    [Senate Hearing 116-536]
    [From the U.S. Government Publishing Office]

                                                           S. Hrg. 116-536

                          THERE'S NO PLACE LIKE HOME:
                       HOME HEALTH CARE IN RURAL AMERICA

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

                                     HEARING

                                   BEFORE THE

                           SPECIAL COMMITTEE ON AGING

                              UNITED STATES SENATE

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 WASHINGTON, DC

                                   __________

                               FEBRUARY 12, 2020

                                   __________

                               Serial No. 116-18

             Printed for the use of the Special Committee on Aging

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                                   __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    47-056 PDF                 WASHINGTON : 2022

    -----------------------------------------------------------------------------------

                           SPECIAL COMMITTEE ON AGING

                       SUSAN M. COLLINS, Maine, Chairman

    TIM SCOTT, South Carolina            ROBERT P. CASEY, JR., Pennsylvania
    RICHARD BURR, North Carolina         KIRSTEN E. GILLIBRAND, New York
    MARTHA McSALLY, Arizona              RICHARD BLUMENTHAL, Connecticut
    MARCO RUBIO, Florida                 ELIZABETH WARREN, Massachusetts
    JOSH HAWLEY, Missouri                DOUG JONES, Alabama
    MIKE BRAUN, Indiana                  KYRSTEN SINEMA, Arizona
    RICK SCOTT, Florida                  JACKY ROSEN, Nevada
                                  ----------
                Sarah Khasawinah, Majority Acting Staff Director
                     Kathryn Mevis, Minority Staff Director

                             C  O  N  T  E  N  T  S

                                  ----------

                                                                       Page

    Opening Statement of Senator Susan M. Collins, Chairman..........     1
    Opening Statement of Senator Robert P. Casey, Jr., Ranking Member     6

                               PANEL OF WITNESSES

    Leigh Ann Howard, RN, DNP, CHFN-K, Director, Home Health and
      Speciality Programs, Northern Light Home Care & Hospice,
      Waterboro, Maine...............................................     4
    William Dombi, President, National Association for Home Care &
      Hospice, Washington, D.C.......................................     7
    Warren Herbert, DNP, RN, CAE, FAAN, Assistant Professor, Loyola
      University, and CEO, Home Health Care Association of Louisiana,
      Lafayette, Louisiana...........................................     9
    Francis Adams, Home Care Worker, Washington, Pennsylvania........    11

                                    APPENDIX
                          Prepared Witness Statements

    Leigh Ann Howard, RN, DNP, CHFN-K, Director, Home Health and
      Speciality Programs, Northern Light Home Care & Hospice,
      Waterboro, Maine...............................................    33
    William Dombi, President, National Association for Home Care &
      Hospice, Washington, D.C.......................................    39
    Warren Herbert, DNP, RN, CAE, FAAN, Assistant Professor, Loyola
      University, and CEO, Home Health Care Association of Louisiana,
      Lafayette, Louisiana...........................................    50
    Francis Adams, Home Care Worker, Washington, Pennsylvania........    55

                            Questions for the Record

    Francis Adams, Home Care Worker, Washington, Pennsylvania........    63
    William Dombi, President, National Association for Home Care &
      Hospice, Washington, D.C.......................................    64
    Leigh Ann Howard, RN, DNP, CHFN-K, Director, Home Health and
      Speciality Programs, Northern Light Home Care & Hospice,
      Waterboro, Maine...............................................    65

                      Additional Statements for the Record

    Senator Tim Scott's Statement for the Record.....................    69
    National Community Pharmacists Association.......................    70
    American Assoication of Nurse Practitioners......................    74
    American Academy of PAs..........................................    81
    Submitted Public Comment of Christopher E. Laxton................    83
    The American Occupational Therapy Association, Inc...............    85
    America's Health Insurance Plans.................................    88
    Leading Age Submission of Statement for the Record...............    96

                          THERE'S NO PLACE LIKE HOME:
                       HOME HEALTH CARE IN RURAL AMERICA

                                  ----------

                          WEDNESDAY, FEBRUARY 12, 2020

                                           U.S. Senate,
                                    Special Committee on Aging,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 9:02 a.m., in
    Room SD-366, Dirksen Senate Office Building, Hon. Susan M.
    Collins, Chairman of the Committee, presiding.
        Present: Senators Collins, Hawley, Braun, Rick Scott,
    Casey, Gillibrand, Blumenthal, Jones, Sinema, and Rosen.

                     OPENING STATEMENT OF SENATOR
                       SUSAN M. COLLINS, CHAIRMAN

        The Chairman. The Committee will come to order.
        Good morning. Let me explain to everyone the early start
    for this hearing. The Senate has scheduled a series of votes to
    begin at 10:30. We did not expect that and we had witnesses on
    the way, so we did not want to postpone the hearing, so I am
    going to start with my opening statement. I expect the Ranking
    Member, Senator Casey, will be here shortly, and when he is
    able to get here I will interrupt the hearing and allow him to
    deliver his opening statement but I want to thank all of our
    witnesses and those who are here today for your flexibility.
    Unfortunately, I do not control the floor schedule, and usually
    our votes are in the afternoon, not the morning, but today is
    different.
        First, let me bid you all a good morning. Year after year,
    when seniors are asked how they want to spend their golden
    years, they overwhelmingly answer ``at home.'' Today's hearing
    will focus on how we can better help our seniors achieve that
    goal.
        I saw first-hand the importance of home care in my very
    first home visit during my second year of Senate service. In my
    hometown in Aroostook County I saw how home health care allowed
    an older couple in their 80's to spend the rest of their lives
    together in the comfort, security, and privacy of their own
    home. They were worried that otherwise they would be separated
    and one of them living in a nursing home. I remembered them
    telling me that all they wanted was to spend the rest of their
    lives together in their own home.
        Highly skilled and caring visiting nurses make such a
    difference in the lives of patients and families like this
    couple. In Maine, home health workers often go to extraordinary
    lengths for their rural patients, sometimes relying on lobster
    boats and mail planes to reach them.
        Home health care not only helps seniors live in the comfort
    of their own homes but it also saves money. According to
    research from the University of Rochester, older adults who
    receive one to two hours of in-home physical therapy, for
    example, are up to 82 percent less likely to face hospital
    readmissions 60 days after discharge. Studies from post-acute
    care discharge patterns have shown that clinically appropriate
    deployment of home health care can yield potential savings of
    more than $32 billion over 10 years.
        In the face of workforce shortages and payment cuts,
    today's hearing will highlight challenges that are facing the
    home health community. For those in rural areas where more than
    one in five older adults live, home health can be a lifeline,
    and we must do more to meet growing needs.
        As we look to the future, the demand for home health
    services will only continue to grow as our population ages.
    According to the Bureau of Labor Statistics, the need for home-
    based aides is projected to grow by 97 percent over the next 10
    years, making it the third-fastest-growing occupation.
        Yet while we recognize the value that home health can
    provide, many home health agencies are struggling in the
    current reimbursement and regulatory environment, precisely at
    the moment when we need their services more than ever.
        I am concerned about the implementation of the new patient-
    driven groupings model and the ability of rural agencies to
    absorb preemptive rate cuts of more than 4 percent based off
    assumptions that somehow agencies will try to maximize
    reimbursement.
        Agencies have weathered several years of reimbursement
    reductions through both regulatory changes as well as
    sequestration, and we cannot assume that they can continue to
    provide the same level of home health services at reduced
    rates. That is why I have introduced the Home Health Payment
    Innovation Act, which has been co-sponsored by 31 Senators,
    including committee members Tim Scott, Jones, Sinema, Burr,
    Rosen, and Rubio. My legislation would prevent further
    inequitable payment rate cuts. It would provide flexibility on
    waiving the homebound requirement for services.
        According to a survey of home health administrators by the
    Walsh Center for Rural Health, more than two-thirds reported
    that there were rural patients who could benefit from home
    health services but simply did not meet the criteria for being
    homebound. Furthermore, one-third reported that it could be
    inconvenient or even dangerous for some senior patients to be
    driving. However, because they did not drive, they did not
    qualify for services--because they did drive, they did not
    qualify for services.
        As home health agencies are adjusting to the new payment
    system, I believe that Congress should revisit the rural add-on
    payment. A well-targeted rural add-on payment is especially
    needed now, and it is needed to compensate home health agencies
    that are operating in vast rural areas, such as northern Maine,
    where they have to drive long distances between patients.
        I have also introduced the Home Health Care Planning
    Improvement Act, which has 41 co-sponsors, including Senators
    Casey, Sinema, and Gillibrand. This bill would improve the
    access Medicare beneficiaries have to home health care by
    allowing physician assistants, nurse practitioners, and
    clinical nurse specialists to order home health care services.
    That would be particularly helpful in rural and underserved
    areas of our Nation.
        In many instances in rural areas, a patient's primary
    health provider may not be a physician. Yet today only
    physicians are allowed to certify home health care for Medicare
    patients, even though they may not be the most familiar with
    the patient's case. In fact, they may not be familiar at all
    with the patient or his or her condition.
        These requirements create obstacles, delays, and
    administrative burdens to receiving home health care services.
    Last summer, Health Affairs featured an article that put a
    human face on the unintended consequences of its policy. A
    rural patient waited several days before a physician was
    available to sign an order for home health care. By that time,
    an open wound on his hip had doubled in size and deepened.
    Instead of taking two to 3 weeks to heal it took nearly 3
    months, so this policy has real consequences for the health of
    our patients. By helping patients to avoid more costly hospital
    visits and nursing homes, home health saves Medicare, Medicaid,
    and private insurers millions of dollars each year and allows
    seniors to age in the comfort and security of their own homes.
        I have never understood why administration after
    administration targets home health care for reimbursement cuts.
    If there are bad apples in the industry, go after those
    agencies. Do not penalize everyone. That makes no sense
    whatsoever when home health care reflects the choice that the
    patient wants and is the most appropriate care, and saves
    money.
        I am looking forward to hearing from each of our witnesses
    today, and I am going to introduce our witnesses, and as I
    said, when Senator Casey arrives we will interrupt and have him
    deliver his opening statement.
        First I am very pleased to welcome Leigh Ann Howard from
    the great State of Maine. Leigh Ann is the Director of Home
    Health and Specialty Programs at Northern Light Home Care &
    Hospice. In this capacity, she is responsible for directing the
    development of new and innovative telemedicine and health
    programs. I am really interested in telemedicine and what that
    could do to help solve some of the distance problems that we
    have.
        Leigh Ann has been on the forefront of bringing
    telemedicine and home health to Mainers, and I am delighted
    that she is able to be with us today.
        Next we will hear from William Dombi. I know Bill very well
    and have worked with him for many years. He is the President of
    the National Association for Home Care & Hospice. This
    association represents more than 33,000 home care and hospice
    providers, as well as more than 2 million nurses, therapists,
    and aides that they employ nationwide. He is also the Director
    of the Center for Health Care Law and Executive Director of the
    Home Care & Hospice Financial Managers Association. He is a
    longstanding champion in the field of home care.
        Next we will hear from Dr. Warren Hebert. I told Dr. Hebert
    that because I am from northern Maine I know how to pronounce
    his last name, since Louisiana and Northern Maine both have a
    lot of Acadian influence. He is an Assistant Professor as well
    as being the CEO of the Home Health Care Association of
    Louisiana. He has worked in home care since 1985, and has
    offered his expertise to panels and reports for many
    institutions, including the Institute for Medicine and CMS.
        Our final witness is from Pennsylvania. Mr. Francis Adams
    is a home care worker from Washington, Pennsylvania. I know
    that Senator Casey has a fuller introduction of you that he
    will want to give, so I will hold up but express my gratitude
    for your being here today as well.
        Ms. Howard, we are going to start with you.

                STATEMENT OF LEIGH ANN HOWARD, RN, DNP,

                   CHFN-K, DIRECTOR, HOME HEALTH AND

                   SPECIALTY PROGRAMS, NORTHERN LIGHT

                 HOME CARE & HOSPICE, WATERBORO, MAINE

        Ms. Howard. Chairman Collins, Ranking Member Casey, and
    members of the U.S. Senate Special Committee on Aging, good
    morning. My name is Leigh Ann Howard and I want to thank you
    for this opportunity to speak to you today to share our
    experiences as a provider of home health care in rural America.
        I currently serve as the Director of Home Health and
    Specialty Programs at Northern Light Home Care and Hospice,
    which a Medicare-certified home care and hospice agency. As a
    member of Northern Light Health, a Maine-based integrated
    health care system, our home health and hospice programs
    provide care throughout the entire State of Maine. Maine
    citizens are among the oldest in the country living in a large
    rural geography.
        Over the last year, Northern Light Home Care and Hospice
    clinicians drove over three million miles to provide care,
    making close to 200,000 home care and hospice visits. At times
    the transportation to get to these patients' homes is just as
    unique as the geography of the State of Maine.
        For example, to serve many of our island communities off
    the coast of Maine, our clinicians need to travel by lobster
    boat or mail boat as this is the only way to access the island.
    This time of year, our staff may have to shovel their way down
    a long snowy driveway to reach the front door.
        Traveling the winding back roads in unpredictable weather
    conditions of western Maine also brings another layer of
    challenge, and many times the travel time between each patient
    can be an hour or more.
        As Maine's rural population continues to decline, so do the
    number of qualified health care professionals. Health care
    workforce shortages have reached critical levels in our State.
    Not only do we experience a significant nursing workforce
    shortage but also in primary care physicians. Nurse
    practitioners many times are the only primary care clinicians
    in our rural areas. Unfortunately, Federal law prohibits those
    nurse practitioners and physician assistants from ordering home
    health services.
        Recently we received a referral for a patient who had just
    been discharged from the hospital. He needed home health and
    physical therapy services. We worked for over 2 weeks with the
    patient's nurse practitioner to try to find a physician who
    would sign for the home health care that he needed. Some
    patients are even readmitted to the hospital before we can even
    find a physician who will sign for the plan of care.
        Rural residents already face many challenges to accessing
    the care they need and it is important that we remove those
    barriers to be able to allow them to access health care,
    regardless of where they live.
        Recent changes in Medicare, brought by PDGM have driven
    home the importance to us of collaboration between our home
    care staff, patients, physicians, and our patients' families.
    We are focused on how technology helps us to achieve the best
    collaboration with all of them.
        To focus on this, we have realized a significant success
    with our home telemonitoring program. This services places
    technology in the patient's home where they check their weight,
    their blood pressure, and their heart rate. That information is
    then transmitted to a web-based portal, either by cell signal
    or by the patient's home Wi-Fi.
        This information is then reviewed daily by the nurse. The
    telemonitoring nurse can then act on those readings, whether it
    is calling the patient to investigate the symptoms further,
    calling a physician, and collaborating with a physician to make
    medication adjustments, all while the patient is still
    remaining in the home.
        Our telemonitoring program has realized a rehospitalization
    rate of between 2 to 4 percent, which when compared to the
    national average or 24 percent rehospitalization rate for heart
    failure patients is a significant improvement.
        One patient we have been seeing for a number of years,
    before coming on to a telemonitoring program, had over 20 ER
    and hospitalizations over a matter of 6 months. While working
    with our health care clinicians, our telemonitoring program,
    and our physicians, we were able to significantly decrease her
    rehospitalization rate, and most importantly, we have kept her
    in her home for over 5 years.
        Telemonitoring services are not reimbursed by Medicare but
    it is allowable in the episodic payments for home health.
    However, we need to always continue to move to a discharge with
    those patients, and with that we need to remove that equipment
    that is in the home, which then brings that patient to be at a
    significant risk of being readmitted to the hospital. We are
    removing a device or a product that is helping us to be able to
    identify symptoms early, treat them in the home or in the
    physician's office, and out of the ER or the hospital.
        Connectivity is also a challenge in our State. There are
    significant areas with little to no cell coverage, poor or no
    broadband access, and sometimes the cost of those services is
    just more than a patient can afford, and this also prevents us
    from continuing to move forward with video-based home visits.
        Other services that we think would help to keep our
    patients in their home longer are home-based pharmacists
    visits, as many of our patients experience polypharmacy, taking
    more than 25 medications.
        Again, I am so honored to be here today to be able to share
    our work with you, and I just thank you for this awesome
    opportunity.
        The Chairman. Thank you very much for your testimony. I am
    now going to turn to our Ranking Member for his opening
    statement and to complete the introduction of Mr. Adams, who I
    introduced just briefly in anticipation of your arrival. Thank
    you.

                     OPENING STATEMENT OF SENATOR
                  ROBERT P. CASEY, JR., RANKING MEMBER

        Senator Casey. Chairman Collins, thanks very much. I
    apologize for being late. We had a scheduling change and I am
    sorry for that delay.
        I am pleased that the Committee today has convened to
    discuss the important issue of access to health care,
    particularly home health care and rural communities. From
    Washington County, which is in southwestern Pennsylvania, where
    our witness, Mr. Adams, is from, from that county to Wayne
    County, way up in northeastern Pennsylvania, near where I live,
    there is about 350 miles of road through rural Pennsylvania. We
    know from research that people who live along that stretch of
    road and along rural roads across the country are more likely
    to be older, to be sicker, and to be less well off than their
    peers, and as a result they require more health care services.
        I visited with seniors and people with disabilities in at
    least 33 of our 67 counties in the last couple of years. One of
    the constants I hear is that they prefer to age and receive
    services and supports in their homes and in their communities.
    Due to transportation constraints and travel distances,
    accessing those services can be challenging, and that is an
    understatement. That is especially true for seniors and people
    with disabilities living in rural areas of our State and our
    country.
        They tell me that they skip medical appointments because
    there is no affordable or easy way to make the trip. This can
    lead to even greater disparities and even worse health
    outcomes. In an effort to meet people where they are and keep
    them healthier longer, we must make investments to expand
    access to rural health services at both the macro level and
    micro level. We must ensure that individuals and families have
    affordable health care.
        It is why I have been fighting to protect the Affordable
    Care Act and Medicaid from cuts by the Administration and
    sabotage. We must protect Medicare from the half a trillion
    dollars in budget cuts that have been recently proposed by the
    Administration. We must support rural hospitals. That is why I
    introduced the Rural Hospital Sustainability Act, which
    provides stable funding for rural hospitals, allowing hospitals
    to redesign their care and remain open in rural communities,
    and we must invest in home health care. I am introducing the
    Home and Community-Based Services Infrastructure Improvement
    Act. This bill will provide Medicaid grants to all states to
    support existing service providers, and encourage the creation
    of new delivery systems to meet the needs of older adults and
    people with disabilities. The bill provides states with funds
    to support more accessible transportation and housing. It will
    also incentivize states to increase wages and benefits for
    direct care workers, people like Mr. Adams, who is with us
    today, and others who do that difficult work in rural
    communities.
        In our State of Pennsylvania, over 13,000 older adults and
    people with disabilities are waiting--waiting for home and
    community-based services. Across the country, that number is
    more than 700,000 people waiting. My bill aims to change that
    to make home-based care and services a reality for all those
    who need it. An investment in home care is an investment in the
    future of rural America. It is also an investment in our care,
    our workforce, and our economy.
        Madam Chair, thank you, and I will do the introduction now?
        The Chairman. That would be great.
        Senator Casey. Thank you so much. I am here to introduce,
    as Chairman Collins noted, and as she began to introduce, and I
    am grateful for that part of the introduction, Mr. Francis
    Adams of Washington, Pennsylvania, as I said, in the
    southwestern corner, just south of Pittsburgh. He is a home
    care worker with over 20 years of experience working in rural
    Pennsylvania, of which I just spoke.
        He began his home care work taking care of his grandfather
    who suffered from black lung disease from the coal mines, and
    too many families and retired coal miners in states like mine
    suffer from black lung. Mr. Adams is also a third-generation
    union member, a proud member of the United Home Care Workers of
    Pennsylvania, a joint program of SEIU Healthcare Pennsylvania,
    and the AFSCME union.
        Mr. Adams' father was a steelworker and his mother was a
    teacher, and as I said, his grandfather was a coal miner. They
    are all proud union members. He will share with us the
    difficulties facing home care workers in rural communities and
    the steps we can take to better serve rural seniors and people
    with disabilities in rural America and rural Pennsylvania.
        Mr. Adams, thanks for being with us today. We look forward
    to your testimony.
        Thank you, Madam Chair.
        The Chairman. Thank you very much. Mr. Dombi.

                 STATEMENT OF WILLIAM DOMBI, PRESIDENT,

                     NATIONAL ASSOCIATION FOR HOME

                    CARE & HOSPICE, WASHINGTON, D.C.

        Mr. Dombi. Thank you, Chairman Collins and Ranking Member
    Casey, and the remainder of the Senate Aging Committee for the
    opportunity to be with you today to testify at this very
    important hearing.
        Since the beginning of Medicaid, the home health care
    benefit has had a special place in that program. Most notably,
    it is the only benefit that is available under both Medicare
    Part A and Part B. Medicaid itself also has led the charge in
    rebalancing long-term services supports into the home care
    setting. Still, there is room to modernize the Medicaid home
    health benefit and to expand home care options in Medicaid.
        To start with, the Home Health Care Planning and
    Improvement Act, which is co-sponsored by Chairman Collins and
    Mr. Casey as well, Ranking Member Casey, is one of the crucial
    modernizations that is needed. We thank you for your
    longstanding sponsorship in support of that bill, which began
    in 2007.
        It is certainly time to revise Medicare to permit the over
    200,000 non-physician practitioners in primary care practice to
    certify Medicare benefit eligibility instead of limiting such
    to physicians. S. 296 would improve program integrity as it is
    compromised when the patient is handed off to a physician for
    the sole purpose of meeting Medicare certification
    requirements. The bill would also enhance quality of care as it
    would no longer be necessary to insert a physician who has not
    cared for the patient into the patient care process.
        Finally, there would be cost savings, since Medicare
    reimbursement rates for non-physician practitioners are less
    than payment rates for physicians, but more importantly, costs
    would be reduced as it avoids duplicative paperwork.
        Today the legislation is supported by numerous patient
    advocacy groups, health care professionals, and physician
    groups as well. There is an obvious reason why there has been
    such widespread support. Our nation depends on non-physician
    practitioners every day. It is now time to pass S. 296 and
    bring the long-overdue modernization of the home health benefit
    requirements into reality. In 2007, when such legislation was
    originally introduced, the reform may have been considered
    innovative. In 2020, it is a necessity.
        Number two, we suggest reinstating the Medicare home health
    rural add-on. The longstanding rural add-on for home health
    services will be phased out completely in 2022, threatening the
    provision of home health benefit in rural areas. Since the
    1990's, the home health service payment system has recognized
    the special needs of rural areas as there are higher travel
    times, travel costs themselves, and often the need for an
    extended duration of the service visit. The absence of
    physicians in rural areas, along with hospital closures,
    compound the problems of care delivery.
        The latest data available shows that home health agencies
    located in rural areas receive an average of 6.2 percent less
    than their cost of care. Most notable is that nearly 40 percent
    of these providers have Medicare margins below zero. Targeting
    an add-on may be considered as the current legislation does,
    but the current approach does not work, with 38 to 69 percent
    of agencies affected by that in the respective target
    categories being paid less than their cost of care.
        We recommend that Congress reinstate the 3 percent rural
    add-on for 3 years and require an expanded study to determine
    whether targeting is warranted.
        Number three, the new home health payment model, the PDGM
    as we call it, took effect January 1 of this year. It includes
    a preemptive first-year reduction in base payment rates of over
    $750 million, derived solely from assumptions as to how home
    health providers might behave in their provision of care and
    documentation practices.
        We strongly supported the Home Health Payment Innovation
    Act, S. 433, as introduced by Senator Collins last year. While
    that proposal may need now some refinements given the issuance
    of the 2020 rule, Congress should call on Medicare to improve
    transparency and restrict the use of bald assumptions in
    setting payment rates.
        It would also be very helpful if Congress committed to
    closely monitoring access to care and changes in service
    utilization. There are clearly anecdotal reports of access
    problems for patients in categories with reduced reimbursement
    levels to home health agencies already, in just a little over a
    month of this new program.
        To finish with just two other items, innovation telehealth.
    Ms. Howard gave all the information necessary to justify that.
    We wholly support moving forward with any steps to provide for
    remote monitoring the patients and other telehealth services in
    rural areas and in the rest of the country. Among the steps to
    be taken would be to increase the availability of broadband for
    the ability of those technologies to actually work, and
    finally, workforce. You know, I look forward to listening to
    the discussions regarding the workforce. There is no delivery
    of home health services without the workforce and we have a
    shortage of nurses, which continues to expand, and even a
    greater shortage of personal care attendants to deliver the
    services to individuals who need support with activities of
    daily living. We need a national solution to this and we need
    it soon, because the aging of our population as well as the
    growing number of persons with disabilities cannot make it in
    the home without that support.
        Thank you for the opportunity to come here today.
        The Chairman. Thank you very much, Mr. Dombi.
        Mr. Hebert, and I am going to ask you to turn on your mic.
    Thank you.

               STATEMENT OF WARREN HEBERT, DNP, RN, CAE,

             FAAN, ASSISTANT PROFESSOR, LOYOLA UNIVERSITY,

               AND CEO, ASSOCIATION OF HOME HEALTH CARE,

                          LAFAYETTE, LOUISIANA

        Mr. Hebert. Thank you. ``My histories and physicals are
    incomplete until I have had a chance to have a meal at the
    table with their family and the patient.'' Those words were
    made famous by Dr. Patch Adams. Patch Adams, a West Virginia
    physician, was made famous by Robin Williams in the movie named
    Patch Adams.
        Dr. Adams understood rural home health care. He knew that
    he did not have a complete picture of the patient and their
    situation until he saw them in their home. This is one of the
    advantages that rural home care agencies have and those that
    are providing rural home and community-based services, and a
    lot of those folks that are doing that are nurse practitioners,
    because physicians cannot be in those rural areas.
        The access to the home is extremely important and social
    determinants of health, that we have talked a lot about over
    the past few years, are certainly very important in our rural
    areas.
        There is much to be joyful and thankful about in our rural
    areas. The peaceful drive through the countryside of the
    mountains of Maine, down in south Louisiana the swamplands and
    the marshes, and you just had the Washington, D.C., Mardi Gras,
    so you probably know that this is crawfish season in Louisiana,
    and we are seeing crawfish ponds as we drive along.
        Our patients in rural areas live there, in those places. A
    trained eye visiting those places can do what is called a
    windshield survey. As we are driving into the area we can see a
    lot of the public health issues that exist. We can understand
    the socioeconomic challenges that are in that area.
        When I knock on a patient's door and cross that sacred
    threshold into their home, health care is very different than
    it is with our friends in the acute care settings. It is their
    place. It is their territory. As I walk in the house I know a
    little bit about how the patient and their family are going to
    engage me. That tells me a lot, related to my assessment. I can
    look at the pictures on the walls and find out what sort of
    support they have within their family unit, and I will speak to
    family caregivers a bit in a few minutes, and if that first
    visit goes well I might be offered a cup of coffee. That
    happens a lot in rural homes and if I am really good at
    building a relationship they will invite me to have a look into
    their refrigerator and their pantry.
        Madam Chair, Ranking Member Casey, Senators and hard-
    working staff, you know, as my colleagues are I am honored to
    be here with you and dive into some of the challenges around
    rural health care.
        Depending on the resource one cites, as many as 45 million
    family caregivers are taking on challenges alone across the
    country with very little support. In rural areas, families are
    very fortunate if they are able to have home and community-
    based services or they are able to have home health care
    assisting them. On occasion, we have nurse practitioners making
    visits to patients in their home. That is a real gift and we
    are very fortunate that we have nurse practitioners who are
    willing to do that critical work.
        AARP reports that daily between 7 and 8 million people are
    providing care as family caregivers, and again, most of the
    time they are unsupported, so it is critical for us to
    understand the work that your Committee is doing, Madam Chair,
    and the need to support that.
        Within my own family, my wife and I are very fortunate to
    have a 29-year-old daughter who has Down syndrome, so besides
    being on the provider side we are also consumers in that she
    receives home and community-based services. My dad had dementia
    for 7 years. We were fortunate that Mom and Dad prepared for
    their senior years.
        I am the oldest of 10 children, and in south Louisiana
    people do not wander too far from home, so the 10 of us all
    lived within 20 minutes of Mom and Dad. Over his 7 years with
    dementia, Dad did not spend one night in a hospital or a
    nursing home, because we were able to help my extraordinary
    mother with Dad's work.
        These are the sort of challenges that rural families are
    dealing with, but the rural families are not experiencing the
    same ability to connect as they did in the past. We are having
    challenges that as conglomerates are taking over a lot of rural
    farms, those farm families are needing to move and find jobs in
    suburban and urban areas, so as a result, the tax base is
    drying up in those communities. As the tax base dries up,
    schools, hospitals, physicians, pharmacists, et cetera, are all
    having to close.
        In closing, I would like to quote Dr. Joseph Coughlin, of
    MIT's AgeLab. About a year ago he tweeted that when it comes to
    aging, independence is overrated. It is interdependence that we
    should be seeking.
        I hope that in this hearing we can be more vibrant and have
    a lively conversation about interdependence. That is a critical
    conversation for people who need home care in rural
    communities.
        Thank you, Madam Chair.
        The Chairman. Thank you very much, Doctor. Mr. Adams,
    welcome.

       STATEMENT OF FRANCIS ADAMS, HOME CARE WORKER, WASHINGTON,
                              PENNSYLVANIA

        Mr. Adams. Good morning. My name is Francis Adams. I am a
    home care provider from Washington, Pennsylvania. I am also a
    proud member of the United Home Care Workers of Pennsylvania, a
    joint program with SEIU Care, and AFSCME.
        I have been helping seniors and people with disabilities
    who live at home for over 20 years. I left my job as a
    steelworker to care for my grandfather when he fell ill from
    black lung. I later cared for my aunt. I wanted to be there for
    my family. That is when somebody told me that home care can be
    a career. I really liked the work and people needed it.
        Every day, more than 10,000 people turn 65 in America. We
    need to attract 1 million more workers to this industry by 2026
    to meet the demand. However, our current long-term care system
    does not support home care workers or our clients.
        Presently I care for my brother, who is blind. I am also a
    on-call home care worker, stepping in at all times when a
    client's regular caregiver is unavailable. Many of my clients
    do not have anyone else. A lot of my job duties are physical--
    bathing, cooking, cleaning, driving to appointments--but it is
    the emotional connection that really makes the impact.
        I never want to leave a client alone. Depression can kill
    you as quickly as lung cancer and because I work on call,
    oftentimes I do not know what equipment someone has in their
    home. That is why training is so important.
        Washington, Pennsylvania, is not like D.C. It is a rural
    area. We cannot cross the street to get to the grocery store or
    hop on a subway to get across town. Neighbors are separated by
    several miles. It takes much longer for fire trucks and
    ambulances to get those in need. Distance and mobility issues
    sometimes leave my clients running out of vital supplies. I
    make sure they have them.
        Home care work was a lifeline for me, after working at the
    mills. My pension was only a small fraction of what had been
    promised to me, so I need this job. I make $10.70 an hour and I
    work 10 to 40 hours any given week. In addition to being a home
    care worker, at age 70 I have a second job in retail to make
    ends meet. If home care paid more, I would not have to take on
    other work.
        It is not that we do not have enough people to do home care
    that creates a shortage. It is that our country undervalues
    this work. We have to fix this. That is why I am joining
    Pennsylvania home care workers fighting for higher wages and a
    union. With a union we have the strength in numbers to
    negotiate wages, basic benefits, and training. We have worked
    together to strengthen Pennsylvania's Medicaid program, and
    importantly, my union has given me a sense of community.
        My grandfather, my father, my mother were union members. I
    saw what the unions do to improve our lives. Unions advocate
    for racial and social justice. My family marched with Dr. King
    and I held that passion as I grew older. As a child I saw
    firsthand the shameful legacy of Jim Crow that held hardworking
    people in my community back.
        The legacy continues in home care, a job that has
    historically been mislabeled as unskilled. We must move past
    this institutional racism so that in 20 years home care is a
    well-respected, sought-after, family sustaining job. Home care
    is the country's future. Home care jobs must be good jobs,
    union jobs, and workers must make at least $15 an hour and have
    affordable health care.
        When we invest in our home care workforce we can improve
    our long-term care system for all. Thank you.
        The Chairman. Thank you very much, Mr. Adams.
        Ms. Howard I want to start with you. Home health agencies
    in Maine and across the Nation have had to weather a series of
    Medicare reimbursement reductions from the reimbursement
    payment cuts that were contained in the Affordable Care Act to
    the latest negative 4-plus percent behavioral adjustment cut.
        I would like you to describe what the impact is on home
    health agencies in Maine. I know I read that a very large
    agency recently closed, that was serving nearly 600 patients,
    so what is the impact of inadequate reimbursements, whether it
    is under the Medicaid program or the Medicare program?
        Ms. Howard. Sure. A number of things are happening, so as
    you know, there are closures. There are also a number of
    mergers and acquisitions, so home care agencies that once
    functioned independently of each other are now merging in order
    to be able to still provide for residents in their area.
        There is also the challenge of workforce, so our more rural
    sites are also where we are most challenged to find staff and
    so because of that we need to pay for high-cost travel staff,
    as we are being reimbursed less and less but our costs to
    provide care are going, you know, higher and higher.
        Also, we are honestly having to make difficult decisions.
    We have a patient that might take 2 hours to get to. We have to
    send a staff out to see a patient that is 2 hours away. Can we
    even do that when we have three other patients who are in a
    more tight geography? Do we go and serve that one patient or do
    we stay closer and serve those three? We are having to make
    those difficult decisions as well.
        Also, with those changes, with the decrease in
    reimbursement, getting more creative about our workforce, so
    being innovative about developing our own internal workforce,
    so personal care assistants train to be CNAs, train to be LPNs,
    and so on. All of that comes at a high cost, and as we are
    continuing to have decreases to our reimbursement, those things
    were getting squeezed tighter and tighter and it is harder to
    do those things.
        The Chairman. Thank you. I think your example of the
    patient who is 2 hours away is a really important one, because
    that is why the rural add-on is so important to compensate for
    that extra time on the road, rather than just not being able to
    serve those patients who are further away from the agency.
        Mr. Hebert, Dr. Hebert, I was struck in listening to you
    about your comments on interdependence and also the reaction
    that home health workers get when they come into a person's
    home, because that was the experience that I have always seen
    when I have gone on home health visits. In fact, I saw the
    senior's face literally light up when the home health nurse
    arrived.
        Sadly, oftentimes that might be the only person who is
    seeing that patient, and thus can take stock of everything. Is
    there enough food? Are other needs being met? We held a hearing
    in which we learned the effect of prolonged isolation and
    loneliness is equivalent to smoking 15 cigarettes a day. That
    is how important this is.
        What do you see as the biggest challenges that you are
    facing in trying to ensure that home health services are
    delivered?
        Mr. Hebert. Madam Chair, you pointed out the isolation. The
    research that has been done related to social isolation and
    loneliness make it very clear. As you said, it has a worse
    impact on morbidity and mortality than smoking 15 cigarettes a
    day, or drinking a half a dozen adult beverages. This issue of
    isolation is not only an issue for us here in the United
    States, it is an issue for aging folks across the world. We
    have, in the room today, guests from Europe who are here to
    learn from the Senate Aging Committee and some of the proactive
    work that you have done here.
        The challenge for the rural patient in that isolation is
    that they do not have, in most cases, the family that my mom
    had, to be able to say, ``Hey, look, I need some help. Come.''
    As a result, that is often, as you indicate, the only person
    they may see.
        As I indicated, that happens a lot here in the United
    States. One nurse talked about over a period of a few weeks she
    saw a calendar with the numbers 1 through 7 struck out. She
    finally had the courage to ask the patient what that was, and
    she said, ``Well, that is my calendar.'' She said, ``Well, tell
    me about it. You have only got the numbers 1 through 7.'' She
    said, ``Sweetheart, when you leave today I am going to write 1
    through 7 again, and I am going to mark each day off because I
    know that is when you are coming back.''
        The exact same experience I had was when I led a group of
    home care and hospice workers to Dharamsala, India, and spent 2
    weeks in Tibetan Buddhist communities. Those people waited for
    their home health nurse because it might be the only visit they
    get in a week, so when you ask the challenges that the patient
    and the family has, essentially that engagement from the rural
    home health nurse or the home and community-based worker, those
    are critical for them to be able to do well. Thank you for
    asking.
        The Chairman. Thank you. Senator Casey.
        Senator Casey. Thank you, Madam Chair. I am going to thank
    our witnesses for their testimony today. I will start with Mr.
    Adams.
        Your story is a powerful story about the work that you had
    to do to transition from the work you had done as a
    steelworker. I think not only your own personal story but the
    reality of home care itself but also home care in the rural
    context is a disturbing story for the country. We are not
    anywhere close to meeting the obligation we have to rural
    seniors and their families if we do not make some changes.
        As you highlighted, we have a very rural State. A lot of
    people do not realize that. We have got 67 counties. Some
    people think of my State as Philadelphia and Pittsburgh and
    just some towns in between. Of the 67 counties, 48 are rural,
    48. Three and a half million people live there, a bigger
    population than the whole State of a lot of states. I think we
    have, if not the top rural population in the country, it is one
    of the top two or three, so millions of people who have
    challenges that frankly exceed, often, the challenges in urban
    communities.
        One of the points you made, Mr. Adams, is the stagnant
    wages, the long hours, the distance, and the difficulty of
    providing care in rural settings. We have got to have more
    resources.
        You also pointed, in your written testimony, to just some
    numbers on turnover. When you talk about turnover in this
    industry, national workforce turnover rates as high as 60
    percent, so if we are not recruiting more people to do this
    work we are not going to meet the need, and as I said, we are
    failing as a country. You cannot ask people to do difficult
    work and drive long hours if you do not pay them enough. What I
    am trying to do with this legislation is to focus on that basic
    problem, a lack of appropriate pay and a lack of investment in
    training.
        Mr. Adams, can you just speak to that question, the
    question of resources that are needed to better support workers
    who are doing the work you are doing in rural communities?
        Mr. Adams. Well, without the resources what it means to me
    is that America has failed to help the people that need them
    most and the people that care for them. Like the man that cuts
    his lights off at 7 in the evening to keep his electric bill
    affordable, or the lady that struggles to sit up in her bed
    when we feed her because she does not have a hospital bed. or
    the woman that waits hours for someone to drive out to her home
    to take her to the grocery store, because she cannot afford
    transportation, or the man that falls in the middle of the
    night because there is no home care worker there, because he
    does not have the funds to keep one through the night, so he
    lays on the floor, afraid to push his call button, because he
    lives outside the city, and an ambulance would cost him an
    exorbitant amount of money. When the home care worker comes in
    there in the morning they struggle to pick him up, because he
    is a 200-pound man, and they do not have the equipment, like a
    lift, to help him get back in the chair, and that is a shame.
        It is important because we have 10,000 people turning 65,
    and these people live in their homes. Lots of times they have
    built those homes with their own hands. They have worked hard
    to pay for these homes. It means that we have failed these
    people, and that is a crying shame.
        Senator Casey. Thanks very much. I wanted to turn, as well,
    to Mr. Dombi, and I appreciate the perspective you gave us in
    highlighting legislation that has been on the agenda of
    Congress for far too long and not passed.
        I mentioned the infrastructure improvements that we are
    trying to bring about and using target investments through
    Medicaid. Do you agree that these kinds of investments are
    necessary to expand care to home and community-based services
    in rural communities?
        Mr. Dombi. Senator Casey, I had the opportunity to review
    your bill last week for the first time and I am very impressed
    with it, and you can have our organization's support throughout
    on that. Medicaid has proven itself to be the best place for
    finding home care options available to people but it is far
    from perfect. The turnover rates, the compensation to the
    workers, there still is a need for rebalancing of care.
        If I find myself in need of home care there are certain
    states I will go to and certain states I will not go to because
    the distribution of support is that varied. Oregon actually is
    the best State among them in terms of support. Pennsylvania is
    doing okay, you know, and Maine is doing pretty darn good as
    well, but it is time that we support seniors as well as persons
    with disabilities with an even approach toward access to home
    and community-based care, and you know, it is not just about
    wages for the workers. It is wages, it is also career
    opportunities, and frankly, having been fired as a home care
    aide by my sister, it is about respect too. You know, these
    workers do the hardest job in the country. Somehow U.S. News
    and World Report picked personal care attendant and home care
    aide as the number 1 job areas to go to for people without a
    college education. It is a great, rewarding job, but you still
    have to put bread on the table.
        Senator Casey. Thanks very much, Chairman Collins.
        The Chairman. Senator Hawley.
        Senator Hawley. Thank you, Madam Chair. Thank you, Ranking
    Member. Thank you for holding this important hearing today
    about the obstacles to expanding health in rural America, and
    thank you to all of our witnesses. Thank you for the work that
    you do. Thank you for taking the time to be with us and share
    your perspective.
        My home State of Missouri is home to a very large number of
    rural communities. I grew up in a rural community. I know when
    I talk to my constituents back at home and in these regions,
    one of their top concerns, if not their number 1 concern, is
    access to quality, affordable health care. That is all the more
    urgent because Missouri's population is rapidly aging. We have
    got a lot of seniors in the State of Missouri and a lot of them
    live in rural areas, so the topic of today's hearing is very,
    very important for my State.
        Mr. Dombi, let me just start with you if I could. In your
    testimony, your written testimony, you discussed the innovative
    uses of telehealth and telehomecare, in particular, as a way to
    bring home health care to patient populations in communities
    like the one where I grew up. I am aware of the infrastructure
    barriers to telehealth expansion, including inadequate access
    to quality broadband. That, of course, places a huge
    restriction on health care providers in rural regions.
        Despite these barriers, Congress, I know, has taken some
    incremental steps to expand telehealth and telemonitoring
    capabilities, but I think that we can probably do more. I just
    want to ask you, what lessons have we learned so far, in your
    judgment, in demonstrating the cost-effectiveness of services
    like telehealth, telehomecare, and what are the most promising
    areas, would you say, where we can utilize those services more
    strategically?
        Mr. Dombi. The number one gain we have seen in the use of
    telehealth, or we call it telehomecare, a term which someday
    might be adopted, but in terms of telehealth it is remote
    monitoring by non-physicians as a way of keeping people from
    going back into the hospital, to avoid readmissions of the
    individual. It is important to have boots on the ground, people
    to see face to face the patients, but that 24/7 monitoring of a
    number of patients categories has proven a high reduction in
    readmissions. One readmission avoided to a hospital saves tens
    of thousands of dollars, with very little cost attendant to it.
        We have actually been working on a proposal to advance to
    the Centers for Medicare and Medicaid innovations to create a
    risk-based telehealth program, where the provider of the
    telehealth services would put tremendous skin in the game so
    that they would only be paid, or they would only be paid fully,
    if they demonstrated cost savings to the Medicare program, so
    we think that opportunity exists today out there, and it does
    not always need physicians, as I mentioned. These are non-
    physician-based remote monitoring services.
        Senator Hawley. That is very helpful. Thank you. Do you
    have any recommendations for home health agencies that are
    looking to set up new programs?
        Mr. Dombi. Well, you know, come in with some capital,
    because the reimbursement systems are not yet up to date where
    it needs to be. That is why our proposal would have a risk-
    based approach to it, because, frankly, you know, when we have
    been working on some of these issues for over 10 years, you
    know, we figure we have to change the dynamic, and that is what
    a risk-based proposal would be about.
        Senator Hawley. Very good. Thank you.
        Ms. Howard, let me ask you, on this topic of access to
    telehealth services, I wonder if you could speak to your
    experience serving on the ground with rural communities. Older
    adults, we know, experience the highest rates of adverse drug
    events, resulting in emergency visits, and are several times
    more likely than younger persons to have an adverse drug event
    that requires emergency hospital admissions. They are also more
    susceptible to chronic pain, we know, and many of them are
    prescribed opioids to control and manage the pain.
        Have you been able to leverage your program's
    telemonitoring technologies to identify changes in patients
    using opioids?
        Ms. Howard. That is not an area that we have currently been
    working on, but, however, you know, having the telemonitoring
    in the home, of course, you know, many of our patients are on
    25 or more medications and many of them, you know, are on
    opioids, so having that nurse checking in every day would help
    to be able to identify certain challenges are things that we
    need to followup on.
        The other thing, too, that I will add about the
    telemonitoring is it really allows us to make those home visits
    on a demonstrated need, meaning we see changes in the patient's
    blood pressure or based on different questions that they
    answer, so when we talk about workforce shortages, this allows
    us to make those, as it is knowing when they need that visit
    instead of anticipating when they may need a home visit.
        Senator Hawley. That is very helpful. Let me ask you this,
    my last question. Beyond expanding access to broadband, which
    is critically important, I think, for so many reasons, and
    telehealth is at the top of that list, and providing more
    reimbursement coverage for telehealth services, do you have any
    insights from your experience for us about what Congress might
    do to make home health care programs better, more available to
    more Americans?
        Ms. Howard. One of those challenges that we have, our
    patients that we see are in their acute State of their disease,
    so maybe they have had a heart failure, readmission to the
    hospital, they are discharged home with our service. We are
    using our telemonitoring equipment during that fragile time to
    clue us in as to any changes that might happen that would send
    them back to the hospital, so we are able to take action based
    on those.
        Currently we can only see that patient for a short period
    of time. Eventually we need to work to discharge, so that
    patient returns to that chronic health State of their heart
    failure, for example, and we need to remove our telemonitoring
    equipment, we remove the nurse, we remove the therapist or the
    home health aide, and that patient is now on their own, and so
    what usually happens is after a period of time eventually that
    patient may run into trouble again, and in order to access our
    care again they end up going to the ER, going to the hospital,
    and then the referral back up to home care again, and here we
    go out to do what we do best, to keep them out, only again for
    a short period of time, and we just are in that cycle.
        We have been able to work with some of our Medicare
    Advantage plans, where we do telemonitor patients after they
    are discharged from their skilled home care benefit, so we
    telemonitor those patients for an extended period of time,
    sometimes make a home visit, but what we are able to do is
    identify those changes in the health status.
        For a heart failure patient, it could be an increase in a
    weight or their reporting through their telemonitoring system
    that they are short of breath. Our nurse goes out and assesses
    the situation, is in contact with the physician, and many times
    we are able to make medication changes at that point in the
    home, readmit them to home care service, and then care for them
    again under that acute state, so we have bypassed that ER and
    that hospitalization visit, which would have normally brought
    them back to us, so we have had great success with that.
        Senator Hawley. Very good. Thank you. Thank you for all
    that you do. Thank you, Madam Chair.
        The Chairman. Thank you. Senator Rosen, welcome.
        Senator Rosen. Thank you, Madam Chair and Ranking Member,
    and I want to thank each and every one of you for being here,
    for everyone else who is here as well.
        I know from my personal family experience as a caregiver
    how critically important each one of these areas are and that
    there are angels that walk among us, and they are the ones who
    help us take care of our loved ones when we can't always be
    there, and I am personally grateful to the angels who helped my
    loved ones through much of their care.
        I want to talk a little bit about palliative care, Mr.
    Dombi. You know, based on my experience as a caregiver, I
    launched a bipartisan Senate Comprehensive Care Caucus. It is
    serving to raise the public's awareness, promote the
    availability, and the benefits of palliative care, and trying
    to find those bipartisan solutions to expand access to
    palliative care services, improve coordinated care, and really
    address issues impacting caregivers.
        I am also proud to have introduced the Provider Training in
    Palliative Care Act with my colleague, Lisa Murkowski, Senator
    Murkowski, which is going to have the National Health Service
    Corps focus on these areas, so we know that the important work
    of hospice home care that providers do in their home, how can
    we take this hospice model, and knowing that also there are
    people who maybe do not need to be on hospice but they have
    chronic, long-term disease--cardiac disease, pulmonary disease,
    diabetes, Parkinson's, whatever. How can we take these
    palliative care, hospice care models and use them, expand them
    across the home health spectrum?
        Mr. Dombi. Well, thank you for that question. We are on a
    new frontier with palliative care. There had been a struggle at
    one time for people to even recognize it as a necessary service
    for individuals. My sister was fighting stage IV breast cancer,
    and her oncologist was hell-bent on killing her cancer. At the
    same time she was having a miserable life and so we brought in
    a palliative care physician to support her. The oncologist,
    then, and the palliative care physician were butting heads for
    a number of weeks until they realized they needed to be in
    partnership.
        My sister did not make it through her breast cancer, but
    palliative care is not just end-of-life services. It is an
    important component to end-of-life but palliative care truly is
    something that should be part of all health care services, at
    all times.
        I think, you know, when I say we are at a new frontier, we
    are at the new frontier of awareness. I do not know if all the
    solutions are out there yet. Probably not, but when we look at
    the solutions we start with the recognition that, while I
    mentioned the physician in palliative care, much of palliative
    care is provided by non-physicians--nurse practitioners,
    nurses, personal care aides. It involves much more than even
    clinical health care kinds of services.
        One of the recommendations that we have been making is that
    you can take existing benefit structure, in Medicare, for
    example, like the home health benefit, and make it a palliative
    care component to it without honestly having to go through
    Congress to do so. It is skilled care. It is care for people
    who are, you know, in their homes. It can be done by the
    professionals with the home health agencies, if they have some
    specialized training, and we do not see it as really increasing
    spending much in any way, if at all.
        At the same time, in a pre-hospice kind of mode, there are
    some efforts to try to experiment with what we would call pre-
    hospice palliative care. We are seeing it in the managed care
    context, but more than half of the country is not in a Medicare
    managed care program. I hate to admit but I am a Medicare
    enrollee, and I am not in Medicare Advantage at this point. I
    do not know if I ever will be, but we need to experiment also
    within the fee-for-service kind of program.
        An example of where to go might be Medicaid, where they
    have used dollars in a very flexible kind of a person. Ranking
    Member Casey, you have support for money follows the person
    within your bill. Similar concepts relative to using the
    dollars that would otherwise go into higher cost settings, into
    palliative care, I think is a good option for us to consider,
    in both Medicare and Medicaid.
        Senator Rosen. Now I have to agree with you, especially as
    we talk about the mental health, the depression. All those
    things really--you're going, what is in the refrigerator?--all
    these things matter to the care and consideration and overall
    health of a person, and contribute to them going up or going
    down. If you would like to say a few words, please.
        Mr. Hebert. Senator Rosen, I really appreciate that
    question. One of the things that a lot of public health folks
    chuckle about today is the change in names and how people are
    excited that we have this new issue of social determinates of
    health, when public health folks know that these are issues
    they have been addressing for decades.
        Palliative care is care that has been provided by home
    health workers for decades, and it is now beginning to be
    recognized that we have got people like the ones you just
    questioned, who have multiple comorbidities, multiple chronic
    illnesses, and to be able to manage those well, palliative care
    benefits could significantly change things.
        You talked about the Training Act. One of the things that
    is critical to this conversation is workforce, so not only
    training for workforce but our medical schools, nursing
    schools, social work, therapy, et cetera, have been educating
    people for many, many decades, based on an acute care model
    that is very hospital-centric, and I would add physician-
    centric, so one of the challenges that we have is to change
    curricula across all of those schools, to include rural
    components of care at home and certainly palliative care.
        Thank you for that very important question.
        Senator Rosen. Thank you for being here today.
        The Chairman. Thank you very much, Senator.
        Senator Braun, welcome.
        Senator Braun. Thank you, Madam Chair. I just got here a
    moment ago, but everyone, I think, knows here, since I have
    been here about a year, that health care is the thing that I
    think is most urgent, and that in my own business many years
    ago I really worked hard to make it consumer driven and
    transparent. I know the particular arena you are in. Indiana, I
    think, would be in the category of where we have not done well
    with home care.
        I would like to know, whoever might be able to give me an
    answer, where it has a foothold, what is the financial
    difference between home care when it is working at its best
    versus traditional, which we have mostly in the State of
    Indiana, which would be through a nursing home?
        Mr. Dombi. I can try that question. I think it is working
    really well in place like Oregon and Washington State. New York
    State, a long time ago, had a policy of directing people to
    kind of a home care first approach, keeping people out of long
    stays in hospitals because no nursing home beds were even
    available for those individuals.
        There have also been several studies, including from New
    York, indicating that the woodwork effect does not happen, the
    woodwork effect meaning that if you make it available, people
    who are currently not costing anything to the system will go to
    that service, and, in fact, that has not been the case.
        Where it is working best as well is where there is support,
    as Dr. Hebert referenced, with the informal caregivers, because
    the bulk of home care services is provided by family and
    friends. I think AARP recently estimated it to exceed $570
    billion a year, whereas total home care spending in the
    business of home care is about $125-$130 billion a year. The VA
    has done pretty well in connecting caregivers in the informal
    sense with paid caregivers for respite services and otherwise,
    so when we were looking to where it is working best, we are
    looking to those kinds of states in the upper Northwest, we are
    looking to New York, and we are looking to some of the other
    government programs. The VA has the most robust home care
    program of any program on paper. I had the privilege, I hope,
    this afternoon I am testifying at the House Veterans' Affairs
    Committee about home care services. It is great on paper. It
    needs a little bit of improvement in practice, though, but it
    still provides a lot of guidance.
        Senator Braun. What were the catalysts that worked for
    Washington, Oregon, New York, or even the VA, to kind of push
    home health care, and how much entrepreneurial energy has there
    been? My main beef with the health care industry in total is
    that it has lacked transparency, it is inherently
    uncompetitive, it has barriers to entry, and the consumer is
    not engaged, to boot. When you take two of those four, you
    generally do not have a well-functioning supply and demand, you
    know, market that drives, generally, prices low in other
    markets, and then you differentiate by your intangibles, so
    when it comes to, what was the original catalyst--let's just
    take Oregon or Washington or the VA--that got it to where it
    has pushed something that seems to be a better value, you know,
    for the customer?
        Mr. Dombi. It was looking for value. It was looking to
    control spending, in Medicaid as well as in the VA. Secondarily
    to that, but very much equally important, is the humanity
    aspect of giving people the opportunity to stay at home but the
    driver was the bottom line.
        With the growing population of need for long-term services
    and supports, the population being served, whether it was in
    the VA or in the Medicaid program, which is a primary funding
    source for long-term care, the recognition was they had to find
    a better way than the high cost of caring for individuals in
    nursing homes, combined with the concern that nobody wanted to
    go to a nursing home and that is what really drove it.
        There is tremendous competition in home care in a number of
    the sectors that are out there. It is an unusual economic
    dynamic, marketplace dynamic. You have mom-and-pop operations
    working at farmhouse in Appalachia and you have public
    companies that operate in 40, 50 states nationwide.
        Senator Braun. That is refreshing, because it is normally
    not the case through any other parts of health care, and then
    do you run into, within certain states, where the nursing home
    industry--in other words, the status quo that has been around a
    long time, that is there--not giving you that good deal, that
    has weighed in to kind of suppress what looks to be some
    grassroots competition? Is that something that occurs?
        Mr. Dombi. Yes. I am going to give you a delicate answer
    there.
        Senator Braun. I figured it would be.
        Mr. Dombi. We tried to work with the nursing home world as
    well, but you can go to every State legislature and they all
    know their nursing home operators. You know, it is harder to
    get to know the home care operators, and it is very hard to get
    to know the home care workers because, you know, they gather at
    the person's home rather than at a facility somewhere.
        Senator Braun. Well put, and I think that is our goal as
    Senators, to provide, where it normally occurs, when you have
    transparency, when you do not have a strong lobby that tries to
    suppress that stuff. It works so well in other places. It is
    good to see that in home health care that it is actually
    succeeding in a system that is basically dysfunctional and
    broken.
        Mr. Adams. If I may add, the states that he mentioned all
    have good unions, good wages for home care workers, and that is
    part of the reason why those states function well. Their wages
    are reasonable, the union is strong, and as he stated, the
    states are doing well.
        Senator Braun. That is good to know as well, and that makes
    sense. It is good to see that it also engendering higher wages
    for that function.
        Did you have----
        Mr. Hebert. Senator, I would add that value-based
    purchasing has had an impact. Even though it is slow and moving
    along, we are moving away from the old sick-care model where
    everything is fee-for-service and reimbursement is based on
    volume, so the move toward value is critical in the home care
    space as well, and I think that is why you have seen that sort
    of progressive activity in the states that you mentioned.
        Senator Braun. Thank you for setting a good example. I hope
    the rest of the industry is paying attention. Thank you.
        The Chairman. Thank you very much. Senator Sinema.
        Senator Sinema. Well, thank you, Chairman Collins, Thank
    you, Ranking Member Casey, and thank you to all of our
    witnesses for being here today.
        As seniors live longer they should be able to access home
    and community-based services wherever they live. I believe we
    must do more to help seniors live safely at home before they
    need to receive specialized medical care at home or in a
    residential facility. A part of this effort includes increasing
    access to home care and assistance with daily activities, such
    as bathing, eating, dressing, or even ensuring medication
    adherence.
        This week I was proud to team up with Senator Cory Gardner
    of Colorado to introduce the Home Care For Seniors Act. Our
    common-sense, bipartisan bill allows seniors to use their tax-
    advantaged health savings accounts to pay for home care. This
    will help seniors remain safely at home and provide needed
    relief for family caregivers. We think it is a first good step
    but we must do more.
        As I have heard from Arizona's local Area Agencies on
    Aging, home health care remains an acute challenge for rural
    communities and seniors, so this leads to my first question for
    Mr. Dombi, although I welcome everyone's thoughts.
        Arizona's Medicaid program is pursuing exciting
    collaborations to build a long-term care workforce, especially
    in our rural communities. Working with technical high schools,
    community colleges, and nursing programs, this initiative will
    develop training courses that help students quickly earn a
    license or certification and enter the home care workforce.
    There are also options for students to continue on to a
    licensed practical nursing program or other advanced jobs in
    the health care industry. The goal is to help increase career
    mobility in rural areas while managing the training and hiring
    costs that can be prohibitive for our rural providers,
    particularly those who need entry-level direct care workers
    now, so do you believe that such a strategic plan could be
    implemented on a larger or national scale to help address the
    short-term need we all face for a qualified workforce?
        Mr. Dombi. We need a multidimensional strategy to improve
    the availability of the workforce within home care, and your
    proposal has many of the elements that are absolutely worth
    employing in that. When we look at the kind of strategies that
    have been employed, they have had a little bit of impact so
    far, but when we look at particularly the personal care
    services supports for activities of daily living and the
    workforce that provides those services, it implicates a broad
    array of elements within our health care delivery system.
    Compensation is absolutely one of them.
        Figuratively, I think the State Medicaid programs combined
    make up the largest employer, figurative employer, of the low-
    wage workers across the country. You cannot pay somebody a
    living wage if you are paying $12 an hour for the services to
    the employer. You could not give $12 an hour to the worker
    because you are paying things like your taxes and, you know,
    your rent, and paying for the billing and such.
        It goes beyond compensation. It goes into other elements,
    like a career ladder opportunity for the individuals who wish
    to be there. Flexibility may be necessary, even in some of the
    Federal wage and hour law to deal with the issue of scheduling
    of these workers, that the workers do not necessarily schedule
    their time based on their interests. They schedule based on
    upon the clients' interests, and they work well to do so but it
    doesn't necessarily fit with the existing wage and hour law
    when calculating such issues as overtime compensation.
        Immigration fits into the issue as well, you know. We know
    that is a very sensitive issue in this country today, but when
    you are looking at the workforce that is out there, a quarter
    of the current workforce providing for personal care supports
    are recent immigrants.
        If we look back perhaps on our own family history, my
    grandparents came from Hungary, Lithuania, and Poland in the
    late 1800's, and they took, as most immigrants do, the hardest,
    lowest-paying jobs that are out there. They worked with trying
    to advance their families along the way. We do have to take a
    look at our immigration policies to see, can we bring that kind
    of workforce to bear?
        The demographics of our country, in many ways, will require
    us to bring in new people. I had four people--children in my
    parents' family that could help care for them as they aged. I
    have two children. Not only am I not liked by them, but they
    cut my resources in half, so somewhere I am going to have to
    find outside caregivers when that need might arise, but I
    appreciate, really, the work that you are doing to explore
    these various things. There is no one silver bullet solution.
        Senator Sinema. Yes. Thank you so much.
        Mr. Hebert. If I could add----
        Senator Sinema. Yes.
        Mr. Hebert [continuing]. Senator, it is a very important
    question. I think that one of the things that we need to find a
    way to do--and, Madam Chair, I am going to borrow a term from a
    couple of your PhD public health folks in Maine---it is
    important for us to find incentives to keep our free-range,
    pass-the-raise children at home. If we can keep those rural
    people in there and give them incentives, they already know the
    culture, they know the climate, they know the people, so part
    of our challenge is to find those folks at home and provide
    incentives.
        Thanks for your good work.
        Senator Sinema. Thank you. Thank you, Madam Chair. My time
    has expired.
        The Chairman. Thank you. Mr. Dombi, as you know, we have
    worked together for years to allow nurse practitioners,
    physician assistants, other advanced practice nurses to
    prescribe home health care, and oftentimes, as I pointed out
    earlier, they are the primary care provider for the person
    needing home health care.
        One nurse practitioner expressed to me her frustration that
    she could prescribe, she could order x-rays, can do all sorts
    of tests, and yet she cannot prescribe home health care for her
    patient, her very own patient who is being discharged from the
    hospital, for example.
        I just do not understand the resistance to allowing more
    health care providers to authorize home health care. What is
    the chief criticism of expanding those who can prescribe home
    health care, and what is your response to that criticism?
        Mr. Dombi. The roadblock is not at the State level. States
    have authorized these practitioners to order home health
    services, to manage patients in the home care setting, to
    varying degrees, either, you know, completely independent or in
    some collaborative relationship.
        The barrier is an antiquated Medicare program, and I think
    the barrier is still there simply because there is, at one
    time, concern on program integrity and concern on quality of
    care, which was not well founded in the first place. Instead,
    as my written testimony points out, we think program integrity
    is compromised and quality of care likewise compromised with
    this antiquated rule, when you have to hand off to a physician.
        There is one other factor that has come into the mix over
    the years, as we have tried to get this legislation passed, and
    that is the Congressional Budget Office. We still do not have a
    score, a formal score, from CBO on this. CBO at one point gave
    us an informal score, gave the House--I say us--gave all of the
    stakeholders an informal score of what they called budget dust,
    under $100 million, something close to my annual salary, you
    know, budget dust, and then, suddenly, the Centers for Medicare
    and Medicaid Services stepped in and advised the CBO that they
    had concerns on program integrity as well as quality of care.
    My information is now that CMS no longer holds those views, but
    we still need a CBO score in order for this to move forward. We
    think this really should be scored as a saver rather than as a
    coster there.
        I do not think there is anybody who is, you know,
    categorically opposing it. More and more physician groups, who
    one time might have been considered competitors, are now coming
    on board because they are partnering in so many different ways,
    business wise as well as caring for patients, with nurse
    practitioners, physician assistants, and the like.
        Mr. Hebert. Madam Chair?
        The Chairman. Yes, Dr. Hebert.
        Mr. Hebert. Madam Chair, I would offer this is even more
    critical in rural areas----
        The Chairman. Yes.
        Mr. Hebert [continuing]. where the primary care
    practitioner is a nurse practitioner or a PA, so this is a
    vital issue for rural communities. Thank you.
        The Chairman. Thank you.
        Mr. Hebert. Thank you for your long-term support of this
    issue.
        The Chairman. I completely agree with your comments, and it
    is one reason that I have felt so frustrated that we cannot get
    this common-sense change made, that is going to improve the
    lives of patients and prevent rehospitalizations or worsening
    of their condition because of the delays that are often
    inherent in finding a physician to authorize the care. It just
    makes no sense and I am going to work on trying to get the CBO
    to give us a score and see if we can enlist the Financial
    Committee leaders to help us in that regard. I personally
    believe that it is going to save money, for a whole host of
    reasons, and we could use that.
        Mr. Adams, I saw that you were nodding when Mr. Dombi was
    talking about the VA doing a good job. Did you have anything
    you wanted to add on that topic? If I could ask you to turn on
    your mic. Thank you.
        Mr. Adams. The thing that I was nodding my head about is
    the fact that he mentioned Washington State and New York. These
    are places that have strong unions, and the unions are the
    people that advocated for the safe working conditions, that
    advocated for the higher pay. When you advocate and you have
    higher pay and better training, it attracts people to the jobs.
    That is why those states are successful, and that is what we
    are trying to do in western Pennsylvania.
        The Chairman. Thank you. Finally, Ms. Howard, I want to
    commend you for being such a leader in telemedicine,
    telemonitoring, because that can be so helpful, especially if
    you are servicing someone who lives on an island off Maine,
    where it is very difficult to get to them. That was an example
    that you had used.
        I have noticed that when I am talking to veterans who have
    come back, who have post-traumatic stress, that they actually
    really like the telemedicine, the younger veterans in
    particular. They prefer it to having to go to the office of a
    psychiatrist or a therapist or a mental health counselor, so
    there are two questions I have and that is, are your older
    patients receptive to telemedicine, first of all, and second,
    what roadblocks do you see to expanding telemedicine?
        Ms. Howard. Thank you for those questions and thank you for
    your recognition of our program. I appreciate that, so some of
    the roadblocks to expanding, of course, are broadband and cell
    connectivity. A patient does not need to have Wi-Fi or internet
    at home. If we can get a cell signal at that patient's home we
    can still transmit the data, and that helps us tremendously to
    be able to get the information that we need. You do not have to
    stray too far off I-95 to start to run into complications,
    especially with a cell signal, and of course the coastal areas
    is also a challenge.
        Our seniors, they enjoy using the equipment. It is very
    simple. It is a tablet-based system, and it walks them through
    it. They enjoy it, which is a surprise to some people. They
    would think they would not be accepting to the technology in
    their home, but we have learned not to assume, because many of
    them are probably more tech savvy than some of us, which is
    great, so, you know, and the other thing is, you know, as we
    look to expand, the challenge is that, you know, yes, it is
    under our episodic payment, but our providing this benefit, we
    have to afford that financially through grants, through cutting
    in other areas because as we have had more and more cuts, you
    know, in looking for where can you cut back, and, you know, as
    you cut more and more in our operations budget and then that
    means we are not as able to utilize as much equipment with as
    many patients as we would like to, because we cannot afford to
    purchase more equipment.
        The Chairman. Thank you. Senator Casey.
        Senator Casey. Thanks very much. I will pick up on the last
    answer by Ms. Howard, referencing broadband. One of the many
    problems that still burden rural America, for lots of reason--
    health care, broadband is a problem for health care, it is a
    problem for business. It is another way that we shortchange
    rural America. Health care itself, when we have got proposals
    in this town all the time to cut Medicaid, for example, it
    disproportionately falls on rural America when that happens.
        We know that more kids, as a percentage, in rural America,
    depend on Medicaid and CHIP than even in urban areas, because
    in urban areas you have low-income folks. We have higher-income
    folks that do not depend upon--who live in cities but do not
    depend on CHIP and Medicaid, so Medicaid is a program that is
    so critical to rural America.
        We have a proposal now by the Administration to allow
    states to cap Medicaid spending for certain populations. I am
    reading here from an Associated Press story, February 6th. The
    first sentence of the article is very simple. It says,
    ``Governors of both major political parties are warning that a
    little-noticed regulation proposed by the President's
    administration could lead to big cuts in Medicaid, reducing
    access to health care for low-income Americans.'' That is
    Governors of both parties saying that about the adverse impact
    on low-income folks through this just one proposal on Medicaid.
    When you combined that with the proposed cuts in the budget
    announced this week, once again we are talking about rural
    America paying the freight, dealing with the impact of Medicaid
    cuts.
        There are some people who walk around this town morning,
    noon, and night, talking about how much they care about rural
    America, and then they propose these cuts to Medicaid, so we
    know what the Governors of both political parties say about it.
    We know what health care experts say about it. Mr. Adams, I am
    just going to ask you. You are in the trenches. You deliver
    home health care to rural communities. Tell us what you think
    the impact would be on your work and the people you take care
    of in rural Pennsylvania, with these cuts.
        Mr. Adams. These cuts, as I stated earlier, would be
    devastating to the community, people that have no
    transportation, and as I stated they would have no ambulances.
    It would be harder for those of us who have low wages to afford
    gas to get to work. They would not have food to eat.
        Senator Casey. What the Federal Government is asking the
    states to do is to stretch their Medicaid dollars much further
    and as our Secretary of Human Services said, ``Permitting
    states to grow--if this happens it would permit states to grow
    health inequities experienced by the poorest Americans.'' That
    is rural America.
        Chairman Collins, thank you very much.
        The Chairman. Thank you, Senator. I want to thank all of
    our witnesses for their contributions to our hearing this
    morning. It was an excellent panel.
        I also want to point out that we had a number of Senators
    who dropped by who were unable to stay due to conflicts in
    their schedule, but I did want to read their names for the
    record: Senator Rick Scott, Senator Gillibrand, Senator Jones,
    with whom I have a bill to expand rural broadband, and Senator
    Blumenthal were all here. I very much appreciate that and know
    that they would have liked to have stayed.
        I also want to recognize Lisa Harvey-McPherson, who is
    here. I have worked with her for literally probably two decades
    on home health care issues. She was one of the people who first
    introduced me to the topic and sparked my great commitment to
    home health care.
        Home health care is clearly a compassionate and less-
    expensive way to care for our seniors, for our disabled
    citizens, and for others who need assistance. It is far less
    expensive than hospitalization or going to a long-term care
    facility. It allows our seniors and disabled citizens to be at
    home, and that is where they overwhelmingly want to be.
        Of an estimated 73 million baby boomers in America, roughly
    10,000 of them turn 65 years old each day. That combined with
    the increasing life expectancy rate illustrate the need for us
    to ensure that we get ahead of this issue and that we ensure
    that we have the workforce, that we have the technology, that
    we have the reimbursements across all of the programs that are
    affected in place for caring for this generation, and that we
    not wait until we have a crisis, which I think we are
    approaching when it comes to workforce issues, to deal with
    these issues.
        As home health care has become even more skilled over the
    years its promise has grown, and we must do everything we can
    to not only keep the doors open for home health agencies but to
    help them thrive so that they can serve those rural patients.
    The two home health care bills that I have introduced have
    received wide bipartisan support, and I look forward to
    shepherding them across the finish line.
        Again, I want to thank our witnesses and Committee members
    for their dedication to the cause, and I also want to thank our
    staff for their hard work too.
        I now will turn to Senator Casey if he has any further
    closing remarks that he wants to make.
        Senator Casey. Chairman Collins, thank you for the hearing.
    I want to thank our witnesses for providing great insight into
    these issues. I will just be really brief and say we have to
    provide much more help for the people doing this work, and we
    have to prioritize the health care needs of rural Americans. We
    are not doing that nearly well enough. One of the best places
    to validate that we care deeply about the people who live in
    those communities is to make sure we do not cut existing
    services that are provided through programs, especially those
    like Medicaid.
        Thank you, Madam Chair.
        The Chairman. Thank you. Committee members will have until
    Friday, February 21st, to submit questions for the record. If
    we get additional questions we will be sending them your way.
        Again thank you, and our timing is exquisite because the
    vote has just begun. This concludes our hearing.
        [Whereupon, at 10:37 a.m., the Committee was adjourned.]

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                            Questions for the Record

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