi Medical Center
in Jackson, Mississippi. I am honored to talk with you this
morning about telehealth and the ways its power can be
harnessed to address the healthcare needs of America's small
businesses.
Mississippi has significant healthcare challenges, leading
the Nation in heart disease, obesity, cardiovascular disease,
and diabetes. These and other chronic conditions require
consistent quality care, a task that is made harder by the
rural nature of our State. In order to improve access to care
and give Mississippians a better quality of life, it is clear
that we need something more than traditional clinic and
hospital-based services.
Telehealth has been a part of the healthcare landscape in
Mississippi for over 13 years, beginning with an aggressive
program to address mortality in rural emergency departments.
This program has had a significant impact not only in bringing
quality care to the residents of these communities but in
supporting the viability of the community hospitals themselves.
In some cases, TelEmergency prevented hospital closures that
would have been detrimental to these underserved communities.
Today, the UMMC Center for Telehealth delivers care in over
200 sites in 68 of our State's 82 counties and provides access
to patients who might otherwise go untreated. Maximizing our
utilization of healthcare resources through the use of
technology is the only way that we can reach all of the
Mississippians who need care.
Small businesses account for 99.9 percent of all firms in
the United States and often cite access to healthcare has their
number one concern. Decreasing absenteeism, increasing
productivity, and improving access to high-quality care are
concerns to small businesses owners and were the drivers behind
the creation of our eCorporate program at UMMC. This program
allows employees to access high-quality care from their
workplace through secure audiovisual connections, avoiding
travel to seek medical care and promoting appropriate use of
healthcare resources at a lower cost.
Several corporations have chosen to pay for this service
for their employees and allow paid time during the workday to
use the service, further reducing barriers to healthcare.
Should an employee have a need outside the scope of
telehealth, UMMC assists in securing appropriate followup with
local providers. The eCorporate program currently covers more
than 4,000 employees and dependents statewide. We offer
wellness services and diabetes prevention management services
for corporations, as well.
Another program that has been very impactful for patients
is remote patient monitoring, which supports patients as they
manage these chronic diseases in their home. RPM is designed to
educate, engage, and empower patients so they can take care of
themselves. Our initial pilot with diabetics in the Mississippi
Delta was a public-private partnership to test the
effectiveness of remote patient monitoring using technology in
rural, underserved areas.
The preliminary results showed a marked decrease in blood
glucose, early recognition of diabetes-related eye disease,
reduced travel to see specialists, and, most remarkably, no
diabetes-related hospitalizations or emergency room visits
among our patients.
The Mississippi Division of Medicaid extrapolated this data
to show a potential savings of $180 million per year if 20
percent of the diabetics in Mississippi on Mississippi Medicaid
participated in the program. Given the success of this diabetes
pilot, UMMC Center for Telehealth has expanded remote patient
monitoring statewide.
Healthcare is a major economic driver across the United
States, and this has already been discussed. In Mississippi,
hospitals boast over 60,000 full-time employees and create an
additional 34,000 jobs outside of their facilities. For every
new physician creates approximately 21 jobs and more than $2
million in revenue for our community. For every three jobs
created by a hospital, an additional job is created by other
businesses in the local economy.
Our telehealth program directly supports the financial
viability of the healthcare system, especially primary care
providers' offices, small rural hospitals, and rural healthcare
clinics. Keeping services in the communities not only supports
the local providers but keeps much needed employment and
revenue in the rural communities.
Businesses in Mississippi that have utilized our telehealth
and remote patient monitoring programs have seen improved
access to care, decreased healthcare costs, and improved
quality of care for their employees. Healthy employees mean
decreased absenteeism, increased productivity, and a greater
chance for small businesses to remain viable.
Thank you all for your time and attention to this very
important matter.
Chairman BLUM. Thank you, Mr. Adcock.
And for some reason, you are a little easier to understand
than my good colleague and friend, Mr. Kelly from Mississippi.
So we appreciate that.
Dr. Schmitz, you are now recognized for 5 minutes.
STATEMENT OF DAVID SCHMITZ, M.D.
Dr. SCHMITZ. Good morning, Mr. Chairman, ranking members,
and members of the Subcommittee. Thank you for inviting me here
to testify. My name is David Schmitz, and I am a family
physician who has practiced and taught in rural America for
more than 20 years. I am here today representing the National
Rural Health Association where I currently serve as president,
and I am grateful to have this opportunity to discuss rural
healthcare and its impact on rural America and local economies.
For 62 million Americans living in rural and remote
communities, access to quality and affordable healthcare is a
major concern. Rural Americans on average are older, sicker,
and poorer than their urban counterparts, as we have heard.
They are also more likely to suffer from chronic diseases that
require ongoing monitoring and follow up care. Local care is
necessary to ensure patient ability to adhere to the treatment
plans to help reduce the overall cost of care and to improve
patient outcomes and their quality of life.
Whether following the delivery of a healthy baby or
significant loss of function due to stroke, local integrated
care for rural people in their own support systems is not only
the right care; it is better care.
Rural communities are resourceful, and the continuity of
care is primary to good outcomes, such as avoidance of hospital
readmissions. Investing dollars locally can save what would
otherwise be wasted dollars lost to inefficiencies, anonymity,
and the gaps that occur in the miles between.
There is no doubt that rural healthcare delivery is
challenging. Workforce shortages, older and poorer patient
populations, geographic barriers, low patient volumes, and high
rates of publically insured Medicare and Medicaid recipients,
uninsured and underinsured populations are just a few of the
barriers.
Unfortunately, a growing number of rural Americans are
living in areas with limited healthcare options. Indeed, 81
rural hospitals have closed since 2010, leaving many rural
Americans without timely access to emergency care. Two of the
most recent of these, closing on June 30 of this year, were in
Florida and Texas.
As noted in my written testimony, health disparities
between rural populations and their urban counterparts are
pronounced, and this can be particularly true among the growing
minority populations in rural America. Rural healthcare
providers are not only critically important for health of rural
Americans, they are also critically important for economic
health of rural communities. While many industries in rural
America have been shrinking, healthcare is an industry with the
potential to reverse declining employment. As factory and
farming jobs have declined, the local rural hospital often
becomes the hub of the local business community, not only
offering critical lifesaving services, but representing as much
as 20 percent of the rural economy. Simply put, hospitals
provide a large number of jobs.
The average critical access hospital creates 195 jobs,
generates $8.4 million in payroll annually, and rural hospitals
are often the largest or second largest employer in a rural
community, along with the school system. This was true in the
community I practiced in of 2,303 people for 6 years.
In addition, a single rural primary care physician, again
as we heard, can generate as many as 23 jobs and more than a
million dollars in annual wages, salaries, and benefits. In my
own personal experience, rural communities are both resourceful
and resilient. As referenced in my written testimony, training
doctors and other health professionals close to home makes it
more likely that they will call that place home.
In order for this to occur, we must have technology across
a rural distributed campus, per se, training our workforce to
meet the needs of rural communities and at the same time
providing economic investment in those rural places.
Graduate medical education or residency training regulatory
reform, allowing for education of physicians in rural
hospitals, is one example of how to address rural economic
development and workforce shortages in one action while
improving quality of care and delivering cost-saving
healthcare.
Technology. Technology, such as telemedicine for
consultation services have supported rural delivery of care but
depend on adequate development of broadband internet into rural
and remote areas. Still hands-on care is needed when an
unexpected car accident or early delivery of a premature baby
occurs in rural America. No matter if you are a local resident
or simply visiting, each one of us who will spend our time and
dollars in rural communities, and at those times, will
appreciate quality local care in those moments.
In addition to these lifesaving measures, healthcare is one
industry capable of playing a critical role in supporting the
local economy and protecting rural communities from further
economic damage. If roads and internet access are the blood
vessels and the nerves, then, in my opinion, healthcare is the
backbone for investing in rural America.
Thank you again for the invitation to speak and to
accompany my written testimony as submitted.
Chairman BLUM. Thank you, Dr. Schmitz.
I now yield to the chairman of the Subcommittee on Health
and Technology, Ms. Radewagen, for her opening statement.
Chairwoman RADEWAGEN. Thank you, Mr. Chairman.
I want to apologize for being a little bit late. I was on
the Senate side testifying on behalf of the Secretary Zinke's
Assistant Secretary for Insular Areas, which is our areas.
So, talofa. Good morning. Thank you, Chairman Blum, and
thank you all for testifying today. Good morning to Chairman
Chabot, as well. It is an honor to chair the Subcommittee on
Health and Technology, and I look forward to learning more
today about how both health and technology can benefit small
businesses and rural communities.
According to recent data from the Kaiser Family Foundation,
American Samoa is facing tremendous shortages of primarily
healthcare professionals and is currently only meeting around
10 percent of need in terms of the number of physicians
available to serve the population. The Samoan Islands have
among the highest rates of obesity and type 2 diabetes in the
world, with one-third of American Samoans suffering from
diabetes.
If medical treatment is unavailable on the island,
patients, including many VA beneficiaries, generally have to
fly nearly 3,000 miles to Hawaii to see a specialist. Recently
CMS granted a waiver that will allow Medicaid patients to go to
New Zealand instead. That has been helpful.
I am very interested in hearing and learning more about
strategies for increasing the use of telehealth in rural and
remote areas, like American Samoa, where provider shortages are
severe. I also look forward to hearing more about how
telehealth could attract more new or current physicians to
locate their practices in rural areas, like American Samoa,
where the tropical scenery, rain forests, beaches, and reefs
are second to none.
I want to thank all the witnesses for being here today, and
I yield back my time to Chairman Blum.
Chairman BLUM. Thank you, Ms. Radewagen, and thank you for
that commercial at the end. We agree with you.
I now recognize myself for 5 minutes of questions. I love
this topic. I think, you know, the increase in costs in
healthcare in our country are not due to one large thing or two
large things. I think, and pardon the pun, it is death by a
thousand cuts. The increased costs are because of a thousand
smaller things, and I also think the solution is not one silver
bullet to solving increased access and decreased costs while
keeping our quality high. There is not one silver bullet. I
think it is a thousand smaller things, if you will. I
absolutely believe one of those things smaller things is
telemedicine.
I would like--this is for the whole panel--ideas of where--
the Federal Government is the largest purchaser of healthcare
in the country, obviously. I would like to hear from you places
the Federal Government can increase the outcomes, the quality
of the outcomes, increase access, decrease costs by utilizing
telemedicine that we are not doing today. Give me two or three
great examples of here's where we can save money and increase--
improve the outcomes for patients. Anyone?
Dr. Schmitz.
Dr. SCHMITZ. Thank you, Mr. Chairman.
Just a couple of brief examples. One is you have heard the
use of Tele-Emergency medicine. Again, how can you develop a
relationship between a, for example, family physician and a
critical access hospital; being able to be simultaneously
supported both in their practice, which retains them, and also
lowering the barrier to recruiting to rural areas. At the same
time the transfer, if necessary, is expedited with high quality
care.
Another example is tele-ICU or intensive care unit,
consultation, allowing again, patients to stay in place, when
possible. A third example is something called Project ECHO,
which is a learning group where you can have essentially
development of teams across the spectrum disease, including
opioids, to be able to develop better practices across the
country. And my final and fourth would be, again, the use of
technology in telemedicine in distributed medical education and
health professions education, training people as close to home
as possible.
Chairman BLUM. So these items you just mentioned, Doctor,
are not being done today?
Dr. SCHMITZ. To a certain extent they are, but there are
also opportunities with regard to reimbursement mechanisms and
regulatory mechanisms that would allow this to be expanded,
particularly into rural areas. One example I mentioned was
graduate medical education funding and residency funding
reform, allowing again, more cost-based reimbursement or more
support of these both workforce initiatives as well as
healthcare delivery mechanisms.
Chairman BLUM. Thank you.
Are there others?
Ms. Johnston?
Ms. JOHNSTON. Thank you. I think the market has the
potential to drive expansion massively if the handcuffs could
come off, and I mean that in reference to my earlier remark,
the limitation of the location of a patient being rural or not
rural. It actually doesn't make any sense to me. It doesn't
make sense to constituents when you have a neighbor who has
Medicaid and they can see a doctor, and their next-door
neighbor has Medicare and they can't, and that conversation is
growing. I am hearing--I am an active member of the American
Telemedicine Association, so I hear it from my colleagues all
over the country. If that one thing could get corrected, I
think the market would drive expansion, and it would help
business in this country.
The other place is in skilled nursing facilities. Skilled
nursing facilities primarily are caring for our elderly, some
disabled, and in those facilities, almost all of the ones that
we have approached even when I was in the position of having
millions of dollars to fund programs, which I did, I couldn't
get one nursing home to accept starting a program for fear that
there would be an incorrect billing and they would be doing
fraud, or because they would have some of their clients not
being able to access care, and they didn't want to look like
they were preferentiating one group over another.
Chairman BLUM. Mr. Adcock?
Mr. ADCOCK. Yeah, another area that is not currently being
paid for through Medicare, not being reimbursed with Medicare,
is remote patient monitoring, so chronic disease management in
patients' homes. As we know, Medicare recipients often struggle
from many chronic diseases, not just one, but diabetes, heart
disease, and that is something we can impact through remote
patient monitoring. Right now, there is not a payment mechanism
for remote patient monitoring through Medicare.
Chairman BLUM. Do you feel this would actually save the
government money or improve the outcome?
Mr. ADCOCK. Absolutely. Yes. I mean, similar to what we
have done in Mississippi with Medicaid, I definitely--Medicaid,
obviously, in Mississippi, is funded by Federal and State
dollars. There is a tremendous savings just in diabetes. So,
yes, we are performing this service in congestive heart
failure, hypertension, asthma, COPD. There are many different
chronic modalities that are costing a lot of money, and a lot
of our healthcare resources that can be taken care of in the
home through technology.
Chairman BLUM. Thank you.
And now my time has expired, and I now recognize the
ranking member, Mr. Schneider, for 5 minutes.
Mr. SCHNEIDER. Thank you, Chairman Blum.
And thanks again to the witnesses for being here and
sharing your perspective.
Ms. Johnston, I just want to say you should not be hiding
the fact that you have been working this area for so long, but
wearing it as a badge of honor because it is critical.
And I will also say you mentioned that we've been doing
telehealth in psychiatry for 50 years. One of the things that
struck me is that the phone was patented--and I had to look it
up--the phone was patented in 1876. As we have new
technologies, I don't want to wait 100 years or 90 years to
start using them again.
Much of the conversation is often around telehealth filling
gaps. If--for rural communities, there are gaps in care. Mr.
Adcock, I think as you were talking about what you are doing in
Mississippi, it's creating opportunities to improve healthcare,
improve its efficiencies, lower its costs, and have better
outcomes. And I hope, over the course of time, we can move our
conversation from filling the gaps to really finding ways to
use telehealth to make a difference. I think the rural
communities and the small businesses, as you discussed, provide
that great opportunity. So I will get off my soap box, but I
did want to just emphasize that.
Dr. Schmitz, you said you've been in this area for a long
time. We hear about the shortage of doctors for so long.
Earlier this year, I was privileged to introduce the
reauthorization of the Conrad 30 program, which would bring
doctors from other countries into our rural communities helping
to fill that gap again. But I would be curious from your
experience, if you have seen that program and other programs of
graduate medical education to support doctors coming into where
the need is the greatest, share your thoughts, please.
Dr. SCHMITZ. Thank you, Ranking Member Schneider. I
appreciate the opportunity to answer. We have seen benefits.
There is no doubt about the need that we have, from a provider
workforce standpoint, in rural America. And I think programs as
such you have mentioned have been an important opportunity to
be able to serve those needs.
I actually have done research looking at the recruitment of
rural providers into both several States here in the United
States as well as comparing that to other countries, such as in
Australia, and I think as we look at a global need with regard
to, as you said, not only beginning to have an adequate
workforce in place, but really have a healthcare team that
provides the most efficient and effective care to people, that
the advent of technology has really changed the dynamic. Not
only do we see doctors who still do house calls, but we also
see physicians and really healthcare teams that can deliver
everything from occupational therapy to dietician services and,
most critically, mental health services locally as a team
through use of technology and local providers. It is still
about the relationship, isn't it, between the patient and the
provider, between a couple of neighbors in a small town, that
really I think to a certain extent impacts the quality of care
and some of that efficiency, but supporting those providers as
teammates and the use of technology has really changed the
dynamic. And I think the example of health monitoring, where
patients are empowered to be able to then access local
healthcare and subspecialty care as needed, can change the
fabric of what that appears to be. That will draw graduates
from all over the world, I think, to appreciate what it means
to be part of a rural community and a provider in those
communities.
Mr. SCHNEIDER. Great. Thank you.
Mr. Adcock, you talked about your program, and I just want
to clarify that I heard it right. Emergency diabetes check-ins
went to zero in the program, you said?
Mr. ADCOCK. That is correct. The first--of the members of
the study, they had zero ER visits, zero hospitalizations for
the first 6 months of the program.
Mr. SCHNEIDER. That is extraordinary.
Mr. ADCOCK. It is.
Mr. SCHNEIDER. Are there things that you identify that were
critical to that? Are there barriers to taking a program like
this across the country?
Mr. ADCOCK. I think that the critical barrier--I mean, the
critical success factors were the fact that we didn't just
monitor. There are a lot of monitoring programs. Even though we
call our program remote patient monitoring, we actually engage
with the patient and provide them education. So I think
providers--all the providers I have talked to would agree that,
if they had the opportunity to educate their patients in small
bits every single day and check on them and provide real-time
intervention, they would, but that is not realistic.
So that is something we can deliver through technology. So
that is where they benefitted was learning about their disease
process. Diabetes, while it is not complicated to me or some of
the providers, it is complicated to someone who is newly
diagnosed and doesn't understand what they should eat, what
they shouldn't eat, when they should exercise, how much water
they should drink. So, when you can provide that education in a
home daily in small, bite-sized pieces, it is extremely
beneficial to them. And, also, when they slip or when they make
a mistake and they eat the pecan pie, which we often do, when
they check their blood sugar, we know it, and we are able to
intervene immediately instead of waiting 3 months for the next
in-person visit.
So I think it is that relationship and the engagement and
the empowerment; teaching them to take care of themselves was
the big success factor.
Mr. SCHNEIDER. Thank you.
And I am out of time. I just want to add one more comment.
Ms. Clowers, thank you for the testimony, but the discussion
around the different pilots that you all are doing to take
those pilots where there are successes and getting it out, if
there is anything we can do to help, please look to us.
And, with that, I yield back. Thank you.
Chairman BLUM. Thank you, Mr. Schneider.
And I will recognize the gentleman from Mississippi, Mr.
Kelly, who is also our chairman of the Subcommittee on
Investigations, Oversight, and Regulations for 5 minutes.
Mr. KELLY. Thank you, Mr. Chairman.
And, Mr. Adcock, it is nice to have someone here who does
not have an accent.
Mr. ADCOCK. It took a lot of practice.
Mr. KELLY. How does Medicare's definition of rural area--
and I know Ms. Johnston talked about this to--present challenge
for providers wishing to incorporate telehealth into their
practices, and specifically I know, in Union County, because
one little area is so many miles from a four-way, they don't
qualify, but from a four-lane highway, but people don't
understand: Driving distance and miles are different,
especially in rural areas. So, if you can do that, Ms.
Johnston, after him, if you would like to follow up, I would
really appreciate that.
Mr. ADCOCK. We talk a lot about rural versus urban settings
and rural designations. What we see in telehealth, and
Mississippi is certainly rural, and we have a lot of rural
areas. We also have urban areas that don't qualify for as a CMS
service. So I would like to steer the conversation away from
geography. The fact is we have healthcare resource shortages,
and it doesn't matter. I can tell you a specific example.
Dermatology in Mississippi, it takes 6 months to get a
dermatology appointment in Mississippi. It doesn't matter if
you live right next to the University of Mississippi Medical
Center or if you live 180 miles away. Geography doesn't matter
in that case.
So it is more to me about healthcare resource shortages and
being able to address those. Those don't always happen exactly
the certain distance from a four-lane highway; they happen all
over the place. So being able to lose that geographic
restriction would be great, if we could lessen that or get rid
of it all together, because the fact is access to care isn't
just about urban versus rural. It is about whether or not there
is a resource available and how a patient can access that
resource.
Mr. KELLY. Ms. Johnston, briefly.
Ms. JOHNSTON. Thank you. Let me give you two quick
examples. Number one, a small town in Wyoming where they have a
huge backlog, patients needed to see a psychiatrist. They
absolutely refused to allow us to provide telepsych, an entire
program paid for, because they were so afraid of complications
with not billing correctly. That is just one example.
Second example, we have been recently approached to provide
telepsychiatry services to Puerto Rico. They identified six
clinics. They gave us the addresses. We went online because
there is a site under CMS to make sure that you are allowed to
do it because they require that the Medicare also be seen. Not
one clinic across Puerto Rico was considered to be meeting that
definition. The program cannot go forward. I have been to
Puerto Rico. I have driven all over it. I still can't find a
nonrural area.
Mr. KELLY. And that being said, you know, Mr. Adcock, I
want to ask this question, but I think it is important: It is
more economy driven than it is rural or urban. There are a lot
of inner city areas that have the exact same issues that rural
areas have. They have the exact same travel distance or
challenges that a rural area would have, and I think it becomes
about people who are a lot of times impoverished, who don't eat
well, and who are not educated in what those diseases are, and
are a long distance in time or access from medical, and I think
we owe it to them to get medical access and I think telehealth
can do that. That being said, Mr. Adcock, what are the benefits
of small businesses offering telehealth in the workplace?
Mr. ADCOCK. I think, again, it is access. It allows access
for employees who may not have access to healthcare otherwise.
Also, it forms that relationship. Once they start seeing a
provider, and we are able to refer them to a local primary care
physician, it completes that relationship. And the earlier they
can get access to care, the more likely they are to recognize a
disease, whether it be prediabetes, whether it is diabetes,
hypertension, it could be, you know, eye disease, any other
disease. So early access is important. And limiting those
barriers.
So a lot of employees are main providers for their home.
They are not able to take off half day to go to a physician's
office, and they may have to drive 40, 50 miles to the
physician's office, wait in the waiting room, be seen, and they
have missed half a day of work, they have to pay their copay,
they will just be sick. And employees who aren't well aren't
productive. It is not good for the small business. So being
able to decrease absenteeism, increase productivity is
extremely important for those small businesses and could mean
the difference between keeping them viable or not.
Mr. KELLY. And just in closing, Mr. Chairman, I will just
say telehealth is the wave of the future. We know preventative
medicine is one of the primary cost-saving benefits that we get
in America, and using technology to get that is a no-brainer to
make sure that we use this and maximize this for small
businesses and for our medical care.
Thank you, and I yield back.
Chairman BLUM. Well said. Thank you, Mr. Kelly.
And I now recognize the gentleman from Florida, Mr. Lawson,
who is also the ranking member on the Subcommittee on Health
and Technology for 5 minutes.
Mr. LAWSON. Thank you.
Dr. Schmitz, rural America includes approximately 57
million people and about 20 percent of the population. There
are 1,855 rural hospitals that support nearly 2 million jobs.
How does improved access to care in rural areas benefit the
local economy?
Dr. SCHMITZ. Thank you, Congressman.
You are exactly right that, again, the testimony that I
provided in writing and accompanying here with you is that
local hospitals are a driver of the local economy, not only
directly with regard to employment of physicians that results
in economic stimulus and further jobs, but also, with regard to
keeping the opportunity for growing other businesses local.
Again, I have had experience in North Dakota but also now
20 years of experience in Idaho, and I can remember times when,
during difficult fiscal discussions, we talked about roads and
we talked about healthcare and we talked about education
because we knew that would bring industry to our small towns.
That was an economic driver in itself but also built, again, a
framework upon which we could see economic growth.
So I would commend the opportunity to speak with you and
agree on the fact that rural hospitals, and at this point, in
particular in time, saving rural hospitals, recognizing not
only their cost effectiveness to quality care but also the fact
that they are an economic driver in our Nation is a timely
discuss. Thank you.
Mr. LAWSON. Okay. Thank you.
And, Doctor, I am going to ask you this question simply
because I was involved in it. In 2000, we in the legislature in
Florida authorized a medical school at Florida State, and a key
factor in authorizing that medical school is that they were
going to train physicians to go into rural areas because other
people might want to comment on that. So that has been 17 years
later, but what I understand, and a lot of these students once
they finish, because of tremendous loans and stuff in medical
school, they want to go into the cities where they can make a
little bit more money to take care of medical loans. Have you
seen in medical schools, has this philosophy changed, and have
we worked out anything to cause them to go into rural areas?
Dr. SCHMITZ. Thank you, Congressman. That has been the
study of my last 10 or 15 years since leaving rural practice
myself but staying in contact with rural medicine as a medical
educator. I think you are right that we have found that
intentional public accountability with regard to medical
education is key, and training in interprofessional health
teams is also important.
One of the things that I have seen is that we train to have
people remain. I could say being from the country from the
sticks, training in the sticks' sticks. And one of the things
that we have found is that, with studies we have actually done,
including rural training track residency education, where we
actually have physicians training during their residency in
rural places such as critical access hospitals have a higher
likelihood that those physicians will remain in rural and
underserved communities.
So I think those sorts of investments and the opportunities
to look at regulatory relief or funding and then encouraging
again our medical schools to have these sorts of tracks for
rural providers shows that there is the evidence, is that,
where they train, they are more likely to remain. This
accompanied by loan repayment opportunities, both at the
Federal and State level, and mentoring--frankly, mentoring of
physicians, so that they can see themselves there, especially
now in the advent of the utilization of technology where now we
can see our patients are supported to be self-empowered around
their disease conditions. But, frankly, I think that I can tell
you, as a 29-year-old doctor in an ER, it is a little bit
scary, and you want to do the best you can, and you know you
will do the best you can, but having an opportunity to have
that consultation and mentoring, not only in person and in
practice with your partners but also through telehealth, makes
a powerful statement to our young students.
Mr. LAWSON. My time has almost expired, but, Ms. Johnston,
since you have been at it for a very long time, do you see any
difference of it really working in the training in medical
schools, a physician to go right in the rural areas?
Ms. JOHNSTON. I think one of the strategies that we have
done in the State of California, I served on the board of
trustees for the Health Education Foundation, and what that
sought to do, and it has been very effective, we provide loan
repayment for primarily physicians but other healthcare workers
who will serve in rural areas. That has been the most
successful thing we have ever done, because some of these
students get out, they owe $150,000, and to get them to go work
in a rural area where their income is going to be so much lower
than in the urban area, this was a huge incentive. And it has
been a very effective program. And we found that, if they stay
in the rural community for 2, 3, 4, 5 years, much higher
percent that they will stay there.
Mr. LAWSON. Okay.
And I yield back, Mr. Chairman.
Chairman BLUM. Ms. Clowers, did you want to add on to that
quickly?
Ms. CLOWERS. Thank you. I just wanted to add that we did
work issued early this spring where we looked at graduate
medical education funding, and most of the funding is still
going to urban areas, and that is important, as Dr. Schmitz
said, because where people train, they tend to stay. And also
what we found is that the Federal efforts to increase graduate
medical education in rural areas is limited, and really that
funding is driven by statute. So I just wanted to add that for
the Subcommittee.
Chairman BLUM. Thank you.
Thank you, Mr. Lawson.
The gentleman from Kentucky, Mr. Comer, is recognized for 5
minutes.
Mr. COMER. Thank you, Mr. Chairman.
I have a question for anyone on the panel. Just out of
curiosity. I assume you all kept track of both the House
healthcare bill and the Senate healthcare bill. And I am
curious, did either of those bills affect telehealth in any way
either positively negatively or no impact whatsoever? Anybody
know?
Mr. ADCOCK. I don't have any idea.
Ms. JOHNSTON. No.
Mr. COMER. What about a complete repeal? That is something
that is obviously being batted around now in the Senate and in
the House. Would a complete repeal have any impact on
telehealth, a complete repeal? Anybody know?
Ms. JOHNSTON. I can only imagine that, if millions of
Americans lose their health insurance, it is going to have an
impact on this Nation. And it for sure is going to impact
anywhere healthcare is provided.
Mr. COMER. But there is no specific part that you can think
of that would have a--I mean, you just assume that?
Ms. JOHNSTON. I would agree with that. Probably the best
source to get that specific answer would be through the
American Telemedicine Association. They have staff that are
specifically looking at this. And we can follow up and get that
information to you from the ATA.
Mr. COMER. I certainly support telehealth. Being in a rural
part of Kentucky, it is very challenging for our hospitals to
get physicians. And this is very important. And we want to
certainly support that. And, hopefully, we can work together
and fix our broken healthcare system. There are parts of
healthcare that are working. There are parts that I think need
to be radically changed. The cost of healthcare is a big issue
that doesn't seem to be getting a lot of attention now. It is
all about health insurance. But, hopefully, we can come to a
solution and look forward to staying in contact with you all as
we try to fix our broken healthcare system. And, certainly, for
those of us that represent rural areas, telehealth is a very,
very important part that I want to support, and I am sure
everyone on this Subcommittee does as well.
Thank you, Mr. Chairman.
Chairman BLUM. Thank you, Mr. Comer.
The gentleman from Kansas, Dr. Marshall, is now recognized
for 5 minutes.
Mr. MARSHALL. Thank you so much, Mr. Chairman. A great
topic, something I am pretty familiar with.
I think, first of all, always talking about success
stories. Colby, Kansas, Citizens Hospital. Part of the stroke
collaborative program that Dr. Bobby Moser has piloted in
Kansas, one of the greatest success stories I have ever seen,
very dependent upon telemedicine. A person has an acute onset
of a stroke. And if we can get that thrombolytic agent within
30 minutes--we talked about cost savings, so much about cost
savings. The true cost savings that this makes is in the
healthcare dollars that we are not going to spend. This stroke
person that we prevented this stroke from becoming permanent,
we just have saved hundreds of thousands of dollars of hospital
bills, rehabilitation bills, and then a person that is maybe on
a disability the rest of their life.
So that is the beauty of this. We could talk about strokes.
We could talk about acute MIs, again, using that thrombolytic
agent. And what people don't understand is these agents have
very significant side effects. And it takes a lot of courage to
give this drug. And if you don't give it on a regular basis,
you just don't give it, especially not in time. The nurses drag
their feet. So Colby, Kansas, is hooked up 24/7 to another
busy, busy ER, and a nurse can take the patient's symptoms. And
while the nurse practitioner is scrambling to get over there,
walks into the room, and everything is already set up and
going. They have got a protocol set. We are getting the CAT
Scan, and within 30 minutes, we can give that drug. And it is
night and day.
Another great success story in Kansas is the Kansas
Enhanced Veterans Service Program. It is a mobile office that
goes across the State. Twenty-two veterans die from suicide
every day in this country. Those veterans are not going to come
to the veterans hospital, both of them, that we have in Kansas.
So we are taking the program to them. They are using
telemedicine to touch base with their psychiatrist, their
psychologist, their social workers back home, making sure they
get their medicines. Absolutely a success story.
My thoughts would be is that government will not solve this
problem but, rather, innovation will continue to solve the
problem. And Medicaid or Medicare is typically in the way of
solving the problem. So I just would just continue to look for
success stories and then try to, not reinvent the wheel, but
keep accentuating those.
So I would ask for anyone, what are the most--I shared my
success stories. We can't use a shotgun and try to use
telemedicine for everything. But it has some great
opportunities in the emergency room, and I think the
psychology/psychiatry as well.
So does anyone have a great success story they want to
share? Dr. Schmitz, you have one?
Dr. SCHMITZ. Thank you, Congressman. Again, I would just
share a success story around tele-ICU. And what that is,
essentially, is in, again, a critical access hospital that
otherwise can provide appropriate care--I have certainly been
in a situation where we were, frankly, weathered in. We were
concerned about the safety of having a helicopter land in our
town because of snow or other conditions, also similarly
concerned, what would a patient be able to do with regard to
ground transport for safety? In my town, there were 104 curves
in a 19-mile piece of road on the way out to the urban center.
So I think you are exactly right.
And one thing we can look at is, how do we have
consultation through telemedicine with, for example, patients
who may or may need to be transferred the next morning and
oftentimes actually don't need to be transferred? Again,
providing not only quality care, access to care, but in a
fairly common scenario better care, and likely empower that
team.
Mr. MARSHALL. I have been in that same position so many
times with a 25-week baby, 600-gram baby, fogged in, snowed in,
and scrambling to try to fix that problem. I can certainly
deliver that baby, but the problem was taking care of the baby
afterwards.
Any other great success stories that you have?
Ms. Johnston, go ahead.
Ms. JOHNSTON. I was PI on the Patient-Centered Medical Home
Project. That was a program funded through CMS' CMMI innovation
initiative. And during the 2 years--3 years that we ran it,
2012 to 2015, we showed significant cost effectiveness. Just as
one example, NIH, their numbers for outpatient for mental
health patients annually averages about $1,557. Ours came out
to $390. Patient satisfaction, over 90 percent. It was huge.
Mr. MARSHALL. So I got 20 seconds. Where is telemedicine
not working? Can you give me examples, anybody, where there is
an area of medicine that it hasn't worked very well?
Ms. JOHNSTON. No.
Mr. MARSHALL. Yes, sir.
Dr. SCHMITZ. I do think we need to continue to coordinate
care so patients have primary care access, and electronic
medical records that are able to integrate patients' global
care.
Mr. MARSHALL. Thank you.
Chairman BLUM. Thank you, Dr. Marshall.
The gentleman from Nebraska, Mr. Bacon, is now recognized
for 5 minutes.
Mr. BACON. Thank you very much to all four of you. We have
got votes coming up. So I will just get right to the questions.
I appreciate you being here.
First of all, a couple of you mentioned the definition for
rural areas hurt telehealth. Is that a regulation or a law?
What do we need to change, specifically, to fix this?
Ms. CLOWERS. For Medicare, it is defined by statute.
Mr. BACON. Okay. So it is on us to make that change then?
Ms. CLOWERS. Correct.
Mr. BACON. Okay.
Ms. CLOWERS. And what it requires is, it requires both in
terms of restrictions on the facilities as well as the
location. So certain facilities are allowed, in Medicare, to be
an originating site.
Mr. BACON. Right.
Ms. CLOWERS. As well as, it has to be located in an area
that has been defined by HHS as being a health professional
shortage area or outside of a metropolitan area.
Mr. BACON. So that is a task for us to work on then. We
will take that on.
Second question, Ms. Clowers, you mentioned the VA using a
lot more telehealth. Can you talk a little more about that?
Because I know we have a big long line of people trying to get
care, and this is one way to help.
Ms. CLOWERS. Right. VA, what we found is that 12 percent of
beneficiaries in 2016 were provided telehealth visits, which is
much greater than what we saw in Medicare. And, in fact, what
we also found was that they have over 50 different types of
specialties or services that are eligible for telehealth, and
they have less restrictions than in Medicare. So, for example,
the program does allow for the patient to be at home for
telehealth visits.
Mr. BACON. That is great news.
Here is one for any of you all. Who are the opponents to
doing this? Are there industries out there or institutions that
are fighting us? Go ahead. Please.
Ms. JOHNSTON. I think the world of telemedicine has
appropriately been challenged by a lot of really important
agencies, the American Medical Association used to be really
concerned. I think the concerns all stem from people wanting to
make sure that we are doing this correctly, that we are
providing quality care. Whenever we get challenged, it is never
from somebody who is just saying no. It is just because they
need to be educated and reassured that anybody who's using
these technologies is meeting, if not exceeding, the quality of
care that people deserve.
Mr. BACON. One last question. It seems that some illnesses
are tailor-made for this, but others may be a little more
challenging. So what is the percentage, would you say, roughly,
that this is--telehealth is perfect for? But there is other
things--sometimes you got to lay eyes on the infection or--you
know what I am saying? There are some things a little more
challenging that the doctor has to actually see it, perhaps, or
take blood or something. I don't know. What do you think the
percentages are?
Dr. SCHMITZ. Congressman, thank you for that important
question.
I think, first of all--and I think in response to the other
question about the pending decisions that will come up around
healthcare and access is in that rural America, we need to have
people who can deliver healthcare and places where it can be
delivered. So we look at rural health clinics, federally
qualified health centers, private practices, and critical
access hospitals as examples. We still need the providers
there. If it is an automobile accident and a chest tube is
required for a collapsed lung, we still need the providers
there. I see telemedicine more to support those services, as
well as to augment them.
And in some ways, telepsychiatry mental health, we have
even seen where patients will be more likely to see a
telehealth provider in an adjunct room of the critical access
hospital as opposed to sometimes driving down the street a
block. I don't know what the future holds. But I don't see one
necessarily replacing the other. They really come together.
Mr. BACON. Well, thank you very much.
I yield back.
Chairman BLUM. Thank you, Mr. Bacon.
As has been mentioned previously, votes have been called.
So this is a very important topic. And we have some members
here that still haven't had a chance to ask their questions. So
we will stand in recess until after the votes, and then we will
reconvene.
We shall stand in recess.
[Recess.]
Mr. LUETKEMEYER. [Presiding.] Okay. We will gavel our
Committee back into session. And thank all of the witnesses for
continuing to stick around. I apologize for the delay, but we
did have to do a little bit of what we are here to do a while
ago, which is go vote on some very important legislation to
certain people, areas of our country.
I am Congressman Luetkemeyer. I am from Missouri. I am the
vice chair of the entire Committee. And Chairman Blum has other
duties to attend to for the moment. So you are stuck with me to
take us out the gate here.
So, with that, let us continue on with the discussion we
are having, and we will recognize Miss Gonzalez for 5 minutes.
Miss GONZALEZ-COLON. Thank you, Mr. Chairman.
And thank you, the whole panel, for staying here so long.
Over the last 5 years, over 3,000 physicians have left
Puerto Rico. And, currently, the island loses one doctor per
day, as you may know. Hospitals and medical practice groups are
finding it very difficult to recruit specialist physicians and
experts. We are trying to have some kind of telehealth by
medical specialists located in the U.S.-based academy medical
centers, maybe can be a great opportunity for the island,
especially in rural areas that are a hundred percent of the
island, maybe 90 percent. Are there any impediments to
telehealth payment arrangement when the patient is located at
their home in Puerto Rico or at a medical facility in Puerto
Rico and the doctor is located at a medical center located on
the mainland? Ms. Johnston?
Ms. JOHNSTON. Hi. It is Barb Johnston. Many. And it is
problematic. As I mentioned, we have been approached, the
company I currently work for. We have the doctors. They want to
work. They have doctors locally that want to learn how to do
this locally in Puerto Rico. And we are more than happy to do
it. The sticking point is getting payment for doing it. As I
said before, Medicare's rule that restricts to their definition
of rural for telemedicine completely blows the whole project.
It prevents us from being able to do that. If there could be
some kind of a waiver, or if we could be allowed to pilot, or
whoever is going to be able to provide the care--because it
won't just be telepsych, which is what we do. There are others.
But that is the desperate need that we have heard from people
in Puerto Rico. So if they could do that.
The other is getting a waiver to allow patients to be seen
in their home. There are many parts of Puerto Rico where--and
we have been told--that people don't have transportation. Even
if there was some, they can't. And, like, the Veterans
Administration in this country has been doing this for 10 years
successfully, seeing patients directly at home.
Miss GONZALEZ-COLON. Quick question. That waiver, it is
going to be for the Federal Government or Federal--do we have
to amend any Federal laws, or we are talking about State laws?
Ms. JOHNSTON. I might----
Miss GONZALEZ-COLON. I defer to Ms. Clowers.
Ms. CLOWERS. The requirement is through statute. So the
statute defines in Medicare where the services can be provided.
And as Ms. Johnston said, it has to be--the originating site
must be in an area that has been designated as a health
professional shortage area or outside of a metropolitan area.
Miss GONZALEZ-COLON. In our case, I mean, the shortage is
there. Actually, we are having the same problems in the VA
facilities, the same as the American Samoa, where we don't even
have the specialists in so many areas in the VA hospital. And
we have tried to recruit them, but it is so difficult. Because
nobody wants to leave the mainland to go to Puerto Rico or even
remote areas to just move their families to attend the patients
there. And I would like to know if you can provide, the whole
panel, specifically what kind of amendments do we need to make
to change that statute? If you can provide--I mean, I know that
we--in 1 minute, you can't provide that. But if you can provide
that to the Committee later on, that will help us a lot to
identify those statutes with the correct language so we don't
mess--mess with the whole situation.
Ms. CLOWERS. And, Representative, I would like to add, too,
that in addition to a potential statute change, CMS, through
their innovation center, has different models and
demonstrations that they can run. And they have the ability to
waive certain requirements. And so they would have the ability
to have a demonstration and waive these rural requirements.
Miss GONZALEZ-COLON. I know.
Ms. CLOWERS. If that would be something that you would be
interested----
Miss GONZALEZ-COLON. I know. We are working with them
directly and we are trying to change the State plan. And even
doing that, we are still facing the same problems. That is
happening in Puerto Rico. That is happening in other States. So
this is not an issue just for--but we are facing--in our case,
in the islands, you can't cross the State line. You can't take
a car or even take a train. You have to take a plane or a boat
to take the service, and that is not enough. So that was the
question. Since my time is running, is there any--can you
provide any information about the security of the patients'
records on telehealth or how secure and private these records
are when telehealth is employed?
Ms. JOHNSTON. The way that most of us work--and I will
speak to the company I currently work for. We use a fully
HIPAA-compliant system end to end. We use a product called
athenahealth. I have no investment in it, don't own it. It is
just a completely secure and HIPAA-compliant system. Anything
that we use technologywise, the videoconferencing, the health
records, any communication--you can't text. There is very
strict--we actually are the only telepsych company in the
country that is Joint Commission accredited. That is just part
of it. But, yeah, end to end.
Mr. ADCOCK. Same thing. Ours is encrypted and all HIPAA
compliant. Everything that we use goes into our electronic
medical record, Epic. So it is all controlled just as it would
be if you came in person.
Miss GONZALEZ-COLON. Thank you.
I yield back. Thank you, Mr. Chairman.
Mr. LUETKEMEYER. The gentlelady's time has expired.
Next we go to Representative Radewagen, from American
Samoa. She is the Chairman of the Subcommittee on Health and
Technology. You are recognized for 5 minutes.
Chairwoman RADEWAGEN. Thank you, Mr. Chairman.
Ms. Clowers, American Samoa could greatly benefit from
using health for patients to access medical care remotely
without leaving the islands. We talked about it a bit today.
However, broadband access is not sufficient. Are there Federal
programs available to assist remote areas like American Samoa
to support broadband for telehealth?
Ms. CLOWERS. Yes, ma'am, there are. And you are correct,
broadband is a challenge, and it is something that we heard in
our work when we surveyed people about the barriers to using
telehealth, the infrastructure that is required to successfully
carry out telehealth. Broadband was identified as one of those
infrastructure challenges. And there are grants that are
available for different communities through different
departments.
And, for example, the USDA has grants. And American Samoa
has received a grant, I believe in the amount of $820,000, for
support in this area. And we would be happy to get you more
information on that grant, if you are interested.
Chairwoman RADEWAGEN. Thank you.
Mr. Adcock, what are some important innovations in
telehealth that you have experienced while working in this
field? And what innovations may we expect in the future as more
American consumers demand telehealth services?
Mr. ADCOCK. Thank you very much. I think the innovations
that we--I am going to go to the second part of the question
first. The innovations that are coming in the future, I
couldn't begin to tell you. There are so many different
wearables and sensors and things that are coming out now, that
are being innovated now, that I can't imagine what the future
is going to look like from that standpoint.
But I think where we focus on technology is that we wrap
technology around our clinical programs. I think that our
focus--while technology is certainly important, I think our
focus is around the patient and what we need to do to provide
excellent clinical care to the patients, and then we use the
appropriate technology around that. But being able to deliver
care into a home to monitor diabetes so that patients don't
have to plug anything in or try to transcribe their outcomes or
their results themselves, I think that, just in the last couple
of years, has come so very far. And being able to Bluetooth
into these devices and use cellular technology to connect to
patients and providers has come so very far in the last couple
of years. Where it is going, I would honestly be scared to say.
But I think that the focus needs to remain on making sure that
providers and patients, not necessarily in that order, but
patients and providers are the center of what we are doing with
telehealth. This should be an extension of healthcare. This
should be something that is used to help better healthcare
services that can be delivered at home.
Ms. Johnston, would you care to answer that question?
Ms. JOHNSTON. I completely agree. At the American
Telemedicine Association annual conference this last year,
Thomas Friedman spoke, keynote, and that is really what he was
echoing. He stood on a stage and said: Right now, with 10,000
people in this audience, there is a couple of guys in a garage
in Silicon Valley, and they are ahead of us. We just need to
catch up with them.
I think it is going to be part of it.
I think, too, the current president of the American
Telemedicine Association, he has been putting forward and doing
a lot of speaking about hybrid healthcare in a model that he
sees more and more individual providers and health systems
where they see some patients on telemedicine, use remote
monitoring, and some in person. And that is happening quite a
bit. It is spreading across major hospitals and health systems
across the country. Thank you.
Mr. Chairman, I yield back.
Chairman LEUTKEMEYER. I understand the lady from Samoa has
a closing statement. You can go ahead and do that.
Chairwoman RADEWAGEN. Thank you, Mr. Chairman.
Well, let me take this opportunity to thank all of the
witnesses for their testimony today. As the chairman of the
Subcommittee on Health and Technology, it is extremely valuable
to hear how telehealth is helping physicians expand the
services they offer and is offering patients more convenient
options to access the healthcare they need.
American Samoa is facing tremendous provider shortages, and
telehealth services could keep our residents and their families
from traveling long distances to receive care or going without
the care they need. This could also benefit other small
businesses by keeping dollars in the community. I was also
pleased to learn that there is hope that telehealth will make
rural areas more viable locations for physicians to operate
their practices. Technology has improved many aspects of daily
life, and it can potentially improve healthcare access as well.
[Speaking foreign language.]
Thank you. And I yield back to Chairman Luetkemeyer.
Mr. LUETKEMEYER. I am glad you interpreted that for us.
Thank you very much.
I will defer my questions to the end. I think Miss Gonzalez
has got a second round question here.
So let's go to Miss Gonzalez. You are recognized for 5
minutes.
Miss GONZALEZ-COLON. Thank you, Mr. Chairman. I really
appreciate that deference. I will be short. I will just leave
you with some questions I got.
And one is regarding Mr. Kelly, in his statement here,
identified the issues regarding rural areas. And one of the
concerns regarding Mississippi was the diabetes situation. And
your experience treating patients with diabetes and using
telehealth, how do they--those patients were improving. Do you
have seen a decrease in the hospitalizations and emergency room
visits in Mississippi? That is one of the questions, because we
got the same situation in the island, and other situations
regarding heart diseases, among others. That would be one of
the questions. I don't want to abuse from the chairman. That
will be one of the questions.
The second one is going to be in terms of is there a need
for a certification requirement when telehealth providers are
located in a jurisdiction other than where the medical provider
is located? What of those requirements, if they are from a CMS,
or HHS, or whatever they are, if the State is involved in that,
and how difficult are those regulations to comply with? And in
terms of having--is there any copayment to the patient if they
are using health in terms of the veterans, if they are using
this kind of program? I don't know. That is going to be one of
the questions.
Mr. ADCOCK. I will take the first question around remote
patient monitoring. And thank you for asking that followup
question. Yes. In our diabetes pilot that we did in the
Mississippi Delta, we saw significant results in the
preliminary results. And the final results will be out later
this month. But we saw a decrease in hemoglobin A1c, which is
the measurement of blood sugar over time. We also saw a
complete elimination of ER visits and hospitalizations for
those patients that were on our program. So, not only did they
just reduce their visits to the ER, we did not have any
diabetes-related ER visits or hospitalizations.
Miss GONZALEZ-COLON. Zero?
Mr. ADCOCK. Zero. Not saying that that would be sustained
over a huge population. But we have seen very similar results
in our--the final results are very much mirroring that. And the
results that we see with our population that is on that program
outside of the pilot have had significant results in
readmissions and hospitalizations. So that is one of the points
of the program. But I think the reasons for that are because of
the education that we provide and the real-time interventions.
So we teach them about their disease so that they can take care
of the disease themselves. You can't expect them to go to a
provider every time something is going on. That is not
realistic. It is not realistic for the provider. It is not
realistic for the patient. So being able to teach them about
their disease and then teach them as they are having issues so,
if their blood sugar goes up, you are able to intervene at that
time and say: This is why your blood sugar went up. This is
what you can do to prevent it in the future. A lot of these ER
visits aren't due to medical emergencies every time. A lot of
times they are due to fear. They don't know what to do when
this happens. So being able to educate them in real time has
been a real success. And we have spread that program statewide.
Miss GONZALEZ-COLON. Mr. Schmitz.
Dr. SCHMITZ. Thank you, Congresswoman. I would just like to
agree with that testimony and just give a quick example. If we
look, for example, as a primary care provider, a family
physician, per se, at the patient-centered medical home having
a dashboard where information comes in, you can literally have,
you know, green, yellow, red where people who are knowledgeable
about this data can then, for example, use what is called open-
access scheduling and decide who gets an acute care visit open
slot with that provider, be it a physician assistant,
physician, or otherwise, and avoid, again, that lack of
information that otherwise might result in an ER encounter with
someone who does not know them as well.
Miss GONZALEZ-COLON. Thank you.
Ms. Johnston or Ms. Clowers?
Ms. CLOWERS. To your second question about other challenges
with licensing, when we spoke to different stakeholders through
our work, we did hear that licensing was a challenge. And an
example of that is when you are at the distant site--if you are
a provider at the distant site, you also have to be licensed in
the State that the patient resides. And that can be challenging
for different providers. And that is driven by State law.
Miss GONZALEZ-COLON. Thank you. You want to add something,
Ms. Johnston?
Ms. JOHNSTON. I was just going to answer--I think you asked
a question about a copayment for telemedicine?
Miss GONZALEZ-COLON. Yes. Is there----
Ms. JOHNSTON. I have never actually heard of that. I don't
have any experience with that.
Miss GONZALEZ-COLON. Okay.
Ms. JOHNSTON. We have never done anything like that.
Miss GONZALEZ-COLON. Okay. Thank you.
With that, I will yield back.
Thank you, Mr. Chairman.
And thank you, all the members of the panel.
Mr. LUETKEMEYER. The Gentlelady's time has expired.
With that, I just want to follow up with a few things.
And I know that, Ms. Clowers, you were talking about some
of the payment and coverage restrictions that cause problems
sometimes. I think it was Ms. Johnston mentioned some of the
things that happened and can be done or changed with regards to
the locations qualifying. But with regards to payment and
coverage restrictions, can CMS do this right now through their
rulemaking process, or does that take legislation?
Ms. CLOWERS. The coverage issue would require legislation.
It is defined by statute.
Mr. LUETKEMEYER. Okay.
Ms. CLOWERS. They do have flexibilities in their
innovations center where they are able to test different
approaches with different models and demonstrations. So that
would be an area that they could explore with a model.
Mr. LUETKEMEYER. Okay. Some of the things you talked about,
do you have studies that show how much it saves?
Ms. CLOWERS. We do not. When we did our work in looking at
the different opportunities, both benefits of telehealth, we
were looking at CBO scores which showed--it is hard to tell
sometimes in terms of the cost savings. It depends on how
telehealth is used. If it is used to replace an in-person
visit, that can result in savings. But if it is used in
addition to an in-person visit, that can increase cost. So that
is what we found in terms of the cost savings. But I know other
witnesses here at the table have other experiences.
Mr. LUETKEMEYER. Yeah. I think, Mr. Adcock, you were
talking about your in-home monitoring programs. And did you put
an analysis on that and see how much you actually saved with
the pilot project you are talking about?
Mr. ADCOCK. So the pilot project, again, was a public/
private partnership. But our division of Medicaid actually took
the data on the actual cost savings of those first 100
patients, first 6 months, and extrapolated that to say that, if
20 percent of the Medicaid patients in Mississippi who were
diabetic were on the program, we would save $180 million a
year. So, yes, there are cost----
Mr. LUETKEMEYER. Your State would save that much?
Mr. ADCOCK. Yes. Yes. Medicaid would save that much so
federal and state together--
Mr. LUETKEMEYER. The State Medicaid program would save $180
million----
Mr. ADCOCK. Correct.
Mr. LUETKEMEYER.--a year just on that one----
Mr. ADCOCK. Just diabetics, just 20 percent. So now we are
doing hypertension and heart failure and all the other chronic
diseases we are monitoring as well. So we will continue to do
cost analysis on those programs. We have legislation in
Mississippi that allows us to get paid for remote patient
monitoring. So there is a fee to it, and we do receive payment.
The cost savings are tremendous.
Mr. LUETKEMEYER. Okay. And you mentioned a couple other
things that you are working on with your more remote abilities
here. And that was heart monitoring and what else?
Mr. ADCOCK. Heart failure. So congestive heart failure.
Hypertension. That is adult and pediatric diabetes. We are
working on asthma and chronic obstructive pulmonary disease.
All of these are high-cost items. We also monitor--this is
outside of the reimbursement legislation in Mississippi. We
also monitor bone marrow transplant and kidney transplant
patients so that we can get them out of the hospital sooner and
get them back home.
Mr. LUETKEMEYER. The hearing today was with regards to
rural telehealth. But, I mean, telehealth is something that
they can utilize--people can utilize every day everywhere else
too, many urban areas, suburban areas. I mean, this isn't
something confined. But what we are talking about here is the
importance of how it helps the quality of life, basically, for
folks in rural areas.
And so, Dr. Schmitz, would you like to add anything to the
discussion with regards to other opportunities and the cost
savings? Have you done any studies or are aware of any of that?
Dr. SCHMITZ. I really appreciate the opportunity,
Congressman. One example, I think, that hasn't been brought up
is the provision of chemotherapy, for example. As you can
imagine, in a rural critical access hospital that is quite
remote from subspecialty care, supporting a local physician/
nurse team, for example, to administer chemotherapy in the same
quality really does prevent patients who otherwise would have
very uncomfortable transport--not only long transport, but
uncomfortable transport, during the treatment of their disease.
Mr. LUETKEMEYER. Okay. So what we are doing is trying to
find ways to improve the quality of health and health services
in rural areas. And the things you are suggesting, is anybody
putting this into a bill that you are aware of or just
discussed it with you to help work on this?
Yes, sir, Dr. Schmitz.
Dr. SCHMITZ. I would be happy to follow up with National
Rural Health Association how telemedicine and teletechnologies
can be incorporated into better care----
Mr. LUETKEMEYER. Because the comment a minute ago was that
some of it has to be done legislatively; some of it can be done
through the rulemaking process. I think we have a friend with
Dr. Price at HHS now who is willing to look at options, look at
different things, different ways to deliver care, deliver
services, upgrade and innovate. But by the same token, if we
need to do something legislatively, I think that is where we
need to go.
Mr. Adcock.
Mr. ADCOCK. The CONNECT for Health Act that is out right
now addresses a lot of these issues.
Mr. LUETKEMEYER. Okay.
Mr. ADCOCK. It addresses the geography issues, addresses a
lot of the reimbursement issues. So that is something that we
fully support and would love to see some more input on that.
Mr. LUETKEMEYER. Very good.
Yeah. Ms. Johnston?
Ms. JOHNSTON. I just want to second that that legislation
is bipartisan, the CONNECT for Health. It would address most of
these things.
Another comment I would like to make, in the CMS grant that
we were given, 2012-2015, we submitted a final report that
showed significant cost savings. Happy to provide that to the
Committee. The VA every year produces very good data on cost
savings. And the American Telemedicine Association is currently
collating data on multiple studies across the country on cost
savings.
Mr. LUETKEMEYER. Does the VA coordinate with--I guess it is
CMS with regards to telehealth stuff? I mean, your veterans are
scattered all over the place. I mean, and they network back,
usually, to a VA facility of some sort. Does that help them or
hurt them with access to care? Are you familiar with that?
Ms. JOHNSTON. I don't know that the VA works in any
capacity with CMS. But I know that they are the largest
provider of telemedicine in this country and have been. Nobody
is even close to what they have been doing, and they keep
proving every year how cost effective it is every year for our
veterans.
Mr. LUETKEMEYER. Okay. Very good. I am at the end of my
questions. Would you all just like to have a closing question
or comment or go ahead and say goodbye? Tired of listening to
us?
Yeah. Dr. Schmitz.
Dr. SCHMITZ. Congressman, I would be just happy to first be
the one to say thank you for the opportunity to speak about the
important matters in rural health. I do think that we are
seeing technology both to change access as well as quality of
care and as we continue to see this again, as our panelists
discussed, as a wraparound, person-to-person services, I think
we will have better care for it. The example with the VA, for
example, CBOCs, and how CBOCs can actually be co-located with
other provider of services and co-supported through technology
might just be one more example. So, again, Congressman, thank
you for this opportunity.
Mr. LUETKEMEYER. Mr. Adcock.
Mr. ADCOCK. I would like to echo that. Thank you for the
opportunity to come and talk about this important subject.
Thank you for your interest and your very thoughtful questions.
I do think that telemedicine is a way that we can spread access
and improve quality across not just the United States but
across the world, certainly across everything that the United
States encompasses. So I think that is extremely important. And
I thank you for your questions and for the time to speak.
Mr. LUETKEMEYER. It is also great to know not everybody in
Mississippi talks like Mr. Kelly.
Ms. Johnston, closing comment?
Ms. JOHNSTON. I just want to echo what has been said. But
also just from myself thank you for what you do every day for
Americans.
Mr. LUETKEMEYER. Thank you.
Ms. Clowers.
Ms. CLOWERS. Thank you for having us. And at GAO, we are
happy to stand ready to help with any further discussions on
this topic.
Mr. LUETKEMEYER. Very good.
With that, again, I want to thank everybody for being here.
As we heard, telehealth has the ability to connect a patient in
a rural area to high-quality medical care at another location.
This not only benefits the patients and their families but also
may help the local physician to expand his or her small
business. Other small businesses will benefit from dollars
staying in the community. Additionally, we have heard that the
availability of telehealth may attract new or current
physicians to locate practices in rural communities and also
how telehealth can benefit small employers and employees by
offering convenient access to medical care and monitoring. In
fact, I would think it would be an attractive way to attract
doctors to the rural area if they know they can do it with
telehealth and be--the quality of life is--coming from a town
of 300 people--it is a whole lot better than it is in the city.
So, therefore, why not move to the country, right? But with
consumer demand growing for more convenient and efficient
options to access healthcare, I hope that we are able to sort
out some of the barriers our witnesses have testified about so
that small businesses and rural communities have all the tools
they need to thrive and keep residents well.
Well, with that, I ask unanimous consent that members have
5 legislative days to submit statements and supporting
materials for the record.
Without objection, so ordered.
We are adjourned.
[Whereupon, at 12:34 p.m., the Subcommittees were
adjourned.]
A P P E N D I X
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Testimony of Michael P. Adcock
Executive Director, Center for Telehealth
University of Mississippi Medical Center
House Small Business Committee
Subcommittee on Agriculture, Energy, and Trade
Subcommittee on Health and Technology
July 20, 2017
Chairman Blum, Chairman Radewagen, Ranking Member
Schneider, Ranking Member Espaillat, and Members of the Small
Business Committee, thank you for the opportunity to appear
before the subcommittees today. I am Michael Adcock, Executive
Director for the Center for Telehealth at the University of
Mississippi Medical Center (UMMC) in Jackson, Mississippi. I am
honored to talk to you this morning about telehealth and the
ways its power can be harnessed to address the healthcare needs
of America's small businesses.
Mississippi has significant healthcare challenges, leading
the nation in heart disease, obesity, cardiovascular disease
and diabetes. These and other chronic conditions require
consistent, quality care--a task that is made harder by the
rural nature of our state. In order to improve access to care
and give Mississippians a better quality of life, it is clear
we need something more than traditional, clinic and hospital-
based services.
Telehealth has been a part of the healthcare landscape in
Mississippi for over 13 years, beginning with an aggressive
program to address mortality in rural emergency departments. In
2003, three rural sites were chosen to participate in a program
that would allow UMMC board certified emergency medicine
physicians to interact with and care for patients in small,
rural emergency rooms via a live, two way, audio-video
connection. The TelEmergency program has grown to serve more
than 20 hospitals and continues to produce outcomes on par with
that of our Level 1 trauma center. This program has had a
significant impact, not only in bringing quality care to the
residents of the community, but in supporting the viability of
the community hospitals themselves. As a result of
TelEmergency, rural hospitals are able to identify and recruit
healthcare professionals who live in the community and desire
to work locally. The program helps communities retain
healthcare revenue that was lost as a result of patients being
transferred out for care. In some cases, Telemergency prevented
hospital closures that would been detrimental to these
underserved communities. The success of this program and
noteworthy outcomes led to the development of additional
healthcare models using technology to address needs statewide.
Today, the UMMC Center for Telehealth delivers more than 30
medical specialties in over 200 sites across the state
including rural clinics, schools, prisons and corporations. It
is important to note that a very small portion of these sites
are actual UMMC sites. As every community has different needs,
we partner with local providers to address their specific
needs. UMMC is committed to supporting the community providers
through collaborative models that promote efficient use of
vulnerable resources. The depth and breadth of our statewide
network allows us to deliver world-class care in 68 of our
state's 82 counties and provides access for patients who might
otherwise go untreated. Over the last decade, we have conducted
over 500,000 patient encounters through telehealth. Maximizing
our utilization of healthcare resources through the use of
technology is the only way we can reach all of the
Mississippians who need lifesaving health care.
Small businesses account for 99.9% of all firms in the
United States and 96.2% of all Mississippi businesses. The one
year survival rate for small businesses averages 78.5%.
Approximately half of these establishments survive five years.
In Mississippi, the small business exit rate is higher than the
startup rate. Small businesses often site access to affordable
healthcare as their number one concern. According to the
Gallup-Healthways Well-Being Index, annual costs for local
productivity for employees having chronic conditions totaled
$84 billion. Multiple publications site that unschedule
absenteeism costs roughly $3,600 per year for each hourly
worker and $2,650 for each salaried employee. These factors
lead to over $250 billion in lost economic output per year in
the United States.\1\
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\1\ U.S. Small Business Administration, Office of Advocacy
Decreasing absenteeism, increasing productivity and
improving access to high quality care were the drivers behind
the creation of the eCorporate and eSchool Health programs at
UMMC. The eCorporate service allows employees to access high
quality care from their workplace through secure audio/visual
connections. This program is employee initiated and avoids
travel to seek medical care, promotes appropriate use of
healthcare resources and is a lower cost alternative to the
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higher cost healthcare settings.
UMMC's eCorporate program is unique in that it is not
designed to be a standalone means for primary care, but as an
additional avenue for employees to access safe healthcare in an
affordable and convenient manner. In many cases, this program
has helped identify healthcare needs that, if gone untreated,
would have resulted in increased healthcare burden and loss of
productivity. For this reason, several corporations have chosen
to pay for this service for their employees and allow paid time
during the workday to use the service, further reducing
barriers to health care. Healthcare is a collaborative effort,
and this program is no different. Should an employee have a
need outside the scope of telehealth, UMMC assists in securing
appropriate follow up with local providers. The goal is to
refer locally and support the local community when possible.
The eCorporate program currently covers more than 4,000
employees and dependents in businesses across Mississippi We
have customers with as few as 15 employees. When you add our
program for State Employees (UMMC 2 You), we cover over 185,000
lives across our state.
Our corporate offerings are not only aimed at patient
initiated services. We currently offer wellness services and
diabetes prevention/management services for corporations across
Mississippi. We are working with some businesses to augment
their current wellness services by helping to risk stratify
their employees' annual lab work and biometric measurements.
This leads to proactive visits with our providers to discuss
risk factors and wellness. The goal is to educate these
employees on healthy living and how they can address their risk
factors to live a healthier life.
Similarly, the eSchool Health program provides the school
nurse with additional provider support needed to reduce
absenteeism and improve student performance. With very few
local primary care providers, nurses and parents have
difficulty ensuring that students will have access to basic,
and sometimes vital health services. With eSchool Health,
school districts partner with UMMC to provide a more
comprehensive health care offering that can assist with health
care related needs such as asthma action plans and medication
refills. Our eCorporate and eSchool Health programs are
examples of working with community leaders to create an
environment that is attractive to business by supporting
efforts to produce healthy families.
Another program that has been very impactful for patients
is remote patient monitoring (RPM), which supports patients as
they manage chronic disease in their homes. RPM is designed to
educate, engage and empower patients so that they can learn to
take care of themselves. Our initial pilot with diabetics in
the Mississippi Delta was a public/private partnership between
critical access hospital North Sunflower Medical Center,
telecommunications provider C Spire, technology partner Care
Innovations, the Mississippi Division of Medicaid, Office of
the Governor of Mississippi and UMMC. The purpose of the pilot
was to test the effectiveness of remote patient monitoring
using technology in a rural, underserved area. Specifically,
the desired outcome was to reduce Hemoglobin A1C by 1% in
uncontrolled diabetics. The participants in this study received
their healthcare in the local and rural health clinic. UMMC
supported these providers by delivering diabetic education,
monitoring biometrics and serving as a liaison between the
patient and their provider as they learn to manage their
condition. The preliminary results through six months of the
study showed: a marked decrease in blood glucose, early
recognition of diabetes-related eye disease, reduced travel to
see specialists and no diabetes-related hospitalizations or
emergency room visits among our patients. This pilot
demonstrated a savings of over $300,000 in the first 100
patients over six months. The Mississippi Division of Medicaid
extrapolated this data to show potential savings of over $180
million per year if 20 percent of the diabetics on Mississippi
Medicaid participated in this program.
Given the success of the diabetes pilot, UMMC Center for
Telehealth has expanded remote patient monitoring to other
disease states, including adult and pediatric diabetes,
congestive health failure, hypertension, bone marrow transplant
and kidney transplant. Working closely with a patient's primary
care provider, we continue to grow this program both in terms
of volume and number of diseases that can be managed. Most
importantly, this program is giving patients the knowledge and
tools they need to improve their health and manage their
chronic disease. Businesses that are a part of our eCorporate
program are also given the option to provide this service to
their high risk employees with chronic disease. The employers
see this as a way to offer their employees additional support
and to reduce costs incurred for after hour clinic visits and
emergency room visits for non-emergent conditions. Many small
businesses are self-insured, so a program of this type provides
quality care at an affordable rate is attractive and
beneficial.
Health care is a major economic driver across the United
States, with the sector growing at over 20% annually. In
Mississippi, hospitals boast over 60,000 full time employees
and create an additional 34,000 outside of their facilities.
Every new physician crates approximately 21 jobs and more than
$2,000,000 in revenue for a community \2\. Critical Access
Hospitals (CAH) are located in small, rural communities and are
an important part of the health system. They are responsible on
average for 170 jobs with $7.1 million in wages salaries and
benefits. For every job in a hospital, an additional .34 jobs
are created in other businesses in the local economy. This
means that the average CAH is responsible for an additional 43
jobs outside of the hospital and $1.8 million of taxable retail
sales \3\.
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\2\ Critical Care, The Economic Impact of Hospitals on
Mississippi's Economy, 2012
\3\ Economic Impact of a Critical Access Hospital on a Rural
Community Gerald A. Doeksen, Cheryl F. St. Clair, and Fred C. Eilrich,
National Center for Rural Health Works
Our telehealth program directly supports the financial
viability of the health care system, especially primary care
providers' offices, small rural hospitals and rural health
clinics. Supporting these small businesses also supports the
overall financial viability of the community. Collaboration
between the Center for Telehealth and providers throughout the
state allow for the delivery of high quality specialty care in
locations that are convenient for patients. These
collaborations deliver multiple benefits: access to specialty
care close to home, continuity of care and originating site
fees to the local providers. These services do not cost the
patients any more than traditional visits, but save them a
tremendous amount of time and money on travel. For the clinics,
we are able to bring a more comprehensive healthcare offering
to their community. Keeping services in communities not only
supports the local providers, but keeps much needed employment
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and revenue in rural communities.
Businesses in Mississippi that have utilized our telehealth
and remote patient monitoring programs have demonstrated
success by improving access to care, decreasing cost of care
and improving quality of care for their employees. Healthy
employees mean decreased absenteeism, increase productivity and
a greater chance for small businesses to remain viable.
Thank you for your time and attention to this very
important matter.
Written Testimony
By
David F. Schmitz, MD
National Rural Health Association, President
On behalf of the National Rural Health Association
For the
United States House
Committee on Small Business
Subcommittee on Health and Technology
July 20, 2017
Good morning, Mr. Chairman, Ranking Member Velazquez, and
members of the Subcommittee. Thank you for inviting me here to
testify. I am Dr. David Schmitz, a family physician who has
practiced and taught in rural America for 20 years. I am here
today representing the National Rural Health Association where
I currently serve as president. I am grateful for this
opportunity to discuss rural health care and its impact on
rural America and local economies.
NRHA's mission is to improve the health and wellbeing of
all rural Americans and as such, we recognize the important
role that health care serves in the economic development of
rural communities across the country. The economic needs of
rural America are vastly different than those faced by
counterparts in other geographic and population settings. So
too are the health care challenges, and opportunities, for
rural health care providers.
Today I will discuss some of the unique challenges to
health care in rural America. I will discuss how rural America
has also faced unique economic challenges, and how strong rural
health care providers can rise to those challenges by providing
direct jobs, stimulating indirect jobs, supporting the growth
of employers in other industries, and bolstering entire rural
communities.
I am here today to talk about the investments that we need
to make to ensure that rural health care thrives and, in
return, rural economies thrive and sustain our communities.
NRHA believes that improving access to care by investing in
rural health care--from workforce to technology
infrastructure--is a means to bolster the local economy. This
must be a priority for both the Administration and Congress.
Barriers and Challenges of Rural Health Care
For the 62 million Americans living in rural and remote
communities, access to quality, affordable health care is a
major concern. Rural Americans on average are older, sicker and
poorer than their urban counterparts. They are also more likely
to suffer from chronic diseases that require monitoring and
follow-up care.
Local care is necessary to ensure patient ability to adhere
to treatment plans, to help reduce the overall cost of care,
and to improve patient outcomes and their quality of life.
Whether following delivery of a baby or a significant loss of
function due to stroke, locally integrated care for rural
people and their own support system is not only the right care,
it's better care. Rural communities are resourceful and
continuity of care is primary to good outcomes such as
avoidance of hospital re-admission. Investing dollars locally
can save many more otherwise wasted dollars lost to
inefficiencies, anonymity and the gaps that occur in the miles
between.
There is no doubt that rural health care delivery is
challenging. Workforce shortages, older and poorer patient
populations, geographic barriers, low patient volumes and high
rates of publicly insured Medicare and Medicaid recipients,
uninsured and underinsured populations are just a few of the
barriers.\1\
Unfortunately, a growing number of rural Americans are
living in areas with limited health care options. Indeed, 81
rural hospitals have closed since 2010, leaving many rural
Americans without timely access to emergency care. The two most
recent of these, closing on June 30th of this year, are in
Florida and Texas. The majority rural closures are in states
that did not expand Medicaid, and with reductions in the
Disproportion Share (DSH) payments that helped hospitals cover
bad debts incurred by serving high rates of uninsured people,
these hospitals could not survive.\2\, \3\, \4\, \5\, \6\ There
are 673 additional rural hospitals that are on the brink of
closure.
The health disparities between rural populations and their
urban counterparts are pronounced. This can be particularly
true among the growing minority populations in rural America. A
recent study in the Journal of Rural Health underscored the
alarming extent of these challenges.
Using data from the National Center for Health Statistics,
and adjusting for age, the researchers found that rural whites
have 102 more deaths per 100,000 members of the population than
their urban counterparts. Rural blacks have 115 more deaths per
100,000 than their urban counterparts. The number of excess
rural deaths from 1986 to 2012 was 694,000 for whites and
53,000 for blacks.\7\
Economic Impact of Rural Providers
Rural health care providers are not only critically
important for the health of rural Americans, the providers are
critically important for the economic health of rural
communities.
Much of rural America was left behind in the economic
recovery. According to the United States Department of
Agriculture (USDA), rural counties were losing 200,000 jobs per
year and the rural unemployment rate stood at nearly 10 percent
during the Great Recession. Since then, economic recovery
hasn't returned to rural America. In fact, 95% of the jobs that
have returned after the Great Recession have been to urban, not
rural areas.
While many industries in rural America have been shrinking,
for a wide variety of reasons, health care is an industry with
the potential to reverse declining employment. As factory and
farming jobs decline, the local rural hospital often becomes
the hub of the local business community--not only offering
critical life-saving services, but representing as much as 20
percent of the rural economy.
Simply put, hospitals provide a large number of jobs. The
economic wellbeing of rural American towns depends on a healthy
rural economy, which is anchored by the local rural hospital
and local provider. The average Critical Access Hospital (CAH)
creates 195 jobs and generates $8.4 million in payroll
annually. Rural hospitals are often the largest or second-
largest employer in a rural co9mmunity (along with the school
system). In addition, even a single rural primary care
physician can generate 23 jobs and more than $1 million in
annual wages, salaries and benefits.\8\
Because hospitals provide so many jobs, it follows that
their closure has a devastating effect on employment. If
Congress allows the 673 additional vulnerable rural hospitals
to shut their doors, 99,000 direct health care jobs and another
137,000 community jobs will vanish.
A critical component of maintaining economic stability in
rural communities is ensuring that rural hospitals and other
health care providers are able to remain in their communities.
Protecting rural hospitals from closure is an immediate step
that can be taken to prevent significant job loss in rural
communities.
Workforce challenges also exist in rural America. The rural
health landscape with its uneven distribution and shortage of
health care professionals is faced with significant problems in
recruiting and retaining a trained health care workforce. This
is compounded by the disparity in federal reimbursement for
rural providers, which if addressed, would not only improve the
recruitment and retention of rural physicians, but would also
stabilize the rural economy.
Providers are more likely to practice in a rural setting if
they have a rural background, participate in a rural training
program (RTT Technical Assistance Program) and have a desire to
serve rural community needs. The RTT Technical Assistance
Program \9\ identified that residents training in rural
training track residency programs were about twice as likely to
practice in rural areas following graduation than family
medicine graduates overall.\10\ Likewise, an emphasis on inter-
professional education, rural medical school tracks, admission
of rural and minority students to health professions education
are all part of the workforce solution. Training doctors and
other health professionals close to home makes it more likely
they will call that place home. Investments in rural
distributed medical education are supported by such programs as
Area Health Education Centers (AHES),\11\ and supported by
organizations such as the RTT Collaborative, a not-for-profit
sustainable result of the RTT Technical Assistance Program.
To train and educate physicians who will practice in rural,
the presence of hospitals and clinics in these rural
communities must be present to become part of the ``rural
medical education campus.'' Distributed medical education
campuses across rural states and rural America then become the
platform for workforce initiatives that work, develop
infrastructure to support quality healthcare delivery and
produce economic value. Graduate medical education regulatory
reform that allows for common sense investment specifically
allowing for education of physicians in rural hospitals is one
example of how to address rural economic development and
workforce shortages in one action, while improving quality and
delivering cost-saving healthcare.
The Local Scale: How a Healthy Population Means a Healthy
Economy
The benefits of strong rural health care providers spread
far beyond the number of people directly employed in a
hospital.
Consider the case of Beatrice, Nebraska, a rural town in
Gage County, Nebraska. The town has a burgeoning economy
largely thanks to the Beatrice Hospital, a CAH with 25 beds,
and its related health services. Beatrice is an example of how
related health care services flourish when a strong local
hospital is nearby. In Beatrice, home health services and
assisted living homes have sprung up around the hospital to
fulfill the necessary care for the town's elderly (the town's
average age is six years higher than the state of Nebraska's
average age).
Beatrice Hospital shows how significant the direct and
indirect effects of a good hospital are for rural communities.
Beatrice Hospital is the town's largest employer with 512
workers. Its payroll is nearly $28 million, and the average
starting salary for a nurse is $40,000.
The wages provided by the hospital's good jobs circulate
throughout the local economy, stimulating small businesses, the
local real estate market and more in a virtuous circle for the
community. That's why across the country, small rural towns
like Beatrice, ``have emerged as oases of economic stability
across the nation's heartland.'' \12\
Rural hospitals provide other types of indirect stimulus as
well. A hospital's construction and maintenance requires non-
hospital-affiliated labor and external contractors to complete.
In order to build and maintain a hospital, and receive these
benefits, investment in local resources and labor are
necessary.
One way to quantify the total impact of the indirect
economic benefits of rural hospitals is using employment and
labor multipliers. These multipliers are used to measure job
and revenue creation upon the entrance of a hospital into a
specific market.
If a hospital has an employment or labor multiplier greater
than one, it has a positive indirect economic impact. For
instance, an employment multiplier of 1.35 would mean that a
100-employee hospital also creates 35 new, non-health-related
jobs for local economy. The typical CAH has an employment
multiplier of 1.38.
An alternate approach is to look at the multiplier on wages
and salaries. For instance, the average wages multiplier for
rural hospitals is estimated at 1.24. That means that a rural
hospital with $10 million in wages, indirectly generates an
additional $2.4 million in local salaries and incomes outside
the hospital.
Consider what these multipliers mean for a hospital like
the one in Beatrice. The 512-direct jobs generate 179-indirect
jobs across the community. The $28 million in direct wages
generates $6.7 million in additional wages throughout the
community.
And, in Apalachicola, Florida, the George E. Weems Memorial
Hospital is a 25-bed Critical Access Hospital that not only
provides dynamic health care services to Franklin County and
the surrounding area, but it also has an employment multiplier
of 1.40. The $1.8 million in local retail sales attributed to
hospital generates significant sales tax collection.
The multipliers for other types of rural hospitals are
similar. The economics are clear that rural hospitals are
powerful engines for boosting job creation and increasing
earnings across a rural community.
Locating and Expanding Businesses in Rural
The quality of a community's local health care system is a
key factor for firms that are considering where to relocate or
expand. Access to quality health care is the number two
priority for firms who are making decisions on relocation and
expansion. The only thing more important to firms is having
access to a skilled workforce.
Without local access to care, the rural economy struggles
to grow and thrive. When a community loses access to local
health care, it affects the ability of all businesses in the
community to go about their business and grow. It is difficult
for companies to attract workers with young or expanding
families when care for a sick child is not available locally,
or if the family must travel hours for prenatal and maternity
care.
Knowing you have an emergency room nearby to treat your
employees is essential for many businesses, especially within
sectors such as farming or energy. The difficult work behind
producing our food and energy supply is vital to our nation's
economy. This work, which must often be performed in rural and
remote areas, has intrinsic risks and dangers. Workers in these
vital sectors of the American economy need and deserve access
to quality and affordable health care.
Technology such as telemedicine for consultation services
have supported rural delivery of care but depend on the
adequate development of broadband internet into rural and
remote areas. Networks developed for education and building
technology-based ``virtual communities'' can share of best
practices and an example such as with Project ECHO will
continue to bring more support to rural hospitals and clinics.
Still, hands-on care is needed when an unexpected car accident
or early delivery of a newborn baby occurs in rural America, no
matter if you are a local resident or visiting. Each one of us
who spend time and dollars in rural communities will appreciate
quality, local care in those moments.
Access to health care is related to the sustainability of
small businesses, another hallmark of healthy economies. A
rural community simply cannot attract entrepreneurial
investment and talent--or entice native talent to remain--
without appropriate health services. Small business leaders
contribute jobs and more circulating dollars, infusing rural
economies with increased assets.
Supporting the Whole Community
The town of Jefferson, Illinois is a testament to the role
of a hospital in economic growth. Rand Fisher, president of the
Iowa Area Development Group, asserts, ``To be successful in
business development today, we believe you also have to be very
focused on community development.''
Fisher is referring to the multi-pronged approach that
development-minded communities must take. They must focus on
industrial retention, recruitment and entrepreneurship, and
community betterment that provides better access to education
and health care. A rural hospital is one agent that fulfills
all these roles.
Jefferson is ``drawing new residents and keeping existing
ones through strong business and community development
programs,'' not least of which is its recent hospital
renovation. A technological investment introduced state-of-the-
art equipment and improved facilities that are better able to
serve patients.\13\
Rural hospitals provide cost-effective primary care. It is
2.5 percent less expensive to provide identical Medicare
services in a rural setting than in an urban or suburban
setting. This focus on primary care, as opposed to specialty
care, saves Medicare $1.5 billion per year. Quality performance
measurements in rural areas are on par with if not superior to
urban facilities. Additionally, CAHs represent nearly 30
percent of acute care hospitals but receive less than 5 percent
of total Medicare payments.
When a rural hospital closes or a physician leaves,
businesses, families, and retirees are forced to leave. Often,
rural physicians are hospital-based. When the hospitals close,
the physicians leave, soon followed by nurses, pharmacists and
other providers. Medical deserts are forming across rural
America. Hundreds of rural jobs are lost, home values drop, and
those who can't sell their home are stuck in a dying town that
can no longer meet their basic needs. A study shows that ``the
closure of a rural county's sole hospital decreases the
economic well-being of the community and likely places the
local economy in a downward cycle that may be very difficult to
recover from.'' \14\
All of these examples show why a strong rural health care
system is vital to our states' economies. The rural health care
system provides a large number of direct jobs, a large number
of indirect jobs, and provides key support for every business
in a local community. We have seen the devastating impact that
the Great Recession has had on rural communities across the
country. Health care is one industry capable of playing a
critical role supporting the local economy, and protecting
rural communities from further economic damage. If roads and
Internet access are the blood vessels and nerves, then health
care is the backbone to investing in rural America.
Recommendations
When rural hospitals and providers thrive, so do the
physical and fiscal health of the community. The following are
NRHA's recommendations:
1. H.R. 2957, the Save Rural Hospitals Act. Passage
of this important bill will provide immediate relief to
rural hospitals by stopping the onslaught of
reimbursement cuts that have hit rural hospitals.
Without increasing reimbursement rates, it will
stabilize payments and stop rural hospital closures. It
will also create a new health care delivery model that
is flexible for the many varied needs in rural
communities. Hospitals are essential to rural
communities, not just for access to emergency care but
for the high-quality jobs supported by the hospital. If
the hospital closes, these rural communities will
likely face higher poverty rates.
2. Education: Continue to fund health workforce
programs to not simply recruit individuals to rural
areas but to reward those individuals that stay for
extended periods of time in these communities.
Regulatory reforms related to rural graduate medical
education can have a near-term positive effect on
workforce and rural economic growth.
3. Rural Health Networks: Expand funding for the
creation of rural health networks with the intention of
identifying innovative strategies to expand services to
all residents through access to quality care at a local
integrated level, lower costs and a better patient
experience.
4. Research: The federal government should support
research that explores the linkages between a strong
healthcare system and sustainable local economies in
rural communities.
5. Technology Infrastructure: Provide access to
capital through grants and loans for facilities to
adopt new technology for Electronic Medical Records
(EMRs) and to meet all stages of meaningful use. In
addition, provide educational programs to train
doctors, nurses and other staff not just how to use the
technology but how to interpret the data and how to
make recommendations for quality improvement. Broadband
access in rural America teamed with health professions
education access and ongoing support of practice
reduces professional isolation, sustains workforce and
improves quality.
6. Telehealth: Rural providers and other agencies are
seeking to implement new medical technologies to
enhance quality and delivery of medical care.
Telehealth is an example of one of the most important
technologies for rural providers. In 2013, over 40,000
rural beneficiaries received at least one telemedicine
visit, and this number is expected to continue to grow.
If rural providers are to move toward an online future,
they must invest in necessary technological
infrastructure and systems. Government grants and
private investment in technological advancements can
increase the flow of new dollars into rural economies,
empowering local resources to further health
infrastructure.
The National Rural Health Association appreciates the
opportunity to provide our testimony and recommendations to the
subcommittee. An investment in the rural health delivery system
is important to maintaining access to high quality care in
rural communities and to a healthy, vibrant economy. We greatly
appreciate the support of the subcommittee and look forward to
working with members of the subcommittee to continue making
these important investments for rural America.
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