[Senate Hearing 115-849]
[From the U.S. Government Publishing Office]


                                                      S. Hrg. 115-849

                     HEALTH CARE IN RURAL AMERICA:
                    EXAMINING EXPERIENCES AND COSTS

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

                                HEARING

                               BEFORE THE

         SUBCOMMITTEE ON PRIMARY HEALTH AND RETIREMENT SECURITY

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                                   ON

  EXAMINING HEALTH CARE IN RURAL AMERICA, FOCUSING ON EXPERIENCES AND 
                                 COSTS

                               __________

                           SEPTEMBER 25, 2018

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
                                
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        Available via the World Wide Web: http://www.govinfo.gov
        
                              __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
32-296 PDF                  WASHINGTON : 2020                     
          
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  LAMAR ALEXANDER, Tennessee, Chairman
MICHAEL B. ENZI, Wyoming		PATTY MURRAY, Washington
RICHARD BURR, North Carolina		BERNARD SANDERS (I), Vermont
JOHNNY ISAKSON, Georgia			ROBERT P. CASEY, JR., Pennsylvania
RAND PAUL, Kentucky			MICHAEL F. BENNET, Colorado
SUSAN M. COLLINS, Maine			TAMMY BALDWIN, Wisconsin
BILL CASSIDY, M.D., Louisiana		CHRISTOPHER S. MURPHY, Connecticut
TODD YOUNG, Indiana			ELIZABETH WARREN, Massachusetts
ORRIN G. HATCH, Utah			TIM KAINE, Virginia
PAT ROBERTS, Kansas			MAGGIE HASSAN, New Hampshire
LISA MURKOWSKI, Alaska			TINA SMITH, Minnesota
TIM SCOTT, South Carolina		DOUG JONES, Alabama                                                                          
                                         
               David P. Cleary, Republican Staff Director
         Lindsey Ward Seidman, Republican Deputy Staff Director
                  Evan Schatz, Democrat Staff Director
              John Righter, Democrat Deputy Staff Director
               
             
                                 ------                                

         SUBCOMMITTEE ON PRIMARY HEALTH AND RETIREMENT SECURITY

                   MICHAEL B. ENZI, Wyoming, Chairman
RICHARD BURR, North Carolina         BERNARD SANDERS (I), Vermont
SUSAN M. COLLINS, Maine              MICHAEL F. BENNET, Colorado
BILL CASSIDY, M.D., Louisiana        TAMMY BALDWIN, Wisconsin
TODD YOUNG, Indiana                  CHRISTOPHER S. MURPHY, Connecticut
ORRIN G. HATCH, Utah                 ELIZABETH WARREN, Massachusetts
PAT ROBERTS, Kansas                  TIM KAINE, Virginia
TIM SCOTT, South Carolina            MAGGIE HASSAN, New Hampshire
LISA MURKOWSKI, Alaska               DOUG JONES, Alabama
LAMAR ALEXANDER, Tennessee (ex       PATTY MURRAY, Washington (ex 
    officio)                             officio)
                            
                            
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                      TUESDAY, SEPTEMBER 25, 2018

                                                                   Page

                           Committee Members

Enzi, Hon. Mike, Chairman, Subcommittee on Primary Health, and 
  Retirement Security, Opening statement.........................     1
Sanders, Hon. Bernard, Ranking Member, a U.S. Senator from the 
  State of Vermont, Opening statement............................     2

                               Witnesses

Glause, Tom, Commissioner, Wyoming Department of Insurance, 
  Cheyenne, WY...................................................     5
    Prepared statement...........................................     6
Reed, Morgan, President, App Association, Executive Director, 
  Connected Health Initiative, Washington, DC....................     9
    Prepared statement...........................................    11
Levine, Alan, Executive Chairman, President, and Chief Executive 
  Officer, Ballad Health, Johnson City, TN.......................    31
    Prepared statement...........................................    33
Richter, Deborah, MD, Family Physician and Addiction Medicine 
  Specialist, and Chair, Vermont Healthcare for All, Cambridge, 
  VT.............................................................    39
    Prepared statement...........................................    41

 
                     HEALTH CARE IN RURAL AMERICA:
                    EXAMINING EXPERIENCES AND COSTS

                              ----------                              


                      Tuesday, September 25, 2018

                                       U.S. Senate,
    Subcommittee on Primary Health and Retirement Security,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 3:42 p.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Mike Enzi 
presiding.
    Present: Senators Enzi [presiding], Alexander, Young, 
Roberts, Sanders, Bennet, Kaine, Hassan, and Jones.

                   OPENING STATEMENT OF SENATOR ENZI

    Senator Enzi. I'm going to go ahead and open this 
roundtable of the Subcommittee on Primary Health and Retirement 
Security, and when Senator Sanders is here we'll give him an 
opportunity to do an opening statement.
    Today we're talking about healthcare in rural America, 
examining experiences and costs and looking for solutions. One 
of the things I always appreciate about my people in Wyoming is 
when they complain to me, they usually have some idea for how 
to solve it. Sometimes they don't work, but sometimes they're 
an excellent idea, and sometimes they are in-between there 
where there's a germ of an idea that just needs to be grown a 
little bit to see if it will work.
    I thank everybody for coming today for this roundtable. I 
want to thank the Ranking Member, Senator Sanders, and his 
staff for working to put together a conversation about rural 
healthcare. I'd also like to thank all my colleagues that are 
here today for being ready to engage in this important 
discussion. I appreciate all of the participants for taking the 
time and making the effort to come today to be part of the 
discussion. I know several of you traveled great distances to 
be here.
    Chairman Alexander has held a series of important hearings 
at the full Committee level to take a close look at healthcare 
costs throughout the system. We hear too often that Americans 
are struggling to afford and understand their medical bills, 
particularly to understand their medical bills, so it's 
important to examine what drives healthcare costs and how we 
can create more value for patients particularly, and 
specifically in rural areas.
    Several years ago I formed a rural caucus, and I found that 
almost every state wanted to be represented in that caucus, 
plus the District of Columbia. I have a little trouble finding 
rural in the District, but I'm sure it's there, and as long as 
they join us in solutions, that's okay, because the purpose is 
to unite and help rural areas.
    I'm from Wyoming, which is the least populated state in the 
Nation. Our biggest city is only 60,000 people. All of our 
towns are at least 40 miles apart, and there are only 17 towns 
where the population is greater than the elevation, and almost 
every one of those towns are at least 100 miles apart. People 
love Wyoming's close-knit communities, the wide-open spaces, 
but Wyomingites also face some of the highest healthcare costs 
in the country, in part due to the challenges that come with 
delivering care in a cost-effective manner when our low 
population is spread across those 97,000 square miles.
    It struck me that as we explore the healthcare costs in 
more depth, we need also to take a serious look at healthcare 
in rural America to understand the unique challenges that rural 
patients and providers face, how those challenges can affect 
the cost of care, and learn more about how our current policies 
are working and where they might be improved.
    The purpose of a roundtable is to gather information. I 
appreciate the witnesses being willing to testify. This works a 
little different than a regular hearing. After the opening 
statements and then your statements, we'll ask some questions. 
But at any point, rather than it just being directed to one 
person, anybody that wants to comment on that, just stand your 
name tag up on end and we'll know you want to speak on it, 
because we need as many ideas as we can possibly get.
    A lot of people have told me that their insurance premiums 
are unaffordable, and some of them said that they have to pay 
more than their mortgage. But a lot of that's related, all of 
it's related to healthcare costs: the provider, the amount of 
choice that there is, how to recruit them, if you're able to 
get specialties--probably isn't going to happen in rural areas. 
So how do you get them the healthcare? Maybe price 
transparency. Another area is more competition in the 
individual market, and telemedicine, of course, is gaining some 
support, and examples in rural states. Then, of course, a 
little bit with the privacy issue. So those are all things I 
hope we can get into a little bit today.
    First I'll have Senator Sanders speak, and then I'll 
introduce the panel and we'll get going.

                  OPENING STATEMENT OF SENATOR SANDERS

    Senator Sanders. Thank you very much, Senator Enzi, for 
calling this important hearing.
    Senator Enzi and I have at least two things in common. One, 
I like him. Number two, we both come from very rural states. We 
don't have big cities like 60,000 in the State of Vermont. We 
only have 40,000 as the largest city, so we kind of are more 
rural than you are, maybe.
    My views might be just a tad different than Senator Enzi's, 
just a tad. The bottom line to me is it is an international 
disgrace--and the day will come, and more and more people 
understand it--that we are the only major country on earth not 
to guarantee healthcare to every man, woman, and child in 
Wyoming and Vermont as a right, not a privilege. That is the 
basic issue. Do we believe healthcare is a right, or do we not? 
And if you don't, and if we think that the function of 
healthcare is for insurance companies and drug companies to 
make billions in profits, fine, then you're over here.
    But if you agree with what I believe the vast majority of 
the American people believe--and I should tell you that the 
latest poll that I saw from Reuters found that 70 percent of 
the American people, including a majority of Republicans, now 
believe in a Medicare-for-all, single-payer system--then you 
hold a different view.
    Second issue is we have got to ask ourselves--Senator Enzi 
appropriately says the cost of healthcare is very, very high. 
Of course it's high. We pay almost twice as much per capita for 
healthcare as any other nation on earth, and we're going to 
have to deal with that. I know my Republican friends don't want 
to deal with it. In Canada, it's about half as much. Other 
countries, less than half as much, and that healthcare outcomes 
in terms of the outcomes in other countries is often better 
than it is in ours in terms of life expectancy and infant 
mortality and how we treat many of the diseases.
    In terms of prescription drugs, I'm sure a major issue in 
Wyoming, certainly a major issue in America, are we satisfied 
that we pay, by far, the highest prices in the world for the 
same damn drugs that are sold around the world for a fraction 
of the price that is sold in the United States? Are we happy 
that the five major drug companies in the world made $50 
billion in profit last year, pay their CEOs exorbitant 
compensation packages, and yet one out of five Americans cannot 
afford the medicine that doctors prescribe? How insane is that? 
You go to the doctor, they write a prescription, and you can't 
afford to fill that prescription, and then you end up in the 
emergency room or you end up in the hospital. Are we satisfied 
that in rural America, parts of urban America, there are no 
doctors?
    I think Senator Roberts a couple of years ago--Senator, 
correct me if I'm wrong, but you were telling me I think in 
parts of Kansas there are counties where there are no doctors. 
That's what you said a couple of years ago. Is that correct? 
Yes. And I was in Mississippi. In large parts of Mississippi, 
there are no doctors. And yet we have a system that says if you 
are a doctor, you're going to graduate medical school $400,000 
in debt, so you're going to become a dermatologist on Park 
Avenue, New York, but you're not going to go to rural Vermont 
or rural Wyoming. So we have to rethink healthcare in general.
    But I'm glad that Senator Enzi has called this hearing, 
because when we look at healthcare, it is a really, really 
serious problem in rural America, part of many other problems 
that rural America faces.
    I was told recently by somebody who seemed to be 
knowledgeable that two-thirds, Senator Enzi, two-thirds of 
rural counties in America are depopulating, two-thirds. I know 
in our most rural areas in Vermont, it's happening. In 
Burlington, Vermont, doing very, very well economically, rural 
American farms going out of business, et cetera, et cetera.
    We have to do a lot of thinking. But I would hope that at 
the end of the day, we understand that healthcare is a right, 
not a privilege, that the function of healthcare is not to make 
huge profits for insurance companies and drug companies, that 
there's something obscenely wrong when we spend twice as much 
per capita on healthcare as the people of other nations, who 
often have better healthcare outcomes than we do.
    But thank you again, Senator, for calling this meeting.
    Senator Enzi. Thank you, Senator Sanders.
    I'll now provide a brief introduction of our panel and then 
invite each of you to give a 5-minute statement, and then we'll 
do some questions.
    First, I'd like to introduce the Wyoming Commissioner, Tom 
Glause. He was appointed Commissioner of the Wyoming Department 
of Insurance by Governor Mead on January 3, 2015, and he has a 
deep understanding of the elements of what drives healthcare 
costs in the State of Wyoming and is an active participant on 
several committees and working groups at the National 
Association of Insurance Commissioners. He is also a prime 
source for me when I have a question about healthcare and comes 
out regularly to appear.
    Next I welcome Morgan Reed of App Association. Morgan Reed 
is originally from Alaska, so he understands rural health 
issues personally, and he's an expert on the ways that health 
information technology can improve patient care.
    Senator Alexander apologizes for not being able to be here 
to introduce the next witness. Mr. Levine is Executive 
Chairman, President, and Chief Executive Officer of Ballad 
Health, which operates 21 hospitals in Virginia and Tennessee. 
In April he had the pleasure of visiting Children's Hospital in 
Johnson City, which is part of Ballad's system, where Senator 
Alexander witnessed firsthand some of the great work Mr. Levine 
and his team are doing on the front lines of opioids by helping 
treat newborn children who suffer from neonatal abstinence 
syndrome. Prior to Ballad Health, Mr. Levine was President and 
CEO of the Mountain States Health Alliance. He has significant 
experience in state government as Secretary of Louisiana's 
Department of Health and Hospitals and as Secretary of 
Florida's Agency for Healthcare administration under Governor 
Bush. In those roles he helped oversee the response to 12 
hurricanes and led the effort to improve Louisiana's child 
immunization rates from 48th in the Nation to second. Tennessee 
ranks second in the Nation with the highest number of rural 
hospital closures, so Mr. Levine knows very well the challenge 
facing rural providers today. I look forward to hearing his 
thoughts.
    Then, Senator Sanders, did you want to introduce the next 
witness?
    Senator Sanders. I'm very pleased to welcome Dr. Deborah 
Richter to be with us. I've known Dr. Richter for many, many 
years. She is an expert and a hard worker in dealing with 
people with addiction issues. But more importantly, in Vermont, 
she has probably been the leader in the fight to make sure that 
all of our people have healthcare as a right, not a privilege. 
In Vermont we're making some progress in that area, and the 
progress we're making Dr. Richter has a lot to do with. So, Dr. 
Richter, thanks so much for being with us.
    Senator Enzi. Okay, we'll get started on the testimony.
    Mr. Glause.

 STATEMENT OF TOM GLAUSE, COMMISSIONER, WYOMING DEPARTMENT OF 
                    INSURANCE, CHEYENNE, WY

    Mr. Glause. Thank you, Chairman Enzi, Committee Members. 
I'd like to invite you to pull on your cowboy boots and take a 
walk through rural America with me as we discuss the issues 
regarding healthcare delivery in rural areas. My son Seth is a 
professional bull rider----
    Senator Enzi. Is your mic on? There should be a little red 
light that comes on.
    Mr. Glause. I'll talk closer to it.
    Senator Enzi. That works. Thank you.
    Mr. Glause. My son Seth is a professional bull rider. In 
2012, he was on the verge of winning a world championship. At 
the fifth round of the national finals rodeo that year, he had 
drawn a bull named Canadian Tuxedo. That bull came out of the 
chute spinning hard to the right. Somehow, Seth managed to stay 
on for the entire eight seconds. But as he was dismounting the 
bull, his arm came over the back of the bull as the bull kicked 
and hyperextended his shoulder. During the course of the next 
two years, he had four major surgeries on his shoulder. None of 
those surgeries occurred within the State of Wyoming, which 
leads me to the first topic that I would like to address with 
you, and that is a lack of providers in rural areas.
    Wyoming only has 179 doctors per 100,000 people and, mind 
you, our population is only 585,000 to start with. So to do the 
simple math, that means we only have about 1,100 doctors 
servicing over 97,000 square miles. That's only 50 doctors per 
100,000, below the national average.
    It's no secret that it's more expensive to deliver 
healthcare in rural areas. Wyoming has the second-highest 
insurance rates in the country. Contributing to those costs are 
long distances between towns and fewer providers. Smaller 
communities simply cannot afford the multi-million-dollar 
equipment that is necessary to practice medicine in today's 
world. Thermopolis, Wyoming, a town of 2,000 people in central 
Wyoming, simply does not have the population base to amortize 
the cost of an MRI machine over the more urban areas.
    Also contributing to the problem is 70 percent of the 
population in Wyoming lives within 70 miles of a state border, 
and we see a large out-migration of healthcare delivery to more 
populated areas.
    Another area of concern in Wyoming is the Medicare 
reimbursement rate. The two largest hospitals in the state 
report that Medicare reimburses them only 65 percent of their 
actual cost and that Medicare patients account for 50 percent 
of their book of business. This amounts to a large cost 
shifting to the non-Medicare population. In short, that means 
that they have to make up for the cost of that care by passing 
it on to those with private insurance.
    Please remember, healthcare costs drive insurance costs, 
not the other way around.
    In the short time I have here, I would like to ask you to 
consider several suggestions for improvement.
    We need to find a way to incentivize residents entering the 
medical profession in rural areas. Simply stated, we need more 
doctors in rural areas.
    We need to increase programs to reduce smoking. Wyoming has 
a higher than national average rate of smoking. I believe it's 
19.6 percent. The image of the Marlboro Man riding down off the 
mountains chasing the horses needs to disappear as we improve 
our health status in Wyoming.
    We also need to increase price transparency. People need to 
know that they're getting low-cost medical care, but they need 
to be assured that they are also getting quality care. Try 
finding out how much it costs to get a procedure done at a 
local hospital and it's nearly impossible.
    We also need to increase the Medicare reimbursement rate so 
we don't have that cost shifting. I would encourage you to 
support suspending the health insurance tax after 2019.
    Air ambulance also needs to be addressed to give states 
greater flexibility in addressing air ambulance service in 
rural communities.
    The people in Wyoming and all of rural America deserve 
quality, affordable, and accessible healthcare. Thank you.
    [The prepared statement of Mr. Glause follows:]
                    prepared statement of tom glause
    Good afternoon. My name is Tom Glause. I am the Insurance 
Commissioner for the State of Wyoming. I would like to thank this 
Committee and especially Wyoming Senator Mike Enzi for the opportunity 
to address you today. In our short time together, I plan to discuss 
several of the issues and concerns facing health care delivery and 
health insurance in rural or frontier states like Wyoming and to 
provide you some considerations for changes.

    Numerous studies report that access to healthcare is important for 
many reasons that effect the physical and mental well-being of our 
citizens. \1\ However, in rural settings healthcare and health 
insurance face additional access and affordability challenges.
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    \1\  Health care effects include overall physical, social, and 
mental health status, prevention of disease, detection and treatment of 
illnesses, quality of life, preventable death and life expectancy as 
identified in Healthy People 2020, https://www.healthypeople.gov/2020/
leading-health-indicators/2020-lhi-topics/Access-to-Health-Services.

    Rural residents often experience barriers to health care that limit 
their ability to obtain the care they need. Increased cost of health 
care in turn increases health insurance costs. We must remember that 
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health care costs drive insurance costs.

    I would like to outline several areas in which rural residents face 
challenges in health care and health insurance:

    Access. Rural areas often have fewer medical providers and 
transportation limitations to reach services that may be located at a 
considerable distance. Further, rural residents have difficulties in 
the ability to take paid time off of work to use such services. 
Frankly, farmers and ranchers don't have ``days off'' from tending to 
livestock. Further, 43.4 percent of uninsured rural residents report 
that they do not have a ``usual source of care.'' \2\, \3\ Only 24 
percent of rural residents can reach a top trauma center within an 
hour. Rural areas suffer 60 percent of America's trauma deaths despite 
having only 20 percent of the Nation's population. Necessary and 
appropriate services must be available and obtainable in a timely 
manner.
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    \2\  June 2016 ASPE issue brief; https://aspe.hhs.gov/system/files/
pdf/204986/ACARuralbrief.pdf.
    \3\  ``Usual source of care'' (USC) refers to the provider or place 
a patient consults when sick or in need of medical advice.

    Available and Affordable Health Insurance Coverage. Rural areas 
tend to have fewer insurance companies offering plans. \4\ Wyoming has 
just one carrier on the Marketplace and two carriers in the Small Group 
market. Premium increases tend to be higher where there is less 
competition among insurers. Although 2019 rates are flat, Wyoming saw 
2018 plans average increases of 48.6 percent for individual plans and 
30.7 percent for small group plans.
---------------------------------------------------------------------------
    \4\  Geographic Variation in Health Insurance Marketplaces: Rural 
and Urban Trends in Enrollment, Firm Participation, Premiums, and Cost 
Sharing in 2016, researchers from the RUPRI Center for Rural Health 
Policy Analysis, August 2016.

    Hospitals in Wyoming report that Medicare reimbursement is just 65 
percent of the actual costs. This low reimbursement rate results in 
cost shifting to the non-Medicare population. Rising costs of care 
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result in rising insurance rates.

    Rural residents often have limited financial resources to pay for 
services, including available and affordable health insurance that is 
accepted by their provider. Rural uninsured are more likely to delay or 
forgo medical care because of the cost of care compared to those with 
insurance. Nearly 30 percent of rural residents report delayed care or 
report they did not receive care in the previous year due to the cost.

    Workforce Shortages--Having an adequate health workforce is 
necessary to providing that ``usual source of care.'' A shortage of 
healthcare professionals in rural America can limit access to care. \5\
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    \5\  In September 2018, rural areas made up 57.27 percent of the 
primary care health professional shortage areas. See data.HRSA.gov 
Preformatted Report, ``Shortage Areas, Health Professional Shortage 
Area (HPSA)--Basic Primary Medical Care: Designated HPSA Statistics.''

    Medical Service Delivery Challenges--It is more challenging to 
deliver healthcare services in sparsely populated areas. Small 
communities are unable to support full-time physicians for many medical 
specialties, and the fixed costs of multi-million-dollar hospital 
equipment cannot be spread across as many patients as in urban or 
densely populated areas. Rural uninsured face greater difficulty 
accessing care due to the limited supply of rural healthcare providers 
who offer low-cost or charity healthcare. \6\ Advanced technologies and 
expensive medical equipment are cost prohibitive to smaller facilities 
and communities.
---------------------------------------------------------------------------
    \6\  Kaiser Family Foundation, 2014, 2016 issue briefs, https://
www.kff.org/uninsured/report/the-uninsured-a-primer-key-facts-about-
health-insurance-and-the-uninsured-under-the-affordable-care-act.

    Privacy/confidentiality. Social stigma and privacy concerns are 
more likely to act as barriers to healthcare access in rural areas. 
Rural residents need confidence in their ability to use services 
without compromising privacy. Residents may be concerned about seeking 
care for issues related to mental health, substance abuse, sexual 
health, pregnancy, or even common chronic illnesses due to privacy 
concerns. This may be caused by personal relationships with their 
healthcare provider or others that work within the health care 
facility. In addition, concerns about other residents noticing them 
utilizing services such as mental healthcare can be a concern. 
---------------------------------------------------------------------------
Integration of behavioral health services with primary care can help.

    Impact on Wyoming. All of these rural population factors affect the 
people of Wyoming. As a result, Wyoming's insurance rates are generally 
regarded as the second highest in the Nation. \7\ Wyoming is truly the 
land of wide open spaces, but that claim comes with a price. We are the 
least populated state in the Nation in the tenth largest geographic 
area of approximately 98,000 square miles. \8\ We know the impact of 
long distances between towns and medical providers and we know the 
effect on health insurance costs. Wyoming knows the impact of having 
fewer medical providers and limited specialists. Wyoming has just 178 
physicians per 100,000 population compared to the national average of 
229. \9\
---------------------------------------------------------------------------
    \7\  Survey rankings vary depending upon criteria evaluated. Price 
alone doesn't reflect access, availability, quality of care, and 
effect. See e.g. ``Health Insurance Coverage of the Total population,'' 
Kaiser Family foundation, KFF, https://www.kff.org/other/state-
indicator/total-population/'currentTimeframe, ``Health Insurance Rates 
by State,'' https://howmuch.net/articles/health-insurance-rates-by-
state; ``Best and Worst States for Health Care,'' https://
wallethub.com/edu/states-with-best-health-care/23457/.
    \8\  Wyoming has a total population of 585,501 in a geographic area 
of 97,814 sq. miles.
    \9\  Skillnan SM, Dahal A. Wyoming's Physician Workforce in 2016., 
Seattle, WA:WWAMI, Center for Health Workforce Studies, University of 
Washington, Feb 2017.

    Additional factors that contribute to Wyoming's high insurance 
rates are that many residents seek medical care from out-of-state 
providers. Approximately 70 percent of Wyoming's population lives 
within 70 miles of a state border and larger urban centers with medical 
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care.

    Lastly, according to the Centers for Disease Control and Prevention 
(CDC) the prevalence of cigarette smoking among U.S. adults is highest 
among those living in rural areas. \10\ Unfortunately, Wyoming has a 
higher than average smoking rate. \11\
---------------------------------------------------------------------------
    \10\  https://www.cdc.gov/tobacco/disparities/geographic/index.htm.
    \11\  https://truthinitiative.org/tobacco-use-wyoming.

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    Possible Solutions or Areas for Development:

    I don't believe in merely exposing a problem without offering areas 
for development or change. I offer the following suggestions:

        1. Allow a lower medical loss ratio (MLR) for insurance 
        carriers who cover rural areas because the administrative costs 
        per person are higher for rural areas. Allowing insurers to 
        have a somewhat higher allowance for higher administrative 
        expenses and profits would make it easier and more attractive 
        for them to operate in rural areas. If more insurers are 
        willing to operate in rural areas, their presence can increase 
        competition and bring premiums down even more than the amount 
        that the premium would increase because of the lower MLR. Also, 
        if there were an increase, subsidized consumers would be 
        protected by the structure of the premium tax credit, though of 
        course unsubsidized consumers are not.

        2. Allow states more flexibility in setting rating areas or 
        rating rules to provide more affordable options in rural areas. 
        States could use rating areas to help spread the higher cost of 
        rural coverage across both rural and urban areas of a state.

        3. Create a Federal grant program to help states work with 
        providers and carriers to provide lower-cost and higher-quality 
        care in rural areas. The funds could be used to assist rural 
        hospitals and clinics, promote telemedicine, and improve 
        transportation. By funding these kinds of services through 
        Federal grants, they don't have to be paid for by enrollee 
        premiums, leading to lower rates for all consumers.

        4. Fund Association Health Plans for Farmers/Ranchers to 
        provide more options as proposed in the Farm Bill 
        reauthorization. Providing initial funding for associations of 
        farmers can help introduce needed competition to rural 
        insurance markets. While co-ops under the ACA did not prove to 
        be successful, agricultural associations--like the Western 
        Growers Association--have demonstrated a proven model for 
        independent businesses to band together to meet their health 
        care needs.

        5. Increase the availability and proper use of telehealth. 
        Through telehealth, rural patients can see specialists in a 
        timely manner while staying in their home communities.

        6. Increase transparency in cost of services. Studies have 
        documented wide differences in the cost of services, even when 
        accounting for differences in income, demography, and health 
        status within regions. Increase transparency on Medicare 
        reimbursements, cost shifting, and rate determinations.

        7. Increase provider competition. Lack of provider competition 
        in some geographic areas gives available providers market power 
        to set rates for services. A study by the National Bureau of 
        Economic Research found that prices charged by hospitals in 
        monopoly markets was 12 percent higher than in markets with 
        four or more hospitals. \12\
---------------------------------------------------------------------------
    \12\  ``The Price Ain't Right, Hospital Prices and Health Spending 
on the Privately Insured,'' Cooper, Craig, Gaynor, van Reenen, NBER 
Working Paper No. 21815, May 2018.

        8. Increase competition among health insurers. When there is 
        more competition insurers seek lower rates and gain greater 
        market share. More enrollees means insurers can spread risk 
---------------------------------------------------------------------------
        across a greater population base and reduce premiums.

        9. Increase programs to reduce smoking. The negative health 
        impact of smoking is widely known. Greater education and 
        programs to reduce smoking in rural areas may go a long way in 
        reducing health and insurance costs.

        10. Support legislation to continue the suspension of the 
        Health Insurance Tax (HIT) beyond 2019 and to restrict balance 
        billing. The HIT tax is paid by insurers but the cost is passed 
        on to consumers. \13\ Consumers too often receive unexpected 
        bills from out-of-network providers, often for thousands of 
        dollars. This can occur even when consumers choose in-network 
        facilities. While some states have taken action to limit this 
        practice, congressional action is needed to address federally 
        regulated plans and to spur further state protections. Balance 
        billing has been particularly egregious with some air ambulance 
        companies.
---------------------------------------------------------------------------
    \13\  See e.g. ``Legislation to suspend the Health Insurance Tax 
Will Help Make Premiums More Affordable,'' AHIP, https://www.ahip.org/
legislation-to-suspend-the-health-insurance-tax/.

        In Wyoming, we depend on air ambulances and want to keep the 
        industry strong, but we do not want consumers caught in the 
        middle of billing disputes between insurers and service 
        providers. Wyoming and other states are prevented by Federal 
        law from addressing the excessive billing practices of some 
        companies. With the Federal Aviation Administration (FAA) 
        Reauthorization moving through Congress, there's an opportunity 
        to address this concern and give insurance commissioners the 
        authority they need to regulate effectively in their states. 
        Although FAA is not within the jurisdiction of this Committee, 
        but I hope all Senators will support the language in the House 
        version of the FAA bill to bring more transparency and consumer 
---------------------------------------------------------------------------
        protections to the air ambulance industry.

    Thank you again for the opportunity to provide some input on the 
health care and health insurance picture in rural America.
                                 ______
                                 
    Senator Enzi. Thank you.
    Mr. Reed.

STATEMENT OF MORGAN REED, PRESIDENT, APP ASSOCIATION, EXECUTIVE 
     DIRECTOR, CONNECTED HEALTH INITIATIVE, WASHINGTON, DC

    Mr. Reed. Thank you, Mr. Chairman. My name is Morgan Reed. 
I'm the President of the App Association and the Executive 
Director of the Connected Health Initiative, a coalition of 
doctors, research universities, patient advocacy groups, and 
leading mobile health tech companies. Our organization focuses 
on clarifying outdated health regulations and using digital 
health tools to improve the lives of patients and their 
doctors.
    Constituents in rural America face serious challenges in 
getting cost-effective, quality care. People are too far away 
from healthcare services. The cost, frankly, is too much, and 
it's likely to get worse. By 2030, more than 70 million 
Americans will be over the age of 65. By 2025, we will have a 
shortfall of more than 90,000 physicians. And while about 20 
percent of Americans live in rural areas, only 10 percent of 
physicians practice there. Finally, 44 percent of rural 
hospitals are currently underwater and are at risk of closure.
    Yet we live in a world where every person can pay their 
mortgage, monitor their package delivery, review their child's 
homework, all while sitting in the waiting room of their 
doctor, who, by the way, can't use those same technologies for 
digital health. What's going on that rural caregivers can't 
better engage with patients using the tools that every single 
one of you currently have in the palm of your hand or on your 
wrist? Why is it that CMS reimburses $1 trillion a year but 
can't reimburse telehealth and remote monitoring in rural areas 
in a meaningful way? Why doesn't the system help doctors to 
treat patients and not the keyboard?
    This hearing takes place at a critical moment for 
healthcare in rural America, and it is of personal importance 
to me. I was born and raised in Alaska, and my father is from a 
town of 500, and I have friends and family where there are no 
roads and where there is not a single healthcare professional 
within 500 miles. So I guess we're all kind of out-ruraling 
each other. I've got the 500-mile range. And yet Federal 
agencies can't even agree on what rural means.
    There's a great chart in my written testimony which shows 
four qualified rural health clinics in extremely remote 
counties in Virginia that agencies like USDA and FCC rightfully 
consider rural. Yet incomprehensibly, CMS does not consider 
these objectively rural areas to be rural. The University of 
Virginia Center for Telehealth finds itself unable to help the 
very people for whom getting to a doctor quickly is an 
insurmountable problem.
    It's not just a Virginia problem. Throughout America, 
academic and other medical centers find CMS' system governing 
telehealth is basically broken. Rather than attempt to get five 
Federal agencies to agree on the definition of rural, we think 
it's best for all of your constituents to have access to 
telehealth and digital medicine, regardless of how close they 
are to Main Street.
    For patients, remote monitoring technologies are life-
saving tools. One of our steering committee members makes a 
foot mat you stand on for 20 seconds when you're brushing your 
teeth. It detects foot ulcers up to 5 weeks before they present 
clinically. This tech is not only more efficient than other 
methods, but it cuts down on hospital bills and ultimately 
saves limbs. Doctors like it because the patient stays engaged, 
but reimbursement under Medicare remains a question mark.
    We're all familiar with the horror stories from doctors 
about EHR adoption and the epic burnout we see as a result. 
Doctors find EHRs can create extra work and ultimately prevent 
entered data from being used predictably as part of machine 
learning or augmented intelligence systems. For taxpayers, it's 
about providing the right incentives for the right things at 
the right time. And when it comes to preventive health, this 
begins with expansion of the CBO scoring window, and I want to 
thank Senator Bennett for his support for the Preventive Health 
Savings Act. That's a good start. Preventive medicine can do 
much more.
    You mentioned Mississippi. The University of Mississippi 
Medical Center's telehealth program would save the State of 
Mississippi $189 million in Medicaid if just 20 percent of 
Mississippi's diabetic population were enrolled. Just think of 
the taxpayer savings for the whole country if CMS actually 
supported what UMMC is doing today.
    Here are a couple of actions that Congress can hit in order 
to make the mark.
    First, pass the Connect for Health Act. I want to thank 
Senators Kaine, Bennet, and Murkowski for co-sponsoring. It 
would clarify that Medicare covers tech-driven tools that 
enhance efficiency and clinical advocacy, including the removal 
of outdated restrictions on 1834(m).
    Second, CMS should provide reimbursement and incentives for 
collecting and using patient-generated health data.
    Third, Congress should file down regulations like the anti-
kickback statute and Stark Law that allow providers to get 
technology into the hands of patients.
    Finally, Congress should support the use of unlicensed 
spectrum, including television white space technology, to help 
cover rural populations and give them the high-speed broadband 
that can help make this a reality.
    We are all part of the system, either as patients or 
caregivers. The least we can ask is for a system that treats 
us, whether we are in rural or urban areas, as real people, not 
just boxes on a spreadsheet.
    Thank you very much, and I look forward to your questions.
    [The prepared statement of Mr. Reed follows:]
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    Senator Enzi. Thank you.
    Mr. Levine.


 STATEMENT OF ALAN LEVINE, EXECUTIVE CHAIRMAN, PRESIDENT, AND 
    CHIEF EXECUTIVE OFFICER, BALLAD HEALTH, JOHNSON CITY, TN

    Mr. Levine. Thank you, Mr. Chairman. My name is Alan 
Levine. I'm the Executive Chairman of Ballad Health, a 21-
hospital integrated health delivery system serving 29 counties 
in Southwest Virginia and Northeast Tennessee. I also formerly 
served as the Secretary of Health for the State of Louisiana, 
and in Florida.
    I'm pleased to provide this oral testimony as a supplement 
to the written testimony I've submitted, and I look forward to 
answering your questions about it later.
    Tennessee has made many contributions to America, and 
yesterday I had the opportunity to visit one such gift, the St. 
Jude Children's Research Hospital, a place in Memphis where 
research and precision medicine are creating cures for 
children's cancer. And as I toured the hospital, it occurred to 
me that just more than an hour away in a small rural community 
in Tennessee, a local hospital was closing that very day and 
people were losing their jobs. This was the ninth such closing 
in Tennessee since 2010.
    What a vivid picture that was of the increasing distance 
between our urban and rural communities. In one, Memphis, we 
have research in progress, led by a world-renowned institution, 
and in a rural community just more than an hour away, the 
community lost its hospital.
    Evidence is mounting that our policies are having 
unintended consequences on our rural health safety net and our 
non-urban hospitals. Almost 90 rural hospitals nationwide have 
closed in the last 8 years, and 673 rural hospitals are 
reported to be at risk of closure. Forty-four percent of them 
have negative operating margins in 2018, up from 40 percent 
just 12 months earlier.
    The healthcare culture of any community revolves around its 
hospital. As non-urban hospitals struggle and rural hospitals 
close, the opportunity to improve the health of these 
communities is diminished. Policies intended to transform the 
government payment system from fee-for-volume to fee-for-value 
are complex and frankly seem more appropriately targeted to 
larger urban and suburban hospitals which have both the 
critical mass of patients and the resources to test these 
models; models, I would add, which are constantly changing and 
which have led in part to increases in bad debt, uncollectible 
revenue, increases in the number of physicians who give up 
private practice and either seek employment or retire, and to 
unpredictability of cash-flow for those hospitals. Smaller non-
urban and rural hospitals have neither the patient volume nor 
the sophistication to deploy these new reimbursement models.
    As the government payers move toward shifting more risk to 
hospitals, smaller hospitals and those with debt simply do not 
have the balance sheet strength to succeed and certainly will 
struggle to invest in the infrastructure needed to improve the 
management of chronic care and population health, which are 
really the intended outcomes of all these policies to begin 
with.
    Consider that in non-urban and rural communities, which 
make up almost 95 percent of our Nation's land area, they are 
seeing population stagnation or decline, and due to the 
policies intended to reduce inpatient utilization, policies I 
think we all agree with, the combination of no population 
growth with reducing inpatient utilization means the non-urban 
and rural hospitals are stuck in a business model which is 
destined to fail.
    For example, as the inpatient utilization rates in 
Nashville, Tennessee declined from 110 per thousand to less 
than 100 per thousand, the population in Nashville grew. So the 
hospitals have thrived there because the economy was expanding 
and the population was growing. But in my region, where many of 
the counties are seeing population declines as inpatient use 
rates decline, there is no population growth to sustain the 
hospital.
    We are therefore seeing year-over-year declines in 
inpatient services in these rural markets. In most cases, this 
begins a death spiral. Reduced revenue means lack of capital to 
invest in technology equipment and recruitment of doctors. Add 
to this the complexity of payment changes imposed by state and 
Federal Governments and the inability of rural hospitals to 
deploy even the simplest of these payment changes and you end 
up with a rural hospital failure.
    I don't think the responsible answer is to either just pay 
more or let rural hospitals close. I think the choice is 
broader than that, but we need to focus on the real problem we 
are trying to solve. We are not trying to save hospitals for 
the sake of bricks and mortar. We actually have real problems 
in these communities we need those hospitals to help solve.
    Rural Americans have a higher rate of death from disease, a 
higher rate of death from overdose, and the incidence of 
complications and deaths for moms and babies is higher in rural 
areas due to the same factors that lead to higher rates of 
disease in rural communities. So rather than just throw money 
at the problem, I think we can build a bridge to a rural safety 
net that serves today's rural health needs better.
    My written testimony highlights steps that I hope we can 
talk about during the Q&A, and I look forward to discussing the 
steps that can build this bridge to a sustainable rural model 
and a sustainable business model. I do believe the area wage 
index is a major problem for our country. Senator Alexander, 
Senator Kaine, you guys have been champions in trying to help 
deal with that issue. That would be one of the single most 
important things you can do for rural hospitals and non-urban 
hospitals.
    I think our rural hospitals can be repurposed. I think 
there are services like mental health, addiction, emergency 
services, and maternal services for women and babies where 
rural hospitals, we have a need for those services rather than 
some of the high-end acute services that we might have needed 
30 years ago. So repurposing of these hospitals is a real 
opportunity.
    I look forward to answering your questions and to the 
dialog we're about to have. Thank you.
    [The prepared statement of Mr. Levine follows:]
                  prepared statement of alan m. levine
    Chairman Enzi, Chairman Alexander, Ranking Member Sanders, Ranking 
Member Murray, and Members of the Committee, thank you for the 
invitation and opportunity to appear before you this afternoon.

    My name is Alan Levine, and I currently serve as the executive 
chairman, president and chief executive officer of Ballad Health, a 21-
hospital, not-for-profit integrated healthcare delivery system uniquely 
created through state action immunity upon the merger of two regional 
health systems. We serve 29 counties in the Appalachian region of Upper 
East Tennessee, Southwest Virginia, East Kentucky, and Western North 
Carolina.

    Thank you for inviting me to discuss the variety of healthcare 
challenges facing Americans in rural areas, and the concerns those of 
us responsible for delivering health care services have with respect to 
ensuring access and improving health. As the evidence shows, rural 
hospitals and clinics are facing unprecedented pressure. Researchers at 
the University of North Carolina have identified almost 90 rural 
hospital closures across the country in just the last 8 years, and 
iVantage Health Analytics has reported that 673 other rural hospitals 
are at risk of closure due to mounting financial pressures.

    These hospitals are the epicenter of most of these communities, not 
just for health care but for community-wide economic stability. In 
addition, the dated reimbursement models and bricks-and-mortar approach 
to health care of yesterday are undermining these assets. Payment 
policies and well-intended policy reforms are overly sophisticated and 
bureaucratic. While the jury is out on whether these policies, which 
continue to quickly evolve, will work, it is highly likely most of the 
thought behind the policies is aimed at urban and higher density 
markets where much of the spending occurs. In my view, not enough 
thought has gone into how these policies weigh on smaller, non-urban 
and rural community assets. The fragmentation of payment and the weight 
of these policies undermine efforts to transition these rural assets 
into what is actually needed in these communities. One need look no 
further than the closings of hospitals, and the financial performance 
of the largest rural and non-urban hospital providers--both publicly 
traded and not-for-profit--to validate this point. We have before us a 
situation where it seems the only two options are: provide more funding 
for rural hospitals through convoluted formulas and one-size-fits-all 
rules, or let rural hospitals close.

    I firmly believe there are options in between these two extremes 
which can help sustain our rural and non-urban communities.

    Let's face it. Rural economies are continuing to struggle, and are 
not yet enjoying the full benefit of the recovery. According to the 
National Rural Health Association, only 3 percent of the job growth 
that has occurred since the Great Recession has happened in rural 
areas, and between 2010 and 2014, more businesses closed than opened in 
rural areas. Today across the Nation, rural and non-urban hospitals 
find themselves in negative feedback loops, increasingly leading to 
bankruptcy and closure. It starts with declining revenues caused by 
declining inpatient utilization rates. Combining declining inpatient 
use rates with stagnant or declining populations is a dangerous mix for 
a rural hospital or health system. Add to this mix the multitude of 
Federal and private insurer payment policies designed to contain or 
even reduce per-unit reimbursement, which remains tied to the fee-for-
service system, and the hospitals lose the necessary revenue to service 
fixed costs. These hospitals have also amassed debt they must service, 
and the ongoing fixed costs of operating a hospital continue to grow. 
If the variable margins decline, the financial model simply does not 
work. Then, add to this scenario the highly complex changes being 
imposed by Medicare and Medicaid, and the cost of compliance, and you 
are left with hospitals that simply don't have a chance, particularly 
if they are not part of a larger health system. But even if they are 
part of a larger system, those same policies that undermine the 
financial health of the larger regional non-urban hospitals is 
beginning to lead to decisions to close or alter the relationships with 
rural hospitals. This very instance is playing out today in West 
Tennessee, where a regional not-for-profit system acquired a rural 
hospital, and closed it. The process of failure is familiar to us all. 
Inability to service fixed costs translates into reduced cash-flow, 
which negatively impacts employee and physician recruitment and 
retention, reduced investment into capital assets like newer equipment 
and technology, and eventually the decline of the physical structure 
itself.

    As these investments deteriorate, patients with means (and 
commercial insurance) travel to urban and suburban hospitals for 
orthopedic, cardiovascular and other procedures, which our current 
reimbursement system disproportionately rewards with higher margins. 
These margins are used by hospitals to offset losses in most other 
service lines of a hospital. Rural hospitals are thus left with a less-
favorable case mix and payor mix, leading to further declines in 
revenue and margin.

    This is the death spiral.

    But, as I have stated, these hospitals don't have to close. There 
is another option. Transitioning these hospitals to what is needed 
today can be financially beneficial and can serve a major public health 
policy purpose. Today's rural hospital does not need to be providing 
high acuity intensive services or high acuity surgeries. Indeed, it may 
be better for patients to go to larger regional facilities that sustain 
the volume necessary to provide high quality intensive services. But, 
since 80 percent of our Nation's land mass is rural, access to many 
needed services is hampered by geography--this is geography that rural 
hospitals can help serve where serious service gaps exist. By building 
a bridge from yesterday's fee-for-service, bricks-and-mortar model 
focused on payment for each inpatient encounter or surgery to one where 
rural hospitals become the epicenter for the evolved needs of mental 
health, addiction services, primary care, chronic care for certain 
chronic conditions, obstetrics and neonatal care, emergency services, 
rehabilitation, specialty access through technology solutions, and 
other services, we can create new opportunities for revenue and job 
growth, and ultimately, we can serve the critical needs of these rural 
communities.

    The area of Southern Appalachia served by Ballad Health serves as a 
case study of sorts. As an example, just last month, I met with school 
superintendents from throughout our region. Many of these 
superintendents oversee rural school systems. These superintendents 
shared their serious concerns for students who are increasingly showing 
up for school in the fall with serious mental health issues, addiction, 
depression and suicidal tendencies. Their teachers don't possess the 
skills needed to manage the serious issues these students come to 
school with, and the school systems in rural areas certainly lack the 
resources to manage this problem on their own. Given the distant nature 
of the hospitals throughout the region, and the location of the 
schools, there is no easy solution, but there is a solution. The 
combination of the use of technology for assessment of these kids by 
qualified counselors who may not even live in those communities with 
the resources of the rural hospital to offer competent crisis services 
with a bridge to treatment makes perfect sense. But the payment system 
doesn't lend itself to supporting these costs or this model for rural 
communities.

    This is where Ballad Health, and its unique model, can be a bridge 
as the larger rural health policies evolve. The vast majority of the 29 
counties Ballad Health serves have flat or negative population growth. 
Our hospitals are also experiencing above-average declines in inpatient 
utilization rates. Sixty-seven percent of our payor mix is Medicare or 
Medicaid and another 6 percent is self pay. The fastest growing segment 
of our patients who are not paying are those who have insurance but 
cannot pay the higher deductibles. In addition, just as rural Americans 
are older and sicker than their urban counterparts, they also suffer 
higher rates of chronic disease such as heart disease, diabetes, 
obesity, substance use disorder, and untreated mental illness. Given 
the higher incidence of chronic conditions that make pregnancy more 
challenging in rural areas, it follows that rates of complications and 
maternal/infant deaths are higher, too. In 1985, 24 percent of rural 
counties lacked obstetric services. Today, 54 percent of rural counties 
lack hospital-based obstetric services. More than 200 rural maternity 
programs closed between 2004 and 2014. All of these issues are faced by 
Ballad Health and the rural communities we serve.

    While rural populations account for only about 20 percent of our 
Nation's population, they populate approximately 80 percent of our 
Nation's land mass. In some regions, this land mass is complicated by 
the significant geographic barriers and distance that make the 
provision of services even more difficult.

    These are some of the reasons our community leadership came 
together to create a new model of healthcare delivery. Formed only 
eight months ago by the merger of two competing health systems serving 
the same region for many decades, Ballad Health represents a 
transformation in the way we are approaching these challenges in our 
part of the country.

    Both legacy systems came to recognize that our status quo was no 
longer sustainable. While we separately invested millions of dollars in 
services and technologies designed to compete with the system down the 
road, our community was becoming less healthy, and our margins still 
continued to decline. We each recognized obtaining synergies of 
increased scale was imperative, yet selling our systems to larger 
outside hospital companies or systems would have likely resulted in the 
closure of some rural hospitals, the devastating loss of at least 1,000 
back-office jobs in our region, and as studies have shown happens, the 
larger systems would have likely increased pricing as they sought to 
leverage their size in negotiations with insurers and government 
payors.

    Unfortunately, Federal anti-trust policy in health care is solely 
focused on preserving competition, with little or no room to consider 
the effects of market failure on health and economic conditions in 
communities such as ours. Without this merger under state action 
immunity laws in Tennessee and Virginia, the hit to our region's 
economic stability would have been severe.

    Instead, we have begun the process of reducing resources tied up in 
destructive and costly duplication. We are redirecting at least $300 
million of these savings to preserve essential services and to invest 
in initiatives that reach further upstream of the emergency department 
or the doctor's office to help address the social determinants that are 
contributing to our region's poor health status.

    Our efforts are an attempt to build a bridge to the future of rural 
health care, but we will only succeed long-term if Federal and state 
policies support what we are trying to do. While other rural hospitals 
are closing, we have pledged to preserve our rural hospital facilities 
and to repurpose many of them so that additional essential services can 
be provided to our community.

    Referencing the conversation I had with our school superintendents, 
because Ballad Health retained its local governance and is a community-
based organization, we decided to become a solution to the problem. 
Ballad Health intends to invest in counselors at our region's only 
children's hospital to do assessments of children in our schools in 
crisis. We plan to hire a counselor in each school district to serve 
those children identified with serious crisis needs. Unfortunately, the 
current payment system does not sufficiently support this model, but 
our commitment to the community is more important than profits. 
Eventually, the business model must support what we are investing in, 
and that's why I'm here today. This is an example where a system 
approach to genuinely improving healthcare services can benefit the 
communities in the region we serve, and we hope to show this is a model 
worth investing in. We would welcome a Federal investment into this 
model of partnership between rural schools and hospitals as we 
demonstrate how it can help solve many of our region's problems.

    Of course, this model relies upon our ability to attract and retain 
a high-quality and dedicated healthcare workforce. Seventy-seven 
percent of counties in our country are considered Health Professional 
Shortage Areas by the National Rural Health Association, and we are 
impacted by this as well. Our children's hospital struggles to attract 
and retain physician talent, and we are the only children's hospital 
within a 2-hour drive of many residents in our region. Again, a payment 
system that only rewards hospital admissions does not contribute to a 
successful healthcare delivery system in a region where admissions are 
declining. Instead, Federal and state policies should align to invest 
in needed services for underserved areas with an eye toward evolving 
existing facilities into centers of excellence for rural health care. I 
imagine a day when our children's hospital can serve children who are 
developmentally disabled or suffer from mental health or other 
behavioral challenges, and can participate in the type of research that 
will help solve future healthcare problems in rural areas. Our 
children's hospital has seen a rate of neonatal abstinence syndrome 
approximately four times greater than the national average, and we do 
not fully know what the impact of this will be on these children as 
they grow. Rural America is at the center of this problem. While urban 
communities typically have the depth and breadth of specialties 
necessary to address the issues in those communities and the research 
strength to obtain the funding required to study these issues, rural 
areas simply cannot sufficiently compete and participate.

    Because of the new model we have created and are funding, our 
region may receive a short reprieve, but many communities are unlikely 
to be as fortunate. According to the Chartis Center for Rural Health, 
40 percent of rural hospitals had negative operating margins in 2017, 
and this same study found that 44 percent of rural hospitals will have 
negative operating margins in 2018. Consistent with this trend, six of 
Ballad Health's 14 rural hospitals had negative operating margins in 
the fiscal year that just ended, in addition to two of our non-urban 
hospitals. We continue to subsidize these losses as we build toward the 
future. On top of this, Ballad Health provided more than $300 million 
in uncompensated care last year, leading to a system-wide operating 
margin of only 0.6 percent, or $12 million.

    Given these realities, I applaud the Members of this Committee for 
their continued leadership and efforts to facilitate passage of a 
comprehensive rural health care package before the end of the 115th 
Congress.

    Simply put, rural hospitals and physicians need a Federal 
regulatory and reimbursement environment that takes into consideration 
the unique circumstances faced by the hospitals and physicians serving 
the 20 percent of our population that lives in 80 percent of our 
country's geography. As this Committee considers a number of weighty 
issues related to health in rural areas, I would urge our policymakers 
to fundamentally reframe the way we think about rural hospitals and 
their role in their communities in two key ways.

    First, we should stop thinking about rural health services in terms 
of bricks-and-mortar facilities and start thinking in terms of the real 
health problems that need to be solved in these communities. The 
National Rural Health Association confirms that rural Americans suffer 
disproportionately from serious health issues like diabetes and heart 
disease, and they are disproportionately more likely to die from 
curable cancers or drug overdose. These are not problems that can 
easily be solved within a traditional bricks-and-mortar inpatient 
hospital, nor can they easily be solved within our country's current 
payment system.

    If we want to make a real impact on improving the health of 
Americans in rural areas, we need to identify the health services that 
are needed in those areas and then incentivize hospitals and health 
systems to come up with innovative solutions that fit their community's 
individual needs. We need to utilize the data we have available to 
identify the problems and then ask the rural hospitals to come to the 
table with solutions. We need to identify the cost of implementing 
these solutions and demonstrate the potential return on investment for 
the payor community and the public. This can be done. While there is 
significant up-front investment, the potential return on investment 
will be undeniable.

    These hospitals could benefit from renewable block funding tied to 
estimable costs, as opposed to the fee-for-service model that relies 
upon traditional service provision, to help create a bridge to what the 
rural hospital of tomorrow should be. This cannot only help address the 
real problems that exist in these communities, it can create new jobs 
and help identify new purposes for old assets. At Ballad Health, we are 
in the process of doing this with two of our rural hospitals in Greene 
County, Tennessee. By consolidating inpatient acute care services at 
one hospital, we will be able to use synergies gained through our 
merger to repurpose the other hospital to provide the critical 
outpatient services, behavioral health, rehabilitation, and drug 
addiction treatment that are so badly needed in the community. Rather 
than making the easy decision to close this rural hospital, thus 
costing 600 jobs, we have found an alternative beneficial use for it. 
Given the fact that these hospitals lost a combined $11 million in 
2017, and $31 million in 2016, this alternative solution, which is 
significantly better for the community, would only be possible within a 
comprehensive health system that is truly focused on the needs of the 
community it serves.

    This brings to me the other point I would like to make about 
reframing our thinking about rural hospitals. Providing the proper 
financial incentives for rural hospitals in order to help solve 
population health problems can help meet the health needs of our rural 
communities, but this will only work if these rural hospitals are able 
to remain open. As you consider factors that help sustain rural 
hospitals, I would urge you to consider the role that many tertiary and 
urban hospitals within a larger, diverse health system play in 
sustaining the rural system of care. Many rural hospitals do not 
operate on their own. They are often part of larger systems that rely 
on the success of the regional hubs for financial viability. This is 
true for Ballad Health. Fourteen of our 21 hospitals are in rural 
areas, and six of those 14 hospitals had negative operating margins in 
fiscal year 2018. Were it not for the margins of our tertiary 
facilities, our entire rural system of care would collapse. As you 
consider and construct the components of a rural health package, please 
keep in mind that some of the non-urban hospitals with a predominantly 
rural health system are often a lifeline for rural hospitals, and their 
importance should not be overlooked.

    One issue that can have a detrimental impact on both rural 
hospitals and the tertiary hubs that support them is the Area Wage 
Index. Our region of the country, like most others, suffers from a 
shockingly low Area Wage Index within Medicare. While our AWI is 
approximately 0.72, there are areas in the country with AWI in excess 
of 1.9. This is a zero-sum system where, despite having done employee 
wage increases every single year, our Medicare area wage index has 
continued to deteriorate, as political and other considerations have 
driven the wage index higher for some parts of the country. As other 
areas have experienced significant annual increases, ours has 
decreased. While the national average is supposed to be an AWI of 1.0, 
only 10 percent of the counties in the United States have an AWI that 
is greater than 1.0, while 2,600 counties have an AWI less than 1.0. 
This distribution is not right, and it punishes non-urban hospitals 
that in many cases are subsidizing the ongoing operation of rural 
hospitals, just as it penalizes the rural hospitals themselves. I 
mentioned that Ballad Health's operating margin last year was $12 
million, or a 0.6 percent margin. If there were a national floor 
established on the AWI of 0.874, as proposed by S. 397, it would 
generate a $30 million annual impact for Ballad Health. In Tennessee, 
healthcare providers in all 95 counties and all 12 core-based 
statistical areas (CBSAs) are reimbursed based on AWI that are less 
than 0.864, which is significantly less than the national average of 
1.0. I applaud the work of Chairman Alexander (R-TN), Senator Isakson 
(R-GA), Senator Warner (D-VA), Senator Brown (D-OH), Senator Shelby (R-
AL), Senator Kaine (D-VA), Senator Roberts (R-KS), Senator Cassidy (R-
LA), and Senator Jones (D-AL), many of whom are original co-sponsors of 
a bipartisan bill that Ballad Health encouraged be filed to help solve 
this problem. This bill, S. 397, the Fair Medicare Hospital Payments 
Act of 2017, while not under the jurisdiction of this Committee, would 
help save rural hospitals and would support the regional provision of 
care in non-urban America. The bill is cost-neutral and would not 
impact other legislative or regulatory adjustments, including the 
``Frontier State Fix'' that established an AWI floor of 1.0 for North 
Dakota, South Dakota, Montana, Wyoming and Nevada. This legislation has 
been endorsed by the Tennessee Hospital Association, the National Rural 
Health Association, the Kentucky Hospital Association, the Louisiana 
Hospital Association, the Georgia Hospital Association, the Virginia 
Hospital and Healthcare Association, and the Alabama Hospital 
Association.

    I also believe our rural hospitals could benefit from Federal 
assistance in helping to build a bridge from the outdated fee-for-
service, bricks-and-mortar model to one that is responsive to our 
Nation's current needs. Many rural hospitals either have debt 
precluding them from additional capitalization, or simply do not have 
sufficient resources to borrow the funds needed to build this bridge.

    Modernization to right-size and reconfigure assets based on the 
needs of the community often needs a capital investment in order to 
make the transition. Community needs may include additional high-
quality diagnostics, emergency medical services, outpatient 
rehabilitation services, mental health services, substance abuse 
treatment services, dentistry services, and optical health services. I 
would like to note that I am not advocating for simply giving away 
money, as I do believe rural health systems have an obligation to 
demonstrate the return on such investments, both financially and in 
terms of public health benefits. These investments would be best made 
in concert with effective and efficient payment reform that moves away 
from pay-for-volume. A Medicaid program operating in South Carolina 
that provides incentive payments to health systems that acquire, 
improve, and operate rural facilities may be a good model for Congress 
to consider.

    I am concerned about possible policy proposals to repeal 
Certificate of Need requirements, which have been advocated for by some 
in Washington. Respectfully, I would argue that while many of us 
support a market-based approach, we should also acknowledge that 
picking and choosing the elements of the marketplace without addressing 
all of the necessary elements does not create a properly functioning 
market system. In a marketplace where more than 60 percent of care is 
provided in a price-prescriptive government model, private insurers 
reflexively copy government policies, and there is significant 
intrusion by both Federal and state governments invoking certain 
mandates onto providers, it is hard to imagine anyone suggesting that 
the delivery of health care services exists within a free-market.

    The suggestion that repealing Certificate of Need requirements in 
order to bring ``market forces'' to bear, in my view, will do more harm 
to our rural health system infrastructure than good. If we agree that 
integration of health care and better coordination would lead to better 
outcomes, then we must also agree that contributing to increased 
fragmentation in rural and non-urban communities will do harm. For 
instance, if Certificate of Need requirements were repealed, and a 
physician-owned surgery center or diagnostic center were opened in a 
rural community, based on current government rules and price setting, 
not only is there no free market, but an unlevel field has been 
established for competition.

    Under Federal law, a comprehensive hospital is not permitted to 
have physician ownership, and because of Stark Law regulations and 
anti-kickback provisions, a comprehensive hospital has very limited 
options for meaningfully integrating with physicians. While one 
competitor in the market enjoys full financial integration with 
physicians, including distribution of profits, which incentivizes 
physicians to reduce costs and increase utilization of the physician-
owned facility, a comprehensive hospital is left without any such 
relationship. In addition, the physician-owned facility is exempt from 
Federal EMTALA and community-benefit requirements. When one competitor 
has physician investment, and that competitor is not required to serve 
the poor, nor does it have any other obligation to help address the 
population health needs of the community, the local market is simply 
not a level-competitive market. Pulling those limited resources away 
from the hospital in order to provide profits to the competing 
physician-owned, limited-service facility only undermines that 
hospital's ability to influence the other aspects of health in that 
community. If a rural or non-urban hospital loses its profitable 
services to a facility that has no obligation to help solve the mental 
health challenges in the region, then where will the resources come 
from for the rural hospital to invest in addiction care, mental health, 
or the other needed services? In this scenario, the hospital has been 
further diminished, and its survival or ability to thrive is undermined 
at the expense of profits for what is often an out-of-market company or 
financier.

    I believe there are strategies that can be deployed in rural 
markets where the relationship between the hospitals and physicians can 
be strengthened. In the old fee-for-service model, Stark Law 
regulations and anti-kickback provisions were designed to keep 
financial entanglements between doctors and hospitals from affecting 
care. In a pay-for-value environment, those same laws inhibit the very 
alignment needed between doctors and hospitals to reduce unnecessary 
care and focus resources on prevention and chronic-care management. If 
the payment system were to invest in rural hospitals that convert to 
these models, and rural hospitals were permitted to create financial 
alignment with physicians, then two things will happen. First, rural 
communities will become more attractive to physicians who would be able 
to diversify their income to include the upside benefits of the 
hospital's financial performance. Second, the financial and public-
health success of the hospital, in alignment with the payment policies 
that support such a transition, would virtually ensure alignment 
between the physicians, hospital, and community as they seek to better 
manage chronic conditions, rather than simply wait until a reimbursable 
procedure is performed.

    Please consider the following real-world example. In one community, 
a rural hospital has general surgeons who perform a large number of 
amputations, most of which are necessary due to complications from 
diabetes. However, that community does not have an endocrinologist. The 
reason many rural hospitals do not have endocrinologists is that 
endocrinologists do not preform procedures at hospitals, and thus, they 
do not generate revenue. In fact, the practice would likely lose money, 
in addition to the very presence of the endocrinologist reducing the 
need for hospitalizations, which is an outcome diametrically opposed to 
the financial interest of the hospital. The general surgeons will see 
the diabetic patients who go without management of the chronic 
condition, and they will perform the amputations, which are services 
for which the hospital and doctor get paid. In addition, the hospital 
does an excellent job with rehabilitation services, which again, is a 
service for which the hospital is paid.

    However, there is an alternative: What if, noticing the high 
incidence of diabetes and amputations, the hospital, in a jointly 
established partnership with the physicians, chose to align and ask for 
an entirely different payment model, one that paid the hospital and 
physicians to invest in endocrinology services, reduce amputations, and 
better manage the diabetes in the population? In that scenario, better 
coordination occurs for the patient, the hospital and physicians may 
invest in technology and other innovative solutions for the management 
of the patients, and instead of only being paid when a procedure is 
performed, the hospital and physicians are compensated based on what is 
saved by the program.

    The margins for this model would be better because the resources 
would be more efficiently used. This is the essence of the bundled-
payments model, but I believe integration in these communities should 
be able to go further than the basic concept of bundled payments. 
Infusing flexibility into the financial relationships between 
physicians and hospitals can have a very positive impact on both 
outcomes and cost in a pay-for-value environment. It is understandable 
that, in a fee-for-service environment, these relationships would be 
problematic. However, they have been freely permitted in many areas, 
such as diagnostics, outpatient surgery, and others. I believe 
integrated models that align hospitals and physicians would open the 
door to many exciting opportunities to reduce cost, eliminate variation 
that leads to waste and poor outcomes, and create more flexible models 
of tackling the management of chronic illness.

    These opportunities may exist, but physician alignment with 
hospitals must happen, and yesterday's Stark Law regulations and anti-
kickback regulations must be modernized to create these opportunities 
for alignment. Holding onto fee-for-service reimbursement models and 
preventing hospitals from more closely aligning with doctors will only 
preserve the outdated models that are harming rural hospitals and the 
health of the communities they serve.

    Finally, I would like to address the need preservations of the 340B 
Drug Discount Program, which is a program of vital importance to the 
financial stability of our health system and our ability to serve 
vulnerable and low-income patients. While no program is free from the 
need for thoughtful reform, I would ask for your support in preserving 
340B program eligibility for rural and non-urban hospitals as well as 
children's hospitals.

    We rely on these drug-acquisition savings to enable us to support 
the provision of care in struggling rural areas. The estimated value of 
the 340B program to Ballad Health in fiscal year 2019 is approximately 
$53 million. Again, considering the fact that our total operating 
margin of 0.6 percent led to only $12 million in operating surplus last 
year, losing access to the savings produced by participation in the 
340B Drug Discount Program would be devastating for our health system 
and the patients and communities we serve.

    Even with our participation in the 340B Drug Discount Program, 
Ballad Health's annual drug spend continues to increase by over 8 
percent annually. Without 340B participation, our drug costs would be 
completely unsustainable. Reforming the 340B Drug Discount Program 
should not come at the cost of bankrupting vitally important hospitals 
and health systems. We stand with you in attempting to properly and 
thoughtfully reform the 340B Drug Discount Program, but we must ensure 
that programmatic reform does not inadvertently devastate rural 
hospitals and children's hospitals across our Nation.

    Much of what I have presented represents a major departure from 60 
years of evolution in our health system. However, I believe such major 
shifts in policy are important, and effective reform cannot be achieved 
on the margins. This is why the very creation of Ballad Health 
happened, and it is why our region's major employers and every 
municipal government and chamber of commerce in our region encouraged 
and supported the merger that created Ballad Health under the doctrine 
of State Action Immunity from Federal anti-trust law, even against the 
strenuous opposition by staff of the Federal Trade Commission. It is 
why the legislatures of the states in which we operate unanimously 
approved the structure of the merger under exemption from Federal anti-
trust law, and it is why two Governors--a Democrat and a Republican--
signed the legislation and authorized the merger under the advice and 
guidance of each state's attorney general.

    In short, there is a pent-up demand for trying something different. 
Ballad Health took the risk and the important step of suggesting that 
we want to be part of the solution rather than simply complaining about 
the problem. We stand ready to be a laboratory for our Federal partners 
to help solve problems, and we stand ready to test new ways of changing 
the landscape of health care. Hopefully, this is just the beginning of 
the dialog.

    Again, I greatly appreciate the invitation and opportunity to 
participate in today's hearing, and I look forward to your questions.
                                 ______
                                 
    Senator Enzi. Thank you.
    Dr. Richter.

   STATEMENT OF DEBORAH RICHTER, M.D., FAMILY PHYSICIAN AND 
 ADDICTION MEDICINE SPECIALIST, AND CHAIR, VERMONT HEALTHCARE 
                     FOR ALL, CAMBRIDGE, VT

    Dr. Richter. Good afternoon, Chairman Enzi and Members of 
the Committee. My name is Deborah Richter----
    Senator Enzi. Hold the mic closer.
    Dr. Richter. I can probably turn it on.
    My name is Deborah Richter. I'm a practicing family 
physician in rural Vermont, and I also have an addiction 
medicine practice in Burlington. I want to thank you for asking 
me to participate in this roundtable.
    I'm particularly interested in examining experiences 
because I see the inadequacies of our healthcare system every 
day in my practice. Regarding the subject of cost, however, I 
wonder whose costs we're referring to, because when I think of 
cost, it is mostly in reference to system costs; that is, how 
much the U.S. spends on healthcare in total. This year it is 
projected we will spend $3.5 trillion on healthcare. And as 
you've heard many times from Senator Sanders, we spend on 
average twice per capita what other countries spend, all of 
whom cover everyone while enjoying a longer life expectancy and 
better health outcomes.
    In every other industrialized country, healthcare is 
considered a public good. There are many reasons we spend more 
per capita on healthcare, not the least of which is our 
enormously complex financing system which consumes 31 percent 
of total healthcare costs. Much of these costs are necessary 
under a multiple-payer system where each payer has different 
rules, regulations, and levels of reimbursement. But under a 
one-payer, publicly funded, universal system such as the one 
embodied in Senator Sanders' Medicare for All Bill simplified 
billing and administration could be reduced by $500 billion by 
some estimates.
    There have been multiple studies showing that the current 
spending is more than enough to cover all Americans with 
comprehensive coverage without spending in total one penny 
more. So if we then focus on payer cost, this would include the 
taxpayer for two-thirds of financing of healthcare, because if 
you include Medicare, Medicaid, the VA, public employee health 
insurance, and the tax subsidy for private employers to pay for 
health insurance for their employees, that equals two-thirds of 
how we're paying for healthcare. The remainder comes from out-
of-pocket payments from the public employers paying for private 
health insurance.
    But we must acknowledge that ultimately every penny comes 
from Americans' pockets, Americans' households. Taxes, out-of-
pocket payments, higher prices for goods and lower wages--if 
our employer pays for health insurance, it all comes from us.
    But there are other costs to the lack of a healthcare 
system. Those are the ones I witness every day. I will give you 
a few examples from my practice alone in the past year. I am 
one physician among thousands, and I can give you dozens of 
examples. If you do the math, it's not hard to see how 37,000 
patients die from lack of insurance every year. I'll give you 
three examples.
    An uninsured 60-year-old delayed seeking care despite being 
unable to swallow solid food and losing 100 pounds. And then 18 
months later, after he couldn't stand it any longer, he finally 
sought care and was diagnosed with Stage IV esophageal cancer. 
It was not treatable, and he has since died.
    An uninsured 40-year-old woman several weeks ago, actually 
several months ago, with a large mass in her breast, delayed 
seeking care for a year until the mass started to bleed. She 
has an aggressive form of breast cancer. She is now undergoing 
treatment. Mind you, she was uninsured. She was working. She 
now has Medicaid. A very aggressive form of cancer, though, 
which she delayed for a year.
    Then there was a 52-year-old I saw about a year ago who was 
suffering from severe shortness of breath. This went on for 4 
days. She thought it was her asthma and she delayed seeking 
care, and it turns out it was an acute myocardial infarct, a 
heart attack. She spent 3 days in the ICU. She had insurance 
but had a deductible.
    The uninsured and underinsured are more likely to die from 
preventable illnesses than their insured counterparts, and many 
of them who delay care, like the ones I mentioned, incur much 
higher costs than they would had they sought care earlier. I 
need not mention the human cost of these tragic cases.
    We can't ignore the economic cost of the way we finance 
healthcare in our country, however. The patient with the breast 
mass was saving to build a house with her fiance. She couldn't 
afford to do that and pay for health insurance. Millions of 
people make these economic decisions every day. When they do, 
the economy suffers. We are a consumer-driven economy, so the 
economic multiplier effect to this regressive way we finance 
healthcare is affecting us all.
    I have only 48 seconds. I'd like to also mention that the 
problems with our current healthcare system are magnified in 
rural America, as we've heard already, because we are older, 
sicker, and poorer. That is particularly true of the impact of 
the opioid epidemic, as we've heard. The majority of these 
programs are funded through taxes, mainly Medicaid programs, 
but the problem is straining rural health systems' ability to 
respond.
    When we're looking at ways to reduce healthcare costs, I 
would urge us to look at the primary care shortage. That's 
something we all seem to have agreed on, and we can discuss 
that. I'd be happy to talk about that. But I do think unless we 
look at the system as a whole and look at it as a public good 
where we include everyone, and look at the solution to include 
everyone, we will not solve these problems.
    Thank you.
    [The prepared statement of Dr. Richter follows:]
                 prepared statement of deborah richter
    Good Afternoon Chairman Enzi and Members of the Subcommittee on 
Primary Health and Retirement Security. My name is Deborah Richter. I 
am a practicing family physician in rural Vermont and I also have an 
addiction medicine practice in Burlington VT. I want to thank you for 
asking me to participate in the roundtable discussion of ``Health Care 
in Rural America: Examining Experiences and Costs.''

    I am particularly interested in the topic examining experiences 
because I see the inadequacies of our health care system every day.

    Regarding the subject of costs however, I wonder whose costs we are 
referring to?
When I think of costs mostly it is in reference to system costs, that 
is, how much the U.S. spends on health care in total. This year it is 
projected we will spend $3.5 trillion on health care. \1\ As you've 
heard many times, we spend on average twice per capita what other 
countries spend. \2\ All of whom cover everyone while enjoying a longer 
life expectancy and \3\ better health outcomes. \4\ In every other 
industrialized country health care is a public good.
---------------------------------------------------------------------------
    \1\  Centers for Medicare and Medicaid Services, 2018.
    \2\  Organization of Economic Cooperation and Development (OECD), 
2018.
    \3\  OECD, 2018.
    \4\  OECD 2018.

    There are many reasons we spend more per capita on health care not 
the least of which is our enormously complex financing system which 
consumes 31 percent of total health care costs. \5\ Much of these costs 
are necessary under a multiple payer system where each payer has 
different rules, regulations and levels of reimbursement. But under a 
one payer publicly funded universal system such as the one embodied in 
Senator Sanders' Medicare for All bill, simplified billing and 
administration could be reduced by $500 billion. \6\ There have been 
multiple studies showing that we are spending more than enough money to 
cover all Americans with comprehensive coverage. \7\
---------------------------------------------------------------------------
    \5\  Woolhandler, S., Campbell, T., Himmelstein, D., ``Costs of 
Health Care Administration in the United States and Canada'' NEJM, Aug, 
2003.
    \6\  Woolhandler, S., Himmelstein, D., ``Single-Payer Reform: The 
Only Way to Fulfill the President's Pledge of More Coverage, Better 
Benefits, and Lower Costs'', Annals of Int. Med., April, 2017.
    \7\  How Much Would Single Payer Cost; A Summary of Studies 
Compiled by Ida Hellander, http://www.pnhp.org/facts/single-payer-
system-cost.

    If we then focus on payer costs this would include the tax payer 
for 2/3 of the financing of health care, \8\ Medicare, Medicaid, the 
VA, public employees' health insurance and the tax subsidy for private 
employers to pay for health insurance for their employees. The 
remainder comes from out of pocket payments from the public and 
employers paying for private health insurance. But we must acknowledge 
that every penny ultimately comes from Americans' pockets. Taxes, out 
of pocket payments, higher prices for goods and lower wages if our 
employer pays for health insurance all come from us.
---------------------------------------------------------------------------
    \8\  Woolhandler, S., Himmelstein, D., ``Paying for National Health 
Insurance and Not Getting It'', Health Affairs, Vol 21. No. 4, 2002.

    But there are other costs to the lack of a health care system. 
Those are the ones I witness every day. I will give you a few examples 
from my practice alone in the past year. I am one physician among 
thousands and I can give you dozens of examples. If we do the math it 
is not hard to see how 37,000 patients died from lack of insurance. \9\
---------------------------------------------------------------------------
    \9\  Woolhandler, S., Himmelstein, D., ``The Relationship of Health 
Insurance and Mortality: Is Lack of Insurance Deadly?'', Annals of Int 
Med, Sept, 2017.

---------------------------------------------------------------------------
    Three examples:

        (1) An uninsured 60-year-old delayed seeking care despite being 
        unable to swallow solid food and losing 100 pounds. Eighteen 
        months later he was diagnosed with Stage 4 esophageal cancer. 
        He has since died.

        (2) An uninsured 40-year-old woman with a large mass in her 
        breast delayed seeking care for a year until the mass started 
        to bleed. She has an aggressive form of breast cancer.

        (3) A 52-year-old woman suffering from severe shortness of 
        breath delayed seeking care due to mounting health care bills 
        from another family member. She was working full-time. They 
        have a $5000 deductible.

    The un- and underinsured are more likely to die from preventable 
illnesses than their well insured counterparts. And many of them who 
delay care like the patients mentioned above, incur much higher costs 
than they would have had they sought care earlier. I need not mention 
the human cost of these tragic cases.

    We also can't ignore the economic cost of the way we finance health 
care in our country. The patient with the breast mass was saving to 
build a house with her fiance. She couldn't afford to do that and pay 
for health insurance. Millions of people make these sorts of economic 
decisions every day. When they do, the economy suffers. We are a 
consumer driven economy so there is an economic multiplier effect to 
the regressive way we finance health care.

    I would like to also mention that all of the above problems with 
our current health care system are magnified in rural America as they 
are older sicker and poorer. \10\ This is particularly true of the 
impact of the opioid epidemic which started in rural America. \11\ The 
Centers for Disease Control and Prevention (CDC), find that the rate of 
death from opioid-related overdoses is 45 percent higher in rural vs 
urban areas.
---------------------------------------------------------------------------
    \10\  Wagnerman, K. ``Health Care in Rural and Urban America''. 
Georgetown University Health Policy Institute, Oct., 2017.
    \11\  Toliver, Z, ``The Opioid Epidemic: Testing the Limits of 
Rural Healthcare'', Rural Health Information Hub, May 2016.

    The majority of treatment programs are funded through taxes--mainly 
Medicaid programs. But this problem is straining rural health systems 
ability to respond. Many patients wait months to get treatment for 
substance abuse, some give up trying. There are also indirect costs to 
opioid use disorder. The foster care system is bursting at the seems. 
\12\
---------------------------------------------------------------------------
    \12\  Stein, P., Bever, L., ``The Opioid Crisis is Straining the 
Nation's Foster Care System'', Washington Post, July 2017.

    Other costs include corrections costs which again are greater on a 
per capita basis in rural vs urban America. \13\
---------------------------------------------------------------------------
    \13\  Sullivan, R., ``The Fiscal Impact of the Opioid Epidemic in 
the New England States'', New England Public Policy Center, May 2018.

    When we are looking to reduce health care costs now and in the 
future we must first address the primary care shortage. Primary care 
represents most of the medical office visits in any one year. \14\ In a 
nutshell primary care is most of the care to most of the people most of 
the time. Yet we represent less than 8 percent of total costs. \15\ We 
know that when a population has free access to primary care, people 
live longer and they cost the system less. \16\ As you must know there 
is a severe shortage in primary care particularly in rural and poor 
communities. \17\ Much of this is due to an aging workforce with 1/4 
over the age of 60 in 2017. \18\ With fewer medical students choosing 
primary care we will see this shortage worsen by 2025. \19\ In addition 
demand has increased due to an aging population and with the expansion 
of the ACA. Added to that, the burnout rate in primary care is causing 
physicians to retire earlier than they might have. \20\
---------------------------------------------------------------------------
    \14\  Center for Disease Control, National Center for Health 
Statistics, 2015.
    \15\  Koller, C., ``Getting More Primary Care-Oriented: Measuring 
Primary Care Spending'', Milbank Memorial Fund, July 2017.
    \16\  Friedberg, M., et al,''Primary Care: A Critical Review of the 
Evidence On Quality And Costs of Health Care'', Health Affairs, Vol 29, 
No. 5, May 2010.
    \17\  Petterson, S., et al, ``Unequal Distribution of the U.S. 
Primary Care Workforce ``, American Family Physician, June, 2013.
    \18\  Petterson S, McNellis R, Klink K, Meyers D, Bazemore A. The 
State of Primary Care in the United States: A Chartbook of Facts and 
Statistics. January 2018.
    \19\  Petterson, S., et al, ``Projecting US Primary Care Physician 
Workforce Needs 2010-2025'', Annals of Family Medicine, 2012.
    \20\  Pechham, C., Medscape National Physician Burnout & Depression 
Report 2018, Jan., 2018.

    As a practicing family physician I can see why physicians are 
burning out. The administrative burden placed on us when dealing with 
multiple payers with different rules, regulations and reimbursements 
would drive anyone mad. Doctors report that for every hour of patient 
care they spend an hour with administrative tasks. If we have any hope 
of rescuing this dying profession we had better address the 
---------------------------------------------------------------------------
administrative burden facing our primary care practitioners.

    In sum, as a physician who has practiced in the US health care 
system for the past 30 years I would say that in my experience, unless 
we address the system as a whole we will not solve any of the pressing 
problems in health care. We need to regard health care as a public good 
and make it accessible to all. We have wonderful health professionals 
and hospitals in this country. We are spending enough money.

    We need a program of expanded Medicare for All Americans.
                                 ______
                                 
    Senator Enzi. Thank you.
    I want to thank the whole panel not only for what you said, 
but also for what testimony has been submitted. A lot of good 
ideas in there. We'll have to probe some of those a little bit 
more. Some we may have to grow a little bit more. But as a 
roundtable we'll ask some specific questions, and then I'm 
going to--since I'll be here for the whole thing, I'm going to 
defer until the end and give Senator Alexander an opportunity 
to ask questions in my place to start the discussion. Again, if 
there's a question asked and you want to add to it, stand your 
name tag on end there. This is a roundtable. It's to gather 
information, not to hound on a point.
    The Chairman. Thank you. Thanks, Mr. Chairman. Thank you 
for your leadership in calling this hearing on healthcare in 
rural areas.
    Mr. Levine, welcome, glad to have you here, appreciate what 
you do in the Upper East Tennessee area. As you indicated, it 
affects both Tennessee and Virginia.
    You mentioned a couple of things I'd like to go back to. 
Tennessee is second in the country in terms of rural hospital 
closings. The first thing I'd like to ask you about is the area 
wage index. Fifty-five hundred hospitals in the country 
received payments from Medicare based upon a formula called the 
area wage index. I met with a group of hospitals yesterday 
morning in the Knoxville area who were talking about how low it 
was, how unfair it is to certain parts of the region.
    How big a problem is it for you in Tennessee and Virginia, 
the area wage index, and do you have any suggestions for fixing 
it?
    Mr. Levine. Senator, it is one of the biggest problems we 
have. All 95 counties in Tennessee and all the counties in 
Southwest Virginia fall among the lowest on the spectrum for 
the area wage index, which ranges anywhere from a low of .68 
all the way up to 1.9. And if you think about the distribution, 
only 10 percent of the counties in the country have an area 
wage index. The average is supposed to be 1. Only 10 percent of 
countries have an area wage index above 1. Eighty percent are 
below 1.
    The distribution--the intent of the area wage index was to 
recognize initially that costs were higher in rural areas, and 
therefore you'd have to pay more to get people there, and 
somewhere along the way it got turned on its head. And once you 
fall behind----
    The Chairman. I've got limited time. It's hard to change 
formulas in the U.S. Congress. Do you have any shrewd 
suggestion for how we might do that?
    Mr. Levine. Pass Senate Bill 397, the Fair Medicare 
Hospital Payments Act, which is initially sponsored by Senator 
Isakson, Senator----
    The Chairman. I'm a co-sponsor of that.
    Mr. Levine. Yes, you are, and Senator Kaine is, and others 
here are as well, Senator Roberts. It's a bipartisan bill that 
would be the single biggest thing near-term you could do to 
help rural hospitals.
    The Chairman. If I could switch to another thing you 
mentioned, I visited Lewis County in Tennessee, and they had a 
big argument about closing their hospital and eventually did it 
and created instead a community health center. It's a big 
success. It's owned by a nearby hospital, and the theory is you 
don't need to do heart transplants in every small rural county.
    What are your suggestions for alternative models for 
delivering healthcare services in rural counties? If I were 
trying to put a plan to Lewis County in Tennessee where that 
community health center is, I would be very impressed because 
you can walk in between 7:00 in the morning and 8:00 at night, 
there's always a couple of doctors there, it's clean, and if 
you have a real problem, they can get you pretty quickly 
somewhere else. But 90 percent of the problems that people walk 
in with they can deal with. What about alternative models?
    Mr. Levine. That's exactly the same thing we're doing in 
Upper East Tennessee and Southwest Virginia. There's 
opportunities to repurpose rural hospitals. Again, instead of 
being full-service acute care hospitals which provide every 
service like they used to, look at what the service needs are 
in those communities now: mental health, addiction, emergency 
medicine, high-quality diagnostics, maternal care. The payment 
system doesn't right now really support those things, and I 
think if we were to build a bridge, it would be to transform 
the payment system so rural hospitals can afford to repurpose, 
and then you can sustain those services through an alternative 
payment system to support them.
    The Chairman. Mr. Chairman, I'll give my time back to you 
or to other Senators so we can have more of a conversation.
    Senator Enzi. Mr. Glause, you wanted to speak on that as 
well? Turn your mic on, please.
    Mr. Glause. Thank you. I would encourage us to be mindful 
of unintended consequences as we look at repurposing rural 
hospitals. The cost of air ambulance transport has skyrocketed. 
Most of our air ambulance transports in Wyoming are between 
facilities, and the states have no ability to regulate those 
rates or routes of their air ambulance company. So I would 
encourage you to also look at that issue when the 
reauthorization of the Federal Aviation administration comes 
up.
    Senator Sanders. Mr. Chairman.
    Senator Enzi. You're next.
    Senator Sanders. I think there is general agreement that we 
have a shortage of physicians in the country and in rural 
America in particular. Under the much-maligned Affordable Care 
Act, we doubled funding for federally qualified community 
health centers, as well as a significant increase in funding 
for the National Health Service Corps, which is, as you know, a 
program that provides debt forgiveness for those doctors and 
dentists who practice in underserved areas.
    Would each of you be supportive of a significant expansion 
of the community health center program and the National Health 
Service Corps? Mr. Glause.
    Mr. Glause. Thank you, Senator Sanders. Generally, the 
answer is yes. We see a significant lack of providers in 
Wyoming, and we need to address that issue, especially in rural 
America. The doctors and----
    Senator Sanders. I apologize and ask you to be brief.
    Mr. Reed.
    Mr. Reed. I'd echo what Mr. Glause said, which is in 
principle, yes. I want to make sure that we don't have any 
provisions in there that limit or restrict the use of digital 
medicine and the ability for remote patient monitoring.
    Senator Sanders. Mr. Levine.
    Mr. Levine. Yes. Plus, I would look at funding additional 
residency slots that are based in rural communities.
    Senator Sanders. Good.
    Dr. Richter. I would absolutely favor that.
    Senator Sanders. Okay. I don't go to a lot of these 
hearings because there's something disingenuous that takes 
place. Everybody here and every Senator and panelist is 
concerned about, in this case, rural health care, but many of 
my colleagues voted to cut $1 trillion in funding over a 10-
year period to Medicaid, and $500 billion to Medicare.
    Mr. Glause, just out of curiosity, if the President's 
budget or the Republican budget were approved, which cut $1 
trillion in funding for Medicaid over a 10-year period, what do 
you think that would do to--what impact would that have on 
rural Wyoming? A hundred billion a year for 10 years.
    Mr. Glause. We have to consider the difference between 
Medicare and Medicaid.
    Senator Sanders. I'm talking about Medicaid funding, a 
trillion dollars over 10 years in the Republican budget cut.
    Mr. Glause. We have not expanded Medicaid in Wyoming, as 
you all know. I don't think that we would see the substantial 
impact with a cut to Medicaid as we would other programs.
    Senator Sanders. Okay. I apologize again.
    Mr. Reed. A trillion-dollar cut over 10 years; would it 
help rural America?
    Mr. Reed. Frankly, I'm really focused on whether or not any 
cut or any improvement in the budget actually allows doctors to 
use the tools that will improve their ability to provide care 
to folks.
    Senator Sanders. You have no comment? You don't think a 
trillion-dollar cut would have any impact on rural America? 
Okay.
    Mr. Levine, a trillion-dollar cut?
    Mr. Levine. I do think a cut to Medicaid would have an 
impact on rural healthcare. But Tennessee has a very unique 
problem because its disproportionate share funding is capped in 
Federal statute. So Tennessee's got a very unique problem where 
the state, the hospitals are willing to come up with the money 
to bring the Federal money down.
    Senator Sanders. Doctor, a trillion-dollar cut in Medicaid 
to rural America?
    Dr. Richter. We're already suffering under underpayment as 
it is, and particularly in primary care, and even worse so in 
mental health. A trillion-dollar cut would be devastating to 
us, and I think we would see even more physicians and nurse 
practitioners exiting rural areas. I think it would be tragic.
    Senator Sanders. Somebody, I think it was Mr. Glause, 
mentioned that Medicare reimbursement rates are about 65 
percent, of course, which I understand to be true. My 
understanding also is that private insurance reimbursement 
rates are actually lower. Comment on that. I was just speaking 
to some doctors actually in the Burlington Community Health 
Center there. They were telling me that Medicare was the 
highest that they got, not good but better than Medicaid, 
better than Blue Cross Blue Shield, which are much lower. 
Thoughts on that? Mr. Levine, is that accurate?
    Mr. Levine. No, and in our market in Upper East Tennessee 
and Southwest Virginia, generally for the hospitals, commercial 
insurance reimburses higher than Medicare. If they didn't, we 
would be in a lot of trouble.
    Senator Sanders. Okay, that's interesting. I don't think 
that's the case in Vermont.
    Dr. Richter.
    Dr. Richter. Well, in terms of Medicare and in terms of my 
addiction practice, Medicare is on par with Medicaid. It is 
actually private insurance that is actually the lower payers in 
the addiction world.
    Senator Sanders. That's true. That's in Vermont. I don't 
know if that's true nationally.
    Mr. Reed, what's the story there?
    Mr. Reed. That's a little bit outside my scope. But I would 
notice that with Senator Kaine here, we have the Center for 
Telemedicine out of UVA, and one of the things you're looking 
at is how do you actually take the reimbursement that goes on 
for the communities they serve in rural Virginia? The problem 
they're finding is they are actually able to deliver the same 
quality of care. For example, getting medication in the case of 
a stroke just as timely as you would if you were next door to a 
healthcare facility. But the reimbursement doesn't put money 
back in their pocket.
    Senator Sanders. Right, that's a valid point.
    Mr. Glause, what about you mentioned Medicare providing 
reimbursement rates only 65 percent of the cost. In Vermont, 
actually, private insurance reimbursement rates are lower. 
What's the case in Wyoming? Is that the case there or not?
    Mr. Glause. No, that's not the case, Senator Sanders. We 
see a lot of cost shifting to the private market.
    Senator Sanders. Private insurance reimbursement rates are 
higher than Medicare in your state?
    Mr. Glause. Absolutely.
    Senator Sanders. That's interesting. Okay, Okay.
    Thank you, Mr. Chairman.
    Senator Enzi. Thank you.
    I guess Senator Roberts left.
    Senator Bennet.
    Senator Bennet. Thank you.
    Just a follow-up to one of Senator Sanders' questions on 
the Medicaid cuts. In many of my rural districts, 50 percent or 
more of the kids are on Medicaid. What would happen to them if 
there was the kind of cut that he described to Medicaid, Mr. 
Glause? These are counties that don't have other insurers, many 
of them.
    Mr. Glause. Thank you, Senator Bennet. First of all, I will 
have to make a disclaimer. I am not an expert on Medicare and 
Medicaid. We don't deal with those issues routinely in the 
insurance department, but there is some overlapping of the 
issues.
    As far as the children suffering effects if the money was 
reduced for Medicaid, I think that we do have other programs in 
Wyoming for the children as far as the ability to obtain care 
through insurance for them.
    Senator Bennet. Thank you, Mr. Glause.
    Mr. Levine.
    Mr. Levine. Yes, sir. I think one of the things that's a 
problem here is the differentiation. There used to be a great 
differentiation between Medicaid and insurance. But in the last 
five or 6 years, we've seen a major shift with even private 
insurance where even if a child or an adult has private health 
insurance, because of all of the high deductibles, many of them 
are not able to pay. And what's happening to us is our biggest 
increase in bad debt and uncollectible revenue isn't the 
uninsured. It's people who have insurance----
    Senator Bennet. That's very common, right.
    Mr. Levine. It's one of the biggest single problems we 
have.
    Senator Bennet. I hear about that a lot. I was in a county 
right next door to my neighbor's state the other day in 
Northern Colorado that's the size of Delaware geographically, 
but 1,300 people live there, as opposed to a million people in 
Delaware. And as we had this conversation it became clear in 
the room that of everybody in the room, there were only three 
people that had insurance. One was the school principal, who 
got it through the district. One was the county commissioner, 
who said that he didn't have it until he got elected county 
commissioner, and now he has health insurance. And then there 
was one person who had managed to get it for herself, although 
her husband and her child--and these were all working people. I 
mean, they were people running the restaurant in town, 50 hours 
a week he was working, and his wife was working 50 hours a 
week, and literally they can't buy health insurance in America.
    This is one of the reasons Senator Kaine and I have offered 
the bill--I don't know if any of you have seen it, this 
Medicare X bill that suggested maybe what we need is a real 
public option that would be administered by Medicare. It starts 
in rural counties in our country that have one or fewer 
insurers.
    By the way, in Medicare Part D, a public option was 
included as part of that. It never was actually triggered. But 
it would allow people all across the country to pool and buy 
this insurance through a premium that they would pay. CBO says 
it would actually save the government money. And then over two 
or 3 years, I guess over 3 years, we'd make it available to 
everybody in America.
    Does that sound like a terrible idea to you guys, or do we 
need some option like that? Because no private insurer is going 
to sell insurance that's worth anything to the people in this 
county. There's just not enough lives here to do it. Even if 
you aggregated the number of people in my state, they wouldn't 
do it, except, Mr. Levine, in the way that you described, with 
impossibly high deductibles and other kinds of things that make 
the insurance, as people in these counties say to me, worthless 
to them.
    Do you have any reaction to the idea of a public option 
like that as a way of solving this? Anybody?
    Dr. Richter. I have a reaction to the idea of us giving 
first-dollar coverage to all Americans for primary care. We do 
know that it's less than 8 percent of total. It's the best 
bargain in medicine. And we also know that it's the only sector 
of healthcare to improve population health when it's freely 
accessible to a population. It's been shown to reduce 
mortality, to lower infant mortality, maternal mortality, 
increase life expectancy, all of those things.
    It seems to me we should start where the basics are, and we 
should make sure that no one does not go to the doctor because 
they have a co-pay or a deductible. People like this women, 4 
days short of breath, ended up with a massive heart attack. 
This I see all the time, or these co-pays and deductibles. And 
particularly when we're dealing with young children and their 
parents avoiding bringing them to the doctor. They end up with 
long-term disabilities as a result.
    That, to me, seems to be where we should start. It's a very 
small price tag for a big payout.
    Senator Bennet. I have 2 seconds left, I think.
    Mr. Reed. Sorry. It was fascinating to listen to you talk 
about how do you get this to work in a community of 1,300 
people, right? So there's not a professional there. How do you 
actually get the physician to engage with them? And as the 
doctor just noted, if you don't have that person engaged early 
in the process, then they get really sick and they cost a 
fortune. Then you're talking about amputations in the case of 
diabetes.
    University of Mississippi Medical Center is such an 
interesting story because they had to serve communities in the 
Delta and other areas where there is, like you, no health care 
professionals at all, a culture where there hasn't been the 
attention paid to diabetes that's necessary. And what they're 
finding to reduce cost to get to where you need to go is, hey, 
you need to get people educated about don't have that next 
slice of pecan pie, with all apologies to Tennessee.
    How do you engage with them? How do you monitor what their 
glucose level was in advance of them getting terribly, terribly 
sick? So if you want to treat the 1,300 people, you need to 
figure out how do you treat the 1,200 people that need to stay 
healthy so that you can use the primary dollars for the 100 
that are already sick and that you need to take care of. I 
think the doctor hinted about it, in preventive medicine. So 
let's look at a way to open up that CBO scoring window so we're 
not stuck with serving only the sickest people when they're the 
most expensive.
    Mr. Levine. May I, Mr. Chairman?
    Senator Enzi. Please.
    Mr. Levine. You know, I think the challenge here is when 
there's a discussion about a larger single-payer model, the 
thing that concerns me is payment policy matters to the 
marketplace. When you have, in our case, 70 percent of our 
reimbursement dictated to us by a central planner somewhere in 
Washington that doesn't know our economy, doesn't know our 
local markets, what ends up happening is that the payment 
system isn't reactive to what the market demands are for the 
physician. So physicians leave, and they go where they can get 
paid more. It's simple economics.
    There have been a lot of ideas historically thrown around 
about catastrophic coverage, which then would create more 
certainty and a more robust insurance market underneath 
catastrophic coverage. I think there are market-driven ways 
that you can create options for insurance with wraparounds for 
primary care and prevention, and then catastrophic on top of 
it. But I just worry about anything where you have centralized 
price setting that doesn't respect the differences in the 
markets and allow a negotiation in the marketplace to occur. 
Otherwise, you just keep losing doctors, because payment policy 
does affect the marketplace.
    Senator Bennet. I'm out of time, but I guess what I would 
say about that, I think all of these are great ideas. I'm very 
happy the Chairman had this Committee hearing. That doesn't 
solve Dr. Richter's issue about how do you get people the 
primary care they need so that we're not driving the prices, to 
say nothing of their own health care.
    The good news in all this, Mr. Chairman, is we're spending 
more than a third more money on a health care system that 
doesn't work for most Americans than all of our competitors are 
spending. So if we could agree on how to take that money and 
use it in ways that could elevate health outcomes, I think we'd 
be heading in the right direction and there would be a lot to 
cheer about in rural America, and urban America.
    Senator Enzi. Thank you. That's what we're searching for.
    Senator Hassan.
    Senator Hassan. Thank you, Senator Enzi.
    I never knew that Manchester, New Hampshire being 150,000 
people would sound so large.
    [Laughter.]
    Senator Hassan. I listened to you and Senator Sanders, and 
all of a sudden we're a metropolis.
    But I am also very grateful to all four of you for being 
here.
    To echo a little bit of what some of my colleagues have 
said, I believe health care is a right. It's also just an 
essential. We can't function without it. Our workforce can't be 
healthy without it. Our employers can't have a workforce 
without it. Our economy won't work without it. So I think it's 
really important that we continue to drill down on how we make 
sure everybody has health care in the United States of America.
    I had two questions particular to health care in our most 
rural areas, and the first is really about maternal health 
care. In New Hampshire, it's one of the things we struggle 
with, especially up in our North Country, which is about the 
top two-thirds of our geography, with about 50,000 people in 
that very large space.
    According to the American College of Obstetricians and 
Gynecologists, rural women have poorer health outcomes and less 
access to care than urban women do, especially when it comes to 
women's health providers. This can be, obviously, a tremendous 
problem, and it's really just not feasible for many women to 
drive hours and hours on end for all of the frequent yet 
critical prenatal visits they really need. We all know how 
important that is, but if you have to drive hours and hours 
once a week and you're trying to work and raise a family, you 
just can't do that. And then you also have to think about how 
to access this care when it's actually time to give birth.
    I'm interested to hear from each one of you how we can help 
address this issue to ensure that pregnant women can access the 
care they need. And I'll start with you, Dr. Richter.
    Dr. Richter. Well, first of all, we should provide 
transportation. That is key. What I find is a challenge is I 
have a large population, I take care of people with addiction, 
particularly opioid addiction.
    Senator Hassan. I wanted to follow-up with you on that, 
too.
    Dr. Richter. Right, very dysfunctional lives. We also have 
a program called Blueprint for Health where we actually have 
people that help manage in terms of getting people to 
appointments and those sorts of things. But they also need the 
transportation. Now, many of them, especially in rural areas, 
can't afford cars. If they do, they can't afford the gas and 
the insurance. So I would say providing transportation, and 
also some advocacy so that it makes it easier for them.
    Senator Hassan. Okay, that's great.
    Anybody else? Mr. Levine.
    Mr. Levine. Yes, absolutely. This is a problem we struggle 
with throughout our whole region, and there are two issues in 
particular. One, I think the idea of repurposing rural 
hospitals and providing them the resources to invest in 
recruiting and retaining physicians and mid-level providers is 
helpful. We suffer from a unique problem where we have a lot of 
drug-addicted women who are pregnant, and all the different 
flows of money that come from Washington and the states are all 
fragmented. So as a health system with 21 hospitals serving a 
geographic region, we'd like a situation where we can provide 
prenatal housing, prenatal treatment, food, prenatal care 
delivery through Medicaid, post-acute housing, post-acute food, 
and post-acute transition back into society. But those funding 
streams are all fragmented.
    We can solve this problem, or at least provide an effort to 
mitigate it, if you can figure out how to braid all these 
different flows of dollars from all these different Federal 
agencies.
    Senator Hassan. Okay. Mr. Reed.
    Mr. Reed. Senator Hassan, I remember sitting in your office 
and getting a lesson on the three, possibly four different 
regions in New Hampshire, and I remember realizing that I 
didn't really understand your state quite as well when it comes 
to those differing areas and how complex New Hampshire ends up 
being.
    But here's the interesting thing. Many of the women you're 
talking about, in fact nearly the majority of those women have 
a smart phone. They have a super-computer in their pocket that 
allows them to reach their doctor. It allows them to, if they 
have a wearable band----
    Senator Hassan. Except in our rural areas, the connectivity 
is terrible for broadband.
    Mr. Reed. That's correct, so you're going to hear me pitch 
a little bit about TV white spaces there as a possibility to 
expand beyond that. But here's the specific. When you are 
looking at reaching out to prenatal care, a lot of it is 
physicians answering questions. How do we make it possible for 
the physician to get appropriately reimbursed for their 
connection with a patient? How do you do population health? How 
do you do that engagement?
    On the other side, don't forget that once that birth 
happens, there's another huge cost. So Mississippi now uses a 
NICU sock that's connected to a smart phone, because it costs 
them $40,000 a day, in some cases, for NICU treatment. How do 
we actually allow this baby to go home with their mom healthy 
in a way that actually gets connected care?
    I like what you're talking about. How do we get it on the 
front end? Let's figure out how we use the technology that 
already exists to make this possible and get physicians 
appropriately reimbursed for using it so those questions get 
answered, people stay healthier longer throughout their 
prenatal care.
    When it comes to opioid addiction and the issues around 
that, again, the number-one issue around that often is societal 
and mental health. So let's figure out how we can use what 
they're doing today to better engage with them for their 
prenatal health.
    Senator Hassan. Mr. Glause.
    Mr. Glause. Thank you, Senator. I agree with the good 
doctor, the transportation is an issue, but Wyoming is unique 
in that we have very small communities that are 40 or 50 miles 
from a small town of 2,000, 2,500 people. And to try to solve 
that issue with public transportation just is not going to work 
if we send public transportation into a remote mountainous area 
to bring somebody to a hospital or a doctor appointment.
    I think one of the keys I keep coming back to is 
incentivize providers to come into small communities, the use 
of digital medicine through telemedicine. But even if one 
doctor is servicing several smaller communities on a weekly 
basis, it still gets the women and children the care they need. 
We have a low birth rate in Wyoming, which is the first sign 
that women are not getting the maternal care that they need.
    Senator Hassan. I appreciate that. I am almost out of time. 
I'm going to have to go to another meeting, but I will follow-
up with all of you on the issue of medication-assisted 
treatment as we combat this opioid epidemic. I know all of our 
states are dealing with this, and I would ask my colleagues 
also to consider that Senator Gardner and I have the airwaves 
full just really trying to get at this connectivity issue in 
rural America, and one of the issues we're trying to crack here 
is using telemedicine and the devices we need in rural America 
so much. So I'd ask folks to look at that bill. We'd love to 
move it forward, and I'll follow-up with all of you on your 
ideas about medication-assisted treatment and the opioid 
epidemic as well. Thank you.
    Senator Enzi. Senator Kaine.
    Senator Kaine. Thank you, Mr. Chairman.
    To the witnesses, excellent testimony.
    Just really three observations, and I think there's some 
really good follow-up from your testimony and the dialog.
    First, a question that Senator Sanders was asking about 
what Medicaid cuts would mean. It's not a hard answer, and I 
get that some of you, that's not your particular focus. But 
just to give you an example, Medicaid and children, much less 
adults, in Virginia, more than 50 percent of the births of 
children in Virginia are paid for by Medicaid, and that was 
before we just did Medicaid expansion. So now it's going to be 
more. If your child gets a wheelchair in Virginia, it is likely 
that Medicaid is paying for that wheelchair. If your child is 
in elementary school or secondary school and is on an IEP, it's 
pretty likely that Medicaid is reimbursing your school district 
for some component of that IEP.
    I'm not talking about adults, those with disabilities. Just 
with kids, Medicaid cut effects are dramatic.
    I hope to bring you back an example early next year. The 
statistics that Mr. Levine laid out--and we're so glad to have 
him in Virginia--hospitals, 90 rural hospital closures in just 
the last 8 years, another 670 hospitals at risk. We are within 
a few months, I believe, of being the first example of 
reopening a hospital that has been closed for a long time in 
rural America that I'm aware of. A hospital in Lee County, 
Virginia, in the coal fields of Appalachia that was closed a 
number of years back is opening by year end. AmeriCorps is 
reopening the hospital.
    Mr. Levine talks about repurposing hospitals. It won't open 
exactly the way it was configured when it was closed, but we've 
been working with these folks in Lee County for a long time, 
and they've had to go through a million hoops and hurdles and 
figure out how to get it done, and it might be--if there are 
670 that are in jeopardy of closing, it might be interesting to 
bring one back after they're up and running so they can offer 
their ideas about here's how we did it and, boy, we wish we had 
done these other things. I hope we might do that. The reopening 
is scheduled in December.
    I just want to comment, Mr. Reed, you used UVA as an 
example on the telemedicine side. The opioid bill that we just 
passed and sent to the--I guess it's in conference, and 
hopefully the President will sign it soon--included a directive 
I guess that came out of the Finance Committee to clarify--for 
CMS to clarify that Medicaid reimbursement could be received 
for telemedicine provision of addiction recovery services. 
There is a bill pending now in the Senate called the Connect 
Act which would do the same thing with respect to Medicare 
reimbursements. I think, as we're talking about rural 
communities or underserved communities generally, the idea of 
telemedicine as the solution--there's no one solution, but as a 
solution to some people's challenges, it's really going to be a 
good solution.
    But if we don't have a reimbursement model that 
accommodates it, then we're going to grapple with the public 
transportation issue, or the challenges of folks' work 
schedules and things like that. Telemedicine isn't the answer 
for everybody, but when there are telemedicine applications, we 
shouldn't be standing in the way because we have outdated 
reimbursement models for the way health care providers provide 
services, and I think that offers some promise to rural 
America.
    I appreciate all of you for coming, and we'll look forward 
to taking these ideas as part of it. We've had a lot of 
hearings about diagnoses, and I'm really interested in getting 
to some prescriptions here soon.
    But thank you, Mr. Chairman, for doing this, and thank all 
of you.
    Mr. Reed. I would be remiss if I didn't mention the fact, 
with Senator Hassan asking about prenatal care, UVA has a fetal 
heart rate monitor system through Locus Health called Imprint, 
and I know, Senator Kaine, you've worked with Dr. Karen Revan 
on some of these exact issues. So earlier we talked about the 
importance of the Connect for Health Act as something that my 
organization and over 190 organizations, companies, patient 
groups and others support. So, thank you, and we'd like all the 
Senators to join together to get that bill passed.
    Senator Enzi. Thank you.
    Dr. Richter.
    Dr. Richter. Yes, I just want to respond to the couple of 
comments that were made about the fragmented financing. I was 
actually happy to hear that Mr. Levine actually sounds like 
he's endorsing a single payer. Is that true, Mr. Levine?
    Mr. Levine. No.
    [Laughter.]
    Dr. Richter. Because he's talking about the fact that when 
you have all these different payments, there's also an 
administrative cost at the provider end. The hospitals, they 
have to erect these bureaucracies to collect the money to keep 
their doors open. The same thing in the doctor's office. And 
again, that's another advantage to having a one-payer system, 
that at least it's one set of rules, regulations, and 
reimbursements that you have to deal with. You definitely still 
have to have administration, but not this amount. And for all 
that money that we're spending on administration and creating 
at the provider and payer end, we could be spending on these 
great ideas that we have. But I think we first have to figure 
out how to streamline that administration. And again, this is a 
plug for single payer, and I thank Mr. Levine for advocating 
for it.
    [Laughter.]
    Senator Enzi. I didn't hear that the same way, either. But 
one of the things that's hindering any kind of single payer is 
the difficulties with the VA. That's a government-run program 
that we thought was operating perfectly, and most of the people 
who were in it thought it was running perfectly, and then a 
bunch of people died in Arizona. And then we found out that the 
workers were fiddling with the figures and postponing 
appointments, and we found that was pretty extensive. I even 
did some checking on our two hospitals in Wyoming and found out 
there was a problem with that, and we've had a bunch of changes 
since then.
    Dr. Richter. Could I respond to that?
    Senator Sanders. No, let me respond to that, as somebody 
who is a member of the Committee, the Veterans Committee. The 
VA is the largest integrated health care system in the country. 
It has problems. The last that I heard, so does the private 
health care system. We have a system in which, as Dr. Richter 
was talking about, tens of thousands of people die each year 
because they either don't have any health insurance or they 
have high deductibles and co-payments, or they can't afford 
their prescription drugs.
    Nobody denies that a system with 137 medical centers, which 
is what the VA has, has its problems. But on the other hand, 
Mr. Chairman, I would suggest you speak to the American Legion 
and the DAV and the VFW and you ask them whether they want to 
privatize the VA, and unanimously they will tell you no, they 
want to strengthen the VA.
    Second of all, in terms of how the American people feel 
about government health insurance, the most popular health 
program in America is Medicare. The second most popular program 
is the VA. So in all instances, we need to improve those 
programs. But veterans feel pretty good about the VA, elderly 
people feel very good about Medicare, and the American people 
in poll after poll want us to move to a Medicare-for-all, 
single-payer program.
    Senator Enzi. I didn't intend to turn my part of the 
questions over to----
    Senator Sanders. Okay. I just wanted to comment.
    Senator Enzi. I appreciate your comments, and all of that 
is helpful.
    I want to go back to Mr. Levine because I know that you had 
21 hospitals, and more than half of them are rural, and I want 
to know how you recruit physicians for that. How do you get 
providers for these rural hospitals? How do you do searches? 
How do you compensate them? Is there this incentivizing that 
we're talking about in Wyoming?
    Mr. Levine. Well, good question, Mr. Chairman, and I would 
say two things. First, somebody earlier mentioned looking at 
Stark and the anti-kickback statutes. That's a big problem. In 
the fee-for-service system, the Stark and anti-kickback statute 
served an important role in preventing fraud. In a system where 
we're going toward value-based purchasing, they have actually 
become an impediment to integration with physicians.
    The reality is in rural communities we have to pay a lot 
more, and we always bump up against these issues of fair market 
value, and my biggest fights are sometimes with my legal 
department where we want to recruit and employ a doctor and we 
find that we have to pay them in excess of what the 90th 
percentile of some XYZ company says we're allowed to pay him. 
So I think the anti-kickback and Stark laws need to be looked 
at, particularly as it relates to non-urban and rural 
communities.
    But the bottom line is cost-based reimbursement helps us 
where we have hospitals that are critical access, where we have 
rural health clinics, being able to compensate them more, and 
getting the cost reimbursement through Medicare and Medicaid is 
very helpful. I think more of that would be helpful. I know 
there's a movement to actually go in the other direction and 
get rid of the provider-based, the hospital-based clinics, but 
they serve a valuable purpose.
    In each of our practices, we lose--for a specialist, we 
lose anywhere from $150,000 to $200,000 a year for a doctor 
that we employ. So it's a huge burden. Our system generally has 
negative operating margins of more than $100 million a year 
sustaining physicians in our rural communities that we 
shoulder, that we don't get paid for.
    Senator Enzi. Thank you.
    I need to shift direction a little bit here again. I need 
to go back to Mr. Reed because you were talking about not being 
able to be billed on digital health. Can you give a little more 
detail on that?
    Mr. Reed. Two basic problems exist in the digital health 
space. One is reimbursement that's appropriate for the care 
that's provided. Let's look at something like population 
health. You're a physician in care, and you have 25 patients 
that are in various conditions. Let's use the obvious example, 
because men are bad about taking their medicine and women are 
good at taking their medicine.
    If you're monitoring those patients through a remote 
patient monitoring tool, right now if Mr. Jones doesn't take 
his medicine and you call him in for an appointment, you get 
reimbursed for that appointment to see Mr. Jones because he 
didn't take his medicine. But Mrs. Jones, who is doing her 
time, she's undergoing her PT, she's taking her medicine on 
time, even though the physician is spending the same amount of 
time to monitor and set that up, the physician doesn't get 
reimbursed for it.
    The incentives are only aligned for you to wait until Mr. 
Jones gets sick and then you bring him in, and that's not what 
the doctor wants to do. The doctor wants healthy people that 
stay healthy.
    Part of it comes from the fact that the codes--I'm going to 
do something unusual. I'm going to say good things about a 
government agency. CMS this year unbundled Code 90991. That was 
a really important first step that allowed for the 
reimbursement of remote patient monitoring in a way that has 
never been allowed before, and we're hopeful. They predict 
about 250,000 uses of that code. We're hopeful that will 
actually unlock some of this digital medicine.
    The second aspect that we get into on some of these coding 
questions is if the code only reimburses at a level that 
doesn't match what the physician actually has to spend because 
they say, well, it's remote, but that physician still has to 
have the bricks and mortar, he still has to have the assistant, 
he still has to have the same facility with the lights on even 
though he's providing that care remotely. So the reimbursement 
for telemedicine and remote patient monitoring needs to be 
appropriate to the fact that what you're getting is a highly 
qualified doctor to answer your questions when you need it.
    Some things have gone well with CMS, some things not so 
good.
    Then finally, I would be remiss if I didn't hit on the 
other aspect, which is we are hopeful that ONC will get their 
anti-blocking report out. My understanding is it's moved over 
to OMB, but we need to see what the numbers look like. We need 
to see the data of what's working and what's not. Right now, 
physicians, organizations like Mr. Levine's, don't have access 
to the data that they need to make the good decisions that they 
want.
    If you're looking at how do we get reimbursed for this, 
first give us the codes; second, make sure that it's 
appropriate to the use; and third, give us the data to know 
what works.
    Senator Enzi. Anybody have any other comments on problems 
with going to telemedicine in rural areas?
    [No response.]
    Senator Enzi. Okay.
    Mr. Glause, you mentioned that 70 percent of the people in 
Wyoming live within 70 miles of the border, and so they're 
taking a lot of their health care to other places like Salt 
Lake City or Billings or Rapid City or Fort Collins. Can you 
talk about how that type of pattern affects the cost of health 
care and the ability to recruit physicians, and any solutions 
you might have?
    Mr. Glause. Thank you, Senator. You are correct with that 
statistic that 70 percent of our population lives within 70 
miles of a border. In Southwest Wyoming we have out-migration 
to Salt Lake City. In Northwest Wyoming we have out-migration 
to the Billings area. In Northeast Wyoming the migration is to 
Rapid City, South Dakota. And in Southeast Wyoming, in the 
Cheyenne and Laramie areas, the migration is to Fort Collins 
and Denver.
    We're already a small population, and when you look at over 
70 percent of the people are seeking their health care out of 
the state, it only reduces that population that the doctors are 
able to draw from. There are no economies of scale left. The 
ability to amortize the cost of equipment over a larger 
population dissipates. The ability to attract doctors to areas 
is further strained because the limited population we have to 
start with is going out of state. So that migration out of 
state really drives the cost up within the state to deliver 
those services.
    Senator Enzi. Thank you. And do you know of any ways to get 
more competition in that individual market?
    Mr. Glause. I wish I had a good answer for you. It gets 
very complicated. To get competition both at the provider level 
and at the insurer level has been one of my main focuses for 
the insurance department. Insurance companies are not 
interested in coming into the small markets. They have to build 
a market share. They have to come in and try to create a 
provider network where there are limited providers. And to 
compete with the carrier that is there, they have to do this on 
a price point. And with the lack of population, it is very, 
very hard to make this sound like a very attractive business 
opportunity.
    Senator Enzi. Anybody else want to comment?
    Dr. Richter. Well, I would say that competition, it depends 
on what you mean by competition. Competition amongst insurance 
companies really means marketing to the healthier population, 
which is about 80 percent of the population that's relatively 
healthy. Twenty percent are sick and use 80 percent of the 
care. So that's not going to reduce costs by increasing that 
sort of risk selection.
    I would say in terms of the provider end, it's really that 
you can't have two rural hospitals competing against each other 
because of what Mr. Levine said, most of the costs are fixed. A 
majority of hospital costs, at least 75 percent, are fixed. So 
the idea that you would have to have all the bells and whistles 
in those competing hospitals, it's not feasible.
    Senator Enzi. Right.
    Mr. Levine. Thank you. Dr. Richter, you just made the case 
for the reason our health system exists. Ballad Health was 
formed through the merger of two health systems that were 
competitors. What was going on in our market, we were spending 
tens of millions of dollars creating redundant, duplicative 
services, and the problem is that we had a declining 
population, and this race of spending capital, we couldn't 
afford it anymore.
    The markets where we had the highest costs, the markets 
where our hospitals are actually losing the most money were the 
ones that were actually the most competitive because there was 
so much duplication of effort and duplication of cost, but 
you'd have two hospitals using only 20 percent of their 
capacity each. So the fixed costs were just unsustainable.
    That's why we ended up merging under what's called the 
State Action Immunity Doctrine of anti-trust law. The FTC staff 
were not happy with our merger and did not like it, but both a 
Republican Governor of Tennessee and a Democratic Governor of 
Virginia signed laws that were passed unanimously by both 
legislatures to permit our merger to occur for the purpose of 
reducing about $300 million in cost, and then reinvesting those 
dollars in repurposing these rural hospitals. That's why we're 
going to have things like maternal care, emergency care, mental 
health and addiction services that were not previously able to 
be provided. We're actually going to fund those.
    As to insurance, I'm not an expert on insurance, but I 
think the bottom line is--I've always been struck, Mr. 
Chairman, by the fact that we've taken, for instance, children, 
we created the SCHIP program. Children are by far the 
healthiest risk. We've carved the healthiest risk out of the 
insurance market and put them in a government program where 
those healthy lives can no longer be part of the risk pool. So 
when you pull healthy lives out of a risk pool, all you're left 
with are older people who are unhealthier, and then the cost of 
insurance goes up.
    The idea fundamentally needs to be to create healthier risk 
pools. The more we carve up healthy populations and put them 
into various government programs, the more we pull them out of 
the risk pools. And I'm not suggesting that--like I said, I'm 
not an expert on this, but I do think that's part of what has 
led to higher spikes in cost of coverage prior to the 
Affordable Care Act. I think there are other factors that led 
to cost increases once the Affordable Care Act went into place.
    Senator Enzi. Rather than get into a debate on that, I need 
to change topics slightly here. Part of this is going back to 
telemedicine, which is something we have to have in Wyoming in 
order to reach the rural population. One of the problems that 
we're having is that some of the providers could be across 
state lines, on a telephone, to serve our people, but the 
licensing for doctors is state by state. So before they can 
call a guy on the telephone, he has to become researched and 
licensed in our state. I think that's one impediment we have, 
even for visiting doctors to come. Is that a problem anywhere 
else?
    Mr. Levine. Yes. Yes, sir.
    Senator Enzi. Okay.
    Dr. Richter. Yes.
    Senator Enzi. Okay. I want to go back to--since Senator 
Bennet mentioned Medicare Part D and the fact that we haven't 
pulled the trigger yet on part of that, I put that trigger in 
there. I was really worried. Wyoming only had two people that 
were providing any medical, any prescription insurance, and I 
was afraid that when we went to this Part D, that we might lose 
both of those. So I thought there ought to be some alternative 
to go in there.
    Now, my mom was one of the people that was eligible for it, 
so I asked her if she was going to need any help on figuring 
out her prescription D or not, and she said that she could use 
a little bit of help. I don't know if you remember the books 
that came out that were about that thick, with really thin 
pages, for these seniors to look through to see if they could 
qualify. So I tried out every mechanism that there was for 
making the selection so that maybe I could also try these 
systems to find out how they work. The reason that book is so 
thick is because we've got competition. It was kind of virtual 
pricing that was done on that. Anyone who put their 
prescriptions in could see what each of the different companies 
would provide on that.
    My question is, are there some other things that 
transparency could help solve some of the rural problems?
    Mr. Glause. One of the issues that I think has been 
successfully addressed is the SHIP program, the Senior Health 
Initiative Plan. Sometimes we're charged with doing the 
Medicare supplement guide that is also part of that Federal 
grant, but the navigators that we have in Wyoming, many of them 
are volunteers, and the money that we get from that grant is 
used to train those people to help seniors navigate those 
waters.
    I often refer people to those navigators to help them, and 
they report back to me that they are very, very informative and 
educational and helpful to them. So the SHIP money I think is 
well spent.
    Mr. Reed. I want to be specific. Cost transparency is 
always a really interesting issue. Mostly, my members tend to 
look at it from an access to data standpoint. They want to see 
the data so that they can help build tools and others that give 
insights into what things actually cost. The difficulty that we 
face on it is, and having met with health systems, sometimes 
health transparency is something that begins on day one that 
you think you'll solve in a 5-minute meeting, and it ends up 
being a 5-month seminar in exactly where that cost is that you 
thought was in the emergency room but ends up over there.
    I want to be respectful of the people who work in hospital 
systems and health systems who understand that cost 
transparency is difficult. But I will say that with effective 
cost transparency, it gives us the ability to give people more 
insight into where their money is going, and hopefully, back to 
your point about competition, provide some competition that 
comes from the digital space.
    We have several members who already build products that 
allow you to choose your doctor, look at what services they 
provide, look at their average cost, make a decision. This is 
terrible if you're in an emergency room, but if you've got a 
plethora of doctors, not in Wyoming, that kind of transparency 
can actually lead you to the ability to say I want to see Dr. 
Bob. He fits my cost structure, I like the things that he's 
done, let's give him a call.
    More transparency can lead to good use of data and more 
competition, but I want to be respectful of the people who run 
health systems that understand that it's not that easy.
    Mr. Levine. Senator, I was proud that I was Secretary of 
Health in Florida when we were the first state in the country 
to publish hospital pricing and prescription drug pricing on 
the Internet. This was back in 2005. And it was interesting to 
see how quickly prices, particularly for prescription drugs, 
got affected by that. When pharmacies right across the street 
from each other found out what the other was charging, the 
pricing came down pretty quick. That was the easy stuff.
    The hard thing, we actually tried to give patients an 
estimate of what it's going to cost. The problem is that 
oftentimes you don't know all the different comorbidities that 
a patient has when they go into the hospital. I hate to sit 
here and say, gee, it's really hard. It is really hard. It's 
something we have to continue to work toward.
    I think as more and more health systems modernize their 
data systems--and I know we may have a disagreement on some of 
that, but the good news about all these data systems that are 
now being deployed is now the data is becoming more unified, 
and I think with that data we can use predictive modeling and 
predictive analytics to determine with more precision what 
those costs are going to be. And let me just tell you, there's 
nothing more frustrating to a CEO of a health system than to 
not be able to tell somebody this is what it's going to cost 
you.
    Now, the problem we have, as I mentioned, even with the 
insured population, the biggest part of their cost they can't 
even pay for anyway, whether it was $100 or $10,000. They just 
can't come up with the money, and unfortunately we're having to 
eat that.
    Senator Enzi. Did you want to make a closing comment?
    Dr. Richter. Well, I guess what I would say too, though, is 
you had asked about the drug costs, and the real problem I have 
as a clinician is not knowing what the drugs cost because they 
change. I prescribed mebendazole, which is a drug for 
intestinal parasites, to a patient thinking, Okay, no big deal, 
ten bucks, and it turns out Medicaid refused to pay it, and I 
couldn't figure out why. So I sent in a prior authorization and 
then looked it up. It's because it went to $455 per pill from 
$7.
    That's part of our problem too, that these drug costs are 
inflating just ridiculous amounts, and we don't really always 
know what they are. So I think the transparency is not so easy 
for those reasons.
    Senator Enzi. That's an area in the whole Committee that 
we've had some hearings on too, on how we get some drug 
transparency pricing, pricing transparency, and finding out 
some of the complexities of that. There isn't anything in the 
health care field that's easy, I don't think.
    Dr. Richter. Who knew?
    [Laughter.]
    Senator Enzi. I want to thank all of you for participating.
    The hearing record will remain open for 10 days so you can 
submit additional information if you want to. I also allow 
Members to submit questions. You need to turn those in by 
tomorrow night, I guess. It's a little too late for tonight by 
5 o'clock. And if you would provide answers to those, we'd 
really appreciate it. Your testimony and your answers will be a 
part of the record.
    Thank you for being here today.
    The Committee stands adjourned.
    Dr. Richter. Thank you, Chairman Enzi.
    [Whereupon, at 5:11 p.m., the hearing was adjourned.]

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