[Senate Hearing 116-515]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 116-515

                        TELEHEALTH: LESSONS FROM
                         THE COVID-19 PANDEMIC

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                                   ON

  EXAMINING TELEHEALTH, FOCUSING ON LESSONS LEARNED FROM THE COVID-19 
                                PANDEMIC

                               __________

                             JUNE 17, 2020

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
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                              __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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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
	RAND Paul, Kentucky			ROBERT P. CASEY, JR., Pennsylvania
	SUSAN M. COLLINS, Maine			TAMMY BALDWIN, Wisconsin
	BILL CASSIDY, M.D., Louisiana		CHRISTOPHER S. MURPHY, Connecticut
	PAT ROBERTS, Kansas		        ELIZABETH WARREN, Massachusetts
	LISA MURKOWSKI, Alaska			TIM KAINE, Virginia
	TIM SCOTT, South Carolina		MARGARET WOOD HASSAN, New Hampshire
	MITT ROMNEY, Utah		        TINA SMITH, Minnesota
	MIKE BRAUN, Indiana			DOUG JONES, Alabama
	KELLY Loeffler, Georgia			JACKY ROSEN, Nevada
	
	                                     
	               David P. Cleary, Republican Staff Director
	         Lindsey Ward Seidman, Republican Deputy Staff Director
	                  Evan Schatz, Minority Staff Director
	              John Righter, Minority Deputy Staff Director

                            
                            
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                        WEDNESDAY, JUNE 17, 2020

                                                                   Page

                           Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, 
  Labor, and Pensions, Opening statement.........................     1
Smith, Hon. Tina, Ranking Member, (pro tempore), a U.S. Senator 
  from the State of Minnesota, Opening statement.................     4

                               Witnesses

Rheuban, Karen S., M.D., Professor of Pediatrics, Senior 
  Associate Dean of Continuing Medical Education, and Director, 
  University of Virginia Karen S. Rheuban Center for Telehealth, 
  Charlottesville, VA............................................     6
    Prepared statement...........................................     8
    Summary statement............................................    17
Kvedar, Joseph C., M.D., President, American Telemedicine 
  Association, Professor, Harvard Medical School, Senior Advisor, 
  Virtual Care, Mass General Brigham, Editor, npj Digital 
  Medicine, Boston, MA...........................................    18
    Prepared statement...........................................    20
    Summary statement............................................    24
Arora, Sanjeev, M.D., M.A.C.P., F.A.C.G., Distinguished and 
  Regents' Professor, University of New Mexico Health Sciences 
  Center, Founder and Director, Project ECHO/ECHO Institute, 
  Albuquerque, NM................................................    25
    Prepared statement...........................................    27
    Summary statement............................................    30
Willis, Andrea D., M.D., M.P.H., F.A.A.P., Senior Vice President, 
  Chief Medical Officer, BlueCross BlueShield Tennessee, 
  Chattanooga, TN................................................    31
    Prepared statement...........................................    32
    Summary statement............................................    34

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.
    Letters of Support...........................................    59

                         QUESTIONS AND ANSWERS

Response by Karen S. Rheuban, to questions of:
    Hon. Robert P. Casey, Jr.....................................    64
    Hon. Elizabeth Warren........................................    65
    Hon. Tina Smith..............................................    66
    Hon. Jacky Rosen.............................................    66
    Hon. Kelly Loeffler..........................................    67

 
                        TELEHEALTH: LESSONS FROM.
                         THE COVID-19 PANDEMIC

                              ----------                              


                        Wednesday, June 17, 2020

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:04 a.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Lamar 
Alexander, Chairman of the Committee, presiding.
    Present: Senators Alexander [presiding], Burr, Collins, 
Cassidy, Roberts, Murkowski, Scott, Romney, Braun, Loeffler, 
Casey, Baldwin, Kaine, Hassan, Smith, Jones, and Rosen.

                 OPENING STATEMENT OF SENATOR ALEXANDER

    The Chairman. Good morning. The Committee on Health, 
Education, Labor, and Pensions will please come to order.
    First, a few administrative matters, which we are getting 
used to. We thank the attending physician and the Sergeant at 
Arms, all of whom have consulted with us. Individuals in the 
hearing room are seated 6 feet apart. There is no room, as a 
result, for the public to attend, but there is a press pool 
relaying all of our information. And anyone who wants can watch 
it online at our website, www.help.senate.gov.
    Witnesses are participating by videoconference, and so are 
most Senators. Senators in the room may remove their mask when 
we talk because we are 6 feet apart.
    We are grateful to the Rules Committee and our staffs, 
Architect of the Capitol, Chung Shek, and Evan Griffis for all 
their hard work, too, to make this hearing possible.
    Senator Smith and I will each have an opening statement, 
and then we will turn to our witnesses, who we thank for being 
with us today. We would ask you to summarize your comments in 5 
minutes, and that will leave Senators more opportunity to ask 
you questions. I will ask Senators in order of seniority, 
alternating between Republicans and Democrats, during the 
question period.
    Senator Kaine and I were just talking about this ought to 
be a very interesting hearing. Here is an example. I just spoke 
recently with Tim Adams, who is the CEO of Ascension Saint 
Thomas Health, which has nine hospitals in Middle Tennessee and 
employs over 800 physicians. He told me that in February, 
before COVID-19, there were about 60,000 visits between 
patients and physicians each month in that hospital system. 
Almost all of those visits were done in person. Only about 50 
of the 60,000 were done remotely through telehealth through the 
internet.
    But, during the last 2 months, Ascension Saint Thomas 
conducted more than 30,000 telehealth visits, or about 45 
percent of all of its visits, because of changes in Government 
policy and the inability of many patients to see doctors in 
person during the COVID-19 Pandemic. Tim Adams expects that 
number to level off at about 15 to 20 percent of its visits 
going forward.
    The largest hospital in San Francisco told me a few weeks 
ago that 5 percent of its visits in February were conducted 
through telehealth, and the hospital considered that to be a 
very high percentage. Then, in March, telehealth visits made up 
more than half of all the visits in that hospital. So, from 5 
percent to more than half.
    Because of COVID-19, our healthcare sector and Government 
have been forced to cram 10 years' worth of telehealth 
experience into just 3 months. As dark as this pandemic has 
been, it creates an opportunity to learn from and act upon 
these 3 months of intensive telehealth experiences, 
specifically what permanent changes need to be made in Federal 
and state policies.
    In 2016, there were almost 884 million visits nationwide 
between doctors and patients according to the Centers for 
Disease Control and Prevention. If, as Tim Adams expects, 15 to 
20 percent of those become remote due to telehealth expansion 
during COVID-19, that would produce a massive change in our 
healthcare delivery system. Our job should be to ensure that 
change is done with the goals of better outcomes and better 
patient experiences, and at a lower cost.
    Part of this explosion in remote meetings between patients 
and physicians has been made possible by temporary changes in 
Federal and state policies. The private sector, too, has made 
important changes. One purpose of this hearing is to find out 
which of these temporary changes in Federal policy should be 
maintained, modified, or reversed; and, also, to find out if 
there are additional Federal policies that would help patients 
and healthcare providers take advantage of delivering medical 
services using telehealth.
    Of the 31 Federal policy changes, the three most important 
seem to me to be, one, physicians now can be reimbursed for 
telehealth appointments wherever the patient is located, 
including in the patient's home. That change was to the so-
called Originating Site Rule, which previously required the 
patient live in a rural area and use telehealth at a doctor's 
office or clinic.
    Number two, Medicare and Medicaid began to reimburse 
providers for nearly twice as many types of telehealth services 
during COVID-19, including emergency department visits, initial 
nursing facility visits, discharges from those facilities, and 
therapy services.
    Three, doctors are allowed during COVID-19 to conduct 
appointments using common video apps on your phone, like Apple 
Facetime or phone texting apps, or even on a landline call, 
which required relaxing Federal privacy and security rules from 
the Health Insurance Portability and Accountability Act, or 
HIPAA.
    Many states made changes, as well--most importantly, making 
it easier for doctors to continue to see their patients who may 
have traveled out of state during the pandemic. For example, a 
college student from Memphis, who attends college in North 
Carolina, has a doctor she sees in Chapel Hill was able to go 
home to Tennessee during the pandemic and continue to see her 
Chapel Hill doctor via Facetime. Or, a patient in Iowa has been 
able to start seeing a new psychiatrist in Nashville.
    The private sector has reacted to these changes, as well. 
One of our witnesses today is from Blue Cross Blue Shield of 
Tennessee, which has already begun to make permanent 
adjustments to its telehealth coverage policies based on some 
of the temporary Federal changes in Medicare.
    Now, looking forward, of the three major Federal changes, 
my instinct is that the Originating Site Rule change and the 
expansion of covered telehealth services change should be made 
permanent. One purpose of this hearing is to hear from experts 
and discuss whether there may be unintended consequences, 
positive or negative, if Congress were to do that.
    It is also important to examine the other 28 temporary 
changes in Federal policy. The question of whether to extend 
the HIPAA privacy waivers should be considered carefully. There 
are privacy and security concerns about the use of personal 
medical information by technology platform companies, as well 
as concerns about criminals hacking into those platforms. When 
HIPAA notification requirements are waived, a person might not 
even know that their personal information has been assessed by 
hackers. Additionally, several of these technology platforms 
have said they want to adjust their platform to conform to the 
HIPAA rules.
    Another lesson from these 3 months is that telehealth or 
teleworking or telelearning is not always the answer, 
especially for those in rural areas or low-income, urban areas 
who do not have access to broadband.
    Still another lesson is that personal relationships matter. 
Personal relationships involved in healthcare, education, and 
the workplace cannot always be replaced by remote technology. 
Children have learned that--learned about all they want to 
learn over the internet in the last few months. Patients like 
to see their doctors, and workplaces benefit from employees 
actually talking and working with one another in person. There 
are some limits on remote learning, healthcare, and working.
    There are obvious benefits to allowing healthcare providers 
to serve patients across state lines during a public health 
crisis. As a former Governor, I am reluctant to override state 
decisions, but it may be possible to encourage further 
participation in interstate compacts or reciprocity agreements.
    Last week, I released a white paper on steps that Congress 
should take before the end of the year in order to get ready 
for the next pandemic. One of those recommendations was to make 
sure that patients do not lose the benefits they have gained 
from using telehealth during this pandemic. Even with an event 
as significant as COVID-19, memories fade. Attention moves 
quickly to the next crisis, so important--it is important for 
Congress to act this year on those things that we believe are 
important for the next pandemic, which we know will surely 
come.
    Because of this 10 years of telehealth experience crammed 
into 3 months, patients, doctors, nurses, therapists, and 
caregivers can write some new rules of the road, and we should 
do so while the experiences are still fresh on everyone's 
minds.
    Senator Smith.

                   OPENING STATEMENT OF SENATOR SMITH

    Senator Smith. Thank you, Mr. Chairman, and thank you so 
much for convening this hearing, and thanks to all of our 
witnesses for being here with us today.
    We are more than 3 months into the economic and public 
health crisis created by the coronavirus pandemic, and more 
than 2 months through the passage of the CARES Act, which 
provided urgent and much-needed emergency support to families 
and our healthcare system.
    While the COVID epidemic has affected everyone in one way 
or another, we have also seen that it is not the great 
equalizer. In fact, it hits hardest those who are already 
struggling without a safe place to call home, because they do 
not have access to healthcare, because of low wages or chronic 
poverty, and because of the generational impacts on Black and 
Brown and indigenous people for the systemic racism that limits 
their freedom, their opportunities, their health, and even 
takes their lives.
    Following the murder of my constituent, Mr. George Floyd, 
Minnesotans and people across this Country have been rising up 
to demand that we address the systemic inequities in every part 
of our community. Congress must step up to this challenge and 
fulfill America's full promise of racial and economic justice, 
and how we respond in this moment will tell the story of our 
values.
    Today, we have the opportunity to consider how we can 
deploy telehealth to expand access to healthcare for everyone, 
and to also address the systemic inequities that result in the 
worst healthcare outcomes for communities of color, or rural 
communities, and for poor families.
    As we grapple with the COVID pandemic, changes to Federal 
telehealth rules and expansion of telehealth coverage have been 
a lifeline for many Americans. Telehealth has helped to support 
continuity of care during the pandemic by helping patients get 
the care that they need without exposing themselves or their 
providers to the risks of the COVID-19 virus.
    Federal changes to telehealth regulations have made it 
possible for patients and providers to receive and deliver 
healthcare from their own homes, and it has also allowed for 
more services to be provided via telehealth, including 
emergency department services, home health visits, speech-
language pathology, physical and occupational therapy, and 
behavioral health services. This has helped Americans continue 
to get the care that they need during the pandemic.
    One of many examples of this is Hennepin Healthcare, a 
Level I trauma center and acute care hospital in my hometown of 
Minneapolis, which serves some of the most diverse and in-need 
communities in Minnesota. They have found that increased audio-
only telehealth--telephone services are reducing the 
disparities that are driven by the digital divide.
    Telehealth has also provided important financial support to 
hospitals and clinics that have been buffeted by dramatic 
losses of revenue and increased costs during the pandemic. 
These hospitals have delayed non-emergency procedures. And, as 
they have followed stay-at-home orders in hopes of flattening 
the curve, this has resulted in, for many of them, a traumatic 
financial challenge. But, new regulatory flexibility has 
allowed healthcare providers to bill Medicare and Medicaid for 
more telehealth services at the same rate as if they were 
provided in person. This has helped these centers to recoup 
some of the financial losses that they have faced.
    But, the move to telehealth has also revealed some 
significant weaknesses in our system. While telehealth has been 
a lifeline to some, the lack of technology, of digital 
literacy, and access to high-speed internet is a digital divide 
that exacerbates health disparities for people of color, rural 
communities, and poor communities.
    According to the Census Bureau, nearly 37 percent of Black 
American households, and 31 percent of Hispanic American 
households, have no broadband or computer access in their 
homes. In 2018, the FCC estimated that 35 percent of Americans 
living on tribal lands lacked access to broadband services. So, 
the disparities in access to technology reflect the underlying 
inequity that exists throughout our society in urban and in 
rural areas.
    This moment presents us with a unique opportunity, I think, 
to learn from the past 3 months, to assess how telehealth has 
worked, and to make the changes we need to make to close these 
disparities and to improve telehealth delivery.
    I hope to learn from our witnesses today the following: 
First, how do we close the digital divide to improve health 
equity?
    Second, how do we protect patients while we expand 
telehealth, particularly patients' privacy?
    Third, what temporary flexibilities that we have adopted 
during the pandemic should we make permanent, and what changes 
and investments do we also still need to make?
    Mr. Chairman, it is my hope that we will use today's 
hearing to learn about what is working, to figure out what more 
needs to be done, and figure out how we can build a telehealth 
delivery system that is accessible to all Americans.
    Thank you.
    The Chairman. Thank you, Senator Smith, and thank you--
Senator Murray has asked Senator Smith to serve today as the 
Ranking Democratic Member of the Committee, and I appreciate 
her doing that.
    Each witness will have up to 5 minutes now. We welcome our 
witnesses. We have some terrific witnesses today. Senator Kaine 
will introduce our first witness, and then I will introduce the 
other three, and then I will call on all four.
    Senator Kaine. Thank you, Mr. Chairman. I am glad we are 
having this important hearing today, and I am happy to 
introduce from the University of Virginia our first witness, 
Dr. Karen Rheuban. I am happy to introduce her. She is an 
expert in this field with many, many years of expertise and 
will be sharing that with us.
    Dr. Rheuban is a pediatric cardiologist, a professor of 
pediatrics, and a leader in the field of telehealth. She is the 
co-founder and director of the University of Virginia Center 
for Telehealth and has made such an impact on our Commonwealth 
that the Center was actually renamed in her honor in 2016 as a 
result of her significant contributions to the field.
    The Center at UVA serves as a hub for 155 site 
telemedicine--155 sites of telemedicine throughout Virginia. It 
is funded in part by Federal grants, and it has supported more 
than 180,000 patient visits, e-consults, remote patient 
monitoring, and thousands of hours of health professional and 
patient education. And, I have had the experience to be in some 
of the telehealth visits at a remote medical clinic that is 
offered every year in the coal fields of Wise County, Virginia 
that is well-supported by UVA telehealth.
    Dr. Rheuban's leadership on telehealth has been 
instrumental in addressing the COVID crisis. She chairs the 
Virginia Department of Health and the Virginia Healthcare and 
Hospital Association's COVID-19 response telehealth working 
group.
    I look forward to hearing from Dr. Rheuban and our other 
witnesses about how we can use telehealth to continue to 
increase access to healthcare, strengthen the workforce, and 
also improve health outcomes.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Kaine.
    Our second witness is Dr. Joe Kvedar. He is a dermatologist 
and professor of dermatology at Harvard Medical School, the 
vice president of Connected Health at Partners Healthcare, 
where he is focused on leveraging information technology to 
improve healthcare delivery. As of today, Dr. Kvedar is the 
president of the American Telemedicine Association.
    The third witness is Dr. Sanjeev Arora. He is director and 
founder of Project ECHO, which is a renowned video technology 
tool that links doctors and medically underserved in rural 
areas with specialists in another location to enhance medical 
knowledge and improve patient outcomes. Our bipartisan Lower 
Healthcare Costs legislation, which was approved by this 
Committee last year 20 to 3, includes a provision to expand 
Project ECHO and build upon its successes. Dr. Arora is a 
Distinguished and Regents' Professor of Medicines in the 
Department of Internal Medicine at the University of New Mexico 
Health Sciences Center.
    Finally, our fourth--our next witness is Dr. Andrea Willis, 
who joins us from Chattanooga, Tennessee. Dr. Willis is a 
pediatrician by training, and currently serves as senior vice 
president and chief medical officer of BlueCross BlueShield of 
Tennessee. She was recently recognized by Modern Healthcare as 
one of the Country's top 25 minority executives in healthcare, 
and one of the 50 most influential clinical executives world--
nationwide. Dr. Willis is a fellow in the American Academy of 
Pediatrics and a member of the Tennessee Medical Association.
    Welcome, again, to all of our witnesses.
    Dr. Rheuban, let us begin with you.

 STATEMENT OF KAREN S. RHEUBAN, M.D., PROFESSOR OF PEDIATRICS, 
  SENIOR ASSOCIATE DEAN OF CONTINUING MEDICAL EDUCATION, AND 
 DIRECTOR, UNIVERSITY OF VIRGINIA KAREN S. RHEUBAN CENTER FOR 
                TELEHEALTH, CHARLOTTESVILLE, VA

    Dr. Rheuban. Can you hear me?
    The Chairman. Yes, we can.
    Dr. Rheuban. Wonderful. Thank you.
    Chairman Alexander, Senator Smith, Senator Kaine, thank you 
for the kind introduction. And distinguished Committee Members, 
thank you for this opportunity to testify today.
    As we have heard, telehealth tools play a critically 
important role during the COVID-19 public health emergency. By 
necessity, and thanks to recent regulatory and statutory 
changes related to the pandemic, patients and their providers 
have turned to digital health platforms, devices, and services 
to provide and receive care in place and to avoid unnecessary 
exposure to the novel coronavirus.
    Prior to COVID-19, the UVA Center for Telehealth's efforts 
included video-based, interactive consults and follow-up visits 
with patients located at more than 150 partner healthcare 
facilities across Virginia.
    We also support a remote patient monitoring program for 
vulnerable adults, high-risk pregnant women, and medically 
complex children.
    We offer a store-and-forward diabetic retinopathy screening 
program, and an e-consult program connecting primary care 
providers with specialists.
    We also present virtual training programs across a number 
of disciplines for health professionals and for patients. We 
rely heavily on the FCC's rural healthcare program for 
affordable connectivity between facilities.
    However, prior to COVID-19, geographic and other 
originating site restrictions and fee-for-service Medicare, a 
lack of alignment by many State Medicaid programs and private 
insurers, outdated prescribing regulations, and other policy 
barriers severely limited the large-scale integration of 
telehealth into everyday care. In particular, due to the 
1834(m) restrictions, Medicare does not reimburse for 
telemedicine services furnished to a patient at home or in a 
metropolitan statistical area.
    As with other healthcare systems, UVA Telehealth response 
to COVID-19 has been a multi-pronged effort designed to 
maintain patient access and ensure continuity of care while 
reducing exposure to this deadly virus.
    Between February and May, as is the case as described by 
Senator Alexander, we experienced a greater than 9,000 percent 
increase in the use of telehealth. At UVA, we converted tens of 
thousands of in-clinic patient appointments to virtual patient 
visits. Within our medical center and our emergency room, we 
configured more than 100 isolation rooms to enable patients, 
providers, and family members to interact virtually with one 
another, conserving personal protective equipment.
    We expanded our remote patient monitoring programs to 
include home-quarantined COVID-19 patients. Our providers make 
virtual rounds at home for these patients as needed, 24/7.
    We deployed telemedicine equipment to support patients in 
high-risk, congregate care settings, such as long-term care 
facilities, to enable our clinicians to consult and escalate 
care as needed.
    We launched a virtual urgent care clinic staffed by our 
emergency physicians.
    We have expanded training of the health professional 
workforce via Project ECHO and other online continuing 
education tools.
    Our HRSA-funded Mid-Atlantic Telehealth Resource Center has 
seen more than a 1,000 percent increase in requests for 
technical assistance.
    Patients have overwhelmingly embraced digital 
transformations in care. Indeed, nationwide, patient 
satisfaction data are exceptionally high.
    Building upon the critical actions taken nationwide during 
the COVID-19 pandemic, to prepare us for subsequent surges or 
any future public health emergency, and to ensure that patients 
do not lose access to telehealth-supported care when the 
declared COVID-19 emergency expires, we strongly urge Congress 
to act now to advance telehealth payment reform, to align 
incentives for adoption within Medicare, Medicaid, and the 
commercial insurers.
    The simplest and most important action needed is for 
Congress to authorize the Secretary of Health and Human 
Services to make permanent many of the telehealth policy 
changes enacted during the public health emergency.
    In addition, as was referenced, Congress should provide 
support for further broadband deployment, including to the home 
as appropriate, to reduce geographic and sociodemographic 
disparities in access to care.
    Also needed is increased funding for the HRSA-funded 
telehealth resource centers and for innovative models of 
virtual continuing education programs for health professionals 
to improve outcomes.
    Over the past 20 years, many thousands of peer-reviewed 
studies have repeatedly demonstrated the benefits of 
telemedicine, but it has taken a global pandemic to showcase 
its full potential.
    Mr. Chairman, the time has finally come to fully utilize 
telehealth in the delivery of healthcare services. Millions of 
Americans and health systems across the Country would be the 
beneficiaries. As a pediatric cardiologist, who regularly uses 
this valuable tool and has seen firsthand the healthcare 
benefits, I urge you and your colleagues to take the needed 
actions discussed more fully in my written testimony and that 
of others.
    Thank you so much.
    [The prepared statement of Dr. Rheuban follows:]
                 prepared statement of karen s. rheuban
    Chairman Alexander, Ranking Member Murray, Senator Kaine and 
Members of the Senate Health, Education, Labor, and Pensions Committee, 
thank you for the opportunity to provide testimony regarding 
``Telehealth--Lessons from the COVID-19 Pandemic''.

    I am the co-founder and Director of the Center for Telehealth at 
the University of Virginia (UVA Health), past President of the American 
Telemedicine Association, Board chair of the Virginia Telehealth 
Network, and chair of the Telehealth subcommittee of the Virginia 
Department of Health/Virginia Hospital and Healthcare Association 
COVID-19 response Working Group.

    It is from these related perspectives that I offer testimony 
regarding the critically important role of telehealth during the COVID-
19 pandemic, the rapid expansion facilitated both by necessity and 
policy change, the related impact on patient care, and enduring policy 
changes that we believe will enable cost-effective, sustainable care 
delivery models.

    Before doing so, Mr. Chairman, I'd like to note that in September, 
2000, I testified before the House Energy and Commerce Subcommittee on 
Health and Environment on a related subject, ``Telehealth: A Cutting 
Edge Tool for the 21st Century''. \1\ Admittedly, telehealth was a 
relatively new concept at the time. However, with thousands of peer 
reviewed studies over the past 20 years that have proven its benefits, 
and a global pandemic that has clearly demonstrated its full potential, 
it is time to make full use of telehealth in the delivery of health 
care services.
---------------------------------------------------------------------------
    \1\ Hearing before the Subcommittee on Health and Environment, 
Committee on Commerce, US House of Representatives, One hundred sixth 
Congress September 7, 2000, Serial No 106-144, US Government Printing 
Service.
---------------------------------------------------------------------------
                               UVA Health
    UVA Health is an academic medical center located in 
Charlottesville, VA and is comprised of the UVA Medical Center, the UVA 
School of Medicine, the UVA School of Nursing, and University 
Physicians Group, our practice plan. UVA Health includes a 612 bed 
state-supported academic medical center, an additional 84 beds in our 
recently completed new bed tower (which currently houses our COVID-19 
patients), a 70 bed Emergency Department, designated as a Level 1 
Trauma Center and a 50 bed long term acute care hospital. UVA is one of 
two safety net hospitals in the Commonwealth. In 2014, we were 
designated as one of two special pathogen hospitals in Virginia by the 
Virginia Department of Health and by the CDC to care for patients with 
suspected Ebola virus, other hemorrhagic fevers, novel respiratory 
viruses and high risk pathogens such as COVID-19.
            The University of Virginia Center for Telehealth
    The UVA telemedicine program was formally established in 1996 as an 
effort to improve access to high quality care for all Virginians, 
regardless of geographic location. Since the establishment of our 
telemedicine program, we have developed collaborations that connect UVA 
providers with patients located in more than 150 healthcare facilities 
across the Commonwealth using high definition video-teleconferencing, 
store and forward technologies, remote patient monitoring and mobile 
health tools. We connect with hospitals, clinics, federally qualified 
health centers, free clinics, community service boards, health 
departments, medical practices, dialysis facilities, correctional 
facilities, PACE programs, rural schools, skilled nursing and long-term 
care facilities, and under certain circumstances, the home. Our 
telemedicine program has reduced the burden of travel for Virginians by 
more than 21 million miles, saved many lives and fostered innovative 
models of care delivery and workforce development. In 2012, we launched 
a care coordination and remote patient monitoring program for patients 
at home that has significantly reduced hospital readmissions by more 
than 40 percent regardless of payer. UVA telemedicine offers services 
in more than 60 different clinical subspecialties, spanning the 
continuum from prenatal services, to emergency and acute care 
consultations and follow-up visits, to chronic disease management and 
palliative care. Prior to COVID-19, we facilitated more than 100,000 
telemedicine related patient services using high definition video-
teleconferencing, monitored more than 11,000 patients at home, screened 
more than 18,000 patients with diabetes for retinopathy, the number one 
cause of blindness in working adults, and through our electronic 
medical record, EPIC, facilitated more than 12,000 e-consults between 
providers. In 2014, with our designation as a special pathogen hospital 
for Ebola and other hemorrhagic fevers, we established a virtual model 
to facilitate care provided to our patients in isolation. The model, 
our Isolation Communication Management System (ISOCOMs) was developed 
to provide remote treatment, guidance and supervision for UVA's Special 
Pathogens Unit and a biocontainment room in UVA's Emergency Department. 
\2\ UVA Health is also the home of the Health Resources & Services 
Administration (HRSA) funded Mid Atlantic Telehealth Resource Center, 
through which we provide technical assistance to providers and systems 
across nine states including the District of Columbia (www.matrc.org).
---------------------------------------------------------------------------
    \2\ Gossen, Allison, Beth Mehring, Brian S. Gunnell, Karen S. 
Rheuban, David C. Cattell-Gordon, Kyle B. Enfield, and Costi D. Sifri. 
``The Isolation Communication Management System. A Telemedicine 
Platform to Care for Patients in a Biocontainment Unit.'' Annals of the 
American Thoracic Society 17, no. 6 (2020): 673-678.

    Our telemedicine programs and partnerships are dependent on 
reliable broadband communications services and in the majority of 
cases, we rely heavily on the Federal Communication Commission (FCC)'s 
Rural Health Care Program for connectivity between facilities. In 2019, 
UVA Health underwent a multi-stakeholder strategic planning process to 
further expand our telehealth program.
                 UVA's telehealth response to COVID-19
    Much like other healthcare systems, UVA's telehealth response to 
COVID-19 has been a multipronged effort designed to reduce patient and 
provider exposure, maintain patient access, ensure continuity of care 
for our patients, and where appropriate, conserve personal protective 
equipment (PPE). Fortunately, our 2019 multi-stakeholder strategic 
planning process enabled us to rapidly scale our telehealth program to 
address pandemic related needs. We initiated these actions prior to the 
(critically important) announcement of the Medicare Interim Final Rule, 
passage of the CARES Act and other enabling Federal and state waivers 
and executive orders.

    These efforts have included:

          Configuring more than 100 isolation rooms in the 
        Medical Center (including the Emergency Department and our 
        newly established COVID clinics) with our iSOCOMs ``virtual 
        PPE'' designed to reduce provider exposure, improve 
        communications between our hospitalized COVID-19 patients and 
        COVID suspected patients with our physicians, nurses and 
        patient families and conserve PPE. Imagine the value of 
        communicating face-to-face with patients and their families 
        (albeit via video) without cumbersome PPE such as isolation 
        gowns/suits, face-shields, goggles and masks.

          The establishment of processes that enabled our 
        providers to convert more than 45,000 in-clinic patient 
        appointments to virtual patient visits beginning in mid-March.

        
        

          The launch of an innovative approach to the rapid 
        deployment of telehealth tools to support the management of at-
        risk patients in congregate care settings experiencing high 
        COVID-19 outbreak rates, such as skilled nursing (SNF) and 
        long-term care (LTC) facilities. This model enabled rapid 
        diagnosis, virtual rounding, escalation of care if needed, and 
        post-acute management after hospitalization. In one LTC 
        facility, in which more than 90 percent of residents and all 
        but one healthcare provider developed COVID-19, we deployed 
        technology, executed a contract and began monitoring and 
        treating patients in less than 24 hours. This could not have 
        been possible but for the Office of the Inspector General 
        notice of enforcement discretion on Stark and Anti-Kickback 
        statutes during the public health emergency.

          The establishment of a new virtual Urgent Care 
        service in the Emergency Department

          The expansion of provider to provider eConsults in 
        outpatient and inpatient settings

          The expansion of our remote patient monitoring 
        program to vulnerable patients and quarantined patients with 
        COVID-19, that allows us to monitor vital signs at home, 
        including through video based virtual rounds by UVA Health 
        advanced practice nurses. Several patients required escalation 
        of care that otherwise might have been delayed had it not been 
        for the video enabled monitoring service.

          The establishment of a COVID-19 Project ECHO 
        (Extension for Community Health Outcomes) educational series 
        for practitioners, including training on the use of PPE, COVID-
        19 testing, treatment and the use of telehealth.

          The rapid scaling of other telehealth training for 
        all levels of providers, students and support staff with a 
        broad range of resources, to include through our Mid-Atlantic 
        Telehealth Resource Center, and through our UVA accredited, 
        online training program, Telehealth Village. 
        (telehealthvillage.com)

        Maps below demonstrate the expansion of UVA telehealth services 
        by patient home zip code beginning in February, 2020 prior to 
        our March COVID-19 expansion of virtual visits

        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
        

                         Patient satisfaction:
    Our experience and that of others is that patients have 
overwhelmingly embraced virtual visits and remote patient monitoring 
tools. Press Ganey recently released patient satisfaction data with 
virtual visits, in which they reported 96.3 percent of respondents were 
likely to recommend a video visit with their provider. \3\ Not 
surprisingly, considering the race to deploy virtual visits, technology 
scores were somewhat lower (in the 70-80 percent range).
---------------------------------------------------------------------------
    \3\ Press Ganey Special Report: The Rapid Transition to 
Telemedicine: Insights and Early Trends, May, 2020

    UVA Health patient satisfaction results are equally favorable as 
reported by Press Ganey. We received more than 1900 survey responses 
---------------------------------------------------------------------------
for our telehealth service from April to June 12, 2020 and

          97.5 percent were likely to recommend their care 
        provider
          90.1 percent were likely to recommend our video visit 
        service
          83.4 percent were willing to have future telemedicine 
        visits after the COVID quarantine is over

    Whether because of convenience, concern for contracting COVID-19, 
reduced clinic appointment availability or a combination of the above 
factors, patient satisfaction data are clear that consumers wish to 
continue to engage with their providers where THEY are, and not 
necessarily always in bricks and mortar healthcare facilities. To quote 
a patient who had a recent UVA virtual visit, ``Thank you for the 
valuable service of a video appointment. It was enormously helpful and 
easy to receive medical services using this modern technology, from 
scheduling the video conference to picking up the medicine at the 
pharmacy and experiencing closure by receiving the directive for me to 
go back to work! It was so comforting and satisfying to have time with 
Dr. (redacted) during this medical emergency during COVID-19, 
eliminating a crisis in my life. Again, thank you for the excellent 
medical service.''

    Committee Members know well, telemedicine is not a new specialty, a 
new procedure or a new clinical service simply defined, it is the use 
of technology designed to enable the provision of healthcare services 
at a distance. 21st century telemedicine services can be provided live, 
via high-definition interactive videoconferencing supported, as 
appropriate, by peripheral devices and remote examination tools; 
asynchronously, using store and forward technologies, or through the 
use of remote patient monitoring tools with biometric monitoring 
devices such as oximeters, blood pressure cuffs, electronic scales, and 
in many cases, with video capabilities.

    Telemedicine has been demonstrated to effectively mitigate the 
significant challenges of workforce shortages, geographic disparities 
in access to care, while improving patient triage and timely access to 
care by the right provider when needed. Telemedicine tools foster 
patient engagement and self-management as appropriate. \4\
---------------------------------------------------------------------------
    \4\ K Rheuban, EA Krupinski , Understanding Telehealth, 2017 McGraw 
Hill.

    Elements that contribute to the success of any telemedicine program 
include the establishment of consistent workflows, training of 
practitioners and staff, technology acquisition, broadband 
connectivity, tracking of clinical and process quality metrics, 
workforce capacity, and careful analyses of outcomes, including return 
on investment. These must be considered in the context of 
---------------------------------------------------------------------------
organizational mission and programmatic alignment with that mission.

    Significant barriers to the broader integration of telemedicine 
services into everyday healthcare remain. More than 16 different 
Federal agencies report engagement in telehealth, be it through 
research and other grant funded opportunities, through the 
establishment of broadband communications networks, clinical service 
delivery, and even device development and regulation. However, despite 
of our multi-billion dollar Federal investment in telemedicine and 
broadband expansion, those good faith efforts remain stifled by 20th 
century Federal and state barriers to widespread adoption and a lack of 
alignment across the payers.
                             Reimbursement
                               Medicare:
    Payment coverage restrictions remain a major impediment to the 
broader adoption of telehealth by providers. Congress, in 1997, through 
the Balanced Budget Act, and later in 2000, though the Medicare, 
Medicaid and SCHIP Benefits Improvement and Protection Act, authorized 
the Centers for Medicare and Medicaid Services (CMS) to reimburse for 
telemedicine services provided to rural Medicare beneficiaries across a 
range of CPT codes and services. However, those Medicare telehealth 
provisions, as established in the Section 1834 (m) of the Social 
Security Act limit eligible patient originating sites to rural, 
eligible types of originating sites, and types of providers eligible to 
furnish those services (not all Medicare providers). The statute allows 
the Secretary to establish a process by which additional telehealth 
services may be added; indeed, CMS has expanded coverage in the 2018, 
2019 and 2020 Physician Fee Schedules. The Bipartisan Budget Act of 
2018 expanded services and requires Medicare Advantage plans to cover 
``additional telehealth benefits'' beyond those covered under Medicare 
fee-for-service beginning in 2020.

    However, prior to COVID-19 public health emergency, Medicare 
reimbursement of telehealth services provided to fee-for-service 
beneficiaries remained limited due to the 1834 (m) restrictions of the 
Social Security Act. The 21st Century Cures Act directed CMS to provide 
an update on telehealth services provided to Medicare beneficiaries. 
\5\ Claims data analyses demonstrated that between 2014-2016, only 0.25 
percent of the more than 35 million Medicare beneficiaries in the fee-
for-service program utilized a telehealth service. That report 
suggested that the most significant statutory restrictions to the 
utilization of telehealth included (1) the requirement that the patient 
originating site be rural and (2) the home is not an eligible 
originating site.
---------------------------------------------------------------------------
    \5\ https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/
Information-on-Medicare-Telehealth-Report.pdf.

    During the public health emergency of the COVID-19 pandemic, 
provisions of the CONNECT for Health Act were included in the 
Coronavirus Preparedness and Response Supplemental Appropriations Act 
and the Coronavirus Aid Relief and Economic Security Act giving the 
Secretary of Health and Human Services authority to waive telehealth 
requirements under Section 1834(m) of the Social Security Act, and 
allowing federally Qualified Health Centers (FQHCs) and Rural Health 
Clinics (RHCs) to provide distant site telehealth services. CMS issued 
regulatory waivers and Interim Final Rules in March and April, 2020 
---------------------------------------------------------------------------
related to the provision of Medicare telehealth services.

    Importantly, these COVID-19 public health emergency waivers 
eliminated geographic restrictions, allowed the home as an eligible 
originating site, expanded eligible distant site providers, enabled 
federally qualified health centers and rural health clinics to serve as 
both an eligible originating and distant site, expanded covered CPT 
codes, and allowed hospitals to charge a (limited) facility fee along 
with other important changes. The facility fee payment, however, was 
not at parity with that of in-person visits. Economic incentives need 
to be in place to enable providers to recover costs associated with 
telemedicine technology acquisition, deployment, and operational costs 
such as investments in HIPAA compliant platforms, electronic medical 
record integration, hardware (dual monitors, webcams and headsets), 
staffing to support patient scheduling and registration, and facility 
broadband services.

    Notably, during the public health emergency, recognizing that audio 
and video based services may not be feasible or available to all 
Medicare beneficiaries, CMS activated evaluation and management codes 
for reimbursement for telephone calls. The Federal Communications 
Commission and the states have found that geographic limitations in 
broadband deployment and sociodemographic factors create a healthcare 
digital divide. The activation of evaluation and management codes for 
telephone-based services has enabled improved access to care, 
particularly within the context of the primary and specialty medical 
home.

    This exponentially scaled coverage expansion during the COVID-19 
public health emergency will further enable HHS to study the cost 
effectiveness, clinical outcomes and any incidents of fraud or abuse 
related to telemedicine services covered by Federal payment programs.

    To build on the important actions taken during the COVID-19 public 
health emergency, to prepare us for any future public health emergency 
and to ensure that providers and patients do not lose access to 
telehealth supported care when the COVID-19 emergency concludes, 
Congress must act to advance telehealth payment reform particularly 
through Medicare and Medicaid, and encourage alignment by the 
commercial plans.

    Recommendations: The simplest and most important step would be for 
Congress to give the Secretary the authority to make permanent the 
telehealth changes made during the public health emergency. This would

        1. Remove outdated restrictions that require patients to be 
        located in a specific geographic location in order to receive 
        telehealth services,

        2. Permanently make the home and other sites eligible places 
        for patients to receive telehealth care

        3. Continue to cover telephone evaluation and management 
        services when provided in the context of the patient's primary 
        or specialty medical home and/or existing doctor-patient 
        relationship

        4. Waive restrictions in order to allow HHS to determine the 
        providers appropriate to practice telehealth for different 
        services

        5. Permanently allow federally qualified health centers (FQHCs) 
        and rural health clinics (RHCs) to provide telehealth both as 
        originating and distant site providers

        6. Give the Secretary of HHS automatic waiver authority during 
        future public health emergencies

        7. Ensure payment at parity for comparable in-person services, 
        and

        8. In addition, we and others also recommend payment of 
        facility fees comparable with in-person facility fees.
                               Medicaid:
    Fifty state Medicaid programs plus the District of Columbia provide 
some form of reimbursement for the delivery of telehealth facilitated 
care to Medicaid beneficiaries. Medicaid innovations adopted by many 
states in addition to video-based telemedicine consults and follow-up 
visits include coverage for remote monitoring, home telehealth and 
store forward services.

    Prior to COVID-19, Virginia Medicaid covered facility based 
telemedicine services without geographic restrictions, some store 
forward services (screening for diabetic retinopathy and limited remote 
monitoring services to include continuous glucose monitoring). 
Following the declaration of the public health emergency, Virginia, 
like other states expanded Medicaid telehealth coverage to the home, 
activated telephone evaluation and management codes, eConsults and 
remote monitoring codes for COVID-19 patients or patients under 
investigation.

    Recommendation: To drive adoption and ensure access to care, 
particularly for vulnerable patients, state Medicaid programs should 
continue to have the flexibility to expand telehealth services and at a 
minimum, align with the Medicare telehealth provisions.
                            Private payers:
    Forty-two states plus the District of Columbia require private 
insurers to cover telehealth services, although not all at parity with 
in-person services. Many of the ERISA plans have chosen to cover 
telehealth services. Post public health emergency, most commercial 
plans expanded coverage for telehealth services aligned with Medicare, 
with variable sunset dates for elimination of coverage.

    Recommendations: Commercial plans should be encouraged to have 
flexibility to expand but at a minimum, align with the Medicare 
telehealth provisions.
                        Other relevant policies
                               Licensure:
    During the COVID-19 public health emergency, through the waiver 
process, Medicare allowed for reimbursement for services provided to 
patients in states where the practitioner is not licensed, so long as 
that individual practitioner holds a valid license in another state, 
and is enrolled in the Medicare program. By executive order, many 
states have implemented similar waivers of licensure during the COVD-19 
public health emergency. For example, Virginia Governor Ralph Northam 
(M.D.) issued several executive orders in the public health emergency 
that have enabled practitioners licensed in other states to provide 
care to patients in the Commonwealth either for purposes of continuity 
of care where a doctor-patient relationship exists, or when contracted 
by healthcare entities in the Commonwealth and those contracted 
providers licensure information is reported to the relevant board 
overseen by the Virginia Department of Health Professions.

    Many states currently participate in the Federation of State 
Medical Board's Interstate Licensure Compact which enables expedited 
licensure. Other states have created their own models of expedited 
licensure, reciprocity or licensure by endorsement. The value of state 
licensure (or regional compacts) is that (1) state (or regional) public 
health information can be disseminated quickly to licensees by state 
public health entities, or by the boards themselves, and (2) patients 
can be assured that potential adverse actions by licensees can be 
appropriately investigated. As we learned, in the face of large numbers 
of practitioners experiencing cancellation of in-person clinics and 
procedures, as the uptake and use of telemedicine has grown, the 
existing workforce within a state often can be sufficient to meet the 
needs of its patients.

    Recommendation: In a public health emergency, states themselves 
should determine models for licensure that best suit the needs of their 
citizens.
                      HIPAA Privacy and Security:
    During the public health emergency, the Office of Civil Rights 
(OCR) issued a waiver of enforcement discretion against health care 
providers who in good faith utilized non HIPAA compliant applications 
to connect with their patients. States may have additional HIPAA 
privacy and security laws, and as such the Federal waiver does not 
eliminate risk for providers, who may still be subject to state 
enforcement action.

    Recommendation: Although OCR waiver of enforcement action helped to 
enable providers to rapidly adopt telemedicine, as a matter of policy, 
with the increasing availability of free and/or low cost HIPAA 
compliant solutions, and to ensure protection of personal health 
information, non HIPAA compliant solutions should only be used in good 
faith in an emergency. As such, telehealth providers should work now to 
execute business associate agreements and ensure that whenever 
possible, telehealth services are delivered via HIPAA-compliant 
electronic communication systems.
                              Prescribing:
    Complicating efforts to combat our Nation's tragic opioid epidemic, 
(which has not disappeared during the COVID pandemic), is our 
nationwide shortage of mental health professionals such as 
psychiatrists and addiction specialists. Telemedicine provides access 
to those providers who otherwise would not be available in-person. 
However, the prescribing of controlled substances over telemedicine is 
currently limited to very few scenarios. The Drug Enforcement Agency 
(DEA) has yet to act on a requirement by Congress in the SUPPORT Act to 
address this more permanently with a special registration process for 
telemedicine providers. The DEA recognized this during the pandemic and 
has increased flexibilities for DEA-registered prescribers to see 
patients over telemedicine.

    Recommendation: The DEA must act to finalize the rule needed to 
implement the Special Registration process and ensure continued access 
to telemedicine for needed services such as medication-assisted 
treatment.
                       Training of the workforce
    Prior to the public health emergency, training in telehealth has 
not been consistently applied across health professions curricula in 
undergraduate, graduate and continuing medical and nursing education. 
In 2019, the Association of American Medical Colleges convened a 
working group to develop competencies for purpose of training. The 
American Medical Association and other health professional 
organizations have provided extensive training, as have the HRSA funded 
telehealth resource centers. Our Mid-Atlantic telehealth resource 
center, much like the other resource centers, has experienced a greater 
than 1000-fold increase in requests for technical assistance and 
guidance. We have launched an accredited training portal, Telehealth 
Village. In addition, the significant expansion of Project ECHO 
(Extension for Community Health Outcomes) training has enabled virtual 
case conferences and training related to a broad range of COVID-19 
related topics, along with other critically important training for 
practitioners.

    Recommendation: Telehealth Resource Centers and Project ECHO should 
receive expanded support to further enable practitioners to deploy 
telehealth capabilities and to expand training for health 
professionals.
                           Broadband access:
    The Federal Communications Commission, as a provision of the 
Telecommunications Act of 1996, established the Rural Health Care 
Program. This program has provided support for critical broadband 
infrastructure to healthcare facilities. The FCC and many of the states 
themselves track broadband availability including to the census tract 
level. The FCC's Connect2Health Task Force mapped both broadband 
availability and health status indicators, and their findings suggest 
that a lack of broadband is indeed a health equity issue. The FCC 
recently voted to establish two additional programs, the ($200 million) 
COVID-19 Telehealth Program funded by the CARES Act, and the ($100 
million) Connected Care Pilot Program, designed to enable healthcare 
providers and systems to deploy broadband to the homes of their 
patients. Other Federal programs have also supported broadband 
expansion particularly in rural and underserved areas.

    Recommendation: Congress should ensure robust funding to expand 
broadband infrastructure across the Nation to ensure that all patients 
have access to telehealth services, both during and after the public 
health emergency.
                              Conclusion:
    In summary, to build on the important actions taken nationwide 
during the COVID-19 public health emergency, to prepare us for any 
future public health emergency and to ensure that patients do not lose 
access to telehealth supported care when the COVID-19 emergency 
concludes, Congress must act to advance telehealth payment reform 
particularly through Medicare and Medicaid, and encourage alignment by 
the commercial plans. The simplest and most important step would be for 
Congress to give the Secretary the authority to make permanent the 
telehealth changes made during the public health emergency. Congress 
must also further invest in broadband expansion to reduce disparities, 
increase funding for the HRSA funded telehealth resource centers, 
encourage the DEA to establish the Special Registration Process for 
prescribing of controlled substances by telemedicine providers, expand 
training of the healthcare workforce in telehealth, and support 
innovative models of virtual continuing health professional education 
such as Project ECHO.
                                 ______
                                 
                [summary statement of karen s. rheuban]
    Telehealth tools are playing a critically important role during the 
COVID-19 pandemic. Because of recent regulatory and statutory changes 
related to the COVID-19 public health emergency, and by necessity, 
patients and providers have turned to digital health platforms, devices 
and services to provide and receive care in place, and avoid 
unnecessary exposure to the novel coronavirus.

    As with other healthcare systems, UVA's telehealth response to 
COVID-19 has been a multi-pronged effort designed to maintain patient 
access and ensure continuity of care, expand monitoring of COVID-19 
infected patients, reduce exposure and where appropriate, conserve 
personal protective equipment (PPE). Within our medical center, we have 
configured more than 100 rooms with videoconferencing that serve as 
``virtual PPE''. We have expanded our remote patient monitoring 
programs to include COVID-19 patients, and have converted tens of 
thousands of in-clinic patient appointments to virtual visits. We have 
also deployed telemedicine equipment to long-term care and skilled 
nursing facilities through which we make virtual rounds and support 
vulnerable patients and have advanced training of the workforce 
virtually through Project ECHO and other tools.

    To build on the important actions taken nationwide during the 
COVID-19 public health emergency, to prepare us for any future public 
health emergency and to ensure that patients do not lose access to 
telehealth supported care when the COVID-19 emergency concludes, 
Congress must act to advance telehealth payment reform particularly 
through Medicare and Medicaid, and encourage alignment by the 
commercial plans. The simplest and most important step would be for 
Congress to give the Secretary the authority to make permanent the 
telehealth changes made during the public health emergency. Congress 
must also invest further in broadband expansion to reduce or eliminate 
disparities, increase funding for the HRSA funded telehealth resource 
centers, expand training of the healthcare workforce in telehealth, and 
support innovative models of virtual continuing health professional 
education such as Project ECHO.
                                 ______
                                 
    The Chairman. Thank you, Dr. Rheuban.
    Dr. Kvedar, welcome, and congratulations on your new 
position.

   STATEMENT OF JOSEPH C. KVEDAR, M.D., PRESIDENT, AMERICAN 
 TELEMEDICINE ASSOCIATION, PROFESSOR, HARVARD MEDICAL SCHOOL, 
    VIRTUAL CARE, MASS GENERAL BRIGHAM, EDITOR, npj DIGITAL 
                      MEDICINE, BOSTON, MA

    Dr. Kvedar. Thank you so much, Chairman Alexander, Ranking 
Member Smith, distinguished Members of the Health, Education, 
Labor, and Pensions Committee, and fellow testifiers.
    Thank you for inviting me to testify virtually on behalf of 
the American Telemedicine Association. I have been affiliated 
with ATA since its inception and remain committed to its vision 
that people should have access to safe, effective, and 
appropriate care where and when they need it.
    As a practicing physician at the Massachusetts General 
Hospital in Boston, I have seen firsthand the many ways 
telehealth bridges the gap between a critical provider shortage 
and a growing patient population. The problem, by the way, that 
was here before COVID and will continue after.
    During the past few months, we have all witnessed what ATA 
and its members and I have known for decades--that telehealth 
works. Telehealth services include real time audio, virtual 
video visits; a synchronous chat-based interaction; and remote 
monitoring. And research has shown that telehealth is as safe 
and effective as in-person care.
    My own health system, which includes the Mass General and 
the Brigham and Women's Hospitals, has seen over--has had over 
605,000 virtual encounters since March, and post-pandemic, we 
expect telehealth usage to be approximately 250,000 visits per 
month compared to 1,600 in February. So, like others, lots and 
lots of expansion has happened.
    In short, telehealth has saved lives, helped flatten the 
curve, and enabled providers to scale the response of an 
overwhelmed healthcare system. COVID-19 has fueled the rapid 
transformation in how care is delivered.
    However, this expanded access has only been possible 
because Federal and State Governments finally removed many of 
the antiquated barriers to telehealth. ATA wholeheartedly 
supports these policy changes that led to this transformation.
    At the Federal level, temporary changes to restrictive 
requirements have enabled access to telehealth for all Medicare 
beneficiaries and allowed providers to reach those--more 
individuals, including those living in underserved and rural 
communities.
    While telehealth will not and should not be entirely 
replacing face-to-face care, it should remain an important and 
active option. Given the high level of satisfaction and the 
clear value it delivers, patients and providers alike will 
demand access to telehealth indefinitely. Federal policymakers 
must take specific actions before the end of the public health 
emergency to make access to these services permanent.
    Chairman Alexander, you referenced your white paper, 
planning--Preparing for the Next Pandemic. It takes a very 
thoughtful view of public health policy, and I would like to 
quote, because we appreciate your recommendation to ``ensure 
that the United States does not lose the gains made in 
telehealth.''
    Specifically, Congress should first modernize the current 
statutory restrictions on patient geography and originating-
site limitations. These limitations serve no other purpose than 
to restrict access to care.
    Congress should also ensure that HHS has the flexibility to 
expand the list of eligible healthcare providers and maintain 
the authority to add or remove specific telehealth services as 
supported by data to make certain all eligible services are 
safe, effective, and clinically appropriate.
    Congress must build on the changes made under the CARES Act 
and ensure federally qualified health centers and rural health 
clinics are empowered to deliver virtual care to underserved 
communities with fair and appropriate reimbursement moving 
forward.
    We also need to support telehealth infrastructure through 
grants and technical assistance programs, including those that 
expand broadband to rural communities. To ensure that we 
leverage this technology, states will need to streamline 
provider licensing to ensure access across state lines.
    Ultimately, we need your support to ensure that patients 
and providers do not go over the telehealth cliff. As our 
Nation eventually emerges from this pandemic, we must make sure 
that essential telehealth services do not abruptly end with the 
public health emergency, especially as we look to enhance 
preparedness for future public health crises and reorient our 
healthcare system to deliver 21st Century care.
    Thank you for inviting me here with you today. I welcome 
your questions and further discussion about how we can work 
together to ensure that all individuals receive care where and 
when they need it in the future.
    Thank you.
    [The prepared statement of Dr. Kvedar follows:]
                 prepared statement of joseph c. kvedar
    Chairman Alexander, Ranking Member Murray, and distinguished 
Members of the Senate Health, Education, Labor, and Pensions Committee. 
Thank you for inviting me to testify at today's hearing on behalf of 
the American Telemedicine Association. I am proud to serve a second 
term as ATA president and to have the opportunity to share with each of 
you--virtually--how telehealth has enabled healthcare providers to 
continue to deliver safe, effective, and needed care, both within and 
outside the hospital, providing a lifeline for patients across the 
country during the COVID-19 pandemic.

    As a practicing physician at Massachusetts General Hospital in 
Boston, I have seen first-hand the multitude of ways telehealth has 
bridged the gap between a critical provider shortage and a growing 
patient population--a problem that existed before the pandemic, and one 
that will only worsen due to an aging population and the increasing 
burden of chronic disease. In my own telehealth clinic, I can deliver 
specialty care to patients in rural and underserved areas, without the 
need for them to travel hours to see me, take time off from work, or 
find someone to care for their child. This is not just happening at my 
institution but is occurring at hospitals and doctors' offices every 
day across the country.

    Nearly 30 years ago, when I founded the Center for Connected Health 
at Partners HealthCare--a healthcare system including two Harvard 
Medical School-affiliated academic medical centers, community and 
specialty hospitals, community health centers, a physician network, 
home health, and long-term care services, now known as Mass General 
Brigham--I envisioned care delivery that was time and place 
independent. As technology has advanced, so too has healthcare 
innovation, creating new and better ways to connect patients and 
providers, empower individuals to manage their health better, and 
create more efficient and effective care and improved clinical 
outcomes. Even just a few short months ago, we could not have 
anticipated a public health emergency of this magnitude, nor the role 
telehealth would play in helping to `flatten the curve' while 
delivering care to millions of Americans.

    Founded in 1993, the ATA is the leading non-profit professional 
association representing the telehealth industry. Our member 
organizations include hospital networks, technology solution providers, 
academic institutions, and payers, as well as partner organizations and 
alliances from around the world. I have been affiliated with the ATA 
since its inception and remain fully committed to its mission--to 
create a healthcare system where more people have access to safe, 
effective, and appropriate care when and where they need it.

    Over these past few months, Members of Congress, regulators, 
patients, and providers across the country have witnessed a reality 
that the ATA, its members, and I have known for decades: telehealth 
works. This pandemic has forced America's healthcare system into the 
21st century. Telehealth has not been merely a novelty; telehealth has 
kept the entire healthcare system afloat and has enabled patients to 
continue to receive care.

    For those previously unfamiliar with telehealth, I realize there 
may be questions about how virtual care and digital health technologies 
have been used during the pandemic and whether we should continue to 
allow providers to care for patients remotely in a post-pandemic world. 
I hope today I can shed light on the critical role telehealth has 
played during the pandemic and why we need to ensure Congress continues 
to allow individuals access to safe, effective, quality care as our 
world adjusts and our healthcare system evolves to meet our new 
reality.

    Telehealth has saved lives, helped reduce the spread of the virus, 
and enabled providers to scale the response of an overwhelmed and 
under-prepared health system during the pandemic. Telehealth options 
also helped keep older adults connected to their healthcare providers 
and extended care to at-risk and underserved patient populations, 
especially in areas where healthcare resources may be limited.

    Many of us who have been using telehealth know that virtual visits, 
remote monitoring, and asynchronous interactions with patients are as 
safe and effective as in-person care. \1\ During the public health 
emergency, even more providers across the country have turned to 
telehealth to deliver primary care, specialty consultations and disease 
management, while making significant investments in technologies to 
better care for more individuals. Likewise, patients have grown 
accustomed to the convenience, safety, and quality of remote visits. 
Right now, three-quarters of U.S. hospitals are using digital 
technology to reach their patients via video, audio, chat, or email. 
\2\ Patient use of telehealth is up from 11 percent in 2019 to 46 
percent this year, with 76 percent of consumers saying they are 
interested in using telehealth in the future. \3\
---------------------------------------------------------------------------
    \1\ https://www.cochranelibrary.com/cdsr/doi/10.1002/
14651858.CD002098.pub2/full.
    \2\ https://www.beckershospitalreview.com/telehealth/telehealth-
may-see-big-long-term-gains-due-to-covid-19-10-observations.html.
    \3\ https://www.mckinsey.com/industries/healthcare-systems-and-
services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-
19-reality.

    I can share with you some extraordinary numbers from my 
organization that includes Massachusetts General Hospital and Brigham 
and Women's Hospital. In just the last three months, our healthcare 
providers completed over 605,000 virtual visits, including nearly 
247,000 in just the month of May. What's equally impressive is our 
projections for telehealth usage post-pandemic. Mass General Brigham 
providers will go from approximately 1,500 virtual visits per month to 
250,000. Pre-pandemic, only .2 percent of all ambulatory outpatient 
visits were conducted via telehealth. Now, we anticipate 60 percent of 
---------------------------------------------------------------------------
ambulatory care will be delivered remotely.

    In my case, as a practicing dermatologist, I cared for many 
patients using these tools during the pandemic. My patients were 
universally happy and grateful for the experience. Perhaps more 
importantly, I was able to diagnose several skin cancers (those 
patients were directed to come into our emergency dermatology clinic 
for further care) and reassure several others that the lesions they 
were concerned about were benign and could wait until their next 
scheduled visit.

    Again, it's not just my organization that has implemented a 
significant shift in care delivery by leveraging the benefits of 
technology-enabled care. Many of our ATA members have also seen 
staggering increases in virtual care services.

    For example, Providence St. Joseph Health (PSJH) cared for the 
first confirmed COVID-19 case in the U.S. and subsequently cared for 
1,400 infected patients across its seven-state footprint. An 
established virtual care leader, PSJH's telehealth network was able to 
scale services from 70,000 telehealth visits in a year to 70,000 in one 
week to support the COVID-19 surge. Their clinicians leveraged 
telehealth technologies in many ways, including helping diagnose 
appendicitis in a young patient, working with a first-trimester 
pregnant patient to guide her using a fetal heart rate monitor, 
providing a more calming experience for behavioral health patients, and 
staying engaged with frail and elderly patients. Underscoring the power 
of telehealth, Providence's reported patient satisfaction was higher 
for virtual visits than standard in-person care.

    Health systems, including Tennessee-based HCA Healthcare and 
LifePoint Health, are effectively using telehealth for specialty care, 
including but not limited to orthopedics, ENT, and urology. Under the 
current Medicare telehealth flexibilities, LifePoint Health, 
representing over 85 community-based hospitals on the front lines 
responding to the COVID-19 emergency, can now provide specialty 
consults to their patients via telehealth without the restraints or 
limitations of an in-person visit. LifePoint also has leveraged 
providers in other locations to help care for patients in hard-to-serve 
communities and its telehealth utilization has grown from a few hundred 
to more than 28,000 telephone-based visits and 26,000 video-based 
visits a month.

    Telehealth companies like Amwell, Teladoc Health, and Zipnosis have 
also played a critical role during this crisis with their on-demand 
platforms and asynchronous solutions, enabling overburdened healthcare 
systems to effectively respond to the extraordinary patient demand 
throughout the Nation. These companies managed, as you know, record 
increases in volume and services in the first several weeks of the 
public health crisis. For example, in the first 45 days of the 
pandemic, Teladoc Health recorded a 67 percent year-over-year increase 
in patient volume nationally and an 84 percent increase in Tennessee.

    Healthcare providers and policymakers often talk about the urgent 
need for healthcare transformation to address the challenges we are 
facing, including rising provider shortages, burgeoning patient 
populations, and growing financial pressure. COVID-19 has fueled a 
rapid transformation, with telehealth and virtual care driving the new 
paradigm in care delivery.

    While many envision telehealth as real-time audio or video 
interactions between a patient and provider, many platforms are 
combined with remote monitoring capabilities, allowing for a virtual 
care model that offers patients around-the-clock clinical support and 
convenience. This expanded care model is especially critical for 
individuals who engage with the healthcare system frequently, including 
patients with chronic conditions such as diabetes, hypertension, and 
congestive heart failure, as well as behavioral health conditions.

    Today, 147 million Americans live with chronic conditions, 
accounting for 90 percent of our total annual healthcare costs. With 
telehealth, we can improve access to care while reducing many of the 
acute and long-term health complications that stem from chronic 
conditions. For example, remote monitoring also allows individuals to 
self-monitor their health and securely share data with their healthcare 
providers. This technology has proven to reduce hospital readmissions 
and trips to see the doctor. Also, by effectively applying data 
science, many leading remote monitoring companies, such as Livongo 
Health, can contextualize health trends, determine which individuals 
might benefit most from a telehealth visit, and offer patients real-
time, personalized and actionable recommendations on how to stay 
healthy--critical for individuals with chronic conditions.

    In response to the pandemic, Federal and state governments finally 
removed many of the antiquated barriers to telehealth that were keeping 
providers from reaching their patients remotely. The ATA wholeheartedly 
supports these policy changes.

    At the Federal level, temporary changes to the unnecessarily 
restrictive requirements in section 1834(m) of the Social Security Act 
now allow all Medicare beneficiaries--including those living in both 
rural and urban areas--to benefit from telehealth. `Originating site' 
restrictions were also waived, enabling providers to interact with new 
and existing Medicare patients over a range of telehealth modalities--
including the telephone--no matter where the patient is. For 
underserved and rural communities, federally Qualified Health Centers 
(FQHCs) and Rural Health Clinics (RHCs) can finally serve as distant 
sites, enabling these essential safety net providers to reach patients 
they serve in ways they have never been able to before. These examples 
of proactive, common-sense policies paired with significant new funding 
opportunities and loosened restrictions on licensure, cost-sharing, and 
the use of certain technologies, have changed the way our Nation 
delivers and receives health care.

    In states across the country, Medicaid policies have largely kept 
pace with the needs of patients and providers. A recent analysis from 
the Medicaid and CHIP Payment and Access Commission (MACPAC) found that 
44 states and territories expanded telehealth services by changing 
Medicaid policies in response to the pandemic. Additional state-based 
policies now allow a patient's home to qualify as an originating site, 
provide payment parity for telehealth visits, enable other providers to 
deliver services through telehealth, and allow providers to consult 
with their patients over the telephone. \4\
---------------------------------------------------------------------------
    \4\ https://www.macpac.gov/wp-content/uploads/2020/06/Changes-in-
Medicaid-Telehealth-Policies-Due-to-COVID-19-Catalog-Overview-and-
Findings.pdf.

    These policy changes have enabled unprecedented telehealth 
utilization during this public health emergency. However, I advise you 
not to be distracted by these numbers. The overwhelming acceptance and 
implementation of telehealth during the pandemic--and the significant 
levels of patient and provider satisfaction--clearly speak to the value 
of these technologies. In fact, a recent poll of Medicare Advantage 
beneficiaries found that more than 90 percent of respondents view their 
recent use of telehealth as favorable, and nearly 80 percent reported 
they would use telehealth for a medical appointment in the future. \5\
---------------------------------------------------------------------------
    \5\ https://www.betterMedicarealliance.org/sites/default/files/
BMA%20Memo%20CT%20D2%5B3%5D.pdf.

    Telehealth will not and should not entirely replace in-person care 
post-pandemic. It should, however, be an option. As patients again feel 
safe to enter healthcare facilities for nonemergent care, we may see a 
natural decline in the use of telehealth. Some patients and providers 
will prefer in-office interactions, while others will want to use 
telehealth for some aspects of care, and still, others may opt to forgo 
virtual care altogether. Given the patient and provider satisfaction we 
have seen, I believe many, if not most, providers and patients will 
---------------------------------------------------------------------------
want to continue to use telehealth in some way indefinitely.

    Now that Medicare beneficiaries have improved access to telehealth, 
Federal policymakers need to take specific actions to make these 
services permanent. Failure to do so will result in unnecessarily 
restricting access to high-quality care. However, if the Federal 
Government--and specifically Congress--does not act before the end of 
the declared national public health emergency, Medicare patients and 
providers will not have the option to continue to use remote care.

    Chairman Alexander, your recent white paper, Preparing for the Next 
Pandemic, takes a thoughtful approach to public health policy, and we 
specifically appreciate your recommendation to ``ensure that the United 
States does not lose the gains made in telehealth.'' \6\ To accomplish 
this, Congress must move quickly to enact targeted telehealth reform 
legislation before the national emergency, and public health emergency 
declarations are rescinded. The ATA and I welcome the opportunity to 
work with lawmakers to inform these policies.
---------------------------------------------------------------------------
    \6\ https://www.alexander.senate.gov/public/cache/files/0b0ca611-
05c0-4555-97a1-5dfd3fa2efa4/preparing-for-the-next-pandemic.pdf.

    Moving forward, Congress should first address the current statutory 
restrictions on patient geography and originating site limitations. 
These restrictions are out-of-date and must be modernized to enable 
Medicare beneficiaries to continue to benefit from telehealth no matter 
where they are, including in their homes. We have seen the value of 
waiving these specific limitations during the current crisis and 
learned that they serve no other purpose than to restrict access to 
---------------------------------------------------------------------------
care.

    Congress should also ensure the Secretary of the Department of 
Health and Human Services (HHS) has the flexibility to expand the list 
of eligible practitioners and therapy services and, similarly, maintain 
the authority to add or remove specific telehealth services, as 
supported by data, to make certain all eligible services are safe, 
effective, and clinically appropriate. Allowing the Centers for 
Medicare and Medicaid (CMS) to determine and manage the range and scope 
of telehealth services through a predictable and transparent regulatory 
process will ensure patients and providers have certainty and clarity 
on the future of telehealth.

    Congress showed great leadership in strengthening the capacity of 
providers treating our Nation's most vulnerable populations by allowing 
FQHCs and RHCs to be distant sites under the CARES Act. As our Nation 
grapples with how to address disparities in health care access and 
health outcomes, Congress should work with stakeholders so that our 
Nation's FQHCs and RHCs are empowered to deliver virtual care to 
underserved communities with fair and appropriate reimbursement.

    These reimbursement challenges represent the most critical barrier 
at the Federal level to the provision of telehealth in a post-pandemic 
world. Understanding how these specific waivers have improved access to 
quality care during the pandemic, and how keeping these changes once 
the public health emergency declaration is rescinded, should be at the 
forefront of all our minds.

    These are not the only policy changes that will be required to 
ensure telehealth can continue post-pandemic, but they are the most 
immediate Federal policies that must be addressed. Additionally, 
technology and telehealth infrastructure remain a critical need. 
Congress can support recent COVID-19 investments by continuing to fund 
targeted grant, and technical assistance programs at the Federal 
Communications Commission and Health Services and Resources 
Administration or consider launching new infrastructure initiatives 
under HHS.

    Federal agencies must also seriously consider other policies that 
have been loosened during the pandemic to determine if they are 
appropriate to continue. Such policies include flexibilities to use 
telehealth for remote prescribing of controlled substances and 
flexibilities around HIPAA requirements. In addition, states will need 
to continue to work together to offer more streamlined licensing across 
state lines. Congress should pay attention to all of these policies, 
but first and foremost, Congress should ensure Federal law does not 
unnecessarily impede access to telehealth.

    Ultimately, we need your support in ensuring patients and providers 
do not go over the telehealth ``cliff'' as our Nation emerges from the 
pandemic. Essential telehealth services will abruptly end with the 
national emergency, and beneficiaries who have come to rely on critical 
virtual services will be forced back into a world with restricted 
access to convenient, digitally enabled care. Ensuring HHS and CMS have 
the needed flexibility to support high quality, safe, and effective 
virtual care is more important than ever as we look to enhance 
preparedness for future public health crises and reorient our 
healthcare system to deliver 21st century care.

    Thank you again for inviting me to be here with you today, and I 
welcome your questions on how we have seen telehealth reach and serve 
patients during the pandemic and how we should work together to ensure 
all individuals receive the care they need--where and when they need 
it--in the future.
           About the American Telemedicine Association (ATA)
    The mission of the ATA is to support the ability of telehealth to 
transform healthcare and the patient and provider experience through 
enhanced, efficient and more convenient delivery of healthcare 
services. The ATA is dedicated to promoting a health care system where 
more people have access to safe, effective, and appropriate care when 
and where they need it.

    The ATA also plays a central role in introducing and supporting 
reforms in public health policy that can expand access to virtual care. 
In just one example, in response to the COVID-19 pandemic, the ATA 
joined with members to partner with Congress and rapidly identify and 
address a range of regulatory barriers that could prevent our Nation's 
ability to expand the use of telehealth services in a period of 
unprecedented demand for remote patient care.

    The ATA continues to work to make sure that regulations and 
guidelines related to the use of telehealth reflect the needs of 
patients and providers as well as advances in technology. Some issues 
where the ATA and its members are working to introduce changes that 
will benefit patients and providers include limiting restrictions on 
access to telehealth services for Medicare beneficiaries, expanding the 
use of advanced technologies that can improve patient care, and 
supporting appropriate licensing requirements for providers.

    The ATA believes policies that allow providers and patients to 
access care when and where they need it--using safe and effective 
technologies--can help improve patient outcomes at reduced costs. As 
such, we believe Congress must enact policies that will empower 
patients and allow for provider discretion when choosing how to best 
treat patients.

    We believe Federal telehealth legislation should reflect the 
following principles:

        1. Ensure patient choice, access, and satisfaction

        2. Enhance provider autonomy

        3. Incentivize 21st century care

        4. Enable healthcare delivery across state lines

        5. Empower advanced practice providers

        6. Expand access for underserved and at-risk populations

        7. Support seniors and expand ``aging in place.''

        8. Protect patient privacy and ensure cybersecurity
                                 ______
                                 
                [summary statement of joseph c. kvedar]
    In response to the COVID-19 pandemic, federal and state governments 
finally removed many of the antiquated barriers to telehealth that were 
keeping providers from reaching their patients remotely. The ATA 
wholeheartedly supports these policy changes.

    At the Federal level, temporary changes to the unnecessarily 
restrictive requirements in section 1834(m) of the Social Security Act 
now allow all Medicare beneficiaries--including those living in both 
rural and urban areas--to benefit from telehealth. `Originating site' 
restrictions were also waived, enabling providers to interact with new 
and existing Medicare patients over a range of telehealth modalities--
including the telephone--no matter where the patient is. For 
underserved and rural communities, federally Qualified Health Centers 
(FQHCs) and Rural Health Clinics (RHCs) can finally serve as distant 
sites, enabling these essential safety net providers to reach patients 
they serve in ways they have never been able to before. These examples 
of proactive, common-sense policies paired with significant new funding 
opportunities and loosened restrictions on licensure, cost-sharing, and 
the use of certain technologies, have changed the way our Nation 
delivers and receives health care.

    Now that Medicare beneficiaries have improved access to telehealth, 
Federal policymakers need to take specific actions to make these 
services permanent. Failure to do so will result in unnecessarily 
restricting access to high-quality care. Moving forward, Congress 
should first address the current statutory restrictions on patient 
geography and originating site limitations. These restrictions are out-
of-date and must be modernized to enable Medicare beneficiaries to 
continue to benefit from telehealth no matter where they are, including 
in their homes. We have seen the value of waiving these specific 
limitations during the current crisis and learned that they serve no 
other purpose than to restrict access to care.

    Reimbursement challenges represent the most critical barrier at the 
Federal level to the provision of telehealth in a post-pandemic world. 
Understanding how these specific waivers have improved access to 
quality care during the pandemic, and how keeping these changes once 
the public health emergency declaration is rescinded, should be at the 
forefront of all our minds.

    These are not the only policy changes that will be required to 
ensure telehealth can continue post-pandemic, but they are the most 
immediate Federal policies that must be addressed. Additionally, 
technology and telehealth infrastructure remain a critical need. 
Congress can support recent COVID-19 investments by continuing to fund 
targeted grant and technical assistance programs at the Federal 
Communications Commission and Health Services and Resources 
Administration or consider launching new infrastructure initiatives 
under HHS.

    Federal agencies must also seriously consider other policies that 
have been loosened during the pandemic to determine if they are 
appropriate to continue. Such policies include flexibilities to use 
telehealth for remote prescribing of controlled substances and 
flexibilities around HIPAA requirements. In addition, states will need 
to continue to work together to offer more streamlined licensing across 
state lines. Congress should pay attention to all of these policies, 
but first and foremost, Congress should ensure Federal law does not 
unnecessarily impede access to telehealth.

    Ultimately, we need your support in ensuring patients and providers 
do not go over the telehealth ``cliff'' as our Nation emerges from the 
pandemic. Essential telehealth services will abruptly end with the 
national emergency, and beneficiaries who have come to rely on critical 
virtual services will be forced back into a world with restricted 
access to convenient, digitally enabled care. Ensuring HHS and CMS have 
the needed flexibility to support high quality, safe, and effective 
virtual care is more important than ever as we look to enhance 
preparedness for future public health crises and reorient our 
healthcare system to deliver 21st century care.
                                 ______
                                 
    The Chairman. Thank you, Dr. Kvedar. And welcome, Dr. 
Arora.

     STATEMENT OF SANJEEV ARORA, M.D., M.A.C.P., F.A.C.G., 
DISTINGUISHED AND REGENTS' PROFESSOR, UNIVERSITY OF NEW MEXICO 
HEALTH SCIENCES CENTER, FOUNDER AND DIRECTOR, PROJECT ECHO/ECHO 
                   INSTITUTE, ALBUQUERQUE, NM

    Dr. Arora. Chairman Alexander, Senator Smith, and Members 
of the Committee, thank you for inviting me to testify at 
today's hearing.
    I want to start by sharing a quick story about a different 
use of telehealth than we have heard so far. One Friday 
afternoon 18 years ago, I walked into my clinic in Albuquerque 
to see a 42-year old woman, who had driven 5 hours with her two 
children. She had been diagnosed with Hepatitis C 8 years 
earlier. She was just now seeking treatment for the first time.
    I asked her why, why now? She said that her doctor told her 
the treatment would require at least a dozen trips to 
Albuquerque over the course of a year, and she could not afford 
to take the time off work, so she did not seek treatment. But, 
now she was experiencing abdominal pain that interfered with 
her ability to work, and that is why she finally came to see 
me. But, it was too late. She now had advanced liver cancer and 
she died 5 months later.
    I asked myself, why did this mother of two children have to 
die from a treatable disease? She died because the right 
knowledge did not exist at the right place at the right time. 
New Mexico had 28,000 patients with Hepatitis C, and hundreds 
of patients were dying every year for lack of access to 
treatment.
    That is why I started Project ECHO. Millions of patients in 
the Country are unable to access specialty care on a timely 
basis. We need to fundamentally reorient our healthcare system 
to enable us to quickly move new information and best practices 
from experts to providers on the front lines caring for 
patients in communities, and telehealth can play a major role 
in making that happen. The COVID-19 pandemic has only 
underscored this urgency.
    That is where ECHO comes in. ECHO, also called Technology-
Enabled Collaborative Learning and Capacity Building, is a 
highly scalable platform to exponentially amplify the 
implementation of best practices in our Nation.
    But, let us look at ECHO to treat Hepatitis C in New 
Mexico. We launched 21 new centers to treat Hepatitis C in 
rural communities. Each center was run by a primary care 
clinician. We shared our protocols with them, and they 
connected with us all together once a week on video to discuss 
cases with us at the University and with each other. Soon, they 
had become experts, and the wait in my clinic fell from 8 
months to 2 weeks. Many thousands of patients got treatment.
    We knew we had an effective model, so we expanded it by 
training academic medical centers around the United States to 
use it. Today, we have 250 hubs in the United States, in 48 
states, training professionals in 20,000 organizations for 70 
different disease areas, and there is strong demand for setting 
up new hubs in the U.S.
    The ECHO model works like this: Teams of experts at 
regional medical centers called hubs use one to many 
videoconferences to engage with local healthcare providers, the 
spokes, in weekly, ongoing knowledge sharing, case-based 
learning and telementoring. Other spokes learn from each other. 
Everyone's knowledge is constantly improving. We call it ``all 
teach and all learn.''
    We know the model works. In a study published in the New 
England Journal of Medicine, funded by the Agency for 
Healthcare Research and Quality, they showed that the primary 
care clinicians supported by ECHO can provide care as safely 
and effectively as specialists. Since then, more than 200 peer-
reviewed publications have demonstrated the effectiveness of 
ECHO.
    All along, we believed that ECHO could be put to work in a 
meaningful way in a pandemic, and 12 weeks ago, the world 
changed. Now we are deploying our entire network to ensure 
healthcare professionals know what to do with COVID-19. We are 
now--hundreds of partners are running 30 training sessions a 
day and answering hundreds of questions, from how to use 
personal protective equipment in the midst of a shortage, how 
much oxygen to deliver, and what ventilator settings to use. We 
are training more than 200,000 public health professionals, 
doctors, and nurses in the U.S. on COVID-19.
    What does this all mean for going forward? In 2016, 
Congress, with broad bipartisan support, passed the original 
ECHO Act. It cleared the Senate by 96-0 and was signed into 
law. Last year, the Senate and House introduced a new act to 
take the next step of exploring how to build a sustainable 
funding stream for Technology-Enabled Collaborative Learning 
and Capacity Building models like ECHO for the healthcare 
system, and which include in--the most recent House-passed 
recovery package takes provisions from the ECHO Act to create a 
grant program under HRSA to support organizations that are 
using ECHO-like models.
    I urge you to support inclusion of provisions from the ECHO 
Act as the Senate considers the next recovery and response 
package.
    Discussions have also turned to CMS. More than 20 Senators, 
including multiple Members of this Committee, signed a letter 
to HHS Secretary requesting that CMS issue guidance to stage 
some financing strategies available through Medicaid and 
Medicare. I encourage the Committee to follow-up on that 
letter.
    In closing, I hope this Committee, and the Congress more 
broadly, will commit to exploring longer term challenge--longer 
term changes to healthcare financing that would help realize 
the promise of telehealth, to de-marketize access to 
specialized knowledge, and ultimately seeing the day when no 
mother dies because of her lack of access to a specialist.
    Thank you for this opportunity to present.
    [The prepared statement of Dr. Arora follows:]
                  prepared statement of sanjeev arora
    Chairman Alexander, Ranking Member Murray and Members of the 
Committee. My name is Sanjeev Arora. I serve as Director and Founder of 
Project ECHO at the University of New Mexico, Health Science Center.

    Thank you for inviting me to testify at today's hearing exploring 
telehealth and lessons from the COVID-19 pandemic.

    I want to start by sharing a quick story that explains why I am 
here with you today.

    One Friday afternoon 18 years ago, I walked into my hepatitis C 
clinic in Albuquerque, New Mexico, to see a 43-year-old woman who had 
driven 5 hours with her two children.

    She had been diagnosed with hepatitis C 8 years earlier. Yet she 
was just now seeking treatment for the first time.

    I asked her why--why now?

    She said that her doctor told her that treatment would require her 
to make at least a dozen trips to Albuquerque over the course of a 
year--and she couldn't afford to take the time off work. She needed 
that money to feed her family.

    She didn't seek treatment.

    But now she was experiencing abdominal pain that interfered with 
her ability to work. And that's why she finally came to see me.

    But it was too late. She now had advanced liver cancer. She was not 
a candidate for a liver transplant and the cancer was too large to be 
removed surgically. There was nothing we could do to prolong her life.

    She died 5 months later.

    I asked myself: Why did this mother of two children have to die?

    We had the medicines and the expertise to treat her. But she didn't 
have the resources to get to us. And no doctor in her community had the 
knowledge to treat her disease.

    A five-hour car drive was too great a barrier for her to overcome.

    That's why I started Project ECHO over a decade ago. And that's why 
I'm here testifying to you today.

    We need to fundamentally reorient our healthcare system to enable 
us to quickly move new information and best practices from top experts 
at academic medical centers to providers at the frontlines caring for 
patients in communities. The COVID-19 pandemic has only underscored the 
urgency with which we need to tackle this challenge.

    Instead of placing the burden on patients to find us--the medical 
experts who can treat and cure them--we need to share our expertise 
with the providers in communities where these patients live. We need to 
enable patients to get the care they need, when they need it, in or 
near the places where they live.

    Telehealth can play a major role in making that happen. But it 
starts by understanding that telehealth is more than technology.

    Technology can help us bridge wide geographic divides in ways we 
wouldn't have imagined possible 20 years ago. But technology is simply 
a tool that enables essential human interaction.

    For example, technology allows us to have the virtual hearing we're 
participating in today, but it's not the technology that makes this 
discussion valuable. What matters is what the technology enables--the 
discussion we're having, the expert testimony, the answers we provide 
to your questions, and, most importantly, how it all informs the 
decisions you make going forward.

    Likewise with telehealth, the technology enables us to interact in 
ways that ultimately improve health and save lives.

    That's where Project ECHO comes in.

    Project ECHO is a model for telementoring or what's now called a 
technology-enabled collaborative learning and capacity-building model. 
Essentially, models like ECHO leverage technology, including 
videoconferencing platforms such as Zoom, to ensure that clinicians on 
the ground have the latest best practices, mentoring and support they 
need to treat patients in their communities.

    On the spectrum of telehealth, it differs from telemedicine, which 
is typically a one-to-one provider and patient virtual visit. It's also 
different from an eConsult, which is usually one specialist consulting 
with one provider about the care of one patient. Technology-enabled 
collaborative learning models like ECHO involve a team of specialists 
in a specific disease area connecting to multiple teams of community 
providers in an ongoing learning community.

    Each of these telehealth approaches is needed and valuable. But for 
the purpose of my testimony, I will be primarily focused on technology-
enabled collaborative learning and capacity building, which is the area 
I know best.

    To explain this difference, I often use the example of teaching 
your daughter to drive a car. I ask how many people would be willing to 
give their daughter a text book, and then give her the keys to the car. 
This example points out that for very complex tasks, we need more than 
a protocol, we need guided practice to help master complexity over 
time. This guided practice is what the ECHO model provides--and is what 
makes it different from traditional telemedicine. The ECHO model builds 
system capacity to implement best practices at scale over time.

    When I started ECHO to treat hepatitis C in my home state, I 
realized that in order to convince clinicians in rural clinics to treat 
this complicated disease, I needed to create something that mimicked 
the grand rounds experience of their residencies. We needed to bring 
the experts to these rural clinicians over video to share up-to-date 
best practices--and the clinicians needed to present their own cases 
and get ongoing guidance and mentorship from experts.

    We launched 21 new centers of excellence to treat hepatitis C in 
rural communities. Each center was run by a primary care clinician. We 
shared our treatment protocols with them, and they connected with us 
all together once a week on video to discuss cases with us, at the 
university and with each other. Soon they had become experts and the 
wait in my clinic fell from 8 months to 2 weeks. Tens of thousands of 
patients got treatment. We knew we had an effective model . . . so we 
expanded it by training academic medical centers around the United 
States to deploy for more than 70 healthcare conditions.

    The all teach and all learn ECHO model works like this:

    Teams of experts at regional medical centers (called ``hubs'') use 
one to many videoconferences to engage with local healthcare providers 
(the ``spokes'') in weekly ongoing knowledge-sharing, case-based 
learning, and tele-mentoring.

    Hub and spokes learn from each another. Everyone's knowledge is 
constantly improving.

    Based on the tremendous need, ECHO has grown from addressing a 
single disease in one state to addressing 75 different health 
conditions across 48 states and reaching learners in 154 countries. 
There are now ECHO projects at more than 250 organizations across the 
U.S. alone, many of these at major academic medical centers.

    We know the model works. A study published in the New England 
Journal of Medicine \1\ and funded by the Agency for Healthcare Quality 
and Research focusing on our hepatitis C work in New Mexico showed that 
patients treated by an ECHO-trained community provider got the same 
quality care they would get if they went to a specialist. There are now 
more than 235 published papers published on different aspects of the 
model. \2\
---------------------------------------------------------------------------
    \1\ S Arora, K Thornton, G Murata et al. Outcomes of Treatment for 
Hepatitis C Infection by Primary Care Providers. N Engl J Med 2011 Jun 
9;364(23):2199-207. doi: 10.1056/NEJMoa1009370. Epub 2011 Jun 1.
    \2\ https://echo.unm.edu/about-echo/research.

    Prior to COVID-19, we had trained more than 100,000 healthcare 
professions in 20,000 organizations in all corners of the Nation. And 
---------------------------------------------------------------------------
there was strong demand for setting up new hubs in the United States.

    We had long believed that ECHO could be put to work in a meaningful 
way in a pandemic. And 12 weeks ago--the world changed.

    Now we are deploying our entire network to ensure healthcare 
professionals know what to do with COVID-19. We mobilized our ECHO 
community to respond to the pandemic on two levels:

          To amplify the public health response to COVID-19 in 
        areas like rapid testing, isolation of patients who test 
        positive, contact tracing and follow-up to contain the spread 
        of the virus.

          And, to scale the clinical delivery response. What do 
        doctors, nurses, EMTs and other clinicians in the field need to 
        know to treat patients with COVID-19? Remember, this is a 
        completely new disease. There is so much we still don't know 
        about COVID-19, yet we need to provide guidance on best-
        practice care even in the absence of firmly established 
        science.

    ECHO projects in at least 33 states have pivoted their efforts to 
COVID-19, including states represented on this Committee like Kentucky, 
Kansas, Maine, Pennsylvania, Minnesota, Nevada, New Hampshire, and 
Massachusetts.

    In addition, the ECHO Institute has partnered with the Office of 
the Assistant Secretary for Preparedness and Response (ASPR) at HHS to 
launch a COVID-19 Clinical Rounds that serves as a peer-to-peer 
learning platform for frontline clinicians across the country and 
around the world. It's supported by more than 15 major medical 
societies and includes expertise from the National Emerging Special 
Pathogen Treatment and Education Center established by Congress after 
the Ebola outbreak. Every week, some 400 to 1,700 clinicians log on to 
navigate the unknowns of COVID-19 together.

    We and our partners are running an estimated 30 training sessions a 
day, answering questions from how to address personal protective 
equipment in the midst of a shortage and how much oxygen to deliver and 
what ventilator settings to use. We have trained more than 200,000 
additional healthcare professionals (nurses, doctors, community health 
workers, pharmacists, emergency response personnel etc . . . ) on 
COVID-19.

    In addition, to underscore the interconnection of different 
telehealth approaches, multiple ECHO projects are now equipping 
providers to do telemedicine effectively. We need ongoing learning 
communities to ensure that the doctors, nurses and other health 
professionals who almost overnight were thrown into a world of virtual 
medicine get access to best practices and the guidance to implement 
them.

    What does this all mean for going forward? How can lessons from 
COVID-19 and the experience of telehealth during this pandemic help us 
to reshape our healthcare system to move life-saving information more 
quickly and efficiently?

    Going forward, we must understand that with healthcare, as with so 
many other areas, you get what you pay for. Steps that Congress and CMS 
have taken in areas like increasing broadband access in rural 
communities and expanding coverage for the virtual services clinicians 
can provide are really important ones.

    But we also need to continue to move beyond the emphasis on the 
technology part of telehealth to the health part. Again, like the 
hearing today, it's what's being virtually delivered across the medium 
and how that allows us to take action that matter most.

    In 2016, Congress--with broad bipartisan support--passed the 
original ECHO Act. It cleared the Senate by a 96-0 vote and was signed 
into law. We're grateful for the support of that measure by so many of 
the Committee members here today. That legislation formally recognized 
technology-enabled collaborative learning and capacity-building and 
directed HHS to produce a report (released in March of last year) to 
explore barriers and opportunities to its use and better understand the 
evidence base supporting it. It was a significant building block in our 
ongoing efforts to scale up the ECHO model across the country and 
globe.

    Last year, efforts emerged in the Senate and House to take the next 
step of exploring how to build a sustainable funding stream for 
technology-enabled collaborative learning and capacity-building in the 
healthcare system. There are now House and Senate ECHO authorization 
bills that establish a grant program through HRSA. The House included 
language in the most recent House-passed recovery package draws on the 
ECHO authorization bill in the House to create a grant program under 
HRSA to support organizations that are using technology-enabled 
collaborative learning and capacity-building for COVID-19 response. If 
enacted, that program will be a critical support to many efforts 
connecting providers on the frontlines of the pandemic with the 
emerging best practices and expert guidance they need to treat their 
patients.

    I urge you to support the House-passed provision of the most recent 
stimulus bill (HEROES Act, H.R. 6800) as the Senate considers the next 
recovery and response package. It would be a major next step in terms 
of both supporting current COVID-19 response efforts and helping to set 
the groundwork for a more responsive health care system in times of 
public health emergencies.

    While efforts to establish a grant program have proceeded, 
discussions have also turned to CMS. More than 20 Senators--including 
multiple members of this Committee--signed a letter to the HHS 
Secretary requesting that CMS issue guidance to states on financing 
strategies available through Medicaid and explore existing authorities 
through Medicare as well. I encourage the Committee to consider 
directing CMS to move quickly on that guidance.

    I hope this Committee--and the Congress more broadly--will commit 
to exploring longer-term changes to healthcare financing that would 
create sustainable and ongoing funding for effective telehealth 
approaches, and specifically for embedding technology-enabled 
collaborative learning and capacity-building into the system.

    If not COVID-19, their lives will be affected by the opioid 
epidemic, cancer, HIV, diabetes, autism or many other diseases or 
conditions.

    I am committed to working with you to help realize the promise of 
telehealth, and ultimately seeing the day when a mother's survival 
doesn't rest on her ability to take a five-hour car ride twelve times a 
year.

    If we together can make that happen, this will have been the most 
powerful telehealth session I've ever been part of.

    Thank you for providing me with the opportunity to testify before 
you today. I look forward to answering your questions.
                                 ______
                                 
                  [summary statement of sanjeev arora]
    Responding to the Committee's request for greater understanding of 
how the COVID-19 pandemic has changed telehealth, Dr. Arora's testimony 
will focus on the role that the ECHO model, as a technology-enabled 
collaborative learning and capacity building model, has played in 
supporting the response to COVID-19.

    A specialist at the University of New Mexico Health Science Center, 
Dr. Arora's testimony will provide a brief overview of the rationale 
for why he developed the ECHO model. Seeing a severe lack of access to 
specialty care, Dr. Arora developed the ECHO model as a way to 
democratize expert knowledge widely and create mini-experts among 
primary care providers around the state of New Mexico.

    What began as a means to support treatment for a single disease, 
hepatitis C, over time the ECHO model has come to be used by academic 
medical centers throughout the United States as a powerful 
telementoring modality to help providers, especially in rural and 
underserved areas, to receive access to ongoing mentorship and 
professional development.

    At the start of the pandemic, there were more than 250 academic 
medical centers, managed care organizations, Departments of Health, and 
nonprofits operating ECHO programs in 48 states. In cities and states 
around the Nation, many ECHO programs shifted these networks of experts 
and providers to support the rapid dissemination of information about 
evolving COVID-19 best practices.

    Today, this network is running at least 30 training sessions a day 
and answering hundreds of questions, from how to reuse personal 
protective equipment in the midst of a shortage, to how much oxygen to 
deliver and what ventilator settings to use. As best practices continue 
to evolve and the `new normal' is defined, technology enabled capacity 
building networks such as Project ECHO are vital to supporting the 
healthcare community in this country and preparing for future 
unforeseen public health emergencies in the future. Dr. Arora will ask 
for the HELP Committee Members to support the provision of the HEROES 
Act, (H.R. 6800, Section 30613) that calls for the creation of a grant 
mechanism within HRSA to provide support for COVID-19 related 
technology-enabled learning and capacity building models. The bill 
provides for an authorization of $20 million to support this work. The 
Committee's support of this section of the bill in the Senate would be 
very much appreciated and would go a long way toward enabling 
University hubs around the country to expand their response to COVID-
19.
                                 ______
                                 
    The Chairman. Thank you, Dr. Arora.
    Now, Dr. Willis, welcome.

 STATEMENT OF ANDREA D. WILLIS, M.D., M.P.H., F.A.A.P., SENIOR 
VICE PRESIDENT, CHIEF MEDICAL OFFICER, BLUECROSS BLUESHIELD OF 
                   TENNESSEE, CHATTANOOGA, TN

    Dr. Willis. Good morning, Chairman Alexander, Ranking 
Member Smith, and Members of the HELP Committee.
    I am Dr. Andrea Willis, and I have the privilege of serving 
as the Chief Medical Officer at BlueCross BlueShield of 
Tennessee. Our mission is peace of mind through better health. 
And, as a tax-paying, not-for-profit health insurer, we serve 
3.5 million members, who are enrolled in a variety of coverage 
options, and we participate with other Blues plans across the 
Nation as part of the BlueCross BlueShield Association. It is 
my honor to join you today to discuss telemedicine and lessons 
we are learning from the COVID-19 pandemic. We have experienced 
and seen the effects of this pandemic on our members, and even 
within our own families.
    As we all know, the healthcare system is ever-changing, and 
BlueCross responded rapidly to meet the needs of individuals 
and families during this unprecedented time. Our foundation 
provided $3.25 million to Tennessee food banks, as well as 
funds to municipal governments to support free COVID-19 
testing.
    Telemedicine is a good example of our member-focused 
response. As the pandemic spread, we joined with other payers 
in relaxing requirements and began covering telemedicine visits 
to retain our members' access to care, and we were the first 
major insurer to commit to making in-network telehealth 
services available for good, even after this crisis ends. 
BlueCross Tennessee made this decision because it was clear our 
members and providers wanted the choice to use virtual care. It 
was another way to collaborate with in-network providers to 
make quality care more convenient, and it was the right thing 
to do for our members and the providers who care for them.
    Prior to COVID-19, utilization rates for telemedicine was 
consistently below 30 percent for members with that benefit. 
Adoption has since risen exponentially, and the key was 
partnering with our in-network providers. In general, those 
doctor-patient relationships transformed and thrived in this 
newly embraced method of interaction.
    Because the data is still accumulating, it is too early to 
definitively say that the expansion of telehealth has improved 
health outcomes, but it has undoubtedly improved access to 
care. It has highlighted the keen abilities for providers to 
hone in on the chief complaint and pertinent history of the 
patients to make an informed diagnosis and plan of care.
    We wanted to ensure adequate reimbursement for medical 
providers treating our members so that there would be no 
barrier to doing so, especially now considering the financial 
impacts this pandemic has had on physician practices and 
hospitals. Expanded telemedicine allows for continued visits 
with primary care providers and specialists, behavioral health 
providers, and other therapists.
    We also believe the availability of telemedicine is 
reducing some inappropriate emergency room and urgent care use. 
From mid-March through mid-May, we saw 50 times more 
telemedicine claims than the same time period last year.
    With the rapid and widespread adoption of telemedicine, we 
recognize there will be some needed changes that could not be 
addressed initially. Existing processes related to 
credentialing, contracting, reimbursement, and audit policies 
will be useful tools to guard against fraud, waste, and abuse.
    While we have privacy and security measures in our current 
physician agreements, we believe there needs to be further 
discussions to continue protecting those served by 
telemedicine.
    As the saying goes, we don't believe we should let perfect 
be the enemy of good. We can address these challenges while 
continuing to support telemedicine. We don't have all the 
answers today, but we are committed to collaborating to build a 
sustainable path forward.
    I am honored by this opportunity to share BlueCross 
BlueShield's of Tennessee approach to telemedicine as we 
continue promoting affordable access to quality, evidence-based 
care for the people we serve.
    Thank you.
    [The prepared statement of Dr. Willis follows:]
                  prepared statement of andrea willis
    Good morning, Chairman Alexander, Ranking Member Murray, and 
Members of the HELP Committee. I am Dr. Andrea Willis, and I have the 
privilege of serving as the Chief Medical Officer at BlueCross 
BlueShield of Tennessee. As a board-certified pediatrician who has had 
the honor of serving as Deputy Commissioner for the Tennessee 
Department of Health and the first director of CoverKids, Tennessee's 
State Children's Health Insurance program, I am also a proud public 
health advocate and champion for the health and wellness of 
Tennesseans.

    At BlueCross Tennessee, a taxpaying, not-for-profit health insurer 
celebrating its 75th year, our priority is the health of our 3.5 
million members and the communities we serve. Our workforce is 
comprised of 6,800 colleagues, including 900 nurses, and as the state's 
largest health plan, we provide benefits to more than 11,000 Tennessee 
companies and partner with over 29,000 providers across the state to 
help carry out our mission: peace of mind through better health.

    Our members are enrolled in a variety of coverage options, 
including Medicaid, Medicare Advantage and commercial plans. We also 
administer coverage for large, self-insured groups and participate with 
other Blues plans across the Nation as part of our affiliation with the 
BlueCross BlueShield Association.

    First, we empathize with those across the Nation and in Tennessee 
who have lost loved ones, have been furloughed or laid off, and seen 
their world change in ways none of us could have imagined.

    Like other parts of our health care community, we've experienced 
the effects of COVID-19--and most importantly, we've seen the effects 
of this pandemic on our members. We recognize the health disparities 
that have been exacerbated by this disease outbreak and are committed 
to doing our part to address those. We've also been fortunate to 
witness amazing and encouraging acts of empathy, compassion, dedication 
and innovation during these past few months. I am extremely proud to be 
a part of the community of medical professionals. I stand in complete 
awe, with reverence for the many health care servants who set aside 
their own personal safety to be on the front lines in this fight. And I 
believe we all owe a tremendous debt of gratitude to all of those who 
are putting the needs of others above themselves each day.

    Our health care system is sometimes slow to change, but I've been 
encouraged at how BlueCross Tennessee and our partners in Tennessee 
have responded so quickly to meet the needs of our communities during 
these unprecedented times. Telemedicine is certainly one of the areas 
in which we've seen change happen quickly and for the benefit of our 
members.

    We've worked hard to adapt to meet the evolving needs of our 
members as COVID-19 spread throughout Tennessee. We were among the 
first plans to commit to waive testing costs and expand access to 
telehealth for our members--and we were the first major insurer to 
commit to making in-network telehealth services available on an ongoing 
basis after this crisis ends. We wanted our members to retain virtual 
access to the physicians they knew and trusted.

    We have long supported telehealth interactions between specialists 
at one location interacting with other health care providers alongside 
their patients at another location. In fact, one of our earliest 
partnerships started back in 2012 to support high-risk maternity care.

    COVID-19 vastly opened up direct telemedicine interactions between 
health care providers and their patients. This included physical and 
behavioral health services, and we reimbursed providers for these 
services at their currently contracted rate, or parity.

    Prior to COVID-19, BlueCross Tennessee, we had seen utilization 
rates for telemedicine consistently below 30 percent for members with 
that benefit. As we expanded and encouraged telemedicine throughout the 
crisis, we saw utilization rates rise. And from mid-March to mid-May, 
we saw 50 times more telemedicine claims than during the same time 
period last year. The key was partnering with in-network providers. In 
general, those doctor-patient relationships transformed and thrived as 
they both turned to this method of interaction.

    As a result of this growth in member interest and provider 
adoption, BlueCross Tennessee announced last month that we will extend 
our coverage of telemedicine services going forward. It was clear our 
members and providers wanted the choice to use virtual care and 
telehealth services was another way to collaborate with in-network 
providers to make quality care more convenient. We believe this was the 
right thing to do for our members and for the providers in Tennessee we 
rely on to care for those members.

    Because the data is still accumulating, it's too early to 
definitively say that the expansion of telehealth has improved health 
outcomes, but it has undoubtedly improved access to care. As a result 
of this expansion, providers are able to continue delivering necessary 
care while maintaining social distancing. Telemedicine has highlighted 
the keen abilities that providers have to truly listen to their 
patients and to hone in on the chief complaint and pertinent history of 
the patients to make an informed diagnosis and plan of care. We wanted 
to ensure adequate reimbursement for medical providers treating our 
members so that there would be no barrier to doing so especially right 
now, considering the financial impact this pandemic has had on 
physician practices and hospitals.

    The increased use of telemedicine we've seen in Tennessee include 
visits with primary care providers and specialists, behavioral health 
providers, and other therapists. While we don't yet have quantifiable 
data to verify it, we also believe the availability of telemedicine is 
reducing some inappropriate emergency room and urgent care use by 
allowing patients to get in touch quickly with their primary care 
physician. That was certainly important as we were collectively 
prioritizing facility services for those with the most severe symptoms 
and needs. Access to physician services via telemedicine also helps our 
members access care they may have foregone otherwise, and without the 
increased risk of infection.

    It is easy to see how this mode of interaction can effectively 
break down a barrier to access to care. Improving access to care in 
rural areas has been a priority in my state of Tennessee and this 
expansion plays an important role toward doing just that. Telemedicine 
allows access to care during work hours in lieu of taking an entire day 
off. It can allow for follow-up interactions with high-risk patients 
that may be negatively impacted by sitting in a waiting room. The use 
cases are many.

    With the rapid and widespread adoption of this new method of care 
delivery, we recognize we may identify and make changes to address 
issues we couldn't address during the crisis that began in March. 
Existing processes related to credentialing, contracting, reimbursement 
and audit policies will be useful tools to guard against fraud, waste 
and abuse--and they need to be a part of telemedicine practice. In 
addition, we carefully monitor data to ensure that our network 
providers are rendering the services and that the level of care is 
appropriate to the practitioner delivering the services. We are closely 
monitoring prescriptions that are generated from telemedicine. And most 
importantly, we listen to both the compliments and complaints coming 
from the consumers. These actions are aligned with our role as a member 
advocate committed to providing access to affordable, evidence-based 
care.

    In addition, we believe there needs to be a discussion around what 
measures need to be in place to protect the privacy and security of our 
members as they interact with their physicians. We have those 
protections and requirements in place with our existing physician 
agreements so we have a basis from which to start. But given the speed 
at which we enabled telemedicine services in March, that's an area we 
believe warrants some additional conversation.

    I do believe we can address these issues while continuing to 
support telemedicine. As the saying goes, we don't believe we should 
let perfect be the enemy of good. We do not need to pull back from 
where we are today to address these challenges. We don't have all the 
answers today, but we are committed to collaborating and building a 
sustainable path forward that serves the interests of our members and 
the providers who care for them.

    I'll conclude by sharing a final thought about telemedicine and its 
ability to improve our health care system:

    We all recognize the need to reduce the cost of care in our 
Nation's health care system. And we likely agree that a payment model 
which places a priority on quality and improved health outcomes is a 
better approach than continuing to pay for services on an at unit-cost 
basis, also known as ``fee for service.''

    Creating a regulatory environment which expands the tools health 
care professionals have available to engage with their patients and 
offer services should be our shared goal. Likewise, the ability to 
apply penalties for abuses of telemedicine should be a necessary 
component to protect those that this is meant to serve.

    As I mentioned earlier, access to care is a key component of 
improving quality and outcomes. Telemedicine provides that opportunity 
and is one of those tools. The increase in utilization demonstrates 
that our members and providers--your constituents--have come to 
appreciate this capability.

    More than 85 percent of primary care physicians in our provider 
network in Tennessee participate in at least one value-based program 
with BlueCross BlueShield of Tennessee. These are programs which reward 
physicians who can successfully engage members, help them manage their 
care and improve overall health.

    Telemedicine can help them achieve that goal. And when that 
happens, our members benefit and we get one step closer to achieving 
our mission of peace of mind through better health.

    I am honored and have appreciated the opportunity to share 
BlueCross of Tennessee's approach to telemedicine as we continue to 
support affordable access to services and high-quality care in line 
with our mission.
                                 ______
                                 
                  [summary statement of andrea willis]
                      Overview and Recommendations
    BlueCross BlueShield of Tennessee (BlueCross Tennessee) has long 
supported the utilization of virtual care as a part of our long-term 
strategy to improve access to care and patient experience. Prior to 
COVID-19, telehealth offerings in Tennessee were either purchased as an 
additional service or delivered when a member and provider consulted 
with a different provider in a separate location. During the COVID-19 
pandemic, BlueCross moved quickly to work with our over 29,000 in 
network provider partners to expand access to telehealth for our 
members as we saw the need to balance access to care with the need to 
practice social distancing. BlueCross Tennessee immediately witnessed a 
significant increase in utilization of telehealth services and 
increased member satisfaction. Subsequently, BlueCross Tennessee 
announced the expansion of telehealth offerings provided by our in-
network providers beyond the pandemic. We believe these actions further 
demonstrate our commitment to affordable, accessible and quality health 
care. At this point, it is too early to share quantifiable data that 
demonstrate the impacts on healthcare outcomes, however, we are closely 
monitoring a plethora of datasets including, but not limited to, 
utilization, fraud waste and abuse, medical efficacy standards and 
patient safety.

    It is often said that healthcare is ``local''. Congress should 
consider policies that ensure the maximum flexibility that is 
appropriate for the health care consumers, providers and payers in 
those markets. It requires a delicate balancing of technological 
advancements while meeting consumer healthcare and financial needs. 
Further, we recommend policies that increase access while incorporating 
measurable patient outcomes that contribute to the health of 
Tennesseans and all Americans. Finally, we suggest efforts that enhance 
the privacy and security of health information in compliance with the 
HIPAA laws.
                                 ______
                                 
    The Chairman. Thank you, Dr. Willis, and thanks to all of 
our witnesses.
    We will now begin a round of five-minute questions, and I 
would ask the Senators and the witnesses to try to keep within 
the five-minute time so all Senators can participate.
    Sometimes we just rush through things without recognizing 
their significance. I think we ought to stop and think for a 
moment about how significant a change this is and how--and 
whether it would have even possibly happened without this 
crisis.
    As I mentioned earlier, we had 884 million doctor-patient 
visits last year, according to CDC. If 20 percent of those, or 
25 or 30 percent of those, continue to be telehealth visits 
that is hundreds of millions of doctor-patient visits that will 
occur by telemedicine rather than in person. I do not know 
enough to know whether that is the biggest change in healthcare 
delivery services in our history or not, but it would be hard 
to think of one that is more significant. So, we have really 
had 10, 20, 30 years of experience crammed into 3 months in a 
pilot program to determine what the effect of this would be, 
and we want to do that carefully.
    Now, Dr. Willis, let me ask you first, and I only have 5 
minutes. Of the 31 changes that the Federal Government made in 
policy, two seem to me to be the most important--the 
originating site rule and that Medicare and Medicaid begin to 
reimburse providers for nearly twice as many telehealth 
services. Do you agree that those two changes should be made 
permanent?
    Dr. Willis. Sir, we would definitely agree with those 
changes. We definitely think while telemedicine largely focuses 
on the technology in some ways, we definitely recognize that 
the power behind this truly is the provider and the clinical--
--
    The Chairman. Okay. Well, let me keep--we only--I only have 
5 minutes. So the answer is yes, right?
    Dr. Willis. Yes, sir.
    The Chairman. Okay. Now, I am interested in--you are 
stepping out--and that is a pretty big risk for BlueCross 
BlueShield of Tennessee, isn't it? When I first heard that you 
were going to cover all these services, I thought, well, that 
is going to cost a lot of money and raise insurance premiums. 
But, then I thought, well, maybe it will save money.
    As we look at cost, quality, and patient experience, what 
have you found in the short period of time that you have begun 
to cover these services? Does it cost more or does it cost 
less?
    Dr. Willis. We are still accumulating data, so we don't 
really know that yet, but we do think that we are going to gain 
efficiencies. We are going to keep people out of the E.R. that 
do not need to be there, and we think people are going to get 
care that they may have foregone. So, down the line, we do 
think that it will save money.
    The Chairman. Do you have any reports on patient 
satisfaction yet?
    Dr. Willis. We do. Overwhelmingly, the patients are very 
thankful for this, as well as the providers.
    The Chairman. Have you looked at the other Federal policy 
changes other than the two that I mentioned? And do you have an 
opinion about whether they should be made permanent or not?
    Dr. Willis. Things as far as licensure goes, we definitely 
realize through the compact experience that there is some 
positives behind that, so we definitely want to do that, but 
still maintaining a personal relationship with the provider. We 
do not want to create fragmentation of care.
    We definitely realize, that connectivity is an issue, so 
anything that we can do along the lines of broadband, and 
anything we can do to make sure we migrate to secure platforms 
that have HIPAA as a foundation is definitely something we 
would be interested in.
    The Chairman. Have any other insurers around the Country, 
to your knowledge, adopted your policies on covering 
telehealth?
    Dr. Willis. Not that I am aware of at this point. We have 
received a lot of questions from others, and so we know the 
interest is out there.
    The Chairman. Okay. I have a minute left. I want to ask the 
other three witnesses, who have a lot to say and they will get 
a chance to say it with the other Senators, if they agree or 
disagree that the two provisions that I mentioned that have 
been temporarily changed should be made permanent. One, the 
originating site rule; and two is the Medicare and Medicaid 
reimbursement of providers for nearly twice as many types of 
telehealth services.
    Dr. Rheuban.
    Dr. Rheuban. I entirely concur, sir, that those are 
incredibly important for us. We have a critical access hospital 
that is considered an urban area because of the geographic 
restrictions--it is crazy--federally qualified health centers 
that are located in what otherwise seems like a rural area but 
are not qualified to be----
    The Chairman. Okay. I have 17 seconds left. Excuse me. Dr. 
Kvedar and Dr. Arora, do you agree that at least those two 
changes should be made permanent?
    Dr. Kvedar. Yes. The ATA would very much support that.
    Dr. Arora. Senator, I agree.
    The Chairman. Thank you very much. We will now go to 
Senator Smith for questions.
    Senator Smith.
    Senator Smith. Thank you, Chairman Alexander. I would like 
to start by asking unanimous consent to submit into the record 
a letter from the American Connection Project.
    [The following information can be found on page 59 in the 
Additional Material.]
    Senator Smith. This is a letter to our Committee. It is a 
partnership with Land-O-Lakes and the business community and 
many healthcare providers, like Mayo Clinic and others, that--
they have created this project to talk about filling the rural 
broadband gap, and specifically related to telehealth.
    In this letter, they say, as an example, that Mayo Clinic 
has conducted more telehealth visits during the pandemic than 
in all of the visits combined in 2019. And Health Partners in 
Minnesota have seen a 10 percent increase in completed visits 
for mental health over a two-month period. So, I think this 
reinforces what we are all saying about how there has been a 
dramatic expansion of telehealth services and how it has helped 
to expand access.
    In Minnesota, the community mental health centers and 
clinics have been using telehealth to help their patients get 
regular mental healthcare treatment, so I want to focus in on 
that.
    Interesting, no-show rates are down and patients are able 
to get the care that they need from home. And it has been a 
real life changer for folks that are living with homelessness 
and for students who usually get their healthcare services when 
they are in school, and of course they are not in school now.
    Let me ask this question. Maybe I will start with Dr. 
Rheuban. Can you just talk to us a little bit about how access 
to behavioral health and substance abuse disorder services via 
telehealth has changed during the pandemic and what we can 
learn from that?
    Dr. Rheuban. Well, to begin with--that is an excellent 
question. But, to begin with, access to behavioral health 
services was our No. 1 request for services prior to the 
pandemic.
    Senator Smith. Right.
    Dr. Rheuban. Those have endured. What we have seen is those 
have been provided also by telephone because many of the 
patients do not have access to broadband services, and so those 
mental health services had been conducted via multiple 
different formats. So, it is incredibly important, especially 
as we see greater need for mental health access, because this 
pandemic has led to many challenges for our patients.
    There are some changes that have happened in the pandemic, 
which include the waiver of--by the DEA to allow prescribing of 
controlled substances to occur when the patient is seen via the 
home; and also, to allow an initial visit to be conducted via 
audio and visual together, video-based services. So, there have 
been some major changes that have been really positively 
affecting the access to mental healthcare services.
    Senator Smith. Thank you so much. I have heard from some of 
my constituents that some folks are even more likely to access 
the mental healthcare services that they need, behavioral 
healthcare services, if it is via telehealth rather than in 
person. Part of that is it might be just sort of their 
reluctance to be--because of the stigma around mental health. 
Have you seen that? Dr. Kvedar, would you like to comment on 
that?
    I think you are muted. There you go.
    Dr. Kvedar. Oh, great. Thank you very much for asking and 
for bringing up behavioral health. It is such a critical issue 
all the way around, and it is a perfect--I will just underscore 
perfect--use of the tool for telehealth, whether it be phone or 
video, because mental health interactions with patients are all 
about a conversation with the patient, so----
    As has been pointed out, the provider can learn things 
seeing you in the--in your home that she might not learn in the 
office. And the patient, as you say, does not have to endure, 
which is sometimes an arduous task of traveling to, waiting in 
a waiting room, et cetera.
    All around, could be, we think, better than face to face. 
But, most importantly, for access. The access part is critical, 
and it is a real boom for that. So, very much endorse your 
idea.
    Senator Smith. Could you comment on how we can make these 
changes permanent while also protecting patient privacy?
    Dr. Kvedar. I would be happy to. I--privacy is something 
that, as a healthcare provider, is a No. 1 priority. As you 
mentioned, as others mentioned, we have, of course, HIPAA as a 
backbone for that. But, I would say that--it might be 
oversimplifying to say this, but for our suppliers in the 
industry, the vendors that help us with these tools, they 
should be--would be willing to sign business associate 
agreements and be part of HIPAA regulations. That would solve a 
lot, I think, if we were simply able to do that. I do not know 
that it makes sense to say one tool or another cannot be in the 
mix, but they should all be willing to protect patients' 
privacy.
    Senator Smith. Well, and I want to just also note in the 
seconds I have left that we continue to have a need, I think, 
for parity in reimbursement for mental healthcare services, as 
well as, physical health services. And it seems to me that 
there is an opportunity to address that here, as well, as we 
move forward.
    I want to just mention to my colleagues as I wrap up that I 
have bipartisan legislation with Senator Murkowski. It is the 
Telehealth Mental Health Improvement Act that would help to 
expand access to telehealth services reimbursement during the 
pandemic. But, clearly, I think this is an opportunity for us 
to move--think about what systemic change we can make after we 
emerge from this public health crisis.
    Thank you, Chairman Alexander.
    The Chairman. Thank you, Senator Smith.
    Senator Burr.
    Senator Burr. Thank you, Mr. Chairman, and welcome to all 
our witnesses today.
    Dr. Rheuban, I read your testimony and you mentioned that 
20 years ago, you--now 20 years ago, you testified in front of 
the Energy and Commerce Committee. I was on the committee at 
the time. And I am reminded that policy requires a degree of 
vision on the part of policymakers, and I am not sure 20 years 
ago we envisioned technology making the rapid advances that we 
did. But, it has, and we are at a different point at a 
different time, and part of successful policy is being 
visionary as we go forward.
    By the end of this year, Starlink, which is part of SpaceX, 
will have the ability to deliver broadband to every footprint 
in America--urban, rural, does not distinguish. So, the answer 
on the broadband access may be solved by the commercial 
marketplace at high speed, and affordable. And, I say to my 
colleagues, this is important as we put together policy. This 
is not reliant on us putting fiber optics in the ground and 
getting the last mile to a home. We have a commercial option, I 
think, that will leverage even faster than private sector 
marketplace to bring these services to every American.
    Dr. Rheuban, in 20 years, what did we get right and what 
did we get wrong since your testimony in front of the Energy 
and Commerce Committee?
    Dr. Rheuban. Well, we did get right that telehealth was a 
covered service, because prior to that, fewer than $14,000 
worth of telemedicine services were actually reimbursed by 
Medicare. So, we have come a long way, but we have a much 
longer way to go.
    I do believe broadband is an important issue, whether--
however it gets to the home of the patient. And I am pleased 
that the Federal Communications Commission's rural healthcare 
programs have been expanded, and that they also now have 
launched a Connected Care Pilot Program to bring broadband to 
the home of the patient. Because, as Senator Smith indicated, 
it is a health equity issue, and there are many patients who 
otherwise could not afford reliable broadband.
    Our plan is more, better connected, and to encourage 
adoption to incentivize providers to invest in the telemedicine 
technologies. We need to change the Medicare reimbursement 
rules, and Medicaid, as well.
    Senator Burr. Well, to all our witnesses and to all my 
colleagues, we would not be having this hearing if it wasn't 
for our use of the internet. Most agencies update daily on 
COVID based upon their internet connection, not based upon a 
physical presence, and I think it is important for us to 
remember how we are advantaged by these electronic connections.
    Let me move to Dr. Kvedar. Is the growth of telemedicine a 
bigger challenge for patients or for providers?
    Dr. Kvedar. Well, in my almost three decades of doing this, 
Senator, I would say I have not met a patient who was not happy 
with it. You get this what I call magic--when you get it, you 
get this magic convergence of access, quality, and convenience. 
And for anyone receiving any service, that is a happy thing.
    Up until the pandemic, it was a challenge for providers, 
primarily because we were very busy with our office space 
practices. We were adopting electronic records. We all had our 
hands full with important issues that just was hard to get 
telehealth on the radar.
    I am quite proud of my colleagues that, during the 
pandemic, they rose to the occasion. We have heard of no 
untoward events. And, they keep telling me anecdotally when I 
talk to them, and I have talked to a lot of them, that they are 
ready for this new world where a good, solid chunk of our 
service offerings are telehealth.
    I think we have made a lot of progress in that regard, and 
we are really looking forward to the future.
    Senator Burr. Thank you for that. And let me open this up 
to any witness that would like to answer.
    What is the biggest hurdle to us utilizing telemedicine in 
the future? Is it private insurance or is it Government 
regulation?
    Dr. Kvedar. Well, I would be happy to start. I don't--it 
might be a tie. It is really important that we, as we have all 
said now, relax the 1834(m) restrictions. That is an incredibly 
important next step for the Federal Government. And it is 
important that Medicare and Medicaid pay at parity. So, those 
are really foundational elements.
    The private sector needs to step up, as well, and it would 
be very difficult to conduct this care model in a world where 
we get some payment for some things and didn't get paid for 
others. So, it is hard for me to choose a favorite on that one.
    Senator Burr. Anybody else?
    Dr. Rheuban. I would like to concur with Dr. Kvedar in 
that, as a healthcare system, it is really hard to--it was 
really hard to stand up an expansive telemedicine program with 
multiple different payers covering different services. So, as 
much harmonization as possible would be a huge incentive for 
adoption and expansion.
    Senator Burr. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Burr.
    Senator Casey.
    Senator Casey. Mr. Chairman, thank you very much for this 
hearing, and I want to thank you and Senator Smith for the 
opportunity to ask these questions today to this distinguished 
panel.
    We know that because of telehealth and telemedicine that 
access to quality medical and behavioral healthcare can be 
available to everyone regardless of their location or their age 
or other ways that they would not access care under normal 
circumstances. There are some concerns, as already have been 
noted, with regard to racial disparities, with regard to 
poverty and insurance coverage, as well as issues that limit 
our ability within Government.
    I wanted to focus the attention of all the panel Members on 
I guess it is about seven categories of Americans. I will call 
this list of Americans vulnerable Americans because of the 
circumstances they face.
    Number one would be children, seniors, people with 
disabilities, LGBTQ+ Americans, those with behavioral and 
substance use disorder problems, and the homeless. And that is 
not an exhaustive list, but when you consider those populations 
of Americans, I really have about three questions for each 
panel member and I will ask them together.
    How has increased access to telehealth services helped 
these vulnerable populations and improve their overall health? 
That is one question.
    The second question is, what are the risks of pulling back 
to those populations?
    Then number three, what additional steps can we take to 
bring this kind of quality care to these Americans?
    How have they been helped, what are the risks, and what are 
the next steps? We could go in order of testimony, starting 
with Dr. Rheuban.
    Dr. Rheuban. Thank you, Senator Casey. It is an excellent 
question, and I want to commend your state for some amazing 
telemedicine programs across Pennsylvania--Lehigh Valley, 
University of Pittsburgh, University of Pennsylvania and CHOP, 
among others.
    Without question, vulnerable populations see benefits of 
telemedicine services. We can, for example, with remote patient 
monitoring monitor vital signs of patients, blood pressure, 
heart failure. Many clinical conditions that are--would 
otherwise require in-person visits. And, so, therefore, we can 
lower the cost of care but improve outcomes. There is plenty of 
published data in that regard.
    I'm sorry. What was the second question?
    Senator Casey. Oh, the--in addition to how they have been 
helped, what are some of the risks to pulling back for those--
--
    Dr. Rheuban. Oh, absolutely. Yes. So, access to healthcare 
should be, frankly, a right. And, if we pull back patients that 
have been relying on these technologies, these services, they 
will lose that access, especially when they are remotely 
located.
    We have supported infant--high-risk pregnant women, 
infants, seniors after discharge from the hospital with, 
complex conditions. So, I think there is a huge risk that those 
services will not be continued if we do not continue to support 
telemedicine.
    Senator Casey. Anything on next steps you would hope or----
    Dr. Rheuban. Well, so, I want to put a plug in. I served as 
board chair of Virginia Medicaid. Virginia Medicaid expanded 
Medicaid, again, enrolling new patients in 2019. We have 
enrolled more than 425,000 Virginians. I think those 
connections allow for improved care. And, having favorable 
regulations both in Medicare and Medicaid will enable continued 
services to be provided and better outcomes for our patients.
    Dr. Kvedar. Thank you for the question. I would echo my 
colleague's comments and not repeat them. That does not mean--I 
want to make sure I emphasize how important they were.
    But, to broaden the conversation, I would just call 
attention to two things. One is the reimbursement for telephone 
encounters, which was really helpful in crossing the digital 
divide during the pandemic. There is a lot we can do by 
telephone. For instance, as a dermatologist, patients send me 
images of various skin lesions or rashes over our patient 
portal, and I am able to converse with them by telephone and 
conduct care perfectly well. Other clinicians have done the 
same. Of those numbers I mentioned earlier in my testimony, 
605,000 visits, about 60 percent were by telephone. So, let us 
not forget that.
    I would just say we should continue that level of 
reimbursement, if for no other reason than to address this 
underserved population problem that you have brought to our 
attention.
    That is really the only thing I would add to what Dr. 
Rheuban said.
    Senator Casey. Thank you, Doctor. Dr. Arora.
    Dr. Arora. Senator Casey----
    Senator Casey. Ten seconds.
    Dr. Arora. Senator Casey, I think there are two issues 
here. Our underserved population, certainly telehealth or 
telemedicine will help alone.
    But, there is a bigger problem, a much bigger problem, 
elephant under the table, that these people, even in the old 
system, never had access to specialty care. If they had 
Medicaid, it was extraordinarily poor.
    In addition to really overcoming the geographic divide, 
there is a massive capacity shortage in this Country for 
taking--providing specialty care for underserved patients of 
the type you describe.
    In your state alone, Penn State, AmeriHealth, Neighborhood 
Health Centers of Lehigh Valley are using it for mental health, 
substance use, are using ECHO for capacity expansion where you 
are increasing what we are doing. You have got forced 
multiplication, exponentially improving capacity, because 
telemedicine alone will not increase capacity, ever. You just 
put the person on a camera, it is not going to have more 
specialists in the Country.
    Senator Casey. Doctor, thank you. Dr. Willis, maybe----
    The Chairman. Senator.
    Senator Casey [continuing]. Provide your comment in 
writing?
    The Chairman. Senator Casey, we need to move on. I am 
afraid we are about a minute over.
    Senator Casey. Thank you.
    The Chairman. Thank you very much for your questions.
    Senator Collins.
    Senator Collins. Thank you, Mr. Chairman.
    As a senator representing a large rural state, I have long 
been a proponent of telemedicine since we have such a shortage 
of healthcare providers, particularly in our rural areas. I 
want to ask the panelists about the types of clinicians that 
should be able to use telemedicine and be reimbursed under the 
Medicare and Medicaid programs, and I will give you an example.
    A speech language pathologist at Waldo General Hospital in 
Maine contacted me some time ago about elderly patients with 
head and neck cancer who were unable to eat due to the effects 
of chemotherapy and radiation. Some of them required feeding 
tubes, in some cases unnecessarily, because of a lack of 
available swallowing therapy.
    These patients live in rural areas. They cannot easily get 
to a specialist who could help them with their swallowing 
problems. He was frustrated that, while commercial insurance 
and Medicaid in the State of Maine allowed the practice to bill 
for telehealth services, Medicare did not. Today, for the 
duration of the pandemic emergency, CMS is waiving limitations 
on the types of clinical practitioners that can furnish 
Medicare telemedicine services, including speech language 
pathologists.
    My question--and if I could get just short answers to my 
long question--for each of the panelists, do you support 
continuing these waivers so that non-physician healthcare 
providers can be reimbursed for their telehealth services?
    Dr. Rheuban. I will start, and I say absolutely, I agree 
with you.
    Senator Collins. Thank you.
    Dr. Kvedar.
    Dr. Kvedar. Yes. Thank you. Likewise, the ATA would support 
your question. It is a very positive answer, yes.
    Senator Collins. Dr. Arora.
    Dr. Arora. Senator, I support it completely. But, in 
addition, I would argue that even in the cities of this Country 
where you live next to these speech and swallow specialists, 
there are long waits to see them. We also need to expand the 
number of people in our Country that can actually provide these 
services through de-marketizing the knowledge of these experts 
so everyone who needs this can get this service.
    Senator Collins. Dr. Willis.
    Dr. Willis. My answer is yes, as well, and we look forward 
to best practices.
    Senator Collins. Thank you all. One footnote on the 
discussion of the provision of mental health services, which is 
of great interest to me.
    The CEO of St. Mary's Hospital in Lewiston, Maine has said 
that the compliance rate--the no-show rate has plummeted with 
behavioral health telehealth medicine visits. In other words, 
that people who are being assisted with mental health problems 
were actually much more likely to keep the appointment if it 
was through telehealth than if they actually had to go to the 
office of the therapist. I think that is a really interesting 
data point for us.
    One other quick question in my time that remains. The Pew 
Research Center notes that half of adults 65 or older do not 
have broadband at home, and rural residents and seniors living 
below the poverty line are less likely to have access to 
broadband.
    Senator Jones and I have introduced a bill to expand 
broadband access. But, as we continue to work to eliminate this 
disparity, for families without access to reliable broadband, 
can audio-only telemedicine be deployed effectively? Is audio-
only as effective as being able to see your healthcare 
provider? The second question to that, is there a chance of 
fraud if we go more to audio for those areas without broadband 
access? And I will just ask that question to one of our 
witnesses, Dr. Kvedar.
    Dr. Kvedar. I think audio-only is very effective. It is not 
100 percent effective. There are certainly times when a visual 
inspection of the patient is important. But, we have been so 
impressed by how much we can get done with audio because so 
much of our diagnostic and therapeutic decisions are around 
data. So, audio can be incredibly effective.
    I think the fraud and abuse question is an important one, 
but I would say that there are ways to authenticate people, and 
it is probably a straightforward way for us to be able to do 
that, so I wouldn't let that stand in our way.
    Senator Collins. Thank you.
    The Chairman. Thank you, Senator Collins. I thank the 
witnesses for their succinctness in the answers.
    Senator Baldwin.
    Senator Baldwin. Thank you, Mr. Chairman. I want to thank 
all the--all of our witnesses.
    Just dovetailing on what Senator Collins was speaking about 
with regard to telephone-only telehealth. I just recently heard 
a story from one of the health systems in Wisconsin, Marshfield 
Clinic, about an individual who--a farmer, who was suffering 
with severe depression, made a telephone-only contact and was 
greatly helped, and probably would not have reached out in 
other--in any other way. So, very much hearing that telephone-
only can be as successful as in person or video also.
    I have a couple of follow-up questions to some of my 
colleagues who have already asked questions. I want to get back 
to the issue of substance abuse disorder, the propensity or the 
fact that life during the pandemic can exacerbate a number of 
issues with regard to mental illness or substance abuse 
disorder.
    It strikes me that some of those--it strikes me that the 
clinics that treat folks may have huge variability in their 
access to various telemedicine platforms, and so I have joined 
Senator Shaheen in making sure that in our next COVID package, 
we look at the provider's side, as well as the patient's side, 
in terms of telemedicine platforms. But, what is the sense of 
the just great variance that exists in terms of the ability of 
different clinicians in different fields to do telehealth to 
begin with? And who needs more help than others?
    Dr. Rheuban. I can start. So, telemedicine has played a 
huge role in the management of substance use disorder, but we 
did have some challenges. Prior to COVID-19, patients would 
need to be seen at an eligible originating site until the 
SUPPORT Act allowed for services to be provided from the home.
    The DEA still has a ways to go in terms of the scenarios 
through which they allow for prescribing of controlled 
substances via telemedicine. There is a waiver in place right 
now. It would be wonderful for that to be continued. Otherwise, 
the patient would need to be seen in the presence of a DEA-
registered provider or at a DEA-registered facility. The 
SUPPORT Act called for a special registration process, but that 
still has not yet happened. So, I think that would support 
providers who wish to provide these services post-COVID-19, as 
well. Thank you.
    Senator Baldwin. Dovetailing on that answer, what 
restrictions exist about the location of the provider? I know 
that there were restrictions on where the patient would have to 
be located in order to receive telehealth that have been 
lifted. Can the provider be teleworking?
    Dr. Rheuban. Yes. Well, under the waiver process, yes. It 
was clarified that they can.
    Senator Baldwin. And----
    Dr. Rheuban. They need to be in the same state, as well, as 
the patient. They need to be licensed in that state.
    Senator Baldwin. Okay. And is that a waiver that you would 
like to see continued in the future?
    Dr. Rheuban. Yes.
    Senator Baldwin. One thing I am curious about is we are 
talking about the explosion of the use of telehealth between 
healthcare providers and patients. What have we seen in terms 
of changes between--telehealth between providers? And let us 
use the example of a rural, critical access hospital that wants 
to get a specialist's eyes on, say, x-rays or some other 
diagnostic. Has that changed significantly also during this 
pandemic, or is that kind of holding steady?
    Dr. Rheuban. I believe those have been--those encounters 
have been supported all the more so during the pandemic, in 
addition to the use of e-consults, which was initially funded 
by CMMI, Center for Medicare and Medicaid Innovation, but now 
has been incorporated into everyday care, especially in the 
2019 physician fee schedule. But, there were some rules 
surrounding that which were problematic. Those have been 
relaxed, so that allows a structured consultation between a 
provider in one location and a provider in another location. 
Those rules have been relaxed, and we would like to see that 
continue.
    Senator Baldwin. Okay. Thank you.
    Dr. Rheuban. You are welcome. Thank you.
    The Chairman. Thank you very much, Senator Baldwin.
    Senator Cassidy.
    Senator Cassidy. Yes. Thank you to all the panelists. While 
you all have been testifying, I have been cleaning up my house, 
and so it is an incredibly convenient platform.
    Dr. Kvedar, in our GOP Republican memo, they mention that 
although platforms are--not all platforms commit to being HIPAA 
compliant. Indeed, some use a platform in which they will 
monetize the information they gather from using the platform.
    By the way, you are a dermatologist. I showed my 
dermatologist my daughter's rash on a Friday evening. He called 
in the prescription. Of course, it was topical steroids. I 
could have done it myself. But, nonetheless, she was, if you 
will, healed by the morning. Convenient for him; convenient for 
her. Saved money.
    That said, what can providers do to make sure that they are 
using platforms--because we used Facetime. What can providers 
do to be sure they are using platforms in which people are not 
monetizing that information?
    Dr. Kvedar. Well, thank you for that, Senator, for that 
question, and can--I would say the first thing to underscore in 
responding is the importance of HIPAA compliance and having 
your vendors sign a business associate agreement. I believe 
that would cover both of your questions. I know it would cover 
the privacy side, and it is very important for us to be careful 
about data governance in the new future----
    Senator Cassidy. Now, let me ask, though. In your practice, 
where you practice, a very prestigious hospital, do you have a 
list of online platforms that your providers can use or not use 
to otherwise alert, if you will, a provider that someone might 
be monetizing?
    Dr. Kvedar. What we do now is we use one, Zoom. It is 
integrated into our electronic medical record in our patient 
portal, and that is what we do. So, we have sort of solved 
that. We were maybe a little bit ahead of the curve on that 
because we had that going before the pandemic.
    Senator Cassidy. If I called you on a Friday night, showing 
my daughter's rash on, just whatever platform, would--how would 
you have handled that? It might not have been I don't think 
applicable as this, but let us imagine somebody did. How would 
you have handled that?
    Dr. Kvedar. We would have asked you to send me those 
pictures via our patient portal, which is secure, and then I 
would have called you back on a telephone.
    Senator Cassidy. Got you. Okay.
    Ms. Willis, there has been discussion here that--of course, 
providers are going to say this, and I am a doctor, so I am 
going to get that--that telemedicine being reimbursed at the 
same as an in-health----
    But, frankly, I am a physician. If I had 1 day of my life 
in which I was only doing telemedicine, I would have sent 
everybody home, gone to my closet, sat in front of my computer 
with my EHR on this screen and my Zoom on that screen, and I 
would have just typed away, answering phone calls, speaking 
through the internet. And, really, my overhead would have been 
markedly diminished in terms of personnel.
    Now, on the other hand, there is the fixed cost of the 
initial investment. So, how is BlueCross BlueShield handling 
that? Will you pay the same, or will you say, once there is an 
initial investment, really, future costs are less? I think that 
is going to be of a lot of interest to the providers.
    You are muted.
    Dr. Willis. Can you hear me now?
    Senator Cassidy. Yes, ma'am.
    Dr. Willis. Okay. So, we did pay parity going into this. We 
did not feel like we could have that kind of conversation in a 
crisis situation, and we are not in a rush to abandon that. 
But, we are going to be looking to the data to make sure that 
we see the efficiencies we think that we are going to see. And, 
what we don't want to do is to inject additional healthcare 
costs into the system. So, we think that is a conversation that 
we are going to need to evaluate, and we agree with 
Administrator Verma in her stance on that, as well.
    Senator Cassidy. Okay. So TBD?
    Dr. Willis. Yes.
    Senator Cassidy. Dr. Arora, I remember on my visit to New 
Mexico, you pointed out that technically, you are not 
telehealth; you are, rather, telehealth education. I think one 
thing that is of interest is whether or not homecare providers, 
as in a husband or wife, could access your telehealth 
education.
    Now, I also remember, though, your Hep C program, and you 
would have a weekly 6 months of therapy--not therapy, of 
education for the provider. So, it was not a, wham bam. It was 
no, we are going to gradually educate you.
    What is the potential of your platform to educate people to 
provide help to a relative? That sort of not formal training, 
but the training that a relative would need in order to--what 
am I going to do for my husband with Alzheimer's sort of thing?
    Dr. Arora. Senator Cassidy, thank you very much also for 
your visit and for your question.
    I think that the most important problem we are trying to 
tackle, Senator, is there is a worldwide shortage of expertise 
in the world. Six billion people in the world do not have 
access to the right knowledge at the right place at the right 
time, and maybe 100 million in the U.S. So, we have to do task 
shifting. And I can think of no----
    That is what ECHO is designed for. We have many ECHOs where 
we train community health partners. There are family members 
who care for patients.
    But, really, we have to--I am to the idea of de-marketizing 
the knowledge of experts. By putting a specialist in front of a 
camera on telemedicine, you cannot increase the total capacity 
of the system, and the system is direly lacking capacity in 
problems like dementia, elder care, substance use disorders, 
and so on and so forth. And yes, in most parts of the world, we 
use ECHO that way. In HIV in Africa, their entire care is 
provided by nurses and the support by family members.
    Senator Cassidy. Thank you. I yield back. Thank you, Mr. 
Chairman, for this great Committee.
    The Chairman. Thank you, Senator Cassidy.
    Senator Kaine.
    Senator Kaine. Thank you, Mr. Chairman, and thanks to the 
witnesses. This is a very important and timely hearing.
    Dr. Arora, I would like to start with you. You know 
firsthand, and we have heard you describe how beneficial it is 
for providers in underserved areas to be connected with 
specialists through Project ECHO. It is a marvelous model. We 
have used it in Virginia to help support treatment of a variety 
of conditions.
    Last year, I introduced the ECHO 2019 Act with Senator 
Murkowski and Senator Schatz, and I was pleased to see that 
portions of it were included in the Heroes Act passed in the 
House. And I hope as we put 10 months of--or 10 years of 
learning into 3 months during this time that we might in our 
next bill be able to include portions, as much as we can, of 
that act into our next COVID response.
    Mr. Chairman, I would like to submit for the record a 
statement in support of the ECHO 2019 Act from the Alzheimer's 
Association.
    The Chairman. So ordered.
    [The following information can be found on page 62 in the 
Additional Material.]
    Senator Kaine. If I could turn to Dr. Rheuban.
    Dr. Rheuban, I was talking to a physician at the University 
of Virginia not long ago, and I asked her how much of her work 
was being done via telehealth before COVID. She said zero 
percent. And I asked her how much now. She said 70 percent. And 
then I said, what should it be when COVID is no more? And she 
said 70 percent.
    Dr. Rheuban. Wow.
    Senator Kaine. She has basically experienced that it 
really, really works, but she pointed out it doesn't work very 
well for a first time visit when you are getting to know your 
patient for the first time. And, obviously, in telehealth 
inquiries, something will come up where she will say, I really 
need to see you in person. So, that would be her 30 percent.
    I had a Zoom call with Virginia Child Welfare Advocates the 
other day and they talked about how they are using 
teletechnology to provide care to children and families. But, 
they said the one area that they just can't use a 
teleconnection on is interviewing children about abuse because, 
in a house, the child may not know the technology, but also the 
parent or the adult who is potentially an abuser might be 
there, and the expert really cannot get a read on the 
situation.
    Talk a little bit about as you have, over many years, done 
this, kind of the things where it works, but also some maybe 
advice or cautions to us about kinds of doctor-patient 
interactions where it is not going to work as well as in person 
and we need to prioritize in person.
    Dr. Rheuban. Thank you for that really great question, and 
I am delighted that one of my colleagues has said it is working 
and she is doing 70 percent now.
    I would say that, in general, most of our telemedicine 
encounters have been in the context of an existing doctor-
patient relationship. However, we certainly can and do see new 
patients. But, when additional testing is required, 
telemedicine alone is not sufficient. So, in my own practice of 
pediatric cardiology, I have done a number of virtual visits 
during the COVID-19 pandemic. But, when my patients need 
another ultrasound, they need to either go someplace where they 
can get that and have that image sent to me, or they need to 
come back to Charlottesville for that visit.
    I think much of what can be done needs to be refined by the 
specialty societies themselves and the organizations that lead 
these efforts on behalf of patients. I know that but for 
behavioral health services and in the Commonwealth of Virginia, 
the Virginia Mental Health Access Program has enabled more 
telemedicine for behavioral health services for pediatric 
patients, as well.
    I think it is a combination, and it needs to be driven by 
the specialty societies themselves as opposed to legislated.
    Senator Kaine. Let me ask one other question and open it up 
to the witnesses. The thing I love about this Committee is it 
is not just health, but it is also education, which includes 
the education of the healthcare workforce. Dr. Arora has talked 
about the need for more specialists, but I also wonder will the 
growth of telehealth create other workforce needs that we need 
to be creative in solving.
    UVA has a joint program with New College Institute in 
Martinsville that is called the Southside Telehealth Training 
Academy and Resource Center. They do training there and 
ultimately will provide a certificate to an individual as a 
telehealth technologist. That certificate is based on a program 
that tries to teach individuals how to either work with 
providers in clinical settings to set up telehealth that is 
effective with patients, or actually go into patients' homes 
for remote patient monitoring and help patients navigate and 
use telehealth. And the educational program is a little bit of 
a combination of bedside manner, technological skills, helping 
a provider get comfortable with the technology, helping a 
patient get comfortable with the technology.
    How much should this education Committee be contemplating 
broader workforce changes if we are going to be in this new 
world of dramatically increased telehealth use?
    Dr. Rheuban. That is an excellent question, and I 
completely concur. We have found training of health 
professionals at all levels in the use of telehealth is an 
important skill set. We have enjoyed working very much with the 
STAR Center in Martinsville at New College Institute. We have 
embraced Project ECHO to also train the workforce in the use of 
telemedicine specifically, as well as in the pandemic. So, I 
fully support additional training modules or training capacity 
amongst a broad range of health professionals in telehealth.
    In addition, we have actually done some patient education 
related to telemedicine, which I consider very important, and 
was a previous question. We do training in diabetes self-
management virtually. That was very--it was a bit challenged 
prior to the pandemic in that Medicare did not cover that 
service, but it is a covered service now.
    Senator Kaine. Thank you so much. Thanks, Mr. Chairman.
    The Chairman. Thank you, Senator Kaine. Dr. Rheuban, your 
camera is off, perhaps accidentally.
    Senator Roberts.
    Senator Roberts. Thank you, Mr. Chairman. Thank you for 
your leadership in holding this hearing.
    In regard to this issue, I want to go back quite a bit of 
time. In 1978, I was working as the chief of staff for The 
Honorable Keith Sebelius, who represented 66 counties out on 
the prairie. It was called the big 1st District, and there were 
three--the first three ever telemedicine demonstration 
projects. One on an Indian reservation in New Mexico--Dr. Arora 
might know something about this--and an island off of Maine. 
Senator Collins is not here to respond to that, but I think she 
was probably in high school at that particular time.
    Then, we were all set up, ready to be included in Cimarron, 
Kansas, out there on the prairie, about 60, 80 miles from Dodge 
City. About one week out, I called over--I said we got Denver 
coming in to cover this, we have Wichita coming in to cover 
this, got Oklahoma City coming in to cover this. This was a big 
deal.
    They said, we really appreciate what you and Keith have 
done for us, and it is just a wonderful effort, but we have 
finally gotten word from the Canadian doctor that we were 
really trying to recruit to come to Cimarron, which he did. 
And, so, we were canceled out of that experiment at that 
particular time.
    The doctor left after 6 months, of course, and then there 
we were, high and dry again. And we had made--we had--trying to 
be at least aware of all the possibilities we have today. In 
many ways, the pandemic, while being a tremendous problem for 
the whole Country, also is a catalyst, as you have indicated, 
sir, in this effort.
    My main question comes from interest in audio-only 
telehealth, especially in our rural areas. We have some rural 
broadband issues. That continues to be a real challenge. So, my 
question to any of the witnesses, how could audio-only visits 
help expand access to care in places where this is an issue? I 
think Senator Collins raised this issue with regards to 
possible fraud, and that could be a problem.
    But, you have a young man who takes his grandmother to the 
nearest rural healthcare clinic. They do not have the broadband 
access that they need to have, but they do have the only--the 
other alternative, of course, which is the audio-only system. I 
am not sure that we can get universal coverage for that, by the 
way, but I would be interested in any of the witnesses.
    Dr. Rheuban, why don't you start off?
    Dr. Rheuban. Thank you, Senator Roberts, and it is an 
excellent question. Since the pandemic, fully one-third, and 
maybe slightly more, of our telemedicine visits have been 
conducted via audio only. In most cases, that is in the context 
of an existing doctor-patient relationship or in the context of 
the medical--primary care medical home or specialty care home. 
But, it has been very effective and it has solved a challenge 
for our patients.
    I would be in support of continuation of coverage for audio 
only, but it is--you cannot do everything via audio only, 
specifically examine the patient. But it is an important tool, 
and particularly for more vulnerable populations who do not 
have access to broadband.
    Senator Roberts. Dr. Arora, what comment might you have, 
please?
    Dr. Arora. Senator Roberts, in my own experience, it has 
been that a phone visit is not as good as a video visit. But, 
as was mentioned, you don't want the perfect to be the enemy of 
the good, and a lot of good work can be done on the telephone. 
Because, as a physician, 80 percent of all the information I 
need comes historically and only a minority actually comes from 
the physical exam and--but there is definitely great value if I 
can touch the patient or see the patient. But, as I said, 80 
percent is as good as we could get probably, and I am very 
happy with that.
    Right now, what is happening, Senator Roberts, is people 
are having to make visits before this new change in the law. 
All the time--just other--a bill to be generated, you have to 
go and see your doctor, and that is not necessary. And, so, a 
lot of challenges would be solved with on-telephone visits.
    Senator Roberts. Thank you very much. My time has run out. 
Mr. Chairman, thank you so much for your continued fight for 
pay parity on this issue. Thank you, sir.
    The Chairman. Thank you very much, Senator Roberts.
    Senator Hassan.
    Senator Hassan. Well, thank you very much, Mr. Chairman, 
and Ranking Member, for having this hearing today. And thank 
you for our witnesses for being here.
    The COVID-19 pandemic has led to a rapid expansion of 
telehealth services, as we are discussing right now, many of 
which are long overdue. Telehealth can continue to increase 
access to care and improve health outcomes even outside of 
pandemic. So, I am glad that we are having bipartisan 
discussions about making many of these services available for 
patients permanent.
    Dr. Arora, I want to start with a question for you, and I 
want to thank you for your work establishing the Project ECHO 
Program. And I want to thank you, too, today for sharing your 
experience with that patient who inspired you to take this on. 
Thank you for dedicating so much of your skill and your heart 
to making telehealth a reality for so many.
    In my home state, University of New Hampshire created an 
ECHO hub that has expanded access to medications systems for 
substance use disorder. However, there are still barriers that 
prevent people from accessing treatment, particularly during 
the COVID-19 pandemic, including an outdated requirement that 
providers obtain a DEA waiver in order to prescribe 
buprenorphine. And there was a discussion between Senator 
Baldwin and Dr. Rheuban about this, but I want to drill into it 
a little bit more.
    The DEA is temporarily allowing teleprescribing of 
medications that treat substance use disorder during the 
pandemic. However, because the DEA buprenorphine waiver 
requirement has significantly limited the number of providers 
who can prescribe, access to telehealth remains unavailable to 
many Americans. Last year, Senator Murkowski and I introduced 
legislation that would eliminate the DEA requirement.
    Dr. Arora, how has COVID-19 exacerbated existing challenges 
for substance use disorder patients and providers in 
underserved areas? And how might those challenges, combined 
with administrative barriers like this DEA waiver requirement, 
limit treatment during the pandemic?
    Dr. Arora. Senator Hassan, thank you for your question. 
And, in addition to University of New Hampshire, Dartmouth-
Hitchcock and John Snow Research Institute in your--also are 
using ECHO for substance use disorders in New Hampshire. And 
I--in New Mexico, when we started ECHO, there were only 33 
doctors who had the DEA waiver, and we used ECHO to train 500 
more and certified 500 more physicians for the--and at that 
time, it was physicians. Now, nurse practitioners do actually 
have the DEA waiver. But, what we found was that even with the 
waiver, most doctors do not have the expertise to take care of 
a patient with substance use because you also needed mental 
health expertise and you needed other kinds of counseling 
expertise. So, when we set up ECHO, what we found was we helped 
them with the DEA waiver, but then gave them the mental health 
support they needed to take care of the patient.
    But my perspective is exactly the same as you, Doctor--
Senator Hassan that in the event--we have now set up 100 hubs 
in the United States for substance use disorder, connecting at 
least 20,000 clinicians to be mentored for this particular 
problem, for which there is a great shortage.
    But, in my view, when a primary care doctor and nurse 
practitioner in a rural area is participating in an ECHO for 
substance use disorder in one of the 100 networks, they do not 
need a DEA number for that. They have much more than a DEA 
number can provide, or a license. In fact, in that 
circumstance, waiving that will dramatically expand access to 
substance use disorders in our Country.
    Senator Hassan. Thank you for that. And, Dr. Rheuban, do 
you have anything to add? I appreciated your earlier testimony.
    Dr. Rheuban. Just that we are appreciative of the home as 
an eligible originating site for patients for substance use 
disorder treatment, and we look forward to the DEA creating, 
also, the special registration for telemedicine providers.
    Senator Hassan. Well, thank you.
    I have a question for Dr. Kvedar, too. As we increasingly 
rely on telehealth services during the pandemic, we need to 
ensure that electronic health records are accessible across 
provider settings and matched to the correct patient. Accurate 
interoperable electronic health records would also play a 
critical role in ensuring that a COVID-19 vaccine is 
distributed efficiently, available to vulnerable populations, 
and if a vaccine requires a booster, that the correct doses are 
being administered to the correct patient at the correct time.
    Dr. Kvedar, can you briefly explain how data 
standardization, better demographic data collection, and 
improved access to electronic health records could increase 
provider efficiency and improve patient experience as we 
continue to respond to COVID-19?
    Dr. Kvedar. Well, thank you so much for the question. It is 
an incredibly important area for us, and slightly outside of 
the tight zone of telehealth, but really an important one.
    For everything that you said, it turns out that there is a 
new set of tools in the provider--in the CODER Lexicon called 
APIs that it was to easily match data sets. That is very 
important.
    The other thing that I would just mention is that the 
postal service has a way of matching addresses that we should 
take advantage of. I think that has been underutilized and is a 
very perhaps elegant solution to some of the problems you are 
mentioning. And, yes, important for all of us to have accurate 
information and to be able to share information, especially in 
this new world where everything is time-and-place independent.
    Senator Hassan. Well, and----
    The Chairman. Thank you, Senator Hassan.
    Senator Hassan. Thank you. Thank you, Mr. Chairman.
    The Chairman. We have a vote in 5 minutes, and we have 
eight Senators who have not had a chance yet to have their 5 
minutes, so succinctness will be appreciated.
    Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman. I will try to 
be succinct. This is an exceptionally important hearing. I 
thank you for this.
    In Alaska, out of necessity, we have been leading on 
telehealth for decades, most particularly within the IHS 
system. Our Alaska Native Tribal Health organizations have 
really been forerunners when it comes to bringing this 
technology out to our villages and to our regional centers.
    I was in a hearing room somewhat like this when I first 
came to the Senate, now 17 years or so ago, and they were 
demonstrating a telehealth cart. And it was less--it was 
smaller than the size of the stand that is holding that TV over 
there.
    I said, well, how does it work?
    They said, well, we can take a picture of you and we can 
send it to Anchorage and we can get the test back.
    I was getting ready to fly on an airplane to go back, and I 
had a stuffy ear and was wondering if I had an ear infection 
and they stuck--I think it was an otoscope in my ear. It showed 
a picture on the camera that I saw. It talked to the doctor in 
Anchorage and he said, you are clear to fly.
    That was my first introduction to it, and it was 
extraordinary. It was like the invention of the telephone, how 
did this all work?
    Well, it has been working, and we have seen it work within 
IHS. We have certainly started to see it take off within V.A. 
in Alaska. It has been slower in application in other areas.
    Mr. Chairman, I want to ask unanimous consent to submit for 
the record a statement that was put together by--coming out of 
the Petersburg Medical Center. I had a conversation with the 
administrator a week or so ago. He is not only the 
administrator there in Petersburg, which is a critical access 
hospital, small community of about 3,000 people, accessible 
only by airplane or boat. It is on an island. He has also been 
an administrator in Nome, so he has broad experience out there. 
And we talked about the benefits that he has seen in his 
professional career as a result of telehealth. He is not only 
an administrator. He is also an audiologist, so he has had 
interest on both sides.
    He said that what they have seen with the increased access 
to care, the improved delivery has been phenomenal. But, we 
have had this lag. We have not seen the gain, the traction, 
that we want in terms of full implementation. It comes back to 
reimbursement. If you have the ability to do it but you are not 
going to be reimbursed for that, it is an impediment.
    But, he said, and I will quote from his letter here, ``More 
progress has been made in telemedicine and in the delivery of 
healthcare in the last 3 months than in the last 20 years.'' 
That is transformative. That is what is happening right now. 
And, so, he has outlined some of the lessons learned and some 
of the things that he wants to have going forward. So, I----
    The Chairman. So ordered.
    Senator Murkowski [continuing]. include that as part of the 
record.
    [The following information was not submitted for the 
record.]
    Senator Murkowski. But I want to ask a question, and this 
may be to any one of you. Senator Cassidy kind of touched on 
it. But, what we are seeking to do here, and the real benefit, 
the real win, is increased access. We all want to be able to do 
that, and particularly for those in our remote areas. But, in 
these remote areas, you have healthcare systems that are often 
very fragile. They are just on the margin of being able to 
cover their overhead, meet their expenses. So, you do not want 
to be in a situation here where you have built something that 
is now not sustainable because the method of delivery, of 
access, has been made more efficient.
    How do you--how do we find this balance here? Can somebody 
address that for me? It--let me start with you, Dr. Rheuban, 
with your perspective on rural healthcare.
    Dr. Rheuban. I might give a quick anecdote from your own 
state, which I visited a number of years ago. Stewart Ferguson, 
another ATA past president, shared that there was a fire in a 
health clinic in Northern Alaska, and the residents of the 
community raced in to save the telemedicine equipment. The rest 
of the clinic burned, but the telemedicine equipment was moved 
to the school. Patients truly appreciate access to care using 
technology.
    I think we will find the balance, and I think the specialty 
societies themselves, organized medicine, nursing, we will 
ascertain what is best practice. And the fact that we have new 
CPT codes that have been activated in the pandemic will also 
enable us to identify cost savings, outcomes, and guide us as 
we move forward. So, I just want to give a huge shout out to 
your state, which has been a leader in telemedicine, as well.
    Senator Murkowski. Thank you. My time is just about 
expired. Anybody else have any quick comments? You get 2 
seconds.
    Dr. Arora. Senator, your state has particularly used 
Project ECHO for training of the workforce out of the 
university, out of the Alaska Native Medical Center. But one of 
the challenges we face in ECHO is there is no sustainable 
mechanism for actually training and keeping the healthcare 
workforce trained and mentored with the best and latest 
knowledge. Medical knowledge is increasing three and a--
doubling every 3 and one-half years.
    We also need, in addition to a sustainable way to pay for 
telemedicine consultation, which is a one-to-one service, we 
need a mechanism, sustainable mechanism, to pay for healthcare 
workforce training and development.
    The Chairman. Thank you very much, Senator Murkowski.
    Senator Jones.
    Senator Jones. Thank you, Mr. Chairman, and thanks to all 
our witnesses for being with us today. I would like to talk a 
little bit about a different form of telemedicine, and that is 
remote monitoring, and think about how we can help those living 
with chronic conditions.
    In Alabama, there is well over 600,000 people with chronic 
conditions that need help on a daily basis. Recently, I 
introduced a bill with Senator McSally called the Increasing 
Rural Health Access During COVID-19 Emergency Act, which would 
provide additional funding for providers and health systems in 
rural America to invest in remote monitoring. Connectivity 
continues to be an issue, and I think that remote monitoring 
can help bridge that divide by utilizing a little bit better 
2G, 3G technology.
    Dr. Kvedar, if you could discuss how remote monitoring is 
used today. I know from personal experience with my parents the 
use of a monitor with regard to a pacemaker for heart patients. 
But, if you could discuss a little bit how those with living--
with chronic conditions, like hypertension, asthma, kidney 
disease, other things can utilize remote monitoring. And what 
is it that we can do as a Congress to encourage the equipment 
and the necessary tools to do more remote monitoring?
    Dr. Kvedar. Thank you for the question, Senator. It is a 
wonderful--and I am so glad you brought it up because we have 
been so focused on video and audio interactions.
    Remote monitoring is a fabulous tool. It enables, as you--
just as you described, individuals with chronic illness to be 
able to share information about their illness--usually vital 
sign information, could be a heart rhythm, et cetera--with a 
provider at another location, and for those individuals to have 
care provided because they have an enriched data stream from 
the patient.
    This has led to, particularly in conditions like congestive 
heart failure, savings in terms of keeping people out of the 
hospital, keeping people out of the high-cost part of the 
system, keeping them healthy in their home. And, I would say 
that in the last 2 years, Medicare has come on board to 
reimburse for those activities. There is a nice, very 
thoughtfully done set of codes now to reimburse for the 
activities. Likewise, with monitoring for hypertension, there 
is a set of codes to reimburse for that now.
    What is left is what can Congress do? I think any way you 
can encourage our colleagues in the private payer space to come 
on board to support those codes would probably be a wonderful 
thing. I don't know that is in your bailiwick, but that is 
really what is needed next.
    Senator Jones. Well, thank you for that. So, following up 
on that, Ms. Willis, what does BlueCross--how does BlueCross 
feel about that and what can Congress do to help encourage 
that? That seems to me a way--it is almost like reimbursing 
for, well-baby visits, other visits that are helping to stop 
real high expenses before they hit. What can we do with you in 
the private sector? What can the private sector do to encourage 
remote monitoring like that?
    Dr. Willis. Thank you for the question. So, we do actually 
have Medicaid within, but we cover at BlueCross BlueShield of 
Tennessee, and we have supported that already in our Medicaid 
population. We are looking at the lessons learned to see how we 
can apply it in the commercial space, as well.
    I can tell you in Tennessee, we are still having 
conversation as to what that means because it means different 
to different people. So, conceptually, we are onboard with 
that, but I think those are the conversations that we need to 
have so that everybody is coming from the same place--is it the 
hypertension monitoring, the things like that you are talking 
about.
    I think we are moving in the right direction on that, as 
well. And as soon as we have clarity between us and the 
providers, I think that we will have recommendations for the 
lawmakers.
    Senator Jones. Well, thank you. Thank you for that. It 
seems to me that one of the things that we can do, as well, is 
to encourage innovation and technology in this area. It seems 
to me with what we are doing now that there are so many 
possibilities out there for this remote monitoring that perhaps 
Congress can figure out a way to encourage scientific 
breakthroughs in technology and innovation to try to help in 
this. Because I think in the long run, it will save America 
money; it will save the taxpayer money.
    Thank you all for that. I appreciate it. Appreciate you 
being here.
    Thank you, Mr. Chairman, for this important hearing.
    The Chairman. Thank you, Senator Jones.
    Senator Braun.
    Senator Braun. Thank you, Mr. Chairman.
    I have been a proponent since I have been here in the 
Senate to drastically change how healthcare is delivered with 
full transparency, no barriers to entry, embrace competition.
    By the way, we were doing telemedicine in my own company 
years ago. One of the benefits would have been that it is 
convenient, and it was less expensive. As a business owner, I 
know you can administer telehealth if you specialize at it at a 
much lower cost than what it would be to have an in-office 
visit with the overhead and so forth.
    Senator Cassidy already covered it, so I won't belabor it. 
I was disappointed to see that already, the most recent 
breakthrough that shows maybe the industry is changing, has got 
this pricing parity. And I am going to give that while the 
demand is so great, maybe it warrants it. Hopefully that gets 
back to where it should be as a bargain and a way to reduce 
costs.
    My question to everyone is going to be transparency in 
general. I am going to keep talking about it. I am going to 
keep pushing it through legislation when I get a chance. Is the 
industry ready--and I would like each one of your opinions--for 
transparency throughout? Exposing the charge masters, 
practitioners putting prices out there so we can see it, 
getting rid of these third-party agreements between insurers 
and providers, and PhRMA telling us what it costs for a drug 
when they advertise it on TV. Humira, for example, you can get 
it for as little a $5 when I know it costs roughly $75,000 a 
year.
    I would like each of you, your opinion on transparency and 
how that changes the healthcare industry to be effective and 
affordable. Who wants to start?
    Dr. Kvedar. I will mention that, as I am here representing 
ATA, I am not really privy to give you my opinion. ATA does not 
have a position on transparency. It is sort of out of the zone 
of telehealth, so I think I will pass on the question.
    Senator Braun. Anyone else?
    Dr. Willis. We would support transparency. I think that we 
have a paradigm for--with the MLR that we will--we are held 
accountable to, making sure that so much of the dollar goes to 
medical costs. So, certainly that is a concept that we would 
like to see applied more broadly.
    Dr. Arora. Senator, I am not an expert in this area at all, 
but in general, for a system to work well, I do support the 
concept of transparency without really--there must be some 
nuances to this, which I do not fully understand not being an 
expert, but I do generally support this idea.
    Dr. Rheuban. I would concur with Dr. Arora. This is not my 
area of expertise, but I certainly support transparency, as 
well.
    Senator Braun. Well, that is good to hear. I am not an 
expert in healthcare, even though I revolutionized how we 
delivered it in my own company, and it was based upon engaging 
my employees in their own well-being. Number one, avoid the 
healthcare system by keeping yourself healthy. That is why we 
pay 100 percent of wellness. And the other thing was to get my 
employees engaged from dollar one on shopping around.
    For the public out there, if that does not happen, there 
are other ideas in terms of what needs to happen to the 
healthcare system, and it is mostly on the other side of the 
aisle, which would make it a one-payer system. I think we would 
lose some of the benefits if that occurs. Inevitably, we will 
go there, and I challenge the healthcare industry, from PhRMA, 
especially hospitals, providers, and insurance companies where 
indemnification is no longer part of what really happens. It is 
a prepaid plan where we all pay into healthcare, and we never 
ask what does it cost before we are served by it.
    Telehealth, being the first thing that has come along in a 
while, please retain transparency. Use it, since I think it is 
lower cost to deliver the service, not to raise to a parity, 
but to start the process of lowering costs. If that is not done 
across the industry, there is going to be a rude awakening for 
it with a much different paradigm down the road.
    Thank you.
    The Chairman. Thank you, Senator Braun.
    Senator Rosen.
    Senator Rosen. Thank you, Chairman Alexander. I know 
Senator Smith was with us today. I want to thank all of our 
witnesses, as well, for being here and the work that you do.
    I would like to talk a little bit about telehealth beyond a 
typical office visit. As a former computer programmer and 
systems analyst, I have long been a strong advocate for 
telehealth and leveraging all this amazing technology to 
improve our access to healthcare. And, so, there are incredible 
ways that telehealth is serving patients in Nevada, even beyond 
the usual visits to the doctor's office.
    Cleveland Clinic's Lou Ruvo Center for Brain Health in Las 
Vegas, it serves patients with neurodegenerative diseases, 
including Alzheimer's and Parksinson's. During the pandemic, 
they have been able to move over about 90 percent of their 
clinical care to virtual or telephone visits, so all their 
patients, very chronically ill patients, can continue to 
receive care.
    In the cancer space, we have heard that doctors in Nevada 
are able to do their planning sessions virtually, not only with 
the patient, but with the whole family, anyone who wants to be 
there, so you have everyone on this video call, participating 
in the patient's care as their support team. And, no patient 
now has to push back their critical treatment because of their 
inability to go to a physician.
    For the panel, we have heard some of the incredible ways 
that telehealth is being used engaging Alzheimer's patients 
with virtual music therapy. We know that can help. And Nevada 
CAN Program is working to provide wraparound services to our 
homebound seniors, keeping them safe, through telehealth. They 
can call our 211 number right now, through the pandemic, all 
seniors can, and get triaged and targeted health that they 
need, medical and social services.
    Besides standard office visits and chronic care management, 
we know their critical needs, but how do we maximize the full 
potential of telehealth, and what barriers do you need Congress 
to still address both during the pandemic and beyond?
    I know we all cannot see each other, so I guess I will 
start with Dr. Kvedar, then Dr. Arora, and Dr. Rheuban.
    Dr. Kvedar. Thanks for the question.
    You are quite right. Telehealth is a tool. So, you can 
imagine if you have a set of tools in a toolbox, all the 
different utilizations for it, and you have touched on a few 
and there are many, many others. It really needs to be decided 
by the clinician and the patient, as a team, what the best use 
of those tools are. And earlier, Dr. Rheuban referenced 
specialty societies playing a role in those decisions. I think 
that is--I would advocate for that, as well.
    What can Congress do? Well, we have been over it, but just 
to reiterate, we--the originating site restrictions should be 
permanently relieved.
    The ability for Federal health--qualified health centers to 
be reimbursed fairly, rural clinics, and those things will 
help.
    Really, again, just being able to use the tool with the 
correct reimbursement, and also the idea of having interstate 
commerce.
    Senator Rosen. Wonderful.
    Dr. Arora.
    Dr. Arora. The biggest challenges I see--well, one of the 
biggest challenges I see for the healthcare industry are this 
explosive growth in knowledge. Until two days ago, what I 
found--what I knew about COVID-19 was actually proven wrong 
when a study from the United Kingdom showing that if you 
basically give dexamethasone to a patient who is in the ICU, 
you can reduce their likelihood of death.
    This exponential growth of knowledge is something that is 
really--we have to deal with it head on because otherwise, 
without the right knowledge at the right place at the right 
time, it is impossible to get the right care at the right place 
at the right time. And, therefore, I would encourage this body 
to use this tech--the telehealth technology not only for direct 
care delivery, but also thinking of our system, optimizing the 
system.
    For example, in the United States, we had a really great 
care delivery system for individuals, but when COVID-19 came 
along, we had no system response. We did not have an adequately 
working system that could respond to a community problem of 
this nature.
    Using this technology to get the right information, at the 
right place, at the right time, mentor our healthcare workforce 
to work at the highest level of their human potential, is an 
urgent need, especially to get care to the underserved people 
of their community who otherwise would have no chance for 
getting care, telemedicine or no telemedicine, if there is not 
specialty capacity in this system.
    Senator Rosen. I believe I have run out of time. I 
apologize to Dr. Rheuban. We will ask our questions for the 
record and you can respond that way.
    Thank you so much for all the work you are doing, and I 
look forward to partnering with you to bring more and more 
exciting technology to care providers and the patients and 
their families.
    The Chairman. Thank you, Senator Rosen. And let me thank 
Senator Smith for serving today as the Ranking Democratic 
member of the Committee. Let me especially thank our excellent 
witnesses--Dr. Rheuban, Dr. Kvedar, Dr. Arora, Dr. Willis--for 
joining us today. It is appropriate to have a remote hearing on 
telehealth, I guess, and that--this has certainly been an 
effective and useful one.
    As I said at the beginning, I suspect we are talking about 
the biggest change in healthcare delivery in a long time, maybe 
ever, when you think about the fact that there were 884 million 
doctor-patient visits last year. Very few were by telehealth. 
And now, the estimates are that maybe that hundreds of millions 
of those doctor-patient visits in the future will be by 
telehealth.
    My recommendation, based upon the testimony that we have 
heard today, is that of the 31 Federal policy changes that we 
have had, which have helped cause this explosion of telehealth, 
that at least two be made permanent, which all the witnesses 
agreed with. One was the originating site rule, and two was the 
Medicare and Medicaid reimbursement rule. The witnesses--or 
Medicare and Medicaid reimbursement provisions, expansion of 
them.
    The witnesses commented extensively on many of the other 31 
changes, and we heard about the importance of the state 
changes, allowing across-state-line delivery of healthcare. And 
we heard about the pioneering work of the BlueCross BlueShield 
organization in Tennessee to step out and begin to cover 
telehealth services in a way that had not been done before.
    What we have experienced in the last 3 months is we have 
crammed at least 10 years of experience into those 3 months. In 
fact, I am not even sure that if we had 10 more years without 
this horrible pandemic we are going through, that we would have 
made the changes in telehealth that it has caused.
    Our purpose is to look at costs, experience of the 
patients, and quality outcome whenever we talk about delivering 
healthcare services, and we will continue to do that here.
    Thanks very much to the witnesses. Your testimony will make 
a big difference in how this Committee reacts to the changes in 
policy at the Federal level. And, all of us feel very 
privileged to be a part of a situation where we may be able to 
help ensure permanent changes in the delivery of healthcare in 
terms of costs, outcome, and patient experience in a way that 
we otherwise could not have done.
    The hearing record will remain open for 10 days. Members 
may submit additional information for the record at that--
during that time if they would like.
    I would encourage the witnesses, if you have any additional 
comments that have come up as a result of today's discussion 
about exactly what we should do about the 31 Federal policy 
changes, we would welcome those.
    Our Committee will meet again at 10 a.m. on next Tuesday, 
the 23rd, for a hearing on COVID-19: Lessons Learned to Prepare 
for the Next Pandemic. I put out a white paper 10 days ago with 
five major areas. Suggesting that our attention spans are 
short, we know another pandemic will someday come and, while 
our minds are on the subject, this year, Congress needs to act 
to do whatever we need to do to be better prepared for the next 
one.
    Thank you for being here today. The Committee will stand 
adjourned.

                          ADDITIONAL MATERIAL

                           Letters of Support

           National Association of Counties (NACo),
                                                     June 16, 2020.
The Hon. Lamar Alexander, Chairman
The Hon. Patty Murray, Ranking Member
Senate Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC.

    Dear Chairman Alexander and Ranking Member Murray:

    On behalf of the National Association of Counties (NACo) and the 
3,069 counties we represent, thank you for holding tomorrow's hearing, 
``Telehealth: Lessons Learned From the COVID-19 Pandemic.'' We 
appreciate your efforts to assess our Nation's telehealth capacity as 
we see increasing demand for health services and, most importantly, for 
your leadership on previous COVID-19 relief packages that helped local 
governments better respond to the pandemic in our communities.

    As counties continue our efforts on the frontlines of the 
coronavirus pandemic, telehealth has emerged as an essential component 
of the local response to COVID-19. Counties operate and support over 
1,900 local public health departments and nearly 1,000 public hospitals 
and critical access clinics. Additionally, counties make investments in 
key Federal programs and services, such as Medicaid and the Children's 
Health Insurance Program (CHIP) as well as county-based behavioral 
health services, which exist in 23 states that represent 75 percent of 
the U.S. population. These investments build and protect the local 
health safety net, which administers wrap-around human service supports 
for our Nation's most vulnerable residents.

    Prior to the pandemic, the use of telehealth was deemed by the 
Centers for Medicare and Medicaid Services' (CMS) as an effective 
strategy in reaching those patients in remote areas and reducing the 
number of in-office visits. Now, this technology has become 
increasingly critical for counties, as the demand for vital medical, 
behavioral health and substance use disorder services increases, and we 
look for ways to protect the medically vulnerable from in-person 
appointments during this public health emergency.

    County health providers across the Nation have rapidly adapted 
telehealth technologies to provide necessary services to residents. 
Examples include:

          Cook County, Ill., has created a multidisciplinary 
        behavioral health tactical team that brings together 
        psychiatrists, mental health professionals, and licensed 
        clinical social workers (LCSWs) to provide telehealth services 
        to individuals experiencing homelessness and residing in 
        shelters. The team helps to develop appropriate protocols to 
        support these individuals as they manage Severe Mental Illness 
        (SMI) and Substance Use Disorders (SUD).

          El Paso County, Colo., Dakota County, Minn., and 
        Coconino County, Ariz., have developed programs that address 
        the challenges associated with treating tuberculosis (TB) 
        through a smartphone telemedicine platform that delivers 
        directly observed therapy (DOT) to patients that are unable to 
        come in for an in-person evaluation. The program has resulted 
        in a cost savings of $7,000 during it's first year in Dakota 
        County.

    Beyond the health and safety benefits of using telehealth services 
to protect residents from the spread of COVID-19, the use of telehealth 
technology provides unique cost-saving opportunities for counties, who 
are facing growing budgetary and economic challenges as a result of the 
pandemic. To ensure that counties can continue to protect our residents 
while providing essential health services, we respectfully urge your 
bipartisan support and cooperation for a new round of direct, flexible 
aid for local governments that could include enhanced telehealth 
resources for counties.

    We thank you again for this hearing and for your efforts to assess 
the scale of this historic crisis and ask you to come together to 
provide critically needed resources to help counties respond.

            Sincerely,
                                          Matthew D. Chase,
                                            Executive Director/CEO,
                                  National Association of Counties.
                                 ______
                                 
   American Connection Project Broadband Coalition,
                                                     June 16, 2020.
The Hon. Lamar Alexander, Chairman
The Hon. Patty Murray, Ranking Member
Senate Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC.

    Dear Chairman Alexander and Ranking Member Murray:

    Thank you for leadership in response to the needs of communities 
and patients during the pandemic and for holding today's hearing 
entitled Telehealth: Lessons from the COVID-19 pandemic.

    We are writing as members of the American Connection Project 
Broadband Coalition, a collection of 25 major companies and trade 
associations being led by Land O'Lakes Inc. The coalition, representing 
agriculture, financial services, healthcare and technology, is 
advocating for robust funding for Federal investment in broadband 
internet connectivity to advance telehealth, distance learning and the 
tremendous economic value that comes with internet connectivity. As the 
pandemic shined a light on the essential nature of connectivity, we 
were grateful for the responsiveness of Governors who called for 
policies to increase telehealth access and broadband internet service, 
and the Members of Congress who took unprecedented action to respond to 
COVID-19. Given the increased access to health care that telehealth has 
provided during this public health emergency, it is clear that expanded 
telehealth policies must be a permanent tenet of our health care 
system.

    Our coalition's healthcare partners have witnessed the positive 
impact of telehealth in improving access to care and improving patient 
experience. For example:

          HealthPartners saw a 10 percent increase in completed 
        visits in mental health over a two-month period of the pandemic 
        compared to visits in 2019 and had their patient no show rate 
        decrease by nearly 50 percent.

          Mayo Clinic conducted more telehealth visits per day 
        during the pandemic than all of the visits combined in 2019. To 
        highlight the utilization of one type of telehealth modality, 
        during April 2020, Mayo Clinic completed over 45,000 video 
        appointments direct to patients. During this time, Mayo Clinic 
        provided care to nearly 8000 patients each day using a variety 
        of digital healthcare tools. Importantly, recent patient 
        surveys indicate that patients are as equally satisfied with 
        video visits as with in-person visits overall.

          Gillette Children's Specialty Healthcare has 
        conducted virtual care visits with nearly 3,700 children since 
        the end of March helping ensuring continuity of care for 
        children with disabilities and complex conditions.

          Cleveland Clinic implemented telephone and app-based 
        monitoring of nearly 13,000 elderly, frail patients with 
        chronic conditions, escalating to a virtual visit to address 
        urgent issues. This resulted in a 35 percent reduction in 
        admissions compared to a risk-adjusted control group.

          CentraCare, serving predominately rural areas and 
        small towns, has seen significant utilization of telehealth 
        services from patients in their 60's, 70's, 80's, and even 
        90's, with no reduction at all in patient satisfaction.

    We must continue momentum to improve public health, now more than 
ever before. We urge Congress to undertake legislative action to make 
permanent those emergency flexibilities that have allowed providers and 
patients to determine where the best care takes place. For many 
patients, including those in both rural and urban areas, this means 
receiving high quality care at home or as close to home as possible, 
through virtual visits. Additionally, we support regulatory efforts by 
the Centers for Medicare and Medicaid Services to make permanent the 
broad array of providers and service lines newly available to Medicare 
and Medicaid beneficiaries during the pandemic.

    We appreciate your consideration of permanently implementing the 
policy changes that have accelerated virtual healthcare access during 
COVID-19. We also know that improving Americans' access to broadband 
can further increase telehealth access and improve the health and well-
being of our communities long into the future. There is no investment 
that will deliver more impactful or immediate returns.

            Sincerely,

                                                 Beth Ford,
                                                 President and CEO,
                                                 Land O'Lakes, Inc.
                                            Kenneth Holman,
                                                 President and CEO,
                                                        CentraCare.
                                           Dr. Steven Ommen
                                                    Associate Dean,
                                         Center for Connected Care,
                                                       Mayo Clinic.
                                   Barbara P. Glenn, Ph.D.,
                                           Chief Executive Officer,
                   National Association of State Departments of Ag.
                                              Chuck Connor,
                                                         President,
                           National Council of Farmer Cooperatives.
                                              Daniel Smith,
                                                 President and CEO,
                                               Cooperative Network.
                                         Brent Christensen,
                                                 President and CEO,
                                        Minnesota Telecom Alliance.
                                              Mike Parrish,
                            Vice President of Government Relations,
                                                             Bayer.
                                              Andrea Walsh,
                                                 President and CEO,
                                                   Health Partners.
                                             Barbara Joers,
                                                 President and CEO,
                          Gillette Children's Specialty Healthcare.
                                 Tomislav Mihaljevic, M.D.,
                                                 CEO and President,
                                                  Cleveland Clinic.
                                               Zippy Duval,
                                                         President,
                                   American Farm Bureau Federation.
                                             Tom Halverson,
                                                 President and CEO,
                                                            CoBank.
                                            Vince Robinson,
                                                             Chair,
                               Minnesota Rural Broadband Coalition.
                                             Deanna Larson,
                                                 President and CEO,
                                                       Avera eCARE.
                                          Hunter Carpenter,
                                         Director of Public Policy,
                                Agricultural Retailers Association.
                                 ______
                                 
    Alzheimer's Association and Alzheimer's Impact 
                  Movement Statement for the Record
                                                      June 17, 2020
    The Alzheimer's Association and Alzheimer's Impact Movement (AIM) 
appreciate the opportunity to submit this statement for the record for 
the Senate Committee on Health, Education, Labor, and Pensions (HELP) 
hearing entitled ``Telehealth: Lessons from the COVID-19 Pandemic.'' 
The Association and AIM thank the Committee for its continued 
leadership on issues important to the millions of people living with 
Alzheimer's and other dementia and their caregivers. This statement 
provides an overview of telehealth policies that would help people 
living with Alzheimer's and other dementia, including efforts to expand 
capacity for health outcomes through Project ECHO, and the temporary 
expansion of Medicare and Medicaid coverage of certain telehealth 
services during the COVID-19 pandemic.

    Founded in 1980, the Alzheimer's Association is the world's leading 
voluntary health organization in Alzheimer's care, support, and 
research. Our mission is to eliminate Alzheimer's and other dementia 
through the advancement of research; to provide and enhance care and 
support for all affected; and to reduce the risk of dementia through 
the promotion of brain health. AIM is the Association's sister 
organization, working in strategic partnership to make Alzheimer's a 
national priority. Together, the Alzheimer's Association and AIM 
advocate for policies to fight Alzheimer's disease, including increased 
investment in research, improved care and support, and development of 
approaches to reduce the risk of developing dementia.
         Expanding Capacity for Health Outcomes (Project ECHO)
    The Alzheimer's Association and AIM support legislative efforts to 
expand the use of technology-enabled collaborative learning and 
capacity-building models. These innovative education models, often 
referred to as Project ECHO, help build workforce capacity and improve 
access to care. These models use a hub-and-spoke approach by linking 
expert specialist teams at a `hub' with the `spokes' of health 
providers in local communities to increase on-the-ground expertise. 
Using case-based learning, Project ECHO models can improve the capacity 
of providers, especially those in rural and underserved areas, on how 
to best meet the needs of people living with Alzheimer's and other 
dementia.

    The Alzheimer's Association has conducted multiple Project ECHO 
programs in primary care and assisted living communities. These Project 
ECHO models focus on increasing access to dementia diagnosis and care 
through primary care providers and on increasing person-centered 
dementia care in assisted living communities. According to an 
evaluation of the Association's first two pilot programs by the Center 
for Evaluation and Applied Research at The New York Academy of 
Medicine, primary care participants reported the most significant 
knowledge gains in identifying and screening for dementia, medication 
management, and communication with patients and family members. The 
evaluation also showed that participants from assisted living 
communities said the increased knowledge led to a change in their 
practices and gave them a better understanding of person-centered care.

    The Alzheimer's Association is formalizing a global network of ECHO 
hubs to address Alzheimer's and other dementia, and will build momentum 
for additional ECHO hub creation by partnering with the research 
community, medical professionals, key stakeholders in the dementia care 
industry and policy leaders and advocates. This consortium of thought 
leaders across the spectrum will increase evidence around the use of 
ECHO in promoting best practice dementia care, accelerate the uptake of 
evidence into practice, and help policymakers understand and support 
Project ECHO dementia models.

    Project ECHO is currently playing an important role in how health 
providers, public health officials, and scientists are sharing best 
practices and information for addressing the COVID-19 pandemic. Project 
ECHO dementia models are helping primary care physicians in real-time 
understand how to use validated assessment tools appropriate for 
virtual use to make early and accurate diagnoses, educate families 
about the diagnosis and home management strategies, and help caregivers 
understand the behavioral changes associated with Alzheimer's, which 
can be heightened during social isolation. Project ECHO is also helping 
long-term care providers in real-time understand how to train temporary 
staff that may not be familiar with how to best care for people with 
Alzheimer's, implement important health strategies, such as hand-
washing and social distancing for people with Alzheimer's, and 
effectively communicate with residents to help them understand the 
COVID-19 pandemic.

    The Alzheimer's Association has also developed a COVID-19-specific 
Project ECHO series based on our guidance Emergency Preparedness: 
Caring for persons living with dementia in a long-term or community-
based care setting. This series focuses on sharing best-practice 
recommendations for person-centered care, illness prevention, resident 
engagement and connectedness to family and friends, nutrition support 
and mobility, and strategies related to dementia-related behaviors in 
emergency situations. This will help providers understand how to best 
respond to challenging cases related to the COVID-19 pandemic within 
their own communities.

    The Alzheimer's Association and AIM urge the Committee to pass the 
Expanding Capacity for Health Outcomes (ECHO) Act of 2019 (S. 1618/H.R. 
5199) and ensure that Alzheimer's and other dementia are included. This 
bipartisan bill would provide Federal funding to help expand the use of 
Project ECHO models. This expansion and evaluation of Project ECHO 
would increase timely access to specialized health care, like better 
dementia diagnosis and care, and improve the quality of life for those 
that need it the most.
                    Expansion of Telehealth Services
    The Alzheimer's Association and AIM also support the expansion of 
Medicare and Medicaid coverage for certain telehealth services in 
response to the COVID-19 pandemic. The Centers for Medicare & Medicaid 
Services (CMS) has temporarily expanded coverage for numerous codes 
that are beneficial to people living with Alzheimer's and other 
dementia. This population is particularly vulnerable to the effects of 
COVID-19 due to their typical age and their co-occurring chronic 
conditions, so we appreciate the flexibilities CMS has implemented to 
reduce the risk of their exposure to the virus and ensure regular 
access to quality care. We encourage CMS to evaluate the effectiveness 
of these temporary codes, to the extent possible, as the pandemic 
subsides to determine whether some are appropriate for permanent 
telehealth eligibility.

    The Alzheimer's Association and AIM particularly support CMS's 
decision to allow for telehealth coverage of the Medicare care planning 
CPT code 99483. Care planning is critical for people with cognitive 
impairment under normal circumstances to help them manage comorbid 
conditions and make decisions about long-term care and support 
services, among others. Ensuring that a plan is established, 
documented, and updated is now more important than ever. Making this 
service available via telehealth will improve access to care planning 
for this vulnerable population. To that end, we also urge Congress to 
pass the bipartisan Improving HOPE for Alzheimer's Act (S. 880/H.R. 
1873), which would educate clinicians on the importance and 
availability of this crucial Medicare care planning service.

    Finally,we appreciate CMS's flexibility in allowing telehealth 
technology to be used in home health delivery. Thirty-two percent of 
individuals using home health services have Alzheimer's or other 
dementia. The ability to receive care in the home decreases visits to 
unfamiliar places that may cause agitation in people with dementia and 
can ease some burden on caregivers. This increased flexibility can 
reduce interruptions in access to this kind of quality care. We also 
support CMS's expansion of the licensed practitioners, such as nurse 
practitioners and physician assistants, who can order Medicaid home 
health services. Twenty-seven percent of older individuals with 
Alzheimer's or other dementia who have Medicare also have Medicaid 
coverage, compared with 11 percent of individuals without dementia.
                               Conclusion
    The Alzheimer's Association and AIM appreciate the steadfast 
support of the Committee and its continued commitment to advancing 
legislation important to the millions of families affected by 
Alzheimer's and other dementia. We look forward to working with the 
Committee and other Members of Congress in a bipartisan way to advance 
policies that would help this vulnerable population during the COVID-19 
pandemic and beyond, through the expansion of Project ECHO models and 
through Medicare and Medicaid coverage of certain telehealth services.
                                 ______
                                 

                         QUESTIONS AND ANSWERS

Responses by Karen S. Rheuban, to Questions From Senator Casey, Senator 
       Warren, Senator Smith, Senator Rosen and Senator Loeffler
                      senator robert p. casey, jr.
    Since the Medicaid program works as a partnership between the 
Federal Government and the states, it does not always receive the focus 
Medicare does when Congress develops policies around telehealth.

    Question 1.

    What more can Congress do to support the inclusion of Medicaid in 
policies that increase access to telehealth, particularly across state 
lines, both now and after the conclusion of the national emergency?

    Answer 1. I believe that Congress should take action to encourage 
or even require alignment across our Medicaid programs. Each state 
Medicaid program provides some form of coverage of telemedicine but 
there is no baseline standard for coverage determination nor alignment 
across the states. This remains a serious barrier to provider adoption.

    Prior to the pandemic, in some states, Medicaid program engagement 
in telehealth has been more expansive than that of Medicare as the 
Section 1834m restrictions had not been applied to Medicaid. Payment, 
even when at parity for in-person care, remains at lesser rates than 
Medicare or commercial payers. Lack of alignment with Medicare coverage 
creates challenges for providers and/or health systems seeking to 
create uniform models and processes that enable the care of patients 
using telehealth tools. In addition, when changes occur in the annual 
Medicare Physician Fee Schedule, these changes are not generally 
reflected in Medicaid coverage which often takes state legislation to 
enable.

    As an example, prior to the COVID-19 pandemic, Virginia Medicaid 
covered facility based telemedicine visits without geographic 
restriction, but did not cover remote patient monitoring, eConsults or 
enabled the home as an eligible originating site. Post public health 
emergency, with the support of our Governor, Virginia Medicaid greatly 
increased telemedicine coverage by enabling home as an eligible 
originating site, telephone visits, and provided limited coverage for 
remote monitoring (for COVID+ or suspected COVID+ patients only) along 
with coverage for eConsults. Those changes were not tied to the state's 
Section 1135 waiver, and as such, will not necessarily sunset with the 
public health emergency.

    The impact of Medicaid program lack of alignment with Medicare is 
exacerbated when providers work in multiple states, in which variable 
coverage policies create a further disincentive to adoption. To add to 
the uncertainty, many states contract with managed care organizations 
(MCOs) who themselves may choose to offer telemedicine as an enhanced 
benefit for their enrollees. The need to contract with multiple MCO 
entities in addition to fee-for-service Medicaid, creates additional 
barriers for those wishing to provide care to our high risk patient 
populations and low income citizens who would most benefit from 
telehealth solutions.

                        senator elizabeth warren
    As part of your testimony, you recommended that Congress ``ensure 
robust funding to expand broadband infrastructure across the Nation to 
ensure that all patients have access to telehealth services, both 
during and after the public health emergency.'' This recommendation 
stems, in part, from your assertion that ``a lack of broadband is a 
health equity issue.'' In other words, people who cannot access the 
Internet--or other technologies necessary to access telehealth 
services--will not be able to see the same benefits from telehealth as 
their more advantaged counterparts. According to the Pew Research 
Center, ``racial minorities, older adults, rural residents, and those 
with lower levels of education and income are less likely to have 
broadband service at home.''

    Question 1.

    What are the primary barriers facing people of color, older adults, 
rural residents, and low-income Americans who struggle to access 
telehealth services?

    Question 2.

    In addition to expanding access to broadband infrastructure, what 
specific policies and programs, if any, do you believe Congress should 
pursue in its effort to ensure equitable access to telehealth services, 
regardless of race, income, age, or zip code?

    Answer 1 & 2. Our experience during the pandemic demonstrated that 
at least 25 percent of our virtual visits had to be conducted via 
telephone because of an inability to facilitate a video-based 
connection to the home of the patient. The inability to provide video-
based care in those instances stemmed from a host of issues to include 
a lack of broadband to the home (whether because of price or 
unavailability), technology related factors, lack of smart phone or 
computer in the home, or age or disability related factors that 
resulted in patients falling back to receiving care via telephone. The 
Federal Communications Commission has done elegant broadband mapping, 
as have many of the states, but even having broadband available in the 
community does not ensure that the home itself or the patient is 
connected. Federal programs such as those supported by the FCC's 
Universal Service Fund, those of the U.S. Department of Agriculture or 
the Department of Commerce can bring connectivity to a community. 
Expansion to underserved communities and to the home should be our next 
priority. Amongst the Universal Service Fund programs, the Lifeline 
program can facilitate services to the home for low income citizens and 
the recent adoption of the FCC's Connected Care Pilot Program will 
enable greater connectivity to the home of patients.

    Of note, in the Commonwealth of Virginia, some of our Medicaid 
managed care organizations offer the use of a smartphone to patients 
with medical complexity as an enhanced benefit. This model could be 
expanded nationwide to dual eligible populations or for other patients 
with medical complexity.
                           senator tina smith
    The internet gap has resulted in millions of Americans not being 
able to access telehealth. Hennepin Healthcare--that serves 
Minneapolis--has found that increased audio-only telephone telehealth 
services are reducing disparities driven by the digital divide. 
Community Mental Health Centers in Minnesota are eating the cost to buy 
this equipment for their patients so they remain connected to their 
care.

    Question 1.

    How is the lack of Internet access impacting telehealth, and how 
has the access to audio-only, phone services helped address this 
disparity?

    Question 2.

    What are the risks for patient outcomes if we rely strictly on 
audio-only, phones services to address this disparity?

    Answer 1. I believe we need a coordinated strategy to ensure that 
all Americans have access to connectivity that enables the delivery of 
video-based healthcare services (and to follow, health related economic 
prosperity). Activation of telephone codes by Medicare and many 
Medicaid programs has been a life saver. A broader approach to 
telemedicine deployment requires coordinated payment policies that 
drive adoption across Medicare and Medicaid, and a strategy that 
mitigates broadband disparities.

    Answer 2. Audio only, while helpful for existing patients in the 
context of the patient's medical home in my opinion, is not an optimal 
solution for new patients. Having video capability enhances the ability 
of the provider to examine the patient; the addition of remote 
examination tools enable care that comports with the standards of in-
person care.
                          senator jacky rosen
    Prior to the pandemic we were already struggling with a shortage of 
mental health services, especially for children who had experienced 
trauma. I have been very supportive of Federal funding for grants that 
pair pediatrician offices with children's mental health providers via 
telehealth.

    Question 1.

    Dr. Rheuban, how might we further expand access to mental health 
care services through telehealth, specifically with providers 
specializing in trauma, to ensure that at-risk youth and other 
vulnerable populations have improved access to care?

    Question 2.

    What else should Congress consider doing to help bring specialized 
mental health services to more people, including through community 
health centers, rural health clinics, and other primary care providers?

    Answer 1 & 2. Our nation faces a critical shortage of mental health 
providers serving all patient age groups. Substance use disorders 
continue to devastate our communities. Telehealth has long been 
utilized to deliver mental health services to underserved communities 
and patients. Indeed, at UVA Health, prior to the pandemic, a full 50 
percent of our telemedicine encounters were provided by adult, child 
and emergency psychiatry providers. During COVID-19, our psychiatrists 
and other behavioral health providers rapidly scaled to replace in-
person services with video-based visits and where necessary, with 
telephone-based services.

    Since passage of the SUPPORT Act permitted the home as an eligible 
patient originating site, many state Medicaid programs have enabled 
that capability. However, we still await the Drug Enforcement Agency 
(DEA) promulgation of rules for the special registration of 
telemedicine providers (called for in the SUPPORT Act) that will 
further enable the establishment of a doctor-patient relationship that 
results in the prescribing of controlled substances. Prior to COVID-19, 
the DEA permitted the establishment of a doctor-patient relationship 
via telemedicine when the patient is located at a DEA registered 
facility or is in the physical presence of a DEA registered 
practitioner.

    There are important programs that integrate behavioral health into 
primary care settings. The Virginia Mental Health Access program is one 
such program which received Federal and state funds to bring pediatric 
behavioral health telemedicine services into primary care. It is an 
appropriate solution to bring care to our patients and to raise the 
knowledge and skills of our primary care provides.

    We also support the use of the Project ECHO model to enable one to 
educate many providers. UVA Health providers host a number of ECHO 
programs, to include training on substance use disorder, pain 
management and neonatal abstinence syndrome. Congress should pass and 
fund ``The ECHO 2019 Act,'' which would create a program to provide 
grants and technical assistance to further develop and evaluate the 
ECHO model and other similar models.

    Many of our federally qualified community health centers and rural 
health clinics operate in networks with multiple physical clinic 
locations and have hired behavioral health practitioners who may work 
in one location or travel to others. Prior to COVID-19, practitioners 
in those clinics were not permitted to serve as distant site providers. 
We urge Congress to continue the waiver process that enables our 
federally qualified health centers and rural health clinics to serve as 
both a patient originating site and a distant site.

    Last, in order to bring specialized mental health services to more 
people, we support increasing Medicare's support for physician resident 
training, which has been effectively frozen since 1997 due to caps on 
the number of medical residents that Medicare supports. Adequate and 
continued support for the health professions and nursing workforce 
development programs authorized under Titles VII and VIII of the Public 
Health Service Act is necessary as well.

                         senator kelly loeffler
    During the pandemic, physicians have reported an increased use of 
telemedicine to treat mental health patients. However, there are still 
mental health conditions that physicians are reticent to use telehealth 
to treat and/or diagnose patients. For example, I have heard that some 
providers are hesitant to make an ADHD diagnosis via telehealth because 
they feel it is a complicated diagnosis. Some physicians, however, have 
said anecdotally that they like telemedicine for ADHD patients because 
it allows the provider to see patient's home environment and better 
understand their circumstances.

    Even if we weren't in the middle of a pandemic, patients in rural 
areas have always faced this treatment barrier.

    Question 1.

    What can be done to enable physicians to embrace the potential of 
telehealth to not only provide continuity of care, but improve outcomes 
for the 1 in 5 US adults who experience mental illness every year?

    Answer 1. Please see my response to the related question from 
Senator Rosen regarding the adoption nationwide of telemental health 
services in support of adult, child, emergency and substance use 
disorder services.

    The psychiatry and behavioral health community have long embraced 
the use of telehealth in the delivery of mental health services. 
Movement toward integration of behavioral health services into primary 
care, where feasible, creates additional capacity, as do continuing 
education and training programs for health care providers such as 
Project ECHO. The benefits of Project ECHO could be expanded with the 
passage and funding of ``The ECHO 2019 Act,'' which would create a 
program to provide grants and technical assistance to further develop 
and evaluate the ECHO model and other similar models. In addition, in 
order to improve access to primary and specialty care, including mental 
health, Congress should increase Medicare's support for physician 
resident training, which has been effectively frozen since 1997 due to 
caps on the number of medical residents that Medicare supports. 
Adequate and continued support for the health professions and nursing 
workforce development programs authorized under Titles VII and VIII of 
the Public Health Service Act is necessary as well. Training programs 
for residents, fellows and advanced practice providers would benefit 
from training in the use of telemedicine as a care delivery model.

    Telemental health services can be conducted effectively with new 
patients. Our UVA Health division head of child psychiatry, Dr. Roger 
Burket, reports his faculty routinely diagnose initially and treat ADHD 
patients via telemedicine. They utilize intake information provided by 
the parent and school teacher, including ADHD rating scales as a part 
of the intake evaluation and are able to rule out other diagnoses. 
Where additional testing is needed, the patient is referred for that 
testing. Follow-up visits are effectively conducted via telemedicine as 
well.

    It is imperative that the DEA promulgate the rules for the special 
telemedicine registration to enable the establishment of a doctor-
patient relationship as it relates to prescribing of controlled 
substances, particularly when the home becomes the patient's 
originating site.
                                 ______
                                 
    [Whereupon, the hearing was adjourned at 12:09 p.m.]

                                  [all]