[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.]
  
=======================================================================


                                APPENDIX    
      
=======================================================================


                      Prepared Witness Statements

=======================================================================
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
      
=======================================================================


                        Questions for the Record

=======================================================================
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]   
      
=======================================================================


                  Additional Statements for the Record

=======================================================================
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                           [all]