[House Hearing, 117 Congress]
[From the U.S. Government Publishing Office]


                    THE FUTURE OF TELEHEALTH: HOW COVID-19 
                   IS CHANGING THE DELIVERY OF VIRTUAL CARE

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

                            VIRTUAL HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               ----------                              

                             MARCH 2, 2021

                               ----------                              

                            Serial No. 117-9
                            
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                            


     Published for the use of the Committee on Energy and Commerce
                   govinfo.gov/committee/house-energy
                        energycommerce.house.gov
                        
                              __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
45-928 PDF                 WASHINGTON : 2022                     
          
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                    COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
BOBBY L. RUSH, Illinois              CATHY McMORRIS RODGERS, Washington
ANNA G. ESHOO, California              Ranking Member
DIANA DeGETTE, Colorado              FRED UPTON, Michigan
MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California          BRETT GUTHRIE, Kentucky
KATHY CASTOR, Florida                DAVID B. McKINLEY, West Virginia
JOHN P. SARBANES, Maryland           ADAM KINZINGER, Illinois
JERRY McNERNEY, California           H. MORGAN GRIFFITH, Virginia
PETER WELCH, Vermont                 GUS M. BILIRAKIS, Florida
PAUL TONKO, New York                 BILL JOHNSON, Ohio
YVETTE D. CLARKE, New York           BILLY LONG, Missouri
KURT SCHRADER, Oregon                LARRY BUCSHON, Indiana
TONY CARDENAS, California            MARKWAYNE MULLIN, Oklahoma
RAUL RUIZ, California                RICHARD HUDSON, North Carolina
SCOTT H. PETERS, California          TIM WALBERG, Michigan
DEBBIE DINGELL, Michigan             EARL L. ``BUDDY'' CARTER, Georgia
MARC A. VEASEY, Texas                JEFF DUNCAN, South Carolina
ANN M. KUSTER, New Hampshire         GARY J. PALMER, Alabama
ROBIN L. KELLY, Illinois, Vice       NEAL P. DUNN, Florida
    Chair                            JOHN R. CURTIS, Utah
NANETTE DIAZ BARRAGAN, California    DEBBBIE LESKO, Arizona
A. DONALD McEACHIN, Virginia         GREG PENCE, Indiana
LISA BLUNT ROCHESTER, Delaware       DAN CRENSHAW, Texas
DARREN SOTO, Florida                 JOHN JOYCE, Pennsylvania
TOM O'HALLERAN, Arizona              KELLY ARMSTRONG, North Dakota
KATHLEEN M. RICE, New York
ANGIE CRAIG, Minnesota
KIM SCHRIER, Washington
LORI TRAHAN, Massachusetts
LIZZIE FLETCHER, Texas
                                 ------                                

                           Professional Staff

                   JEFFREY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                  NATE HODSON, Minority Staff Director
                         Subcommittee on Health

                       ANNA G. ESHOO, California
                                Chairwoman
G. K. BUTTERFIELD, North Carolina    BRETT GUTHRIE, Kentucky
DORIS O. MATSUI, California            Ranking Member
KATHY CASTOR, Florida                FRED UPTON, Michigan
JOHN P. SARBANES, Maryland           MICHAEL C. BURGESS, Texas
PETER WELCH, Vermont                 H. MORGAN GRIFFITH, Virginia
KURT SCHRADER, Oregon                GUS M. BILIRAKIS, Florida
TONY CARDENAS, California            BILLY LONG, Missouri
RAUL RUIZ, California                LARRY BUCSHON, Indiana
DEBBIE DINGELL, Michigan             MARKWAYNE MULLIN, Oklahoma
ANN M. KUSTER, New Hampshire         RICHARD HUDSON, North Carolina
ROBIN L. KELLY, Illinois             EARL L. ``BUDDY'' CARTER, Georgia
NANETTE DIAZ BARRAGAN, California    NEAL P. DUNN, Florida
LISA BLUNT ROCHESTER, Delaware       JOHN R. CURTIS, Utah
ANGIE CRAIG, Minnesota               DAN CRENSHAW, Texas
KIM SCHRIER, Washington              JOHN JOYCE, Pennsylvania
LORI TRAHAN, Massachusetts           CATHY McMORRIS RODGERS, Washington 
LIZZIE FLETCHER, Texas                   (ex officio)
FRANK PALLONE, Jr., New Jersey (ex 
    officio)
                             
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................     2
    Prepared statement...........................................     3
Hon. Doris O. Matsui, a Representative in Congress from the State 
  of California, prepared statement..............................     4
Hon. Brett Guthrie, a Representative in Congress from the 
  Commonwealth of Kentucky, opening statement....................     5
    Prepared statement...........................................     6
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     7
    Prepared statement...........................................     8
Hon. Cathy McMorris Rodgers, a Representative in Congress from 
  the State of Washington, opening statement.....................     9
    Prepared statement...........................................    11

                               Witnesses

Megan Mahoney, M.D., Chief of Staff, Stanford Health Care........    13
    Prepared statement...........................................    15
    Answers to submitted questions...............................   328
Ateev Mehrotra, M.D., Associate Professor of Health Policy and 
  Medicine, Harvard Medical School...............................    21
    Prepared statement...........................................    23
    Answers to submitted questions...............................   330
Elizabeth Mitchell, President and Chief Executive Officer, 
  Purchaser Business Group on Health.............................    31
    Prepared statement...........................................    33
    Answers to submitted questions...............................   333
Jack Resneck, M.D., Member, Board of Trustees, American Medical 
  Association....................................................    44
    Prepared statement...........................................    46
    Answers to submitted questions...............................   336
Frederic Riccardi, President, Medicare Rights Center.............    55
    Prepared statement...........................................    57
    Answers to submitted questions...............................   339

                           Submitted Material

Statement of the ERISA Industry Committee ``Employers on 
  Telehealth: Government Standing in the Way,'' March 2, 2021, 
  submitted by Ms. Eshoo.........................................   134
Fact sheet of March 2021, ``Expanding Access to Care Through 
  Telehealth During COVID-19 and Beyond,'' BlueCross BlueShield 
  Association, submitted by Ms. Eshoo............................   141
Letter of March 1, 2021, from Jeffrey A. Singer, Senior Fellow, 
  Department of Health Policy Studies, Cato Institute, to Ms. 
  Eshoo and Mr. Guthrie, submitted by Ms. Eshoo..................   142
Letter of March 2, 2021, from Graham Dufault, Connected Health 
  Initiative, to Ms. Eshoo and Mr. Guthrie, submitted by Ms. 
  Eshoo..........................................................   146
Statement of the Cystic Fibrosis Foundation, February 25, 2021, 
  submitted by Ms. Eshoo.........................................   153
Statement of the American Hospital Association, March 2, 2021, 
  submitted by Ms. Eshoo.........................................   155
Letter of March 1, 2021, from Gary L. LeRoy, Board Chair, 
  American Academy of Family Physicians, to Ms. Eshoo and Mr. 
  Guthrie, submitted by Ms. Eshoo................................   160
Statement of the Association of American Medical Colleges, March 
  2, 2021, submitted by Ms. Eshoo................................   163
Letter of March 2, 2021, from Ceci Connolly, President and Chief 
  Executive Officer, Alliance of Community Health Plans, to Ms. 
  Eshoo and Mr. Guthrie, submitted by Ms. Eshoo..................   168
Letter of March 1, 2021, from Meghan Woltman, Interim Chief 
  Government Affairs Officer, Advocate Aurora Health, to Ms. 
  Eshoo and Mr. Guthrie, with letter of December 28, 2020, from 
  Denise Keefe, President, Post-Acute Division, Advocate Aurora 
  Health, to Seema Verma, Administrator, Centers for Medicare & 
  Medicaid Services, submitted by Ms. Eshoo......................   172
Memorandum of March 2, 2021, from Charlie Katebi, Health Policy 
  Analyst, Americans for Prosperity, submitted by Ms. Eshoo......   182
Summary, ``AHRQ portfolio on chronic pain and/or telehealth 
  2021,'' Agency for Healthcare Research and Quality, submitted 
  by Ms. Eshoo...................................................   185
Letter of March 3, 2020, from Krista Drobac, Executive Director, 
  Alliance for Connected Care, to Ms. Eshoo, et al., submitted by 
  Ms. Eshoo......................................................   187
Statement of The ALS Association by Neil Thakur, Chief Mission 
  Officer, March 2, 2021, submitted by Ms. Eshoo.................   194
Statement of the Alzheimer's Association and Alzheimer's Impact 
  Movement, March 2, 2021, submitted by Ms. Eshoo................   197
Statement of the American Nurses Association, March 2, 2021, 
  submitted by Ms. Eshoo.........................................   200
Letter of February 26, 2021, from Sharon L. Dunn, President, 
  American Physical Therapy Association, to Ms. Eshoo and Mr. 
  Guthrie, submitted by Ms. Eshoo................................   202
Letter of February 4, 2021, from Kyle Zebley, Public Policy 
  Director, American Telemedicine Association, to Hon. Charles E. 
  Schumer, Majority Leader, United States Senate, submitted by 
  Ms. Eshoo......................................................   208
Letter of March 2, 2021, from Alliance of Community Health Plans, 
  et al., to Hon. Catherine Cortez Masto, United States Senate, 
  et al., submitted by Mr. Bilirakis.............................   212
Statement of the Children's National Medical Center-Rare Disease 
  Institute by Dr. Marshall Summar, Division Chief, Genetics and 
  Metabolism, submitted by Ms. Eshoo.............................   214
Statement of CommonSpirit Health, March 2, 2021, submitted by Ms. 
  Eshoo..........................................................   217
Statement of the American College of Physicians, March 2, 2021, 
  submitted by Ms. Eshoo.........................................   219
Statement of the American Psychological Association, March 2, 
  2021, submitted by Ms. Eshoo...................................   227
Article of February 17, 2021, ``Health Experts Misjudged EHR 
  Clinician Burnout at HITECH Act Passage,'' by Christopher 
  Jason, EHR Intelligence, submitted by Mr. Burgess..............   230
Statement of the Heart Failure Society of America, March 2, 2021, 
  submitted by Ms. Eshoo.........................................   232
Technical Assistance, ``Telehealth: Potential Program Integrity 
  Issues,'' February 2021, Office of Inspector General, 
  Department of Health and Human Services, submitted by Mr. 
  Guthrie........................................................   235
Letter of March 1, 2021, from Mary R. Grealy, President, 
  Healthcare Leadership Council, to Ms. Eshoo and Mr. Guthrie, 
  submitted by Ms. Eshoo.........................................   239
Letter of March 2, 2021, from Jody L. Dietel, Senior Vice 
  President, Advocacy and Government Affairs, HealthEquity, Inc., 
  to Ms. Eshoo and Mr. Guthrie, submitted by Ms. Eshoo...........   241
Summary, ``COVID-19 & Rural Health Equity in Northern New 
  England,'' by Elizabeth Carpenter-Song and Anne N. Sosin, 
  Center for Global Health Equity, Geisel School of Medicine, 
  Dartmouth College, submitted by Ms. Kuster.....................   243
Letter of March 2, 2021, from Bobby Patrick VI, Vice President, 
  Strategic Growth and Policy, Medical Alley Association, to Ms. 
  Craig, submitted by Ms. Eshoo..................................   247
Letter of March 2, 2021, from Piper Nieters Su, Division Chair, 
  External Relations, Mayo Clinic, to Ms. Eshoo and Mr. Guthrie, 
  submitted by Ms. Eshoo.........................................   250
Letter of March 1, 2021, from Anders Silberg, Senior Vice 
  President, Government Affairs, Medical Group Management 
  Association, to Ms. Eshoo and Mr. Guthrie, submitted by Ms. 
  Eshoo..........................................................   253
Letter of March 1, 2021, from the Mental Health Liaison Group to 
  Mr. Pallone, et al., submitted by Ms. Eshoo....................   256
Article, ``Amyotrophic lateral sclerosis care and research in the 
  United States during the COVID-19 pandemic: Challenges and 
  opportunities'' by James D. Berry, et al., Muscle & Nerve. 
  2020;62:182-186, submitted by Ms. Eshoo........................   262
Statement of the National Safety Council, March 2, 2021, 
  submitted by Ms. Eshoo.........................................   267
Letter of March 1, 2021, from Will Crump, Director of Public 
  Health Policy, Ochsner Health, to Ms. Eshoo and Mr. Guthrie, 
  submitted by Ms. Eshoo.........................................   270
Statement of the Oncology Nursing Society, March 2, 2021, 
  submitted by Ms. Eshoo.........................................   281
Statement of the Partnership for Employer-Sponsored Coverage, 
  March 2, 2021, submitted by Ms. Eshoo..........................   283
Statement of the Physician Assistant Education Association, March 
  2, 2021, submitted by Ms. Eshoo................................   285
Letter, undated, from Courtney M. Joslin, Resident Fellow, R 
  Street Institute, to Ms. Eshoo and Mr. Guthrie, submitted by 
  Ms. Eshoo......................................................   288
Statement of America's Health Insurance Plans, March 2, 2021, 
  submitted by Ms. Eshoo.........................................   291
Statement of Johns Hopkins Medicine by Brian Hasselfield, Medical 
  Director, Digital Health and Telemedicine, March 2, 2021, 
  submitted by Ms. Eshoo.........................................   297
Statement of the American Pharmacists Association, March 2, 2021, 
  submitted by Ms. Eshoo.........................................   305
Fact sheet, ``Telehealth: Addressing the Growing Demand for 
  Behavioral Health Services During COVID and Beyond,'' 
  Centerstone, submitted by Ms. Eshoo............................   309
Letter of February 22, 2021, from the Mental Health Liaison Group 
  to Hon. Patty Murray, Chairwoman, Senate Committee on Health, 
  Education, Labor, and Pensions, et al., submitted by Ms. Eshoo.   310
Memorandum of February 26, 2021, from Andrew Schwab, Director of 
  Policy, Federal Affairs & Partnerships, United States of Care, 
  submitted by Ms. Eshoo.........................................   314
Statement of the California Hospital Association, March 2, 2021, 
  submitted by Ms. Eshoo.........................................   317
Summary, COVID-19 Telehealth Grants, submitted by Ms. Eshoo......   319
Statement of the National Association of Free and Charitable 
  Clinics by Nicole Lamoureux, President and Chief Executive 
  Officer, submitted by Ms. Eshoo................................   322
Statement of the Society for Women's Health Research by Kathryn 
  G. Schubert, President and Chief Executive Officer, submitted 
  by Ms. Eshoo...................................................   324

 
  THE FUTURE OF TELEHEALTH: HOW COVID-19 IS CHANGING THE DELIVERY OF 
                              VIRTUAL CARE

                              ----------                              


                         TUESDAY, MARCH 2, 2021

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:30 a.m. via 
Cisco Webex online video conferencing, Hon. Anna G. Eshoo 
(chairwoman of the subcommittee), presiding.
    Members present: Representatives Eshoo, Butterfield, 
Matsui, Castor, Sarbanes, Welch, Schrader, Cardenas, Ruiz, 
Dingell, Kuster, Kelly, Barragan, Blunt Rochester, Craig, 
Schrier, Trahan, Fletcher, Pallone (ex officio), Guthrie 
(subcommittee ranking member), Upton, Burgess, Griffith, 
Bilirakis, Long, Bucshon, Mullin, Hudson, Carter, Dunn, Curtis, 
Crenshaw, Joyce, and Rodgers (ex officio).
    Also present: Representatives O'Halleran, Latta, Johnson, 
and Pence.
    Staff present: Jeffrey C. Carroll, Staff Director; Waverly 
Gordon, General Counsel; Tiffany Guarascio, Deputy Staff 
Director; Perry Hamilton, Deputy Chief Clerk; Mackenzie Kuhl, 
Digital Assistant; Una Lee, Chief Health Counsel; Aisling 
McDonough, Policy Coordinator; Meghan Mullon, Policy Analyst; 
Juan Negrete, Junior Professional Staff Member; Kaitlyn Peel, 
Digital Director; Chloe Rodriguez, Deputy Chief Clerk; Samantha 
Satchell, Professional Staff Member; C.J. Young, Deputy 
Communications Director; Sarah Burke, Minority Deputy Staff 
Director; Theresa Gambo, Minority Financial and Office 
Administrator; Grace Graham, Minority Chief Counsel, Health; 
Caleb Graff, Minority Deputy Chief Counsel, Health; Peter 
Kielty, Minority General Counsel; Emily King, Minority Member 
Services Director; Bijan Koohmaraie, Minority Chief Counsel; 
Clare Paoletta, Minority Policy Analyst, Health; Kristin Seum, 
Minority Counsel, Health; Kristen Shatynski, Minority 
Professional Staff Member, Health; Michael Taggart, Minority 
Policy Director; and Everett Winnick, Minority Director of 
Information Technology.
    Ms. Eshoo. The Subcommittee on Health will now come to 
order. Due to COVID-19, today's hearing is being held remotely. 
And all Members and witnesses will be participating via 
teleconferencing--video conferencing.
    As part of our hearing today, microphones will be set on 
mute to eliminate background noise. And Members and witnesses, 
you need to unmute your microphone each time you wish to speak.
    Documents for the record should be sent to Meghan Mullon at 
the email address that we have provided to the staff. And all 
documents will be entered into the record at the conclusion of 
the hearing.
    The Chair now recognizes herself for 5 minutes for an 
opening statement.

 OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    As the chairwoman of this subcommittee and a senior member 
of the Communications and Technology Subcommittee, I have been 
highlighting the importance of telehealth for years, and I am 
not the only one. This has been a longstanding bipartisan issue 
for many Members on this subcommittee, including 
Representatives Welch, Matsui, and Johnson, who are all leads 
on the CONNECT for Health Act, and Representative Kelly, who 
leads the Evaluating Disparities and Outcomes of Telehealth 
Act.
    I think it is time to make Medicare reimbursement for 
telehealth service permanent. Over the last several months, I 
have talked to many healthcare professionals and providers in 
my district, and I think the members of the subcommittee have, 
as well, including Dr. Mahoney of Stanford Health, who I am so 
pleased to have on our expert panel today. I have heard how the 
wide adoption of telehealth has been a bright spot during a 
very dark time in our country.
    One reason is that HHS waived many outdated rules and 
payment policies surrounding telehealth coverage in traditional 
Medicare during the public health emergency. A nonpartisan HHS 
report found that, from mid-March through early July of last 
year, more than 10.1 million traditional Medicare beneficiaries 
used telehealth, thanks to those waivers. It is also the first 
time we have had substantive data on the quality and the use of 
telehealth at scale.
    We are quickly learning how telehealth can be used to 
address specialty shortages. For example, 70 percent of U.S. 
counties do not have a child psychiatrist. Telehealth could 
help close that gap. Telehealth can also address racial 
disparities in health outcomes. Our subcommittee has studied 
racial bias in doctors and how it impacts maternal mortality. A 
new landmark study by the University of Minnesota School of 
Public Health recently showed that the mortality rate for Black 
babies is cut in half when Black doctors care for them. That is 
highly instructive. Telehealth could make it easier for 
patients of color to find a doctor of the same race or who 
speaks the same language.
    I know that telehealth isn't the silver bullet for the 
deeper problems that exist in our healthcare system, but it has 
demonstrated great promise for high-quality, innovative care if 
we intentionally create legislation that fits our Nation's 
needs. Now that Medicare beneficiaries and Americans are 
receiving this important benefit, we need to find a way to 
continue affordable telehealth access for seniors and other 
Americans.
    So, from today's hearing, we will learn from providers, 
payers, and patients about their experiences with telehealth 
and be better able to chart a legislative path forward to 
deliver on the promise of telehealth.
    [The prepared statement of Ms. Eshoo follows:]

                Prepared Statement of Hon. Anna G. Eshoo

    As the chairwoman of the Health Subcommittee and a senior 
member of the Communications and Technology Subcommittee, I've 
been highlighting the importance of telehealth for years.
    And I'm not the only one. This has been a longstanding, 
bipartisan issue for many Members on this subcommittee, 
including Representatives Peter Welch, Doris Matsui, and Bill 
Johnson, who are all leads on the CONNECT for Health Act, and 
Robin Kelly, who leads the Evaluating Disparities and Outcomes 
of Telehealth Act.
    It's time to make Medicare reimbursement for telehealth 
service permanent.
    Over the last several months, I've talked to healthcare 
professionals and providers in my district, including Dr. 
Mahoney of Stanford Health, who I'm so pleased to have on our 
expert panel today. I've heard how the wide adoption of 
telehealth has been a bright spot during a very dark time.
    One reason is that HHS waived many outdated rules and 
payment policies surrounding telehealth coverage in traditional 
Medicare during the public health emergency.
    A nonpartisan HHS report found that, from mid-March through 
early July 2020, more than 10.1 million traditional Medicare 
beneficiaries used telehealth thanks to those waivers.
    It's also the first time we've had substantive data on the 
quality and use of telehealth at scale.
    We're quickly learning how telehealth can be used to 
address specialty shortages. For example, 70% of U.S. counties 
have no child psychiatrist. Telehealth could help close that 
gap.
    Telehealth can also address racial disparities in health 
outcomes. Our subcommittee has studied racial bias in doctors 
and how it impacts maternal mortality. A new landmark study by 
the University of Minnesota School of Public Health recently 
showed that the mortality rate for Black babies is cut in half 
when Black doctors care for them. Telehealth could make it 
easier for patients of color to find a doctor of their same 
race or who speaks the same language.
    I know telehealth isn't the silver bullet for the deeper 
problems that exist in our healthcare system, but it does show 
promise for high-quality, innovative care if we intentionally 
create legislation that fits our Nation's needs.
    Now that Medicare beneficiaries and Americans are receiving 
this important benefit, we need to find a way to continue 
affordable telehealth access for seniors and other Americans.
    From today's hearing we will learn from providers, payers, 
and patients about their experiences with telehealth and be 
better able to chart a legislative path forward to deliver on 
the promise of telehealth.

    Ms. Eshoo. I now yield the rest of my time to the 
gentlewoman from California, Congresswoman Matsui.
    Ms. Matsui. Thank you very much, Madam Chair, for calling 
this very important hearing, and thank you for the witnesses 
for being here today.
    Telehealth has been, without a doubt, critical to 
preserving access to care during the public health emergency. 
We are seeing virtual care being embraced like never before, 
largely due to providers quickly scaling and adopting 
technology at the start of the pandemic. For years we have been 
working on policy to incentivize this adoption. But it was the 
CMS waivers issued early in the pandemic that were key to jump 
starting the widespread telehealth investment.
    What is striking to me is that many of the changes made by 
CMS to waive geographic and site requirements and increase 
flexibility for telehealth under Medicare were not new ideas. 
They are the same policy changes we have been fighting for in 
Congress for years, commonsense solutions that broaden where 
services can be provided, and you can provide them breaking 
down longstanding, inequitable barriers to digital care.
    I am proud to colead several efforts that would give our 
providers more certainty about how care will be delivered in 
the future, such as the comprehensive CONNECT for Health Act, 
aimed to remove the most onerous roadblocks in telehealth, to 
ensure its extension beyond this public health emergency.
    Modernizing telehealth policy to meet the moment is one of 
the most important responsibilities of this Health 
Subcommittee. I look forward to hearing from witnesses today 
and working with my colleagues on solutions that promote safe 
and equitable access to health telehealth for years to come.
    Thank you very much, Madam Chair, and I yield back.
    [The prepared statement of Ms. Matsui follows:]

               Prepared Statement of Hon. Doris O. Matsui

    Thank you, Madam Chair for calling this important hearing 
and thank you to our witnesses for being here today.
    Telehealth has been critical to preserving access to care 
during the public health emergency.
    We are seeing virtual care being embraced like never 
before. largely due to providers quickly scaling and adopting 
technology at the start of the pandemic.
    For years we have been working on policy to incentivize 
this adoption. but it was the CMS waivers issued early in the 
pandemic that were key to jump starting the widespread 
telehealth investment.
    What is striking to me is that many of the changes made by 
CMS.to waive geographic and site requirements and increase 
flexibility for telehealth under Medicare.were not new ideas.
    They are the same policy changes we have been fighting for 
in Congress for years, common sense solutions that broaden 
where services can be provided and who can provide them, 
breaking down long-standing, inequitable barriers to digital 
care.
    I am proud to colead several efforts that will give our 
providers more certainty about how care will be delivered in 
the future. Both the Protecting Access to Post-COVID-19 
Telehealth Act and the comprehensive CONNECT for Health Act 
would remove the most onerous roadblocks in telehealth ensuring 
its continued use beyond the public health emergency.
    Modernizing telehealth policy to meet the moment is one of 
the most important responsibilities of this Health Subcommittee 
in the near term.
    I look forward to hearing from our witnesses today and 
working with my colleagues on solutions that promote safe and 
equitable access to telehealth for years to come.

    Ms. Eshoo. Thank you, Congresswoman Matsui. The Chair now 
recognizes Mr. Brett Guthrie, the ranking member of the 
subcommittee, for 5 minutes for his opening statement.
    And remember to unmute.

 OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN 
           CONGRESS FROM THE COMMONWEALTH OF KENTUCKY

    Mr. Guthrie. Thank you. Thank you, Madam Chair, I 
appreciate it. I am sorry I was a few minutes late getting on. 
I was doing typos or something, trying to get on to the 
website. So thank you for holding this important hearing.
    Almost a year ago today the public health emergency began. 
All of our lives changed, and we all had to adapt. Telehealth 
was rarely used prior to the public health emergency for many 
Americans but has since increased substantially due to COVID-
19.
    I have heard from mental health providers that have seen a 
huge growth in telehealth services. One mental health provider 
group has seen telehealth services grow from 5 percent to more 
than 80 percent. I have also heard from a Kentucky provider who 
expressed how helpful their telehealth has been--over 600 
telehealth visits--has been to stay connected with medically 
fragile patients during COVID-19, especially pediatric 
patients. These patients are very vulnerable to infections and 
must limit any contact in order to prevent exposure to COVID-
19.
    I am grateful for the providers who stepped up and worked 
hard to provide telehealth services to their patients.
    I was very pleased that the Centers for Medicare and 
Medicaid Services, CMS, the Trump administration, and Congress 
worked together to make sure telehealth was accessible and 
available during the public health emergency. Swift action last 
year provided flexibilities for telehealth usage to grow. More 
recently, in the December COVID-19 relief package, Congress 
allowed Medicare to permanently waive the originating site 
requirement for mental health services. I was very supportive 
of these measures that are key to adapting to a COVID-19 world.
    I have said before the genie is out of the bottle 
concerning telehealth flexibilities and expansion, and I 
continue to believe this. We have seen good development and 
progress so far. However, not every medical condition is 
appropriate to receive medical care through telehealth, or some 
patients can't access telehealth due to their specific needs, 
such as disorders--
    Additionally, in my district, broadband continues to be a 
limiting factor. In five COVID-19 relief packages that were 
signed into law, Congress has worked to help resolve this 
issue. But our work is not done. I am committed to working with 
my colleagues on ways to address infrastructure limitations for 
telehealth access.
    Additionally, we must examine appropriate guardrails for 
telehealth services to combat bad actors who are taking 
advantage of this terrible circumstance. Criminals have gotten 
very creative with telehealth scams, including cold calling 
Medicare beneficiaries and using fraudulent overseas providers 
to bill for services, to name a few.
    I look forward to hearing from our witnesses and examining 
solutions today on ways to prevent fraud and abuse, as well as 
ensure Americans have access to valuable telehealth services.
    HHS is currently conducting reports on telehealth during 
the pandemic. They are focusing on three--the OIG are focusing 
on three key areas of telehealth, including quality of care and 
patient safety; verification of services and patient consent; 
and infrastructure. While more is to come from OIG's research, 
I believe we should fully examine these issues now and also 
revisit once OIG investigations are complete.
    We need to examine ways to continue to allow telehealth. 
But there are several factors we need to consider and improve 
on as we move forward. Telehealth can't replace all in-person 
business, and we need to ensure quality of care is still given 
by the provider no matter the setting. Additionally, we need to 
make sure telehealth isn't being used for fraud and abuse.
    I look forward to hearing from our witnesses in examining 
solutions today in order to ensure Americans have access to 
valuable telehealth services.
    I yield back.
    [The prepared statement of Mr. Guthrie follows:]

                Prepared Statement of Hon. Brett Guthrie

    Thank you, Chair Eshoo, for holding this important hearing 
about telehealth.
    Almost a year ago today, the public health emergency began, 
our lives changed, and we all had to adapt. Telehealth was 
rarely used prior to the public health emergency for many 
Americans but has since increased substantially due to COVID-
19. I have also heard from mental health providers who have 
seen a huge growth in telehealth services. One mental health 
provider group has seen telehealth services grow from 5% to 
more than 80%. I also heard from a Kentucky provider, who 
expressed how helpful their over 600 telehealth visits have 
been to stay connected with medically fragile patients during 
COVID-19, especially pediatric patients. These patients are 
very vulnerable to infections and must continue having care 
they need to be protected from COVID-19. I am grateful for the 
providers who stepped up and worked hard to provide telehealth 
access to their patients.
    I was very pleased that the Centers for Medicare and 
Medicaid Services (CMS), the Trump administration and Congress 
worked together to make sure telehealth was accessible and 
available during the pandemic. Quick action last year allowed 
for Medicare to waive many telehealth requirements including 
the originating site requirement for the duration of the public 
health emergency. Most recently, I was very supportive of the 
recent measure Congress took to waive originating site 
requirement for mental health services in the December COVID-19 
relief package. These flexibilities are key to adapting to a 
COVID-19 world.
    I've said before the ``genie is out of the bottle'' 
concerning telehealth flexibilities and expansion, and I 
continue to believe this. We have seen good development and 
progress so far; however, not everyone is a good candidate for 
telehealth or can access telehealth due to their disease or 
condition. In my district, broadband continues to be a limiting 
factor. In the five COVID-19 relief packages that were signed 
into law, Congress has worked to help resolve this issue, but 
our work is not done. I am committed to working with my 
colleagues on ways to address infrastructures limitations for 
telehealth access. Additionally, we must examine appropriate 
guardrails for telehealth services to combat bad actors who are 
taking advantage of this terrible circumstance. Criminals have 
gotten very creative with telehealth scams including cold 
calling Medicare beneficiaries, and using fraudulent overseas 
providers to bill for services, to name a few. I look forward 
to hearing from our witnesses and examining solutions today on 
ways to prevent fraud and abuse as well as ensure Americans 
have access to valuable telehealth services.
    HHS OIG is currently conducting reports on telehealth 
during the pandemic. They are focusing on three key areas of 
telehealth, including quality of care and patient safety, 
verification of services and patient consent, and 
infrastructure. While more is to come from OIG's research, I 
believe we should fully examine these issues now and also 
revisit once the OIG investigations are complete. We examine 
ways to continue to allow telehealth, but there are several 
factors we need to consider and improve as we move forward. 
Telehealth can't replace all in-person visits, and we need to 
ensure quality of care is still given by the provider, no 
matter the setting. Additionally, we need to make sure 
telehealth isn't being used for fraud and abuse.
    I look forward to hearing from our witnesses and examining 
solutions today on ways to prevent fraud and abuse as well as 
ensure Americans have access to valuable telehealth services. I 
yield back.

    Ms. Eshoo. I just want to add that we are all really 
delighted that you are the ranking member of this subcommittee. 
I believe--I don't remember what Congress it was, but 
colleagues--our ranking member was voted the nicest Member of 
Congress. So we are blessed to have him aboard.
    The Chair now recognizes Mr. Pallone, the chairman of the 
full committee, for his 5 minutes for an opening statement.
    Good morning.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Good morning. Thank you, Chairwoman Eshoo.
    Over the course of this pandemic, millions of Americans 
have used telehealth, some perhaps for the first time, to stay 
connected to their healthcare providers without increasing 
their risk of exposure to COVID-19. When the pandemic was 
beginning to take hold, we moved quickly to significantly 
expand access to telehealth for Medicare beneficiaries, and 
this was critically important because Medicare beneficiaries 
are some of the most vulnerable to COVID-19. And since then, 
Medicare has waived its originating site and rural requirements 
for the duration of the public health emergency.
    Medicare is also now covering an expanded list of 
telehealth services that beneficiaries across the country can 
access without ever leaving their homes. Most private insurers 
have also acted to expand coverage of telehealth benefits by 
allowing coverage of more services, and reducing cost sharing 
for those telehealth services.
    Expanding access to this critical tool early on helped save 
lives and also helped keep providers afloat during a time when 
patients are rightfully hesitant to receive health services in 
person. Early data shows that telehealth utilization has 
skyrocketed, not only in the Medicare program but also in 
Medicaid and private insurance plans. And, unlike Medicare, 
private insurance plans and Medicaid did not have the same 
statutory restrictions on telehealth services, such as the 
rural and originating site requirements.
    And our committee has a long history of working to expand 
access to health--to telehealth services in Medicare. For 
example, the Bipartisan Budget Act of 2018 expanded access to 
telestroke services and provided additional flexibility for 
accountable care organizations to expand telehealth. The 
SUPPORT Act expanded access to substance use disorder services 
delivered via telehealth. And most recently, the Consolidated 
Appropriations Act in, you know, the end-of-the-year package, 
permanently expanded access to telemental health services in 
Medicare.
    In each of these examples, Congress expanded access after 
carefully looking at the evidence and weighing tradeoffs with 
respect to quality of care, access, and value. And while I 
applaud the work that has been done so far to rapidly expand 
telehealth in Medicare and elsewhere during these times, I 
think it is important for the committee to carefully consider 
the impacts of the current waivers.
    We must also ensure that the data being collected today 
informs our decisions going forward. For example, there are 
several key areas for our committee to consider.
    The first is value. While the convenience of telehealth can 
help provide critical services to hard-to-reach populations, it 
can also lead to overutilization or low-value care. So it is 
important to consider how future policies can encourage the use 
of high-value care while at the same time discouraging 
potentially low-value care and over-utilization in Medicare 
fee-for-service.
    Second, it is important to consider ways to strengthen 
program integrity and prevent potential bad actors from taking 
advantage of the system and consumers. In recent years the 
Department of Health and Human Services Office of the Inspector 
General has warned of increased fraud connected to telehealth-
related schemes. While there are significant benefits to 
telehealth, we should not ignore the potential for illegitimate 
uses of telehealth and scams that prey on consumers, especially 
seniors.
    And third, it is critical that we ensure equitable access 
to telehealth. Ideally, telehealth would help those areas that 
are already underserved and individuals who lack access to 
providers or individuals who are managing serious health 
conditions. Utilization data should be analyzed to ensure that 
we are effectively reaching these populations and to help 
identify any barriers in reaching them. We know that many 
Americans lack the digital literacy, technology, or Internet 
access needed to use telehealth as effectively as others. These 
are all issues that Congress has to work to address. And in 
providing increased access to telehealth, we need to ensure 
that we are not further fragmenting care.
    And these are just some of the many issues that warrant 
further consideration. But we have all seen various tangible 
benefits to telehealth, particularly during the pandemic. It is 
important for us to continue to investigate the impact of these 
changes on our healthcare system before enacting permanent 
policies.
    So I look forward to working with members of the committee 
to examine the data and ultimately provide certainty to 
patients and providers on future telehealth policy. We have a 
unique opportunity to use the lessons learned from the 
pandemic, and translate them into legislation that ensures that 
these critical telehealth tools are used appropriately to 
advance health equity and improve quality of care for all 
Americans.
    I know, Madam Chair, that, you know, I hear about this 
telehealth all the time. And, you know, we obviously want to 
make things permanent, but we also have to be careful about how 
we do it. So thank you again. This is a very important hearing. 
I thank the chair.
    I yield back.
    [The prepared statement of Mr. Pallone follows:]

             Prepared Statement of Hon. Frank Pallone, Jr.

    Over the course of this pandemic millions of Americans have 
used telehealth, some perhaps for the first time, to stay 
connected to their healthcare providers without increasing 
their risk of exposure to COVID-19.
    When the pandemic was beginning to take hold in America, we 
moved quickly to significantly expand access to telehealth for 
Medicare beneficiaries. This was critically important because 
Medicare beneficiaries are some of the most vulnerable to 
COVID-19. Since then, Medicare has waived its originating site 
and rural requirements for the duration of the public health 
emergency. Medicare is also now covering an expanded list of 
telehealth services that beneficiaries across the country can 
access without ever leaving their homes. Most private insurers 
have also acted to expand coverage of telehealth benefits by 
allowing coverage of more services and reducing cost-sharing 
for telehealth services.
    Expanding access to this critical tool early on helped save 
lives and also helped keep providers afloat during a time when 
patients are rightfully hesitant to receive healthcare services 
in person. Early data shows that telehealth utilization has 
skyrocketed not only in the Medicare program but also in 
Medicaid and private insurance plans. Unlike Medicare, private 
insurance plans and Medicaid do not have the same statutory 
restrictions on telehealth such as rural and originating site 
requirements.
    Our committee has a long history of working to expand 
access to telehealth services in the Medicare program. For 
example, the Bipartisan Budget Act of 2018 expanded access to 
telestroke services and provided additional flexibility for 
Accountable Care Organizations (ACOs) to expand telehealth. The 
SUPPORT Act expanded access to substance use disorder services 
delivered via telehealth. And most recently the Consolidated 
Appropriations Act, 2021 permanently expanded access to 
telemental health services in Medicare.
    In each of those examples, Congress expanded access after 
carefully looking at the evidence and weighing trade-offs with 
respect to quality of care, access, and value. While I applaud 
the work that has been done so far to rapidly expand telehealth 
in Medicare and elsewhere during these unprecedented times, I 
think it's important for the committee to carefully consider 
the impacts of the current waivers. We must also ensure that 
the data being collected today informs our decisions going 
forward.
    For example, there are several key areas for our committee 
to consider. The first is value. While the convenience of 
telehealth can help provide critical services to hard-to-reach 
populations, it can also lead to overutilization or low-value 
care. It's important to consider how future policies can 
encourage the use of high-value care, while, at the same time, 
discouraging potential low-value care and overutilization in 
Medicare fee-for-service.
    Second, it is important to consider ways to strengthen 
program integrity and prevent potential bad actors from taking 
advantage of the system and consumers. In recent years the 
Department of Health and Human Services' (HHS) Office of the 
Inspector General has warned of increased fraud connected to 
telehealth related schemes. While there are significant 
benefits to telehealth, we should not ignore the potential for 
illegitimate uses of telehealth and scams that prey on 
consumers, especially seniors.
    Third, it's critical that we ensure equitable access to 
telehealth services. Ideally telehealth will help those areas 
that are already underserved and individuals who lack access to 
providers or individuals who are managing serious health 
conditions. Utilization data should be analyzed to ensure that 
we're effectively reaching those populations and to help 
identify any barriers in reaching them. We know that many 
Americans may lack the digital literacy, technology, or 
internet access needed to use telehealth as effectively as 
others. These are all issue Congress must work to address. And, 
in providing increased access through telehealth, we need to 
ensure that we're not further fragmenting care.
    These are just some of the many issues that warrant further 
consideration. Though we have all seen various tangible 
benefits to telehealth, particularly during the pandemic, it is 
important for us to continue to investigate the impact of these 
changes on our healthcare system before enacting permanent 
policies.
    I look forward to working with members of the committee to 
examine the data and ultimately provide certainty to patients 
and providers on future telehealth policy. We have a unique 
opportunity to use the lessons learned from this pandemic and 
translate them into legislation that ensures that these 
critical telehealth tools are used appropriately to advance 
health equity and improve quality of care for all Americans.

    Ms. Eshoo. The gentleman yields back. The Chair is now 
pleased to recognize the ranking member of the full committee, 
Representative Cathy McMorris Rodgers, for 5 minutes for her 
opening statement.
    Good morning to you.

      OPENING STATEMENT OF HON. CATHY McMORRIS RODGERS, A 
    REPRESENTATIVE IN CONGRESS FROM THE STATE OF WASHINGTON

    Mrs. Rodgers. Good morning, everyone, and thank you, Madam 
Chair. Thank you. A big thank you to all our witnesses for 
joining us today.
    Telehealth is a vital way for patients to access care, 
especially in rural communities and during a pandemic. I am 
from a small town in eastern Washington, Kettle Falls, and I 
have lived through the challenges that people face in rural 
communities when it comes to accessing healthcare. I have also 
visited hospitals and healthcare facilities in eastern 
Washington.
    As a leader on the Rural Healthcare Caucus, our 
conversations about expanding telehealth to address doctor 
shortages is no longer just a goal for the future. It is 
happening today. In response to COVID-19, Providence Health 
System, which has four hospitals in my district, scaled up 
their telehealth services from more than 7,000 visits in 2019 
to more than 100,000 visits in 2020. This is more than a 1,000 
percent increase in volume.
    Physicians across Washington State have leverage telehealth 
technology to reach more patients, save lives, and improve 
care. They diagnosed appendicitis in a young patient, worked 
with a pregnant woman to help her find her baby's fetal 
heartbeat, and are providing care for behavioral health 
patients. Across America COVID-19 led to a massive expansion of 
telehealth when nonemergency visits were shuttered. It was the 
only way for people to get routine care.
    The Trump administration took bold and rapid action by 
waiving certain requirements so technology like Facetime could 
be used for telehealth, requiring Medicare to pay for more 
services by telehealth, and reducing out-of-pocket for 
telehealth, removing any Federal licensing requirements, and 
expanding the availability of telehealth services in long-term 
care facilities, where people are especially vulnerable to 
COVID-19.
    According to the CDC, the number of telehealth visits 
increased by 154 percent during the first quarter of 2020. HHS 
reported that nearly half of all Medicare primary care visits 
were via telehealth in April, compared to less than 1 percent 
in February before the start of the COVID-19 pandemic.
    Now is the time for us to plan for the future of 
telehealth. Thanks to the groundwork we laid with 21st Century 
Cures, leadership by the private sector, and Operation Warp 
Speed, the third vaccine for COVID-19 was just authorized for 
emergency use. Also, this past weekend, more than 2 million 
shots made it into people's arms each day.
    With continued work, I am hopeful we will crush this virus 
and restore our way of life. That includes patients returning 
to the doctor's office without fear of contracting COVID-19. 
However, the pandemic has made clear that telehealth can and 
should be a part of modernizing healthcare delivery in America.
    It is up to Congress to make sure we understand how this 
dramatic expansion has helped patients get the care they need. 
That means examining both where telehealth may not be 
appropriate and when it drives better outcomes for patients. 
Our shared goal should be to promote solutions that help 
patients recover from their illnesses and manage their chronic 
conditions better, whether it is through a video call or in-
person care.
    With the rise of anxiety and suicide, I am especially 
interested in the advantages of telehealth to reach people who 
are in need of mental healthcare.
    We have also seen a risk of waste, fraud, and abuse when it 
comes to the deployment of telehealth. And we need to take that 
into account.
    We need to be aware of the cost to the healthcare system of 
changes that we make permanent. The Medicare Hospital Trust 
Fund is projected to go bankrupt in 2024, less than 5 years 
from now. We need to make sure we expand telehealth and 
maintain our commitment to our Nation's seniors to provide a 
top-notch level of care.
    I am optimistic about telehealth and its ability to improve 
the health and wellness of America. It is bringing doctors 
right into the family's living room. And this is an example of 
how innovation can improve and save people's lives.
    This hearing today is just the beginning of a discussion, 
and we need to talk about the future of healthcare. And Madam 
Chair, I appreciate you bringing us together in a bipartisan 
way to review the experiences of the last year and where we can 
further unleash lifesaving innovation and medical 
breakthroughs. Let's have a plan for America to lead the way on 
the best use of telehealth for the benefit of every patient.
    Thank you, and I yield back.
    [The prepared statement of Mrs. Rodgers follows:]

           Prepared Statement of Hon. Cathy McMorris Rodgers

    EASTERN WASHINGTON
    Thank you Chair...and thank you to our witnesses for 
participating today.
    Telehealth is a vital way for patients to access care, 
especially in rural communities and during the pandemic.
    I grew up in a small town in Kettle Falls.
    . and I have lived through the challenges that people face 
in rural communities when it comes to accessing healthcare.
    I have also visited hospitals and healthcare facilities all 
throughout my district in Eastern Washington too.
    As a leader on the Rural Healthcare Caucus, our 
conversations about expanding telehealth to address doctor 
shortages is no longer just a goal for the future, it's 
happening today.
    In response to COVID-19, Providence Health System--which 
has four hospitals in my district--scaled up their telehealth 
services from more than 7 thousand visits in 2019 to more than 
100 thousand visits in 2020.
    This is more than a 1,000% increase in volume.
    Physicians across Washington State have leveraged 
telehealth technologies to reach more patients, save lives, and 
improve care.
    They diagnosed appendicitis in a young patient...
    ...worked with a pregnant woman to help find her baby's 
fetal heartbeat...
    ..and providing care for behavioral health patients.
    REPUBLICAN LEADERSHIP
    Across America, COVID-19 led to a massive expansion of 
telehealth, when non-emergency visits where shuttered.
    It was the only way for people to get routine care.
    The Trump administration took bold and rapid action by...
    . waiving certain requirements so technology like Facetime 
could be used for telehealth ...
    . requiring Medicare to pay for more services by 
telehealth, and reducing out of pocket costs for telehealth...
    . removing any Federal licensing requirements and...
    . expanding the availability of telehealth services in 
long-term care settings, where people are particularly 
vulnerable to COVID-19.
    According to the CDC, the number of telehealth visits 
increased by 154 percent during the first quarter of 2020.
    HHS reported that nearly half of all Medicare primary care 
visits were via telehealth in April, compared with less than 1% 
in February before the start of the COVID-19 pandemic.
    WIN THE FUTURE OF TELEHEALTH
    Now, it's time to plan for the future of telehealth.
    Thanks to the groundwork we laid with 21st Century Cures, 
leadership by the private sector, and Operation Warp Speed, the 
third vaccine for COVID-19 was just authorized for emergency 
use.
    Also, this past weekend, more than 2 million shots made it 
into people's arms each day.
    With continued work, I'm hopeful we will crush this virus 
and restore our way of life that includes patients returning to 
the doctor's office without fear of contracting COVID-19.
    However, the pandemic has made clear that telehealth can 
and should be a part of modernizing healthcare delivery in 
America.
    It's up to Congress to make sure we understand how this 
dramatic expansion has helped patients get the care they need.
    That means examining both where telehealth may not be 
appropriate and when it drives better outcomes for patients.
    Our shared goal should be to promote solutions that help 
patients recover from their illnesses and manage their chronic 
conditions better--whether it is through a video call OR in-
person care.
    With the rise of anxiety and suicides, I'm especially 
interested in the advantages of telehealth to reach people who 
are need of mental healthcare.
    We have also seen a real risk of waste, fraud, and abuse in 
telehealth. We need to take that into account.
    We also need to be aware of the cost to the healthcare 
system of changes we want to make permanent.
    The Medicare Hospital Trust Fund is projected to go 
bankrupt in 2024--less than 5 years from now.
    We need to make sure we expand telehealth and maintain our 
commitment to the Nation's seniors to provide a top-notch level 
of care.
    CONCLUSION
    I'm optimistic about telehealth and its ability to improve 
the health and wellness of Americans.
    It's bringing doctors right into families' living rooms...
    . and it's an example of how innovation can improve and 
save people's lives.
    This hearing today is just the beginning of a discussion we 
need to have about the future of healthcare.
    Let's work together in a bipartisan way to review the 
experiences of the last year and where we can further unleash 
life-saving innovation and medical breakthroughs.
    Let's have a plan for America to lead the way on the best 
use of telehealth for the benefit of every patient.
    Thank you and I yield back.

    Ms. Eshoo. The gentlewoman yields back. Thank you for your 
kind and timely comments.
    The Chair would like to remind Members that, pursuant to 
committee rules, all Members' written opening statements shall 
be made part of the record.
    And now I would like to introduce our witnesses and thank 
them for being with us today.
    First, Dr. Megan Mahoney, chief of staff of Stanford 
Healthcare. I am so pleased to welcome her, she is my 
constituent. She has dedicated her career to developing 
innovative, compassionate approaches to healthcare that 
empowers patients.
    Welcome to you, and thank you.
    Dr. Ateev Mehrotra, associate professor of healthcare 
policy at Harvard Medical School. Thank you and welcome, 
Doctor.
    Ms. Elizabeth Mitchell, president and CEO of the Purchaser 
Business Group on Health. Welcome to you and thank you.
    Dr. Jack Resneck, Jr., board of trustees of the American 
Medical Association. We welcome you back to the subcommittee to 
testify today. It is always great to see you.
    And Mr. Frederic Riccardi, president of the Medicare Rights 
Center. Welcome back to the committee to you, Mr. Riccardi, and 
thank you for being willing to testify.
    So, Dr. Mahoney, you are recognized for 5 minutes. And 
please unmute.

  STATEMENT OF MEGAN MAHONEY, M.D., CHIEF OF STAFF, STANFORD 
   HEALTH CARE; ATEEV MEHROTRA, M.D., ASSOCIATE PROFESSOR OF 
 HEALTH POLICY AND MEDICINE, HARVARD MEDICAL SCHOOL; ELIZABETH 
  MITCHELL, PRESIDENT AND CHIEF EXECUTIVE OFFICER, PURCHASER 
BUSINESS GROUP ON HEALTH; JACK RESNECK, M.D., MEMBER, BOARD OF 
TRUSTEES, AMERICAN MEDICAL ASSOCIATION; AND FREDERIC RICCARDI, 
               PRESIDENT, MEDICARE RIGHTS CENTER

                STATEMENT OF MEGAN MAHONEY, M.D.

    Dr. Mahoney. Thank you. Good morning, Chairwoman Eshoo, 
Ranking Member Guthrie, and members of the subcommittee. I am 
Dr. Megan Mahoney, a family physician of over 20 years, chief 
of staff at Stanford Healthcare, and a clinical professor in 
the department of medicine at Stanford University.
    The COVID-19 pandemic accelerated broad adoption of 
telehealth, and healthcare systems across the Nation had to 
make significant investments to rapidly develop virtual care 
capabilities. Stanford Medicine enabled telehealth for 2,000 
providers and 300,000 patients since the beginning of the 
pandemic. We have had several learnings that I would like to 
share with you.
    We learned that virtual care is broadly adopted as a 
clinically effective tool, even after we return to offering in-
person care across all specialties. In rheumatology, 
endocrinology, gastroenterology, and cancer care, well over 50 
percent of our visits are now being conducted virtually. Across 
all Stanford clinics we have stabilized at around 30 to 40 
percent of visits being conducted virtually, and we believe 
this is our new normal.
    We learned virtual care is appropriate and broadly adopted 
by nonphysician practitioners such as physical therapists and 
speech pathologists. These vital team members are eligible to 
independently bill Medicare for in-person services yet are 
statutorily excluded from offering those same services via 
telehealth under section 1834(m) of the Social Security Act.
    We also found that we were able to offer unique and safe 
specialty care via telehealth across State lines. Patients from 
all 50 States sought care at Stanford Medicine for 
subspecialties not available in their State when interstate 
restrictions were waived.
    In many ways, telehealth hearkens back to days when the 
doctor would make house calls. As a family physician, it is 
incredibly valuable for me to see my patient's home 
environment. I have found that a thorough medication review can 
be more easily and accurately done at home, where patients can 
access medicine bottles and supplements.
    There is a perception that telehealth may be overused and 
lead to increased healthcare costs, something I worry about, as 
a value-based care champion at my institution. Fortunately, 
this has not been our experience. Telehealth is a tool in our 
toolkit that is largely substitutive, not additive to in-person 
care.
    Practically speaking, we find that the physician's time is 
still the rate-limiting factor for visits per day. We learned a 
tremendous amount over the past 12 months, but large-scale 
studies in a postpandemic environment still need to be 
conducted to determine telehealth's long-term quality and 
patient safety outcomes.
    First, the restrictions of 1834(m) need to be addressed to 
conserve Medicare beneficiary access to telehealth. We need the 
ability to provide video visits to patients regardless of 
whether the patient is at home, at work, or any other private 
location of their choosing, rural or nonrural. And all provider 
types that are enrolled to independently bill Medicare for in-
person services should also be able to provide clinically 
appropriate telehealth services.
    Second, we need continued expansion of covered telehealth 
services by CMS in the annual physician fee schedule and for 
those services to be available to both new and established 
patients.
    Third, we need recognition that visits provided via video 
require the same effort and medical decisionmaking by the 
provider. Reimbursements should be equivalent for clinically 
equivalent services.
    And finally, we need a reevaluation and a national view of 
medical licensure that allows physicians to care for patients 
across State lines. We support the TREAT Act as a positive step 
in this direction.
    Thank you for this opportunity to share our experience and 
recommendations with the subcommittee. Telehealth 
transformation would not have been possible without the rapid 
actions you and your colleagues in Congress took to ensure 
access to millions of Americans. We look forward to discussing 
the continued role of telehealth to realize its promise of 
high-quality, sustainable, and equitable care for the people of 
the United States.
    Thank you.
    [The prepared statement of Dr. Mahoney follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, Dr. Mahoney, for your very important 
testimony.
    And now I would like to recognize Dr. Mehrotra for your 5 
minutes of testimony, and welcome, and thank you again for 
being with us.

               STATEMENT OF ATEEV MEHROTRA, M.D.

    Dr. Mehrotra. Well, thank you, Chairwoman Eshoo and Ranking 
Member Guthrie, and the other distinguished members of the 
subcommittee. I am really honored to speak before you on a 
topic of such importance for Americans and their health.
    My name is Ateev Mehrotra. I am a physician and in practice 
at the Beth Israel Deaconess Medical Center. I am an associate 
professor at Harvard Medical School, where my research focuses 
on telemedicine.
    Today I was hoping to emphasize several points from my 
written testimony that the committee members might consider as 
they shape the future of telemedicine policy.
    I want to start with--a key question is why do we even need 
telemedicine-specific policies? We don't have similar 
regulations or guardrails for in-person visits. And I think the 
key point here is that telemedicine's ability to make care more 
accessible, why it has so much enormous potential to improve 
the health of Americans, may also be its Achilles' heel: It can 
be too convenient in some circumstances, and that convenience 
translates into more care and increased healthcare spending. 
And that puts private insurers and government payers in a very 
difficult situation.
    How do we build upon this enormous success that we have had 
during the pandemic in improving and maintaining access for 
Americans, but also not leading to unsustainable increases in 
healthcare spending? The likely path forward, I believe, is to 
compromise, to expand telemedicine coverage beyond what we had 
prior to the pandemic, but not maintain the full access that we 
currently have.
    How do we meet that compromise? How do we judge current 
policies? I have emphasized that the lens by which we should 
judge telemedicine policies is value. Value simply means how 
much improvement in outcomes or access is observed, and at what 
cost. High value and low value are kind of abstract ideas. What 
does that really mean, concretely, when it comes to 
telemedicine?
    A high-value use of telemedicine could be a patient in a 
rural community with poorly controlled depression who now can 
finally access a provider to help him with his depression, or a 
person with diabetes who struggles to get to doctor's 
appointments, who can now go to their primary care provider and 
check in and improve their blood glucoses.
    But what do low-value applications look like? A person with 
well-controlled depression who has weekly check-in visits with 
their provider. It is so easy. He doesn't have to worry about 
the inconvenience of travel. Or a person who thinks they 
probably have a cold but decides to have a video visit because 
it is so much easier to get an appointment.
    The point to emphasize is that neither of these low-value 
applications is malicious, but in aggregate they may greatly 
increase the amount of care that Americans receive without 
substantially improving their health. In my written testimony I 
emphasize a number of ways to encourage high-value uses of 
telemedicine.
    I want to touch upon two particularly thorny issues: Should 
audio-only telemedicine services be covered, and should the 
payment for telemedicine visits be the same as in-person 
visits?
    Audio-only telemedicine visits are a fancy name for a phone 
call. It is key to recognize that, in many communities, in 
particular rural areas as well as poorer communities, many 
Americans do not have access to a video visit because they lack 
the technology, or they don't have high-speed Internet. And for 
those Americans, the only way they can have a telemedicine 
visit is by a phone call.
    However, as emphasized before, there is concern that a 
telephone call is insufficient to address many clinical issues 
and that phone calls are more prone to fraud and abuse. And I 
am also concerned that we create a two-tiered system in the 
United States, where the wealthy get video calls and the poor 
have phone calls. And so I believe the longer-term solution is 
to--as many of the committee members have already pushed--to 
try to ensure that all Americans have access to video visits.
    So I have advocated for a temporary period, 1 to 2 years, 
where we cover for phone calls in the hope that that time will 
be used to accelerate efforts to expand access to the necessary 
technology.
    I have also advocated that we pay for telemedicine visits 
at a lower rate than in-person visits. Critics argue that lower 
payment rates means that no providers will use telemedicine. I 
disagree. While I recognize that implementing telemedicine 
requires some short-term investment, I think in the longer term 
telemedicine visits have a lower overhead per visit, and those 
payments should reflect those lower costs. Lower payment rates 
would also, hopefully, spur more competition through new, more 
efficient providers.
    Thank you again for this opportunity to speak today on this 
really critical topic, and I look forward to the questions.
    [The prepared statement of Dr. Mehrotra follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, Dr. Mehrotra. That was fascinating 
testimony.
    Ms. Mitchell, thank you for being with us and testifying 
today. You have 5 minutes. And please unmute.

                STATEMENT OF ELIZABETH MITCHELL

    Ms. Mitchell. Thank you, Chairwoman Eshoo, Congressman 
Guthrie, and members of the subcommittee. And thank you 
particularly for inviting the perspective of purchasers and 
large employers.
    The Purchaser Business Group on Health, who I am 
representing, represents over 40 jumbo private employers and 
public entities across the U.S. Together we pay for healthcare 
for more than 15 million Americans and spend more than 100 
billion a year on healthcare services. So we are truly invested 
in improving the U.S. healthcare system.
    I want to start by saying that we strongly support patient-
centered innovation and digital modernization in healthcare. 
There are few industries that still rely on fax machines, and 
leveraging new technology is long overdue. The U.S. healthcare 
system needs urgent reforms in care delivery, including more 
effective use of technology. But in our view, simply adding a 
new service or technology to an already dysfunctional system 
without consideration for quality outcomes, patient experience, 
and total cost is not the right approach.
    However, we see enormous promise for telehealth. By making 
care more accessible, telehealth can function as a highly 
useful tool in providing care to underserved areas, like we 
have heard today, particularly in rural communities, and 
expanding care to sectors like behavioral health, which is a 
top priority for my employer members.
    Not only can telehealth improve access and outcomes, 
telehealth can be cost effective, which is a rare trifecta in 
healthcare, and why my employer members are so supportive. By 
reducing overhead costs and enabling healthcare providers to 
efficiently treat more patients, several studies have concluded 
that broader availability of telehealth could bring significant 
cost savings to the healthcare system.
    One of our member companies, eBay, has calculated that, if 
they were to enable appropriate adoption of telehealth among 
their U.S.-based employees, the company could reduce its self-
insured medical and pharmacy costs by roughly 8 percent 
annually, without sacrificing quality and improving the patient 
experience. That type of savings is very significant, and that 
investment can go back into core business and wages.
    Another of my members, a manufacturer, just shared 
yesterday that they see huge promise for telehealth for 
improving access for their employees to primary care. We see 
these as truly necessary and important innovations.
    But even better news is that people like it. We recently 
completed research among California-based HMOs and Medicare, 
and nearly 9 in 10 people report that they would recommend 
telehealth, and nearly three-quarters wished to continue using 
it. So, from a patient perspective, this is a positive change.
    In addition, physicians and other healthcare providers also 
tell us that they are satisfied with providing care via 
telehealth. So this really has the potential to be a win and 
win.
    So why hasn't telehealth been broadly adopted? Telehealth 
is not even a new technology, it has been with us for over 2 
decades. As we have heard already today, the primary barrier is 
payment. Payment for U.S. healthcare is irrational.
    We need to change the payment system to a value-based 
payment system that actually rewards telehealth and other 
innovative, cost-effective services appropriately. We need to 
change how we pay for healthcare generally to reduce physician 
burden, reduce inequity, and get better outcomes for patients 
and better value for the employers and governments who are 
paying the bills.
    We need to rapidly expand the effective use of telehealth 
or, as we heard this morning, do it with intentionality as part 
of a broader shift to a long-overdue transition to value-based 
care. And the key to getting this right is to adopt payment 
models and hold healthcare systems accountable for quality, 
patient experience, equity, and total cost of care. We believe 
in a system where accountability for outcomes and total cost is 
present, you will see rapid adoption of these patient-centered 
innovations.
    And, as you have also heard today, we believe this is a 
huge opportunity to address equity. We know that too often low-
income communities, rural communities, communities of color do 
not have the same access to needed care. We believe that 
telehealth provides a unique opportunity to address those 
disparities and improve outcomes for low-income communities.
    We will be expanding our research on patient experience 
with telehealth to include Medicaid. We believe there is much 
to be learned and meaningful improvements to be had in care for 
all populations through telehealth. However, there is too 
little data. We need more research. We need more experience 
with quality and cost measurement. But we believe, 
collectively, there is an enormous opportunity here to improve 
care and improve value in the U.S. healthcare system. We thank 
you for your time and attention, and we look forward to talking 
with you further.
    [The prepared statement of Ms. Mitchell follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Just in time to answer the phone.
    [Laughter.]
    Ms. Eshoo. Thank you to Ms. Mitchell for your important 
testimony.
    Now the Chair recognizes Dr. Resneck for your 5 minutes of 
testimony. And again, thank you, and welcome back to the 
subcommittee.

                STATEMENT OF JACK RESNECK, M.D.

    Dr. Resneck. Thank you, Madam Chair. Thank you, Ranking 
Member and subcommittee members. It is a pleasure to be back 
with the subcommittee today.
    I am Jack Resneck. I am here as a member of AMA's board of 
trustees, but I am also a practicing dermatologist and the vice 
chair of dermatology at the University of California, San 
Francisco. My specialty is one that has been researching and 
providing telehealth for many years.
    Telehealth has emerged, as you have heard, as a critical 
tool during the pandemic, maintaining access for patients while 
supporting physical distancing efforts. This has really been a 
success story. Changes in coverage have led many of my 
colleagues around the country in both big and small practices 
to integrate telemedicine into their work. And our patients 
have seen benefits far beyond COVID care and social distancing.
    This rapid expansion has made millions of patients 
comfortable with the technology, and it has advanced our 
knowledge in, frankly, every specialty about when it is most 
useful and when it is best deployed versus when we need to see 
a patient in person. We have seen high-quality telehealth 
increase access and convenience for patients, saving them 
transportation time, avoiding missed work, and avoiding child 
care issues. It has helped underserved communities in rural and 
inner-city areas, where a lack of sufficient medical services 
has really contributed to health inequities over decades.
    It can give us new insights about an individual patient's 
social determinants of health. Patients on a video visit 
sometimes share more about their living environment or tell us 
about their food insecurity, information we can use to better 
coordinate their care and improve health outcomes. Integrated 
into existing healthcare practices and systems as one option to 
access care, telehealth has improved patient-physician 
communication and has built trust with our patients.
    Survey data show overwhelmingly positive patient and 
physician reactions to telehealth during the pandemic. You have 
heard some of it from other witnesses. But I would like to 
share with you how it typically plays out in my own practice.
    While I work in a large city, many of my patients drive 
from suburbs an hour away and rural areas several hours outside 
of San Francisco. I specifically recall a few patients I was 
seeing in the year before the pandemic with severe cases of 
chronic skin conditions like lupus, psoriasis, and one with an 
autoimmune blistering disease called pemphigus.
    Though each of them lived hours away, the initial in-person 
visit had, in these particular cases, been important to 
diagnosing their condition, doing biopsies, and getting them 
stable on medications. But I felt awful that every time they 
had to see me, they had to do repeated, several-hour-round-trip 
car journeys to come back for me to evaluate their progress and 
adjust their medications. One of them worried she would get 
fired for missing work. Another had to pile his three kids in 
the car each and every visit because he didn't have childcare 
backup.
    You know, I knew I could manage most of these follow-ups by 
telemedicine, but neither Medicare nor most private insurance 
would cover it at the time. The ones with commercial insurance 
sometimes had access to corporate Internet-based telehealth 
providers. But when they tried to use them, the clinicians they 
were connected to didn't know their medical histories, 
sometimes hadn't heard of their diseases, and were, frankly, 
unable to do much. The patients really had to start from 
scratch with them.
    For the last 11 months, being able to offer coordinated 
telehealth services for some portion of these patients' visits 
has been a game changer. But, without further action from 
Congress, my Medicare patients and millions of other Medicare 
beneficiaries will lose access to covered telehealth services 
at the end of the public health emergency. We would revert back 
to the old rules, old rules under which access to telehealth 
services was restricted only to those Medicare beneficiaries 
who live in designated rural areas, old rules that only allow 
those individuals to access care and specific authorized 
medical sites, not using their own personal devices in their 
own homes or wherever they may be located at the time.
    So I am here to ask you to take two very clear steps this 
year.
    First, we strongly urge Congress to amend section 1834(m) 
of the Social Security Act to remove permanently the geographic 
and site-of-service restrictions that bar most Medicare 
beneficiaries from using widely available, two-way audio visual 
technologies to access covered telehealth services.
    Second, in conjunction with expanded access to telehealth 
services, we urge Congress to continue to support the expansion 
of high-speed broadband Internet access to under-served 
communities. My colleagues and I continue to be surprised by 
how many patients can't take advantage of telehealth services 
due to a lack of affordable Internet connectivity.
    Telehealth is not a service unto itself, but it is a vital 
part of high-quality, coordinated healthcare. Congress needs to 
act now to ensure that Medicare patients can continue to rely 
on these essential tools after the current emergency ends. The 
AMA and I welcome the opportunity to work with you to expand 
telehealth services for our patients, and I am really looking 
forward to today's conversation and to responding to some of 
the more thorny topics that have already come up. Thanks so 
much.
    [The prepared statement of Dr. Resneck follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you so much, Dr. Resneck. I think all the 
Members are thinking exactly what I am, and that is that every 
witness that we have heard from so far--it is a really high 
value.
    And now I would like to recognize Frederic Riccardi, our 
last witness on the panel, for your 5 minutes of testimony. 
Welcome, and thank you.

                 STATEMENT OF FREDERIC RICCARDI

    Mr. Riccardi. Good morning. Thank you, Chairwoman Eshoo, 
Ranking Member Guthrie, and members of the House Committee of 
Energy and Commerce Subcommittee on Health, for the opportunity 
to speak with you today about Medicare telehealth.
    I am the president of the Medicare Rights Center, and we 
are a national nonprofit organization that has worked for over 
30 years to ensure access to affordable healthcare for older 
adults and people with disabilities through counseling and 
advocacy, educational programs, and public policy initiatives. 
We are the largest and most reliable independent source of 
Medicare information and assistance in the United States.
    While new information about the COVID-19 virus continues to 
emerge, it has long been clear that Medicare beneficiaries are 
at high risk of infection, serious illness, and death. We are 
grateful that Congress quickly recognized and responded to 
these threats, ensuring Medicare telehealth coverage could help 
beneficiaries safely obtain needed care during this pandemic, 
protecting patients, caregivers, providers, and communities.
    The idea of telehealth as only important to people in rural 
areas or only for a limited set of services has long been 
outdated. During the pandemic Medicare is allowing more 
beneficiaries to receive more telehealth services, using more 
types of technology for more providers and locations--
importantly, their own homes.
    The uptick has been swift and dramatic. Before the 
pandemic, about 13,000 beneficiaries received telemedicine a 
week. By the end of April 2020, that number had skyrocketed to 
1.7 million people. This represents the biggest shift in 
Medicare telehealth policy and utilization since the services 
were created nearly 25 years ago.
    Although these expansions address some longstanding 
barriers, the beneficiary experience has been mixed. Some 
clients of our national help line have reported greater access 
to care, while others have been unable to purchase or use the 
technology to find a provider that uses the technology, or to 
feel comfortable with remote care in general. This is 
concerning, but it is also not surprising. Undoubtedly, there 
is a lot that we don't know about how this is all really 
working for beneficiaries. We also don't know the impact of 
these changes on costs and health disparities, though early 
research shows inequities in accessing telemedicine across 
numerous demographic categories.
    With so much unstudied, we view sweeping calls to make the 
emergency system permanent as premature. Medicare's limitations 
on telehealth no longer reflect the technology landscape or the 
beneficiary experience. But we must move forward with caution.
    We respectfully ask you to move forward deliberately, 
collecting and following the data, centering beneficiary needs 
and preferences in a way that recognizes telehealth as a 
valuable supplement to in-person care. And to allow time for 
this, we support a glide path to prevent a beneficiary's access 
to services from ending the moment or soon after the public 
health emergency does.
    In our written testimony we outline a set of principles. We 
urge the inclusion of robust consumer protection and oversight 
requirements, ensuring the provision of high-quality care, 
increased access to such care, and to promote health equity. 
Policies that meet these criteria will help create a Medicare 
telehealth system that works for all beneficiaries, regardless 
of where they live, the coverage pathway that they choose, or 
how they want to receive their care.
    I also want to add that other near-term Medicare 
improvements are also needed to promote access to care. We have 
consistently heard from Medicare-eligible individuals who have 
been unable to connect with their earned benefits. Most have to 
wait several months for care. This is why we request a COVID-19 
special Medicare enrollment period for premium part A and part 
B, and expanded relief to help people who are locked out of the 
system.
    Thank you again for the opportunity to be here today, and I 
look forward to answering your questions.
    [The prepared statement of Mr. Riccardi follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much for your testimony.
    On the last point that you made, Mr. Riccardi, we can write 
to CMS on that. So we will follow up with you on that.
    We are now going to move to Member questions. And I think 
all of us have many of them, but we have to squeeze them into 5 
minutes--not just 5 minutes of us asking questions, that 
includes your answers. So I recognize myself for that 5-minute 
period.
    At the heart of the debate around Medicare's coverage of 
telehealth is whether telehealth will increase utilization and, 
in turn, increase costs. So Ms. Mitchell says we can save 
money. Dr. Mehrotra pointed out the costs. So my question to 
Dr. Mahoney is, when we use the word ``utilization,'' what does 
that mean?
    Dr. Mahoney. Thank you----
    Ms. Eshoo. Is all utilization the same?
    Are the--will one reimbursement cover the costs, can you 
give us some direction on that? And do you think that it is 
possible to write that type of clinical determination into law?
    Dr. Mahoney. Sure. So thank you for the question, Ms. 
Eshoo.
    Yes, the utilization typically refers to patient 
consumption of healthcare services, whether it is----
    Ms. Eshoo. Does that mean the time that is used?
    Dr. Mahoney. So, yes, so the time that the physician would 
spend seeing the patient, and also any related ancillary 
services that are provided: lab tests or imaging studies.
    So, yes, so there is a concern that telehealth would be 
additive, and so I would see a patient through a video visit, 
and then I would later see them that week in person because I 
wasn't able to complete what I wanted to do. But that simply 
hasn't been what we have observed.
    Really, like I mentioned earlier, the time that the 
physician has is the rate-limiting factor. And really, we just 
use our schedule, our templated schedule, to spend our time on 
either an in-person visit or a telehealth visit. And so it is 
actually substitutive, it is not additive in the way that we--
--
    Ms. Eshoo. So does your----
    Dr. Mahoney [continuing]. Provide our care----
    Ms. Eshoo [continuing]. Show that telehealth could 
substitute for in-person care?
    Dr. Mahoney. That has not been our experience. Or our 
experience has been that it has been substitutive, exactly. 
Yes.
    Ms. Eshoo. And, Dr. Mehrotra, when you gave your testimony, 
you were cautionary. Do you agree with Dr. Mahoney?
    Dr. Mehrotra. Yes, though I think during the pandemic we 
haven't seen an increase in utilization. But I think it is hard 
to use the data from the pandemic. At least my patients, and I 
think many of us today are--I mean, it is a bit nervous right 
now to go to the provider. And so I think we need to look at 
the period prior to the pandemic to try to assess that.
    And there is--honestly, right now, we don't have that much 
research on this particular topic. We did one study looking at 
one form of telemedicine, and we found that the vast majority 
was additive and it increased healthcare spending.
    Ms. Eshoo. I think that we need more data.
    Have any of you examined the CONNECT bill? Do you think it 
accomplishes what we want to accomplish?
    Do you--I know this is not a legislative hearing, but 
since, you know, receiving all of your testimony, I am just 
curious to know if you have read it, if you think it is going 
to accomplish what we need to do. Any of you?
    Dr. Resneck. This is Jack.
    Ms. Eshoo. Go ahead.
    Dr. Resneck. So we have been tremendously supportive and 
appreciative of the efforts on this front, including last 
year's version of the CONNECT bill, and we are generally 
supportive. I think we prefer the approach this year of the 
Telehealth Modernization Act, and the CONNECT for Health Act 
could certainly incorporate this provision. But adding sort of 
permanent repeal of the rural exclusions and the originating 
site exclusions, rather than giving CMS the authority to do 
ongoing waivers, really would give us the certainty in our 
practices to be able to----
    Ms. Eshoo. I only have 33 seconds left.
    So Dr. Mahoney, do you want to add anything, and the other 
witnesses?
    Dr. Mahoney. Oh, I was actually going to say something very 
similar to what Dr. Resneck said----
    Ms. Eshoo. OK.
    Dr. Mahoney [continuing]. That we would be supportive of 
anything that expands access to care, removing geographic 
barriers and the----
    Ms. Eshoo. Frederic?
    Mr. Riccardi. Yes. And we also support the CONNECT Act, and 
we believe that it would provide important assistance.
    Ms. Eshoo. And Dr. Resneck, Ms. Mitchell?
    Going, going, gone. No? No weighing in?
    Dr. Resneck. Can I come back to this utilization issue?
    Ms. Eshoo. Pardon me?
    Dr. Resneck. Can I come back to one point on this 
utilization issue?
    Ms. Eshoo. Well, I have 2 seconds left.
    Dr. Resneck. I will get to it later.
    Ms. Eshoo. All right, OK, so now we will move to--recognize 
Mr. Guthrie, the ranking member of our subcommittee, for your 5 
minutes of questions.
    Thank you to all the witnesses.
    Mr. Guthrie. Thank you. Thank you, Madam Chair. And yes, 
thank you to all the witnesses.
    I would like to enter into the record a February 23rd 
technical assistance document from the Department of Health and 
Human Services Office of Inspector General that I mentioned in 
my opening statement.
    The OIG highlights critical vulnerabilities that could 
exist within telehealth. As Congress thinks about expanding 
these very important benefits, we need to carefully weigh the 
potential vulnerabilities expressed in the documents.
    I would like to enter that in the record and look at these 
vulnerabilities.
    First, Ms. Mitchell, you write in your testimony that there 
is relatively little academic research regarding the clinical 
appropriateness of telehealth as an alternative to traditional, 
in-person care.
    I support the expansion of telehealth but want to make sure 
we are balancing the needs of patients and doing our best to 
ensure their care is provided in the setting best suited for 
them.
    So my question: As Congress examines making some of these 
flexibilities permanent, how do you think we should address 
clinical appropriateness?
    Ms. Mitchell. Well, if that is to me, I want to be very 
clear I am not a clinician. However, I do think research is 
absolutely needed on clinical effectiveness. We need to measure 
both the quality and patient experience of the telehealth 
service itself, as well as the outcomes and experience within 
the practice when telehealth is integrated.
    I think you heard already that telehealth, in many cases, 
is not duplicative, but substitutive. However, when you look 
across the different providers, that is where you can come up 
against real problems with coordination. So let's say a private 
vendor calls you for a visit. They don't share the data with 
your practice. You have to have another visit for the same 
reason. We think there has to be coordination across the system 
to--and then true measurement of patient outcomes and 
experience.
    Mr. Guthrie. OK, thank you for that. And I will go to Mr. 
Riccardi on the next issue.
    Some of the healthcare providers in my district would like 
to continue--because we have some of the broadband areas and 
some of the issues--using technology that has only been able to 
be used for telehealth during the pandemic, due to enforcement 
discretion of HIPAA, such as Facetime, Google Hangout that may 
not be HIPAA-compliant. How do we balance the accessibility of 
technology with patient privacy?
    Mr. Riccardi. Thank you for that question. And we also 
support the permanent expansion of some telehealth services. 
But an expansion must not, you know, exacerbate existing health 
disparities, and also go back to prior, prepandemic protections 
such as the HIPAA rules.
    So we would like to see a glide path, where people do not 
automatically lose access to such important services. But it is 
incredibly important that the HIPAA rules be reapplied again 
as--the waivers during the public health emergency have allowed 
use of technology such as FaceTime or Skype that may be 
appropriate during an emergency situation but potentially 
exposes beneficiaries' information and data to sometimes, you 
know, predatory companies and app makers. So it is really 
important that we must not permanently waive HIPAA enforcement 
for the future of telehealth services and Medicare.
    Mr. Guthrie. OK, thank you for your answer.
    Then, Dr. Resneck, you stated in your testimony that State 
medical boards play a pivotal role in protecting the safety of 
patients to physician licensure regulations and disciplinary 
action. And before coming to Congress I was in the State 
legislature and chair of our licensing professionals committee, 
and understand the role States play in regulating healthcare. 
Can you tell us more about the safeguards State legislators--
legislatures and medical boards have put in place to ensure the 
safe practice of telemedicine?
    Dr. Resneck. Thanks, Ranking Member Guthrie. I think it is 
an important question.
    You know, States really do set the rules of the road for 
physicians through their State medical practice acts. And I get 
nervous when I think about things like Federal licensure, 
because those rules determine how we deal with end-of-life 
care, medical marijuana, age of consent, reproductive health. 
All of those things are enforced through licensure and State 
medical practice acts, and I get very nervous at the thought of 
Congress trying to unify that with a Federal license 
nationwide.
    I also get nervous when I hear about people being licensed 
in the State where the physician sits instead of the patient 
sits, because the State medical boards are really what hold 
physicians accountable for the care of patients and their 
jurisdictions. And that is where the enforcement lies. And they 
don't really have interstate policing authority. If I take care 
of a patient in Florida, or Texas, or another State without a 
license there, it doesn't give authorities in those States the 
ability to come and see about the quality of care I have been 
providing to their patients.
    Mr. Guthrie. OK, thank you very much. I only have 7 
seconds, so I will stop there, and I will yield back to the 
chair. Thank you.
    Ms. Eshoo. The gentleman yields back.
    I am reminded that we don't really examine what takes place 
in terms of quality and whatever in in-person appointments, 
the--when doctors see their patients. So, you know, we are--we 
need to build something, I think really credible, relative to 
telehealth. But, you know, we don't--the scale seemed like this 
to me. It is just an observation.
    The Chair now recognizes Mr. Pallone, the chairman of the 
full committee, for his 5 minutes of questions.
    Mr. Pallone. Thank you, Madam Chair. Theres still a lot of 
questions about whether telehealth service is a substitute or 
add to in-person services. And CBO, MedPAC, and others have 
raised concerns that telehealth services could be overutilized, 
given Medicare's fee-for-service payment system, which can 
incentivize volume over value. So I wanted to start with Dr. 
Mehrotra.
    What does the data from before and during the pandemic say 
about whether telehealth services tend to substitute or add to 
in-person services?
    And could you discuss strategies for incentivizing high-
value telehealth services and avoiding overutilization? 
Quickly, of course, because I have other questions, if you 
could, Doctor.
    Dr. Mehrotra. So, as I noted before, in terms of the 
pandemic, we have not seen an increase in overall use, how many 
visits people are receiving in the U.S. But that, I am not 
sure, can really generalize to after the pandemic. Prior to the 
pandemic, the limited research that I have done and others have 
done has demonstrated it does increase use of care.
    So then the question that you asked was how do we address 
that we have high-value uses. I will maybe just touch upon one 
or two that haven't been addressed so far, and the first one is 
really payment reform. I think it is a really key issue that we 
have a fee-for-service system and we are paying for each visit. 
And there is a lot of interest and, I think, appropriate 
movement in--particularly in primary care--to moving towards a 
capitated or an alternative payment model. And we give the 
primary care provider or other provider the flexibility of 
which model to use, in terms of payment.
    Mr. Pallone. Right----
    Dr. Mehrotra [continuing]. Which model of care to provide, 
excuse me.
    Mr. Pallone. Thank you. I wanted to ask you another 
question about whether telehealth can be cost effective for 
Medicare and other payers. What does the research show in terms 
of cost effectiveness of telehealth services relative to in-
person services?
    And are there any policy considerations you would recommend 
with respect to cost effectiveness?
    Dr. Mehrotra. You know, one thing I would like to emphasize 
is that we should think about telemedicine not as this 
monolithic, but there are certain applications of telemedicine 
conditions, patient populations where it will be cost 
effective, and others where it has not. We have some evidence 
in certain areas--one that we have already mentioned today is 
stroke care, where telestroke, we have evidence that it has 
saved lives, and the Congress has expanded access to that.
    And so that is the kind of model in which I think we should 
move forward. As we gain more evidence clinically, then we 
expand into those clinical areas where it is clinically 
effective----
    Mr. Pallone. Thank you----
    Dr. Mehrotra [continuing]. And cost effective.
    Mr. Pallone. Thank you, Doctor.
    Ms. Mitchell, in cost effectiveness--like, is cost 
effectiveness an important consideration for purchases?
    And are there other factors that warrant additional study? 
If you would.
    Ms. Mitchell. Absolutely. And I really want to underscore 
the need to move away from fee-for-service. We do not believe 
tossing in another service, however beneficial, into the 
dysfunctional system will help make it better.
    So we believe we need to thoughtfully increase the use of 
telehealth within a total cost of care or other model. And we 
also think that payment parity assumes that there is similar 
input on a cost basis. Medicare is, you know--pay is by 
relative value units, or RVUs, which are derived from an 
assessment of the time and intensity required to provide the 
service. We are not convinced that it is the same requirement 
for telehealth. We believe providers may be able to see more 
patients in a shorter amount of time.
    So again, we strongly support adoption of telehealth but 
believe it needs to be within a total cost model.
    Mr. Pallone. Thank you. Then I was going to ask last, Dr. 
Mahoney, is there a need for additional data on cost, quality, 
and outcomes of telehealth services, compared to in-person 
services?
    And if you would like to comment--I have got about a minute 
left--I would appreciate it.
    Dr. Mahoney. No, thank you for the question. I absolutely 
agree that now we have 12 months of real data, a real-world 
data set on scaled telehealth implementation across the 
country, and we definitely have an opportunity to leverage the 
data to conduct large-scale analyses and determine conclusively 
what is the association between clinical outcomes and 
telehealth.
    I think that, largely, those questions are unanswered, but 
we need to have continued access to telehealth to be able to 
answer those questions, in addition to the questions that are 
related to health equity that have come up, as well.
    Mr. Pallone. Thank you. I have to tell you, I always worry 
that when CBO, MedPAC, and these other agencies look at 
overutilization, they don't pay enough attention to whether or 
not--yes, OK, maybe there is more utilization because it is 
actually better, you know?
    And so imaging is always the one that comes to mind, where, 
you know, they say, ``Oh,'' you know, ``you have come up with 
these new diagnostic methods, and everybody is using it, and it 
is overutilization.'' But on the other hand, it is good, 
because they find things out that they didn't know before. And 
so I always worry how these analyses are actually done.
    But thank you so much. Thank you, Madam Chair.
    Ms. Eshoo. We thank the chairman. Well, the outfits that 
you just referred to, Mr. Chairman, are number crunchers only, 
so they don't take other things into consideration. We have 
learned that.
    It is a pleasure for the Chair to recognize the ranking 
member of the full committee, Mrs. Cathy McMorris Rodgers, for 
your 5 minutes of questions.
    Mrs. Rodgers. Thank you, Madam Chair. Today is Teen Mental 
Wellness Day, and my heart is burdened over the crisis that our 
Nation's children face, both before this pandemic, when we were 
seeing record depths of despair, the suicides, addiction, 
opioids, substance abuse. And it has only been magnified 
because of COVID, where we are seeing the tragic headlines 
about the increases in suicide, mental health, anxiety.
    Just last night I got a text from a friend. His beautiful 
teenage granddaughter, McKenna, had attempted to end her life. 
Unfortunately, because of COVID and the continued lockdowns and 
isolation, this is too common these days. I believe that one of 
the best ways to help our kids is to get them back in school.
    But I also believe that telehealth has great potential to 
help address behavioral and mental health challenges. So, Dr. 
Mehrotra, I wanted to start with you, and I just wanted to ask 
if you would talk about what the data shows on patient outcomes 
and satisfaction with mental and behavioral health treatment 
using telehealth. Speak to the data about its use in children 
and adolescents. And what can we in Congress do to make sure 
that our kids get the care that they need?
    Dr. Mehrotra. So I think that there is broad consensus that 
this is an area of great crisis in the United States and an 
application of telemedicine which has great, obviously, 
potential. And that is reflected in the recent congressional 
action to permanently expand telemedicine for behavioral health 
services.
    I think the research is, in this particular area, pretty 
consistent, that when we look at patients who receive their 
care via telemedicine versus in-person care, the outcomes are 
generally the same or--and sometimes even better for, you know, 
the treatment of mental illness. And that is also true among 
our adolescents and children. And so I think there is a lot of 
excitement, and this is a clear area of telemedicine where I 
think I would term it as high value, or where we should focus 
on.
    You asked a really important question, which is how can we 
then--what can the Congress do?
    I would emphasize maybe a couple of things that have 
already been touched upon. I think there is consensus among 
many of us that licensure is an area that can be addressed, 
because there's a lot of private companies that have been 
coming into this space that offer an option for parents who are 
really struggling to find a therapist or a psychiatrist nearby. 
And those companies struggle, in terms of their business model, 
because they have to get licensure in all 50 States. And so how 
can we--I think that is a key area for the Congress to 
potentially focus on.
    The other thing is that there have been laws and--to 
require an in-person visit before they have--they can start 
mental health treatment. And I think those kinds of regulations 
are inappropriate, because they will limit the ability of 
Americans and adolescents to access care.
    So those are two points that I wanted to emphasize to 
increase the access to care for our adolescents in the U.S.
    Mrs. Rodgers. Thank you. The rapid expansion of telehealth, 
especially over the last year with COVID-19--and maybe one of 
the bright spots in this tragedy, in this trying time--we now 
have three safe and effective vaccines in less than a year, and 
the hope that the pandemic, the end of the pandemic, is in 
sight.
    I wanted to ask each one of the panelists to speak as to 
what they see as the future of telehealth being. Just what do 
you think telehealth should look like 10 years from now?
    And how do you see patients using it, being paid by private 
plans, employers, Medicare?
    And if you want to speak to licensure again, that is great. 
But let's start with Dr. Mahoney, and then Mehrotra, Ms. 
Mitchell, and Dr. Resneck, and then Mr. Riccardi. And let's--a 
little over a minute, but just whatever you want to add would 
be great.
    Dr. Mahoney. All right. Thanks, Mrs. Rodgers, for this 
fascinating question. I think about the future. How I envision 
the application of telehealth in the next 10 years, let's say, 
or how it will progress is I first of all think that the office 
space visit will change quite a bit. Our need to and 
expectation for an annual physical, in-person visit and primary 
care will definitely change. And we will start to think about 
the specific indications for an in-person visit, because of the 
inconvenience on the part of the patient.
    It is just proving to be much better for patients to 
receive all sorts of services through telehealth. So I think it 
will be part of our toolkit. Like we mentioned earlier, are we 
substitutive? And it will be used when it is most appropriate, 
taking into consideration the clinical conditions, and then 
also the patient, the preference of the patient. And we are 
already seeing that come to light.
    I also would say that the application of remote patient 
monitoring will also be probably increasingly utilized, and 
home diagnostics. And so it is exciting to think about how all 
of these, in combination with e-visits, e-consultations, we 
will be able to meet the needs of our patients, and then also 
get that value that we are expecting out of telehealth.
    Mrs. Rodgers. Thank you. And I ran out of time. I have to 
yield back, but I just really want to continue to hear from 
others about the future.
    Ms. Eshoo. The gentlewoman yields back. And of course, 
every Member can submit written questions to our witnesses, as 
well.
    Now we will go to the gentleman from North Carolina, Mr. 
Butterfield.
    And I just want to--I think it is worth stating the 
following, that Members are called on based on seniority at 
gavel, arrival after the gavel, and waive-ons. So that is the 
way we do it.
    And so, again, the gentleman from North Carolina, Mr. 
Butterfield, is recognized for his 5 minutes of questions.
    [Pause.]
    Ms. Eshoo. Where are you, Mr. Butterfield?
    [No response.]
    Ms. Eshoo. All right. Going, going, gone.
    We will--I will recognize the gentlewoman from California, 
Ms. Matsui, and thank her for her leadership on this issue.
    You are recognized for 5 minutes.
    Ms. Matsui. Thank you, Madam Chair. And I really appreciate 
this hearing. It has been fascinating.
    The pandemic has brought on serious increases in anxiety, 
depression, and other mental health concerns that are likely to 
last long after we get the virus under control.
    In my district, WellSpace Health, our local FQHC, has found 
that conducting an initial assessment virtually has been 
critical to breaking down trust issues and building 
relationships with new patients. That is why I am working on a 
comprehensive legislation to ensure access to tele-mental 
health--clinically appropriate without limiting access. This 
legislation would take a close look at the inequities of an in-
person requirement for tele-mental health, and address other 
outstanding access issues like maintaining coverage for a wide 
range of delivery platforms.
    Dr. Mahoney, from your practice experience, can you expand 
on how new patient visits by modality has changed over the 
course of the pandemic?
    What has been a primary driver of these changes?
    Dr. Mahoney. Sure. So what we have noticed is that the in-
person requirement, as--is probably outdated at this point. We 
are able to provide high-quality care through telehealth, even 
at the initial visit with our patients. And, in fact, we had a 
high percentage of new visits this year because of the 
lockdown. And we were happy that we were able to deliver a 
high-quality care through telehealth for our new patients into 
Stanford.
    I also wanted to highlight the important point that you are 
making about behavioral health, and we would like to be able to 
provide access to patients when they are ready when it comes to 
behavioral health and addiction services. And I have heard from 
my colleagues who practice in addiction medicine and behavioral 
health that they have actually seen an increase, an uptick in 
the number of patients who are showing up for their visits 
because of the added convenience of being able to see them 
through telehealth.
    Ms. Matsui. Certainly. And Dr. Resneck, in your view, what 
is the clinical necessity of an in-person requirement for tele-
mental health services?
    Dr. Resneck. For mental health services, in particular?
    I mean, so we really look to each specialty to figure out 
the standard of care for a variety of conditions. In the last 
year, built on top of several years of evidence before, has 
brought us a long way. So that, for example, a psychiatrist in 
mental health knows--just like I know in dermatology--which 
conditions they can take care of with and without an in-person 
visit first.
    So we are not in favor of freezing in statute arbitrary 
things like a requirement for an in-person visit first, because 
that standard of care is evolving. We have a big evidence base. 
We have 50 States that allow a new patient relationship to be 
established via a virtual visit, and we just wouldn't want to 
see that frozen in statute.
    Ms. Matsui. Certainly. And we have seen a surge in audio 
telehealth use in the past year, particularly, as you know, 
among lower-income patients. Audio-only telehealth services 
were rarely reimbursed by commercial payers and government 
programs before the pandemic. And now we have critical policy 
decisions to make about the long-term scope of coverage for 
audio-only visits. Quality and cost are important factors to 
consider, but we cannot lose sight of the role audio-only has 
had in promoting health equity.
    Dr. Riccardi, CMS has said it may stop reimbursing for 
audio only. Can you comment on how that might impact the one-
third of Medicare beneficiaries who used telehealth during the 
pandemic?
    Mr. Riccardi. Yes, and that is concerning. You know, what 
we have heard from our clients and through our help line is 
that audio-only visits have been a lifeline through this 
pandemic. As you had mentioned, one-third of these visits have 
been audio-only because a significant number of Medicare 
beneficiaries based on age, race, ethnicity do not have access 
to audio-video technology.
    And so, as we think about the purpose and use of audio-only 
going forward, I think decisions can be made on the clinical 
appropriateness of them, although there is quite a bit of 
research and data that suggests that audio-only visits are 
applicable and should be used for people who need behavioral 
health services. So that is another consideration.
    And I agree with some of the sentiments that Dr. Mehrotra 
had shared earlier about the importance of audio-only services.
    Ms. Matsui. Right, certainly. And I think, particularly for 
behavioral health, there is that sense of hearing the voice and 
not necessarily having to face the person many times, in tele-
mental health in particular, with audio-only.
    I see my time is gone, and thank you very much.
    And thank you, Madam Chair, and I yield the balance of my 
time.
    Ms. Eshoo. We thank the gentlewoman again for her 
leadership on this.
    It is a pleasure to recognize the former chairman of the 
full committee, the gentleman from Michigan, Mr. Upton, for 
your 5 minutes of questions.
    Mr. Upton. Well, thank you, Madam Chair. And I just--you 
know, as we all think about telemedicine, this is such a win-
win, one of the best things, probably, since sliced bread. It 
is a no-brainer. We should move on this as fast as we can, not 
only for the physician and medical community, but also for the 
patient community, as well. And so I appreciate the opportunity 
for this hearing.
    I just have to relate a story that I had earlier this--last 
year. I spoke to the urologists nationwide, and one of the 
doctors said--you know what she said? ``I am from the Bronx. We 
are at the very center of the COVID issue right now. I am so 
grateful that I can practice medicine and talk to and 
communicate with my patients because we are using the 
telemedicine. Don't take those tools away. This is the best 
thing that we have to do.''
    But I have got a couple of questions. I want to first go to 
Dr. Resneck.
    In your full testimony you talked a lot about the concerns 
about fraud and abuse, and the possibility of overutilization. 
And I just wonder if you think that the OIG, the Office of the 
Inspector General, in fact--the tools to really go after fraud 
and abuse, and if there is anything more that we should be 
doing to clamp down on that Medicare fraud, all those 
different--because, I mean, it makes us all furious when we see 
that. Do we have the tools to stop the unscrupulous folks, the 
very few who are ripping off the system?
    Dr. Resneck. Congressman, thank you. I share your 
frustration when I see those examples. And I am glad OIG and 
the Department of Justice are keeping an eye on it. I am 
actually serving as an expert on some of the national takedown 
cases that have come up related to telehealth fraud. So I have 
some insight into this, and I feel pretty strongly that they 
have the tools they need, and they are doing a good job.
    Most of what they are describing in terms of telefraud 
actually has nothing to do with telemedicine. It is 
unscrupulous marketing companies that are reaching out to 
patients saying, ``Hey, do you want free, durable medical 
equipment, or free compounded medications, or free genetic 
testing that you don't need?'' And then maybe, since some of 
the subcases--they might document a telehealth visit, which is 
not even a real telehealth visit, just to justify their 
prescription, but they are not even billing for the telehealth 
visit. They are not using these new codes, largely, that 
Medicare has authorized. So this is a type of fraud that 
existed before Medicare's expansion during the pandemic.
    Frankly, when I look at the before and after, it feels to 
me like denying patients, Medicare patients, access to 
telehealth as a result of these few fraudsters doesn't solve 
the fraud problem and just harms our patients.
    And the waivers have really tipped the balance. We are 
seeing more and more patients following up, seeing physicians 
they know, as opposed to being tempted to go to corporate--
other telehealth providers, or being ripe for fraud. So I think 
the tools are there for OIG and for DOJ.
    Mr. Upton. So you don't think we need harsher penalties for 
those that are actually convicted?
    Dr. Resneck. Well, I am not sure I commented on the level 
of penalties, and I need to refresh and get back to you on the 
level of penalties. But in terms of OIG and DOJ's ability under 
the law to investigate this fraud and telehealth fraud, it is 
no different than any other healthcare fraud that is going on, 
and I think they have the tools to investigate it.
    Mr. Upton. My last question--I don't have a lot of time 
left, a minute--a broad body of research links the social 
isolation and loneliness to poor mental health. Data from April 
of this year showed that significantly higher shares of people 
who were sheltering in place reported negative mental health 
effects resulting from worry or stress related to coronavirus 
than among those not sheltering in place.
    Additionally, research shows that job loss is associated 
with increased depression, anxiety, et cetera, suicide. We need 
to make sure that these issues are not forgotten while we work 
on the physical toll that coronavirus took us on. That is why I 
am anxious and continue to work with colleagues on both sides 
of the aisle that would help give access to mental health 
services through telehealth platforms.
    Who would like to comment on that, in terms of expanding it 
even further on the mental health side?
    Ms. Mitchell. Congressman, as a representative of jumbo 
employers, this is a top priority for them, expanding access to 
mental healthcare. We believe telehealth can play a critical 
role there.
    However, we also know that the concentration of mental 
health providers is often inversely related to the need. So you 
might have a lot of psychiatrists in Los Angeles, for example, 
but the need might be in rural communities, and they don't have 
those practitioners there. We think telehealth can play a 
critical role in expanding access, but we are going to need to 
address broadband, because many communities don't even have the 
broadband they need to enable telehealth services. And we are 
going to have to look at licensure to make sure that we are not 
limiting access unnecessarily.
    Mr. Upton. Well, thank you. To all my colleagues, we all--
clearly ought to be unanimous within our committee to do all 
that we can to help those really most in need.
    And with that, Madam Chair, I yield back my time.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the gentlewoman from Florida, 
Ms. Castor, for your 5 minutes of questioning. Great to see 
you.
    Ms. Castor. Good morning, Chairwoman Eshoo, and thank you 
so much for calling this hearing on the future of telehealth. 
And you are right, our witnesses have been outstanding this 
morning. Thank you very much.
    And let me just say that, during this very difficult past 
year, while we have been grappling with COVID-19, I have heard 
from many of my neighbors back home in Florida and many health 
professionals on what telehealth has meant to making sure that 
they can continue to receive the health services they need, and 
that all-important connection during a time of enormous 
disconnection from everyday life.
    So we know that, in addition to the flexibility provided by 
Congress, CMS added a number of new covered telehealth services 
for Medicare beneficiaries over the past year. And now we know 
that CMS has indicated that they will not continue to cover all 
of these services after the pandemic, due to the lack of strong 
evidence of clinical benefit. But what I have heard from a 
number of our witnesses today is that certain telehealth 
services simply have been studied more than others and have 
clear quality outcomes and all of that important data.
    So, as the committee moves forward with telehealth 
legislation, we need to ensure that we are funding or 
supporting that research, and that--so that we can balance the 
quality needs of the patient. Dr. Mehrotra talked about this, 
and I appreciate that.
    So I would like to ask you all--start with Mr. Riccardi. 
Where would you prioritize additional research to build the 
evidence based on quality and outcomes for certain services to 
ensure that our older neighbors are getting the services they 
need?
    Mr. Riccardi. Yes, and thank you for the question. We think 
it is important that the geographic and the site restrictions 
for telehealth are reviewed.
    And speaking to your point, I think that is why it is so 
important that there is an established period of time where 
individuals who are receiving these vital services are not cut 
off from them. And this would allow more time to examine the 
system prepandemic and currently, looking at the services 
provided, the outcomes and the quality, the participation 
rates, any barriers based on either beneficiary spending and, 
importantly, the impact of health disparities. Because there 
are many older adults and people with disabilities that just 
don't have access to either the technology or the broadband. 
And so clearly there needs to be more research done to ensure 
we are setting up a system that works for all people with 
Medicare.
    Ms. Castor. So, Dr. Mahoney, you are conducting some of 
this research at Stanford. Where would you prioritize research 
so that we have the data we need on patient outcomes and 
quality?
    Dr. Mahoney. So thank you, Congressman Castor. Yes, we need 
to complete peer-reviewed research to quantify the clinical 
quality, costs, and safety outcomes of telehealth compared to 
in-person. At this point we are applying the standard quality 
measures for in-person and virtual care, but we still want to 
better define those associations.
    So, as you mentioned, we are conducting research with 
MedStar Health and Intermountain Health to develop one of the 
Nation's largest cumulative data sets of primary care video 
visits looking at longitudinal outcomes, and this is funded by 
AHRQ. So what we are trying to determine are the clinical 
outcomes.
    And then, furthermore, we need to better understand the 
association between access to Internet, smartphone or computer, 
and digital literacy, and how that might affect the clinical 
outcomes that we can expect with telehealth, looking at the 
health equity issues.
    Ms. Castor. OK. Dr. Mehrotra, the same question to you. And 
then, if you could also add in quickly, have we--is there data 
available for Medicaid, where Medicaid systems have been using 
telehealth to a greater extent?
    Dr. Mehrotra. Yes. On the Medicaid side, unfortunately, we 
don't have that--as much data yet. I am sure that will be 
coming very shortly.
    I do want to emphasize that--you have emphasized, and other 
committee members have emphasized the lack of evidence right 
now, and it creates a dilemma right now on where to go. There 
are a number of States that have either proposed or have 
implemented trial periods after the end of the pandemic--1, 2 
years--for a broader coverage of telemedicine in that--in the 
effort that that would allow for an opportunity to study more, 
and see where it is most effective. And that is something that 
the committee could also consider.
    Ms. Castor. Thank you very much.
    Ms. Eshoo. The gentlewoman yields back. It is noted that 
there is a vote on the floor, so I am going to excuse myself 
and ask Congresswoman Kuster to chair.
    And I would now recognize Mr. Burgess from Texas for his 5 
minutes of questions.
    And thank you to Congresswoman Kuster. I know the gavel is 
safe in your good hands. I will go as fast as I can to the 
floor. Thank you.
    Ms. Kuster [presiding]. I am happy to help.
    Mr. Burgess, you are recognized for 5 minutes, and please 
remember to unmute.
    Mr. Burgess. Well, I have unmuted. Did it work?
    Ms. Kuster. Yes, we can hear you.
    Mr. Burgess. Very well. So, look, we all know we are not 
going back to what was the status quo a year ago, before the 
expansion of telehealth occurred during the pandemic.
    I do have a concern, and I think it has been brought up by 
several of our witnesses today: We do need to be mindful of 
cybersecurity. Yes, there are criminal elements who might seek 
to exploit the system, but there are also state actors. And the 
security of the network has been underscored several times with 
events in recent weeks, but this is another area where I 
believe we have significant vulnerability. Of course, it is the 
task of this committee to identify and prevent those 
vulnerabilities.
    Elizabeth Mitchell, first off, thank you for your service 
on the Physicians Technical Advisory Committee, a committee 
that was created by this committee back in 2014 with the 
Medicare Access and CHIP Reauthorization Act. You have talked 
some about data collection and how we don't know exactly how 
much money we might save, because we don't have the data. But 
is there any congressionally directed research that might be 
useful in assessing the cost-effectiveness of telehealth?
    Ms. Mitchell. Thank you, Congressman. And yes, and thank 
you for recognizing PTAC.
    And one of the reasons that I am as confident as I am that 
telehealth can be used to expand access meaningfully is because 
so many of the PTAC models envisioned alternative sites of 
care, like hospital at home. We need to be able to reach 
patients where they are, where they live, and we can improve 
access, affordability, and patient experience.
    I would say that more research is definitely needed. We 
need to evaluate and increase the use of patient-reported 
outcome measures. Are patients able to resume their activities 
of daily living? Are they pain free? Are they able to go back 
to work? These measures have existed for decades, but they have 
not been adequately used. So we want to increase that.
    And we need to measure total cost of care, the impact of 
telehealth and other innovations on the use of--on total cost 
of care. So we believe that that is an important area of 
research.
    We have also conducted significant research on patient 
experience. We have the largest data set of patient experience 
in the country, of over 40,000 patients a year. And we are 
seeing significant opportunity for improved patient experience 
with telehealth.
    Mr. Burgess. Very good. Now, you mentioned in your 
testimony how this moment for telehealth is not unlike the 
rollout of electronic health records. I was mindful, at last 
Saturday morning at 2:30 a.m., we were passing a big stimulus 
bill, and it was actually the stimulus bill of 2009 that 
brought electronic health records into the world of the 
practicing physician.
    And I do have an article I want to make available for the 
record, how health experts misjudge clinician burnout. So we do 
need to be mindful of the potential negative effects.
    But at the same time, is there anything that Congress can 
do on the front end to ensure that telehealth does not become 
overly burdensome to further silo health records or health 
data?
    Ms. Mitchell. Well, I think that we need to ensure that 
data is effectively shared. Again, this isn't about me, but I 
had a telehealth visit with my health plan provider, and they 
did not share the information with the primary care provider. 
That just makes the primary care provider's job even harder to 
get the information they need to--duplicative service. We have 
got to ensure data is meaningfully shared in a way that is easy 
for physicians to use.
    Mr. Burgess. Well, and Dr. Resneck, I so appreciate your 
testimony on this panel. You may remember it was this committee 
that--in the world of dermatology, it was this committee that 
worked very hard on allowing the use of a camera that might 
help in the detection of melanoma. And you could just imagine 
now extrapolating that to the telehealth world.
    But are there any services that you provided via telehealth 
in the past year, where you felt limited in treating the 
patient because of the virtual nature of the visit?
    Dr. Resneck. Thank you, Doctor, Congressman Burgess, I 
appreciate the question.
    Yes. And that is part of the evolving evidence base. So I 
know that, when I--when a patient reaches out to me who has had 
five skin cancers and needs a full body check, to tell them, 
you know what, you need to come in person and see me because I 
need to look you over for--from head to toe, and telehealth is 
not perfect for that.
    When a primary care colleague refers me a patient with a 
new rash that needs to be seen urgently, and I have the whole 
wonderful history from the primary care physician, I can take a 
look on video. Perfect.
    So, yes, we have learned over the last few years what 
things work well, what things don't. We actually have a pretty 
large evidence base in most specialties now about what things 
work well, and that really is built into the standard of care 
for each of us.
    Again, we wouldn't want to see that in statute, because it 
does evolve over time, and those coverage decisions can be made 
by Medicare and by commercial insurers.
    Mr. Burgess. Yes. And--but, you know, there is so much 
that--where it depends upon the type of patient you have in 
your practice, how comfortable you are in accepting their 
assessment of things. And we can't forget that as we go 
forward----
    Dr. Resneck. Yes.
    Mr. Burgess [continuing]. With policy. There are going to 
be significant differences between practice types, and I hope 
we are mindful of that.
    Thank you, Madam Chair. I will yield back.
    Ms. Kuster. Thank you. The gentleman yields back, and the 
Chair now recognizes Representative Peter Welch for 5 minutes 
of questions.
    Mr. Welch. Thanks very much.
    First of all, I want to thank Chairwoman Eshoo for giving 
this hearing to all of us who are really committed to expanding 
telehealth. Thank you.
    And I want to thank many of my colleagues, but particularly 
the ones I have been working with on legislation: Congresswoman 
Matsui and, of course, Congressman Johnson and Congressman 
Curtis. But I know all of us on this committee have a real 
interest.
    I want to start with a preliminary observation. In 
listening to the witnesses, it appears that telehealth works. 
It works for patients, and it works for providers. And that has 
certainly been the experience that we have had in Vermont. And 
many of my colleagues have raised similar instances of it 
really working. And it is not just in rural areas, it is in 
urban areas, as well.
    The concerns that were raised--Mr. Pallone did a good job 
of raising some of those concerns, where--will this result in 
overutilization? Will it result in effective care? Will it 
result in fraud? I want to make a point, and then I will go to 
our panelists for reactions.
    But those concerns that are raised about fraud, about 
overutilization, about efficacy, they apply to every procedure, 
to every item that is delivered in the healthcare system. So it 
seems to me that, if we are going to address those concerns--we 
should always be addressing those concerns--we don't cherry 
pick telehealth and bring down those concerns as a reason not 
to expand it and integrate it into the delivery of care.
    And I want to go back to something that Ms. Mitchell 
mentioned, and that was about the cost of care. We have a 
crisis in this country on healthcare, in my view, that neither 
the Republicans or the Democrats have effectively addressed. It 
costs too much.
    In 1970 the U.S. spent 60--6 percent of its GDP on 
healthcare. The European countries that are our near 
competitors spent 5 percent. We are now at 18 percent, they are 
at 11 percent. And my view is that, unless we can address the 
cost of healthcare, we are not going to have access to 
healthcare. The burden on employers, the burden on taxpayers, 
the burden on individuals is unsustainable. But that should not 
become an excuse not to utilize a method of delivery that works 
for people and makes it easy.
    So, Ms. Mitchell, you mentioned the fee-for-service system. 
What--as long as you have a fee-for-service system, you 
encourage utilization. And we can do all the patient surveys we 
want, we can do all the utilization studies we want, but if you 
have that embedded in the system--the more services you 
provide, the more money you make--how are we going to get out 
of this? Perhaps you could address that.
    Ms. Mitchell. Thank you, and thank you for raising the 
issue of affordability. It is a crisis, and it is a drag on 
U.S. employers who are truly absorbing those costs on behalf of 
their employees. Employers, private purchasers, provide all of 
the profit to the U.S. healthcare system, and the 
accountability for spending is simply not there.
    However, to your point, adding another service to the fee-
for-service system is not optimal. There are ways that we can 
use telehealth in our current system to reduce total cost. For 
example, expanded access to primary care can and does reduce 
unnecessary visits to the emergency room. That is better care 
in a more cost-effective setting.
    So there are ways that we can be intentional and smart 
about integrating behavioral up, integrating telehealth. But we 
do need----
    Mr. Welch. [Inaudible] time, but thank you very much for 
that. I just want to hear from Dr. Mehrotra about this, as 
well. But thank you, Ms. Mitchell.
    Dr. Mehrotra. Yes, no, I think you--Representative Welch, 
you raise some really critical issues. I will make two quick 
points.
    The first is why do we care more about telemedicine than 
we--say, surgeries or endoscopies or et cetera?
    And I think the issue and the reason that so many people 
have particular concern is that its basic strength, 
convenience, makes the risk of overutilization or overuse 
higher. So I just wanted to emphasize that.
    The only other point I wanted to make was Representative 
Rodgers had asked the question of where are we headed with 
telemedicine, and I think the key thing is the idea of remote 
patient monitoring. And when we are now moving away from visits 
to all sorts of other ways of communicating with your provider 
for--text messages, for example, adolescents love text 
messages, they don't like video visits. And yet we then face a 
problem that, when we get to the fee-for-service system, we are 
not going to pay for each text message.
    And that really emphasizes Ms. Mitchell's point that we 
need to--and your point, that we need to move away from paying 
for everything fee-for-service to more models, alternative 
payment models.
    Mr. Welch. Thank you very much. I yield back, Madam Chair.
    Ms. Kuster. Thank you, Mr. Welch.
    The gentleman yields back, and the Chair now recognizes 
Representative Griffith for 5 minutes of questioning.
    And Mr. Griffith, please remember to unmute.
    Mr. Griffith. Thank you very much. I hope I can be heard.
    I would--I would start by just touching on a couple of 
points that have been brought up previously. And I know that we 
are worried about overutilization, but I represent a relatively 
economically poor area of the mountains of Virginia. And a lot 
of folks have a hard time getting healthcare, as it is. 
Telemedicine is a wonderful concept that is helping them 
greatly.
    And somebody mentioned telestroke. I was one of the 
sponsors of that, and it took us a long time to convince people 
that that would be helpful. So I am glad that it is working out 
well.
    But I will tell you also that I am worried about the--and I 
know we want a glide path, and I recognize that that has merit, 
but for a lot of my district, even when we get--and we are now 
deploying low orbit, satellite broadband in the district, it is 
just starting. But even when we get access to that, it is $100 
a month, and a lot of the folks in my district can't afford 
$100 a month. So we have to try to figure out how to do that 
because, for a lot of these people, when it works the audio 
makes a lot of sense.
    Dr. Resneck, I would like to learn more about your opinion 
on audio-only versus audio-video patient interactions. CMS 
estimates about 30 percent of telehealth visits to be audio 
only, and a recent study of California-based FQHCs found that 
audio-only visits accounted for nearly half of all telehealth 
visits. When is it appropriate to use audio-only?
    Dr. Resneck. Thanks, Congressman. I would say it is 
interesting. It is typically not our first choice, but it has 
been a lifeline for patients in rural areas and disadvantaged 
patients, as you have heard from some of my colleagues today.
    I am surprised at how many of my patients don't have 
broadband access, even in a technologically advanced bay area 
like where I live. And I know it is true in rural areas, as 
well. Sometimes it is just an emergency backup. A patient will 
be with you on a video visit, and something will go wrong with 
their technology. You know, who among us today has not had a 
Zoom or Microsoft Teams meeting go awry, where we end up using 
the phone as a backup? And being able to have that be a covered 
service is important.
    We have entire Native American reservations in the United 
States where there is no broadband access. We have Black and 
Brown communities who particularly have less broadband access.
    So I think, while it is--while we wouldn't want to go to it 
as a first choice for any particular patient population, any 
arbitrary end to it as a backup option would particularly harm 
disadvantaged patients. And that would leave me worried for the 
future, and our work on disparities for those patients.
    Mr. Griffith. And I would agree, sometimes that problem 
exists in areas you wouldn't expect, because just a few miles 
away from Virginia Tech, a highly wired community, are pockets 
where we currently don't have any broadband. Now, some of those 
folks could afford it once we get the satellite broadband 
going, but they are not able to now. And I do appreciate that.
    So do you believe it is appropriate for providers to 
receive a lower reimbursement rate for audio-only visits, 
compared to the audio-video visits?
    Dr. Resneck. I don't. That was in effect in the past. It 
hasn't been true during the pandemic, but a lot of the patients 
I end up taking care of via audio-only are just as sick as the 
person I saw before via video. The care is congruent.
    You know, the audio visit in itself is not a service to be 
valued differently. We think of it as just another method to 
deliver care. And the value of that service should depend on 
how long it takes me and how sick the patient is, just like any 
other service. From an overhead standpoint, I am still 
maintaining my entire office and my office staff, the nurse who 
calls the patient in advance to the med reconciliation, the 
backup space to bring the patient in, if they need to come in 
person.
    So, unlike remote patient monitoring and other things where 
it is not equivalent to an in-person service, it is a totally 
newly defined, different thing that needs to be valued, I see 
it as equivalent.
    Mr. Griffith. Let me get one more question in, and I 
appreciate that, and I hate to cut you off, but I am running 
out of time.
    Many devices that we use in telemedicine are able to 
operate entirely on 2G cellular networks. And this helps for a 
lot of folks in areas that don't have better service. These 
devices can remotely monitor things like blood pressure, et 
cetera. Do any of you--and this will be for anybody--do any of 
you know of any capabilities that are lacking among 2G-capable 
devices?
    I will open it up to any of the witnesses, but I only have 
26 seconds.
    [No response.]
    Mr. Griffith. Does that mean that everything you know of 
applies to 2G, or you just don't have the knowledge base to 
answer? Which is fine, I mean, we can't know everything.
    Dr. Mehrotra. You have a bunch of dumb docs here, we don't 
know about 2G, I think, is the key point.
    [Laughter.]
    Dr. Resneck. I will have to get back to you on that one.
    Mr. Griffith. I appreciate that. And look, I understand, 
that is why I am asking the question. I don't know the answer, 
either. But I appreciate you all being here today.
    And thank you very much, Madam Chair. And I yield back.
    Ms. Kuster. Thank you.
    The gentleman yields back, and the Chair now recognizes 
Representative Schrader for 5 minutes of questions.
    And Kurt, you are already unmuted, so you are good to go.
    Mr. Schrader. Thank you, Madam Chair. You look pretty good 
up there, if I may say so. Good to see you again.
    This is a great hearing, a nice hearing, and it is nice to 
see that telehealth has more from do it or do we not, but yes, 
we are going to do it, and how do we do it best. And I think 
that is a much better spot to be in.
    It has been a lifeline for folks in my rural district, for 
veterans with comorbidities who have a tough time getting into 
the office. I had some personal interactions with a physician 
and a veteran, both very leery of telehealth, only to find out 
that, geez, they really like that, as the pandemic curtailed 
their in-person visits. It--more accessible, more opportunity, 
going forward.
    And to that end, I guess, Dr. Mahoney, you talked a little 
bit about your experience with the relatively flat utilization. 
You haven't seen a big increase in overutilization. Do you have 
any cost data you can share with us on the--on maybe the 
savings the system is seeing, as a result of telehealth?
    I mean, quite frankly, I have always been convinced that if 
you get to these people early on, make it easy and accessible, 
you can prevent a lot of much more costly problems later on.
    Dr. Mahoney. Yes, thank you for the question, Congressman 
Schrader. I agree with you. I like that story about the veteran 
who initially thought that, you know, he would not be 
interested in doing a video visit. I have seen that across many 
of my patients who, you know, traditionally, I would have just 
thought that they would have been resistant. But then they are 
the biggest fans, because they gave it a try and maybe had a 
caregiver help them get on. So I appreciate that comment.
    You know, telehealth has the potential to reduce total cost 
of care across populations because it is providing more timely 
access to care by ensuring the right level of care by the right 
provider at the right place and time. And we heard about the 
association between timely care and the prevention of emergency 
room use.
    And so, you know, we don't have any cost savings data at 
this point. But at Stanford Healthcare we are committed to 
analyzing our cost data and providing that as soon as it is 
available. We suspect that we will see--we definitely have seen 
no increased utilization, it is just related to the question of 
cost savings. I think that is a----
    Mr. Schrader. Well, some of my groups, you know, we do a 
lot of capitated healthcare in the State of Oregon and in my 
district, and several of the providers have found significant 
savings, you know, not tremendous, but, you know, 15 percent, 
20 percent. That is great. That is great. It is good for the 
system, it allows more flexibility. You can redirect, frankly, 
some of the payments to those who really need it. And I think 
that is important.
    I think one thing I am hearing--I guess I would go to Dr. 
Mehrotra now about, you know, alternative payment models. With 
fee-for-service I think it is a little constraining, to be very 
honest with you. I would suggest in human medicine it is a--it 
is an older-school, somewhat outdated way of providing 
healthcare. It is unavoidable in some areas. I do get that.
    But to coordinate the best healthcare for that individual, 
I think bundling healthcare payments with groups that are grown 
up locally and regionally based, that know what their 
constituents, their clients need at the end of the day, their 
patients need, is really important. So what needs to be done, 
from a policy perspective, to help facilitate that transition 
from fee-for-service to alternative payment models, and make 
sense out of the--if--because you can--if there are some 
savings, maybe there are some rate changes that could go into 
play for different types of visits, telehealth versus in-
person. I would love your opinion on that.
    Dr. Mehrotra. Yes. So first I want to emphasize I agree 
with your sentiment, that it is very difficult for us to 
determine what is clinically appropriate for each clinical 
circumstance. And we want to provide as much as possible that 
the physician or other provider can choose: this is worth a 
text message, this can be a phone call, ``I will do a video 
visit,'' or ``I will have to bring them in for an in-person 
visit.''
    And so we want to provide that flexibility, and that is--
flexibility is going to be most easily provided via those sort 
of models that you are describing in Oregon and that are all 
across our Nation. And so it is really about how do we build 
the next generation of the ACO models that we already have, as 
well as CPC-Plus, Primary Care First, and others, all these 
models that are being developed, and how do we accelerate the 
adoption and refine them so that they are better accepted by 
providers? Because I think that is really going to drive a lot 
of telemedicine use.
    Mr. Schrader. I totally agree, Doctor.
    Thank you so much, Madam Chair, and I yield back.
    Dr. Resneck. Madam Chair, do you mind if I jump in for 15 
seconds on the APM issue?
    Ms. Kuster. Sure, go right ahead.
    Dr. Resneck. Well, so the AMA and physician groups across 
the country have been very supportive of and worked towards 
developing more APMs. We are with you on this. But I would say 
two quick things.
    Number one is the massive innovation in telemedicine that 
happened during the pandemic mostly happened in the fee-for-
service setting. So we shouldn't forget that, that innovation 
can happen in both spaces.
    And the other thing is, as hard as we are all working to 
advance alternative payment models, Medicare has only adopted 
so many of them yet, and they are not available to many 
physicians. So if we all of a sudden say telehealth is only 
available to patients in alternative payment models, we would 
be stripping it away from enormous parts of the Medicare 
beneficiary population. Thank you.
    Mr. Schrader. And just to emphasize we need to have more 
opportunities for APMs for those that don't have access right 
now.
    Ms. Kuster. Sounds good. Thank you very much. The gentleman 
yields back, and the Chair now recognizes Representative 
Bilirakis for 5 minutes of questioning.
    Mr. Bilirakis, you are on.
    Mr. Bilirakis. Yes, thank you, Madam Chair. Can you hear 
me?
    [No response.]
    Mr. Bilirakis. Can you hear me?
    Ms. Kuster. Yes, we can, yes.
    Mr. Bilirakis. Good, thank you. Thanks for, again, 
Chairwoman Eshoo, for scheduling this hearing. And I thank the 
participants, they have done an outstanding job.
    And I do want to see us--and we may have done this in the 
past, just a suggestion--having a demonstration available to us 
with regard to behavioral health, telehealth services, but also 
primary care services. I have done it in my district, and I 
encourage other Members to, and I am a strong supporter.
    We have seen throughout this pandemic that telehealth 
services have provided a critical lifeline for millions of 
Americans, especially seniors, allowing them to receive quality 
medical and behavioral healthcare from the comfort and safety 
of their homes. They are more comfortable, they really are.
    As we build on the successes of the previous 
administration's response to COVID-19 and look beyond, we must 
ensure patients, especially our seniors and those managing 
chronic conditions, are able to confidently access the 
appropriate care they need.
    Patients and their providers should also be empowered with 
more, not less, options to capture health statuses accurately, 
safely, and conveniently.
    I have a question here for Mr. Riccardi and Dr. Mehrotra. 
As a supporter of the Medicare Advantage Program--and most of 
us are--I was pleased to see CMS provide much-needed 
flexibility to allow healthcare providers to offer telehealth 
services under the Medicare Advantage plans.
    However, CMS guidance requires that these services include 
a video component, which is not an option for some patients. 
And I know some of our members have expressed concern about 
that. Low-income and rural patients, for example, may have 
trouble accessing technology or broadband services supporting 
video communications.
    Additionally, seniors or frail populations may have 
physical limitations that prevent them from using video 
communications. And that is true. For these patients an audio-
only telehealth visit may be the only option--again, as our 
witnesses have stated, it may be the only option besides 
delaying needed healthcare, and we don't want that.
    On August 3rd, 2021 CMS updated the risk adjustment 
telehealth policy for ACA plans to allow for reimbursement for 
audio-only visits for purposes of risk adjustment. However, the 
same has not yet been extended to Medicare Advantage plans, 
even though the same audio-only services are being provided by 
the same clinicians using the same coding guidelines.
    Are there any--and this is the question--are there any 
ongoing concerns that you are aware of with programmatic fraud 
that may merit differences between the two programs?
    Or should certain guardrails be put into place if such a 
policy was extended to Medicare Advantage plans? And if so, 
what should those guardrails be?
    Again, the question is for Mr. Riccardi and Dr. Mehrotra.
    Mr. Riccardi. Thank you for your question. I have just 
three quick points that I would like to share.
    First, you know, we support the flexibilities for 
telehealth in the Medicare Advantage program, and also through 
the demonstration projects and the alternative payment models.
    It is crucial that the expansion of telehealth benefits, 
such as the geographic site--removing those restrictions, it is 
really essential that it is also applied to fee-for-service 
original Medicare, because we could potentially leave behind 
millions of people who have been using these services and where 
this innovation has truly occurred over the last several 
months.
    In respect to the barriers that people face using 
technology, that is correct. People may have compromised immune 
systems, physical disabilities, an inability to leave the home, 
a lack of transportation. So telehealth really is essential 
across the program coverage options that people use to access 
their services.
    And so, with respect to program integrity, fraud is always 
a concern, and utilization. But we recommend removing barriers 
to access, and then using data and information on the back end 
to kind of detect any potential fraud, you know, waste, or 
abuse. And audio-only clearly, you know, has a role in helping 
people, in particular with behavioral health issues, access the 
services that they need. So it should be considered.
    Mr. Bilirakis. Very good. Thank you, Doctor.
    Dr. Mehrotra. Yes, two points. On the risk adjustment 
aspect, Representative Bilirakis, I don't know the details 
behind that, but I do think that, if those visits have 
diagnoses that should go into the risk-adjusted algorithm, it 
seems reasonable to me.
    But, more to your point about the audio-only telemedicine 
visits, I think--and the Medicare Advantage program--I think I 
would emphasize that, if we look at both private insurers and 
those in the Medicare Advantage plan who, obviously, have to 
worry about overall spending, they are also very judiciously 
moving forward here. And I think their experience should also 
give us a lesson because they are concerned about the same 
issues. And, to my knowledge, most are not planning on covering 
audio-only telemedicine visits in the future.
    And so I think that should be, like, a lesson to all of us, 
as we think about the Medicare fee-for-service program, also.
    Mr. Bilirakis. All right, thank you very much.
    Madam Chair, for inclusion I provide this committee with a 
copy of a letter of support for a bipartisan bill I plan to 
soon reintroduce called the Insurance Parity and Medicare 
Advantage for Audio Only Telehealth Act, which includes 
guardrails to prevent potential Medicare fraud and abuse by 
ensuring patients have an established provider or practice 
relationship where audio-only diagnosis is being utilized, and 
that diagnoses were previously documented in person. I think it 
is so important. So I would like to admit this into the record, 
please.
    Ms. Kuster. Did you just read the letter to us?
    So ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Bilirakis. Thank you so----
    Ms. Kuster. We will make it part of the record.
    Mr. Bilirakis. Yes, I have got a couple more questions, but 
I am not going to go into them.
    But I will tell you this--and I have got 30 seconds--I 
remember years ago we did one of these field hearings in 
Pennsylvania, rural Pennsylvania, and I was really impressed 
because the patient actually came to the hospital, and was 
treated--or maybe it was a clinic--was treated for primary 
care. However, a specialist was needed. And then the 
telemedicine, the telehealth was done from Philadelphia, I 
believe, and the specialist was able to speak with the primary 
care physician and the patient. And I thought that was a great 
idea.
    So I think that that is being done quite a bit. But anyway, 
my time has expired, and I appreciate it very much. Thank you.
    Ms. Eshoo [presiding]. Thank you, Mr. Bilirakis.
    Mr. Bilirakis. My pleasure.
    Ms. Eshoo. I remember many years ago bringing the FCC 
Chairman to Stanford Hospital--actually, Lucile Packard 
Children's Hospital--and he wanted to know why he was going 
there. I said, ``You will see when you get there.'' But I 
wanted him to see the surgery that was taking place on a baby, 
and an entire wall of equipment relative to broadband. So these 
are all advances. He never forgot that and became a great 
advocate for it.
    So it is--thank you to Congresswoman Kuster for chairing in 
my absence while I voted, and it is a pleasure to recognize Mr. 
Cardenas from California for his 5 minutes of questions.
    Mr. Cardenas. Thank you, Madam Chairwoman, and I would like 
to thank you and the ranking member for--Guthrie for having 
this important hearing. And you are the--two of the nicest 
Members of Congress, even though it seems they only give one 
award a year.
    But anyway, since the beginning of the pandemic, we have 
seen the disproportionate impact of COVID-19 on communities of 
color and low-income communities. Telehealth has the potential 
to improve health equity by increasing access to care for rural 
and underserved communities across America. Some studies 
indicate that those same communities are having trouble 
accessing telehealth. It is critical that we make sure that 
populations who can benefit the most from telehealth can access 
it, so that telehealth, in the long term, does not contribute 
to health inequities that are so prevalent in our country.
    Mr. Riccardi, what are some of the potential barriers to 
accessing telehealth that exist today, and what can be done to 
break down those barriers?
    Mr. Riccardi. Yes, thank you for your question. I think 
this is an opportunity to invest in telehealth to improve 
health outcomes and not exacerbate existing health disparities.
    Crucially, research shows approximately one-third of older 
adults age 65 and over do not use the Internet, and half lack 
broadband. And it is even worse for Black older adults. Almost 
70 percent don't have broadband access at home, and this is for 
a variety of reasons. And so this is why it is incredibly 
important that there are investments in the infrastructure of 
broadband and technology in general. People lack broadband 
coverage where they can't afford the technology. They just 
generally may be uncomfortable with telehealth. And so it is 
important that the investments are also made into digital and 
technological training to improve health literacy.
    Mr. Cardenas. Yes----
    Mr. Riccardi. And many individuals are also challenged 
because they may have cognitive impairment, physical 
limitations, or disabilities. And so telehealth really can be a 
supplement to in-person care. But, you know, follow-up care may 
be needed after a telehealth visit. So I think it is really 
important that we envision this as an opportunity to eliminate 
these disparities.
    Mr. Cardenas. OK, thank you, Mr. Riccardi.
    And there are many, many factors that limit people with low 
income in this country. And when I say low income, I want to 
point out two things that are derogatory, in my opinion, in too 
many minds of Americans. When Americans think of low income, 
far too often they have been convinced that the low-income 
person is lazy, they don't work, and they don't want to work, 
and they are just sucking off the system. Well, with all due 
respect, we have the working poor in America, which are 
millions and millions of adults and children, and they 
deserve--they are hard-working, they are probably minimum-wage 
workers. They deserve the opportunity to get the same 
healthcare that anybody else in our great country deserves.
    And then, in addition to that, when you are talking about 
seniors, seniors already spent their whole life working maybe 
30, 40, or maybe 50 years, and they are finally retired, and 
they have limited incomes, and they don't--can't afford the 
kind of broadband access that maybe everybody on this call can 
afford. And they are limited in being able to take advantage of 
telehealth.
    So those are some of the things that I think that we need 
to be respectful about in this country, and not to make 
assumptions that people are just in that plight, situation, and 
they deserve it, or they don't care, or they are not taking 
care of themselves. With all due respect, I am saying that 
every person in America, regardless of their circumstance, 
deserves to have that dignity and opportunity to have that 
quality healthcare.
    Mr. Resneck, I will give you a few seconds. Go ahead.
    Dr. Resneck. Yes. Well, you mentioned employed low-income 
Americans. And I just want to say the worst--one of the worst 
things we could do is if we implemented telehealth in a way 
that cements existing disparities.
    An irony I have noticed is that commercial insurers before 
the pandemic were sending my patients postcards saying, ``Hey, 
you can access these commercial direct-consumer telehealth 
sites for free. We will waive your copays.'' But they wouldn't 
cover coordinated care with the physicians who already knew 
those patients.
    So, going back to closing down that access for commercial 
payers, I think, would actually worsen disparities, especially 
for that employee-covered working poor.
    Mr. Cardenas. Again, thank you, Mr. Resneck. And I think it 
is really important for everybody to understand, and that is 
why this is complicated, because it is not as simple as black 
and white. There are a lot of guardrails that we need to make 
sure exist, because in every environment there is going to be 
bad actors, and there is going to be folks who just want to 
keep pushing and pushing and pushing across that gray line. So 
thank you very much.
    My time is limited, and I yield back.
    Ms. Eshoo. I thank the gentleman, excellent observations 
and questions. We keep learning, we keep learning. That is why 
hearings are so great.
    It is a pleasure to recognize the gentleman from Missouri, 
Mr. Long, for his 5 minutes of questions.
    Mr. Long. Thank you, Madam Chairwoman, and I appreciate you 
putting on the hearing here today.
    A few weeks ago I conducted a 3-day, districtwide tour of 
six hospitals, two clinics, and one vaccination center. And 
what I wanted to do was I wanted to hear from frontline 
doctors, nurses, people that have been dealing with this for 
right at a year at the time that I went. At every visit, they 
praised the expansion of telehealth services and said that it 
worked well for them.
    One of the concerns was that telehealth might revert to 
pre-COVID policies, once the public health emergency is over. 
We are here to examine telehealth in a post-COVID world. Aren't 
those nice words, ``post-COVID world''?
    And I think it is important, as we consider its cost, 
coverage, and program integrity we don't lose sight of its 
value and end up throwing the baby out with the bath water.
    Dr. Resneck, can you talk about how telehealth can deliver 
value to our healthcare system beyond just replacing the face-
to-face visit? How can it lead to greater efficiency for both 
patients and physicians?
    Dr. Resneck. Thanks, Congressman. You know, mental health 
has come up. I think, broadly, what we are on the verge of 
seeing--and we have seen in this last year, and I think people 
asked about the next 10 years--the growth of telemedicine for 
chronic disease, where we have a huge possibility to impact 
value of care, so whether that is mental health, prediabetes, 
hypertension, things that affect so many Americans, and that we 
know have been exacerbated in this year due to COVID, and 
measuring the financial savings from that, those are things--
benefits we are going to see in years out, in terms of 
decreased chronic care for those diseases.
    So having that as a part of the toolkit, we are seeing 
physician offices and health systems around the country doing 
really innovative things in the diabetes and hypertension and 
mental health spaces. So there is tremendous value there.
    I also think it is really important that we measure--when 
we offer somebody who lives 3 hours away telehealth, one of the 
benefits that I mentioned earlier is they are not missing a day 
of work. They are not having the economic impact on their 
family of that, they are not paying to park at my health 
system, they are not spending all those hours in the car. So I 
think there are just so many areas of value, and I really look 
forward to seeing the progress in the chronic health space.
    Mr. Long. One of the unfortunate trends in healthcare is a 
shortage of physicians and nurses, as you know. I mean, there 
was a terrible nursing shortage in this country before anyone 
had ever heard the word ``coronavirus,'' particularly in rural 
areas, which--I represent a lot of rural areas in southwest 
Missouri. Over the years I focused on closing the gap in the 
rural healthcare workforce.
    How can telehealth help overcome clinician shortages, and 
especially in rural areas and for our underserved populations?
    Dr. Resneck. Well, thanks to Congress for the GME, for the 
downpayment on improving GME funding in the last couple of 
months. That was a huge thing. Thank you.
    Telehealth, in particular, it is not a magic sort of 
panacea for workforce issues because, at the end of the day, we 
don't have doctors and nurses twiddling their thumbs. They are 
busy everywhere. So we certainly have some maldistributions, 
and particularly in rural areas and some inner-city areas where 
there is not enough healthcare infrastructure. It is a piece of 
the puzzle for folks who live in those areas to be able to 
access specialty care, primary care. It is an important piece.
    Mr. Long. You say that it will be very difficult for 
providers to invest in the technology required to provide 
telehealth services and incorporate telehealth into the work 
flows if its future is uncertain. What constitutes certainty?
    In other words, is a statutory coverage expansion the only 
way to provide certainty to providers?
    Dr. Resneck. I think, one way or another, we need to know 
that payers, including government payers, understand that this 
is part of the future of healthcare delivery, and that it is 
not going to suddenly disappear, or its coverage is not going 
to suddenly disappear.
    So I think permanently removing the Medicare restrictions 
is a really important part of that. You know, the big 
investments are not always technology investments on this. Yes, 
you oftentimes have to acquire software that works with your 
EHR, et cetera, but it is really about retooling your entire 
office to be able to try and figure out in advance which 
patients need to come in in person and which don't, how to 
coordinate all that care. So there is a real expense there.
    Mr. Long. There is a concern that expanded telehealth could 
lead to greater fraud and abuse or duplication of services. You 
say that these concerns are misplaced. Why?
    Dr. Resneck. So I think that OIG and DOJ already have the 
tools.
    I am involved in some of these cases of telehealth fraud. 
They really have little to do with telemedicine and are really 
about, you know, using almost sham telemedicine that they are 
not even billing for to try to provide prescriptions and 
unneeded genetic testing and other things.
    It is interesting, the statement that came out 3 or 4 days 
ago from the Deputy IG, Mr. Grimm, on telehealth really 
corroborated that and said that the telefraud cases that they 
are seeing and investigating right now are mostly related to 
telefraud, not telemedicine fraud. Again, where these 
unscrupulous marketing firms are convincing patients to sign up 
for things they don't need, but they are not actually using 
telehealth or any of these codes that we are contemplating, or 
the Medicare broadened coverage that we are talking about.
    Mr. Long. OK, thank you.
    And Madam Chairwoman, I have no time to yield back. But if 
I did, I sure would.
    Ms. Eshoo. I thank the gentleman. Wonderful, 
straightforward questions and wonderful, straightforward 
answers from our witnesses.
    It is a pleasure to recognize the gentleman from 
California, Dr. Ruiz, for your 5 minutes of questions.
    Mr. Ruiz. Thank you very much for holding this hearing 
today on this important subject. The expansion of telehealth 
has played a critical role in the access to care during the 
COVID-19 pandemic. And we have seen on a large scale how 
beneficial it can be for both the patients and their providers.
    So, as we move forward past the current health crisis, it 
is important that we take a hard look at what the future of 
healthcare delivery looks like and strategically adopt policies 
that will move us in that direction with a key eye on equity. 
We must reimagine and redesign healthcare. Home and community-
based care is the future of healthcare delivery in this 
country. It is already moving there, organically.
    However, in my experience as an emergency physician taking 
care of very complex chronic patients who visit the emergency 
department, there has been studies conducted by insurance 
companies, hospitals, and academicians who have seen that, if 
you provide home-based care with tailored protocols, usually 
accompanied with a nurse after discharge or even before, then 
patients actually have better satisfaction, you reduce costs 
because their health outcomes have improved, and they have less 
emergency department visits, and their health is better. So the 
trifecta, or the Holy Grail, of a healthcare system has meant 
better health outcomes, lower costs, and patients and providers 
are happy.
    So more and more we are seeing the importance of being able 
to meet people where they are. The question we need to ask 
ourselves is, What are the current barriers to home-based care, 
and how do we address them?
    How do we make better use of promotoras, or the community 
health worker, to get to patients that can't get to a clinic or 
health center, someone who can--from the community, who knows 
the community, who can visit patients and help them connect 
with their provider?
    How we ensure equity--how do we ensure equity and create 
policies that not only increase telehealth coverage when 
appropriate, but ensure that everyone has access to the 
technology that allows them to take advantage of its 
availability?
    I don't just want to only increase convenience 
accessibility for high-paying concierge patients who already 
have access, and leave behind the same communities being left 
behind now. I want to increase accessibility for all people, 
especially those that currently go without seeing a doctor 
because of time, money, or distance; or the seniors in my 
district that can't drive anymore and can't find someone to 
take them to multiple follow-up appointments; for the farm 
workers that can't afford to take hours off of work to go to 
the clinic, and then another to go to another appointment to 
see the referred dermatologist; for the single mom working two 
jobs who can't offer to cut her hours to see a doctor for 
something that she thinks can wait until she has more time.
    Increased focus on telehealth and home health will change 
the face of healthcare for many communities like the one I grew 
up in and now represent in eastern Riverside County, 
California, California's 36th district.
    My first question is to Dr. Mahoney.
    Can you tell us how telehealth can be used to improve and 
expand the use of home healthcare?
    Dr. Mahoney. Dr. Ruiz, I really appreciate your comments, 
and I wholeheartedly agree with the sentiments that you have 
made about the potential promise of telehealth in meeting the 
needs of all of our patients across the United States, and 
particularly patients who historically have been underserved.
    You know, just the idea of tapping into the resources that 
are available, promotoras, you know, other caregivers who are 
in a community who will help us overcome the well-described 
issues that we are already talking about today along the lines 
of digital literacy or, you know, being disadvantaged from 
understanding the technology that--it is required. If we are 
skillful in leveraging the existing resources that are 
available, that are culturally sensitive, language concordant, 
I have seen as a frontline provider that those barriers can 
absolutely be overcome.
    I will also mention that there are a number of licensed 
nonphysician practitioners who are incredibly useful in helping 
us extend the access to care, people like pharmacists or 
physical therapists. And currently these vital team members are 
not eligible to bill for telehealth services----
    Mr. Ruiz. So I think that----
    Dr. Mahoney [continuing]. That can in person----
    Mr. Ruiz. I really do believe, since 80 percent of what we 
spend in healthcare is--are on 20 percent of the complex 
patients, we can focus--to reduce those costs, focus on home 
care for those patients, as well, to put them on a protocol to 
improve their health and prevent them from going to the 
emergency department.
    In addition, we can reduce healthcare disparities, promote 
equity by doing a concurrent community-based healthcare 
promoter track with telehealth and home-based medicine, 
combining those two with good, old-fashioned community public 
health, and we can change the health of Americans, and we can 
extend our lifespan, and reduce costs, and satisfy patients and 
providers in doing so.
    And I yield back.
    Ms. Eshoo. The gentleman from Indiana--I am sorry, the 
gentleman from Indiana, Mr. Bucshon, is recognized for his 5 
minutes of questions.
    And I am going to run to the floor to vote and turn the 
gavel over to--is she there? Oh, we are waiting for her.
    All right, well, we will wait for her. And when Congressman 
Kuster returns, I will get a--put the gavel in her hand.
    But meanwhile, Mr. Bucshon, you are recognized.
    Mr. Bucshon. Thank you, Madam Chairwoman. And providers and 
patients like telehealth, so let's do our best not to mess this 
up.
    I want to thank all of the witnesses today. It is a 
critically important hearing. I was a cardiovascular surgeon 
before I was in Congress, and it is too bad that it took a 
pandemic to finally get us to recognize that we need to make 
some advances here in telehealth. But it is what it is.
    I applaud the committee for beginning the process of 
reviewing what has been accomplished by the unprecedented steps 
made by the by the administration, the previous administration, 
and continued by this administration, and examining which 
policies should be made permanent as we look towards life on 
the other side of the pandemic. In order for telehealth to 
continue to be effective, Congress must advance policies that 
support accessibility and quality of care.
    Dr. Resneck, in your testimony you referenced a recent 
survey of physicians which shows that over 73 percent of 
respondents cited low or no reimbursement as a barrier to 
maintaining telehealth usage after COVID-19. As a physician, 
this is a real concern of mine, moving forward. I believe 
doctors should be reimbursed appropriately for telehealth 
services based on the standard of care. And if we want to find 
a very quick way to end telehealth, then we can not reimburse 
providers for the services that they are providing.
    Dr. Resneck, would you agree that doctors should be 
reimbursed for audio-visual visits at a same or similar rate as 
in-person visits?
    And secondly, can you elaborate on the provider concerns 
expressed in the survey and share what you are hearing on the 
ground regarding provider reimbursement for telehealth 
services?
    Dr. Resneck. Dr. Bucshon, thank you. I do agree. I think, 
again, telemedicine is a mode of delivering a service, and not 
a service unto itself. And the coding should be based on the 
amount of time you spend, and the complexity of the patient, 
whether you are on the telephone, on a video visit, or in 
person.
    I think on the ground what I am hearing is, you know, 
coverage at parity rates has allowed physicians to provide this 
care to our patients, which we have wanted to do for a long 
time. It has not created some giant inappropriate incentive. 
Telemedicine is actually hard to do. It is a lot of work. And 
it is work we like doing, and want to do for our patients. But 
just paying equitably for it has made a lot of sense and 
allowed people to do things they have wanted--services they 
have wanted to provide for a while.
    Mr. Bucshon. And I will bring up another concern that, as a 
physician, you might imagine I would bring up. It is the 
liability issue and how we address that. For example, say a 
primary care doctor does a virtual visit, or a dermatologist 
does a virtual visit, examines a mole on a patient's arm. The 
doctor determines that it is not suspicious and doesn't need 
further evaluation. But, unfortunately, later on it turns out 
to be something more severe, like a melanoma.
    Is the doctor going to be liable if the picture quality 
wasn't what it should be? And was the tech company that 
provided the Internet access liable? Is it the camera--the 
person that developed the camera? Is it the provider? These are 
serious questions that maybe we will have to address. Do you 
have any comments on that----
    Dr. Resneck. I do. Those are serious questions. And, as you 
can imagine, liability reform is something that is on a lot of 
physicians' minds.
    I think, you know, you won't be surprised that this 
happens. I sometimes get very blurry photos. I sometimes get a 
patient thinking they are photographing their skin, and I see 
the dog on the grass in the background. Right?
    Mr. Bucshon. Absolutely.
    Dr. Resneck. So it--on the one hand, I can't be held 
accountable, nor can my colleagues, for what we weren't shown 
or can't see. And that would be really frustrating if we were.
    On the other hand, what I would say is we hold, ethically, 
physicians to the same standard of care, no matter how they are 
providing that care. So, if you see somebody--you know, if I 
see a patient with a mole, and I think that is a mole that I 
would need to look at under a dermatoscope in person, it is my 
responsibility to tell that patient, ``You know what? You have 
got to come in person.''
    Or if the pediatrician feels like they really need to look 
in someone's ear, that standard of care should still apply when 
they are doing telehealth. And if it is something where what 
you see is adequate to make a diagnosis and treatment plan, 
then you should go ahead and do it via telehealth. But that 
standard of care should really be the same.
    Mr. Bucshon. Yes, I would agree. The standard of care 
should be the same. I think there are technical--there can be 
technical challenges.
    And I would also agree that it is not the patient's 
responsibility to do the right thing. I mean, if you can't get 
an adequate evaluation of the patient by telehealth, then you 
have to see them in person.
    Dr. Resneck. Yes.
    Mr. Bucshon. I do think, though, that this will become an 
issue. I think it will become an issue for the technology 
space, for the Internet providers, and others, because we all 
know how that goes in healthcare, when this comes down. So we 
will have to think about all those things.
    Dr. Resneck. Dr. Bucshon, that reminds me, this is another 
reason why we support physicians being licensed in the State 
where the patient receives the service, because if the standard 
isn't met by the technology company, by the doctor, the 
physician or the technology company can be--the patient can 
pursue that in their own State.
    Mr. Bucshon. I am in agreement with you. I think a national 
licensing is not the way to go.
    I have--well, I am out of time. So with that, I yield back. 
Thank you.
    Ms. Eshoo. The gentleman yields back. I think what I am 
learning is that there are many commonsense practices right now 
that just really need to be retained. The answer is already 
there, when I listen to the answers of the witnesses. But it is 
good to have an exchange between two doctors.S
    It is my pleasure to recognize the gentlewoman from 
Michigan, Mrs. Dingell, for her 5 minutes of questions.
    Mrs. Dingell. Thank you, Chairwoman Eshoo and Ranking 
Member Guthrie, for this important and very timely hearing to 
discuss telehealth. This subject really matters, and I think 
that telemedicine is here to stay.
    We have seen a dramatic increase in its use during the 
pandemic, but we need to thoughtfully explore reforms that 
build on what works while coming together in a bipartisan way 
to address challenges in the implementation moving forward, 
some that were just discussed in the last questions.
    Dr. Mehrotra, in 2018 Congress allowed clinicians working 
with the U.S. veterans--with the VA Health System--to practice 
both in-person and telehealth across State lines, as long as 
they were licensed in good standing in their home States. At 
the time, veterans were experiencing long wait times for care, 
which required action, and Congress responded. Congress did the 
same thing for DHS providers last spring in the CARES Act.
    Given the extraordinary public health crisis we are now 
facing, what is your view on a temporary, time-limited 
licensing--I can't even talk today--proposal to address the 
current public health emergency like that in the TREAT Act, 
which my colleague Representative Latta and I have introduced?
    Dr. Mehrotra. First, I really appreciate the question. I 
think there is broad consensus. I think most everyone here 
that--we need to address licensure reform. And how do we 
facilitate interstate practice of medicine?
    It is--we--I was--in a recent piece we were just describing 
how we created this very silly situation where you have a 
patient crossing the State line, driving a mile down the 
street, so they can have a telemedicine visit with their 
primary care doctor, because the primary care doctor is not 
licensed in the State they live in. So they are now having a 
telemedicine visit via the--in their car. That is silly.
    I think, in terms of how we make that reform, I think you 
have--I think the TREAT Act is a great--and I am very 
supportive of the--where--of creating a licensure reform, so 
that there is reciprocity across States. And I have argued, 
actually, that we should do something that is more--also go 
further, and make something that is permanent, because I do 
think we need to address that artificial barrier of licensure.
    Mrs. Dingell. I mean, it is very real. The University of 
Michigan treats many patients in Ohio, Indiana. It is--and it 
is facing real problems in treating its patients during COVID 
on this. So--and there are other hospitals. Many hospitals are 
experiencing that. So thank you.
    I look forward to continuing to work on this issue, and I 
would like to hear your ideas for making it more permanent. 
However, I also want to make sure that we are taking steps to 
protect the Medicare program integrity, given the dramatic 
changes we are seeing in telehealth adoption and uptick. And, 
while we all recognize the many legitimate benefits of 
telehealth and how impactful the expansion has been during the 
pandemic, we shouldn't ignore the potential for new, 
sophisticated schemes that could leave our Nation's seniors at 
risk of fraud.
    I have already met with seniors that are experiencing this. 
For example, cold calling beneficiaries will get personal 
information from a senior and then bill Medicare for services 
or equipment the beneficiary did not request and, in one case, 
didn't even receive.
    Mr. Riccardi, do you have any suggestions for how we can 
strengthen Medicare program integrity to, for example, prevent 
cold calling or billing for unnecessary services?
    Mr. Riccardi. Thank you for your question. And I think 
that, you know, as we consider moving forward with telehealth, 
that we can draw upon, you know, previous experiences with 
fraud, waste, or abuse, and also the privacy concerns that many 
older adults have, you know, with the advent of and expansion 
of telehealth during this pandemic.
    And just stepping back, it is just important to remember 
that, as we consider any measures for combating, you know, 
fraud and scams, that we don't arbitrarily impose barriers onto 
people who need access to that care. I think that there are 
sophisticated technologies that can be used to analyze the data 
that is available as it is connected to telehealth.
    But also, as we move forward, we have to consider other 
protections that are related to Medicare law, like HIPAA, you 
know, considering whether we should include additional entities 
that should be covered by HIPAA, and investing in the 
infrastructure of the technology, ensuring that the protections 
are there in place to prevent seniors from these types of 
scams, and lastly to draw upon not only the healthcare system, 
but also on supporting the community-based organizations that 
serve Medicare beneficiaries to help them combat fraud and 
scams.
    Mrs. Dingell. Thank you.
    I am out of time. I yield back, Madam Chair.
    Ms. Eshoo. The gentlewoman yields back. The Chair wants--
will recognize Mr. Mullin from Oklahoma for his 5 minutes, but 
I am going to hand the gavel over to Congresswoman Kuster 
because I am going to go to the floor to vote. So I shall 
return.
    Mr. Mullin. Thank you, Chairwoman Eshoo, and I appreciate 
you. And I know you asked earlier about my son, except the 
irony of that is I was actually doing a telehealth with my--
with the neurologist. And so, while you asked me, I was 
actually on the phone with the--or on the telehealth with the 
neurologist, speaking. Because, you know, my son has had a 
traumatic brain injury.
    And I will say this real quick: My son is doing great, but 
his specialist, we meet through telehealth. There are several--
his--several specialists that we haven't even had an in-person 
meeting with, because he is case study number one for 
accidents, for pediatric neurology care, and what he is going 
through. He is actually experimental. And so UNLV--or UCLA, I 
am sorry--has taken on his case. Then there is a specialist out 
of Beverly Hills that is overseeing it. And then we have 
another specialist in Illinois, while we are in Oklahoma, rural 
Oklahoma.
    Telemedicine and telehealth is something that has opened up 
an opportunity for all of us, no matter where we live, to have 
those specialties come into our home, come into our 
communities, and allow us to have the same adequate care as we 
would if we were living in California or we were living in 
Houston or we were living in Chicago or Washington, DC.
    And, while the pandemic has been horrific, it has also 
advanced the technology that we knew was here, but we weren't--
as Congress, we weren't ready to look at it, we weren't ready 
to embrace it, because we didn't know how to reimburse doctors. 
We didn't understand how to regulate it. We didn't understand 
how the doctor visits would work. But because of technology, we 
are here.
    And I have a good friend of mine that is an orthopedic 
surgeon that--he does surgeries robotic. And while he has to be 
in the same room, he actually never has to lay his hands on the 
patient, other than to comfort the patient. But he stands 3 
foot away and replaces hips or does surgery on the shoulder or 
does surgeries on the knee. And by the way, he came to us 
through our Army, because he was in the service, and performed 
surgeries even at the--at Walter Reed.
    And our Government is the one that taught him this 
technology. And it is capable now for us to bring home to our 
rural hospitals, where it was hard for us to get specialists to 
be there. And so the technology exists, but a lot of people, 
they don't even know how to embrace it yet.
    And so that is--and by the way, my family has been the 
recipient of this. I mean, it is--this whole year, because of 
the traumatic brain injury that my son had, we have embraced 
this.
    And I will tell you personally, at first I didn't know if I 
liked it or not. I am a very in-person--I like to be in person. 
But once I started it, I realized that I became the physician 
assistant. I became the P.A., which was positive because, as a 
caregiver for my son, I also--I am interacting with the doctor. 
I am putting my hands on my son.
    Or the--or we are having the conversation, we are having a 
conversation about costs, really. Because when they send over 
the prescription, they send it to me. Instead of me just being 
on my phone, checking my emails, waiting for the doctor to 
schedule the next surgery, or schedule the imaging or lab work, 
I am having to interact. And so it made me more cognitive of 
the care that my son was given. But it also made me more 
cognitive of the cost, which is a good thing. There is nothing 
wrong with that.
    I have actually embraced it fully, where I enjoy them now. 
And I know I went long on explaining that, but I want to 
understand that I am living this life, and it is beneficial. It 
is beneficial for us in rural parts of America, because we had 
the same access to the care of those in major metropolitan 
areas.
    Now, with that, real quick, Dr. Resneck, I have a couple of 
questions, because rural providers in my area are having a hard 
time actually understanding even how to gain access to 
telehealth grants. Do you feel like there is more that can be 
done to provide this information to the providers?
    Dr. Resneck. I know the AMA and specialty societies have, 
just in the last several months, rolled out a lot of additional 
information about some of the grants to help with 
implementation. You know, CMS has actually been very 
cooperative and supportive in terms--over the last year, in 
terms of helping us when we have needed to reach out to improve 
that process.
    So--but definitely put your colleagues in touch with me, 
and I am happy to see what we can do to help.
    Mr. Mullin. Do you think it would be helpful to maybe have 
a one-stop shop for funding opportunities for telehealth?
    Dr. Resneck. I don't see any harm in that, and it could be 
helpful.
    Mr. Mullin. OK. Maybe we can work with you on doing 
something like that too.
    And my office has been working on a bill with Chairman 
Eshoo's office to ensure the Federal Government creates a 
national telehealth strategy that streamlines and coordinates 
these things. Would it be beneficial for maybe there to be an 
elevated presence within HHS to coordinate these telehealth 
investments and policies across our Government?
    Dr. Resneck. We would love to talk more with you about 
that. I mean, I think our observation, again, has been that CMS 
has actually made this a big priority and been incredibly 
responsive to physicians and patients during the pandemic 
around this. And we are optimistic that that responsiveness 
will continue.
    But this is a really important issue, and we do need to 
continue to have a national strategy. So let's follow up and 
talk more about what we can do.
    Mr. Mullin. Absolutely, because we--I--this is a great 
opportunity for rural America to have adequate and quality 
healthcare like all others. And I think this is a great 
starting point.
    Dr. Resneck. I am so glad to hear your son is doing better. 
And I know this----
    Mr. Mullin. Thank you.
    Dr. Resneck [continuing]. Has been a really hard year for 
you and your family.
    Mr. Mullin. It has, but we have been very blessed. The Lord 
has been good to us.
    Thank you, I yield back.
    Ms. Kuster [presiding]. Thank you so much, Mr. Mullin, and 
thank you for your remarks. I think, as a rural member, I can 
certainly say this is a really important hearing.
    So, as chair, I will now recognize myself for 5 minutes, 
and I want to thank Chairwoman Eshoo for holding this hearing 
today. It is so important.
    In New Hampshire and rural States like Oklahoma, attending 
in-person treatment for substance use disorder can be a big 
challenge in and of itself due to our weather and geography and 
lack of access to transportation, work obligations, child care, 
and all the rest. And that was before COVID-19.
    So, when the coronavirus added yet another barrier to 
addiction to mental health treatment, our behavioral health 
providers transformed their delivery of care to ensure that 
they could continue to provide critical treatments while this 
country battles two epidemics, the opioid crisis and COVID-19. 
This was made possible by flexibilities during the pandemic, 
and I am so grateful for this discussion to highlight these 
measures and provide a framework as we look ahead to expanding 
access to care through telehealth post-COVID-19.
    I have heard from treatment providers, addiction treatment 
providers, who emphasize how telehealth has in many ways 
resulted in greater appointment attendance, fewer 
cancellations, and more patients arriving on time.
    Dr. Mehrotra, you and your colleagues at RAND recently 
released a study examining transitioning to telemedicine for 
opioid use disorder treatment, outlining how buprenorphine 
prescribers quickly transitioned to provide telemedicine 
benefits--visits. Could you please describe how the current 
flexibilities around prescribing medication-assisted treatment 
has actually improved access to care?
    Dr. Mehrotra. Congresswoman Kuster, thank you for the 
question. And the study that we did was looking within the 
pandemic for treatment of opioid use disorder, and I think that 
is a real success story, and a feel-good story that, in the 
context of the pandemic, patients who were in treatment were 
able to use telemedicine to access care, stay on their 
medications, and get the appropriate care and not go back to, 
unfortunately, using opioids again. So that is a real success 
story from the work we have done.
    And through the SUPPORT Act, post the pandemic, that is 
going to be accessible to folks.
    I think there has been some frustration with the changes 
that have been asked for--the Ryan Haight Act--to allow all 
providers to prescribe Suboxone and other medications for 
opioid use disorder and have that flexibility so it can be done 
via telemedicine. And I think that is a key area for us to 
provide that flexibility so we can provide that treatment in 
New Hampshire and the rest of the Nation.
    Ms. Kuster. Well, I think it is so important.
    Now, you have mentioned that several of the participants 
were hesitant to see new patients, and that is concerning. What 
can be done to encourage greater uptake among providers who 
might be hesitant for using some of these new flexibilities, 
and especially for new patients?
    Dr. Mehrotra. So I think we have been surveying and talking 
to a lot of opioid use disorder providers, and there is wide 
variation in how comfortable they feel.
    One thing that we have called for is--this is more not on 
the congressional side, but on the clinical side--to create 
guidelines among the treatment community so that people feel 
more comfortable that this is a reasonable way to treat opioid 
use disorder. And I think that is going to be the key to 
convincing providers to move in that direction.
    Ms. Kuster. OK, great. Thank you. Thank you so much.
    I wanted to question you about flexibilities allowed for 
opioid use disorder treatment providers in providing telehealth 
across State lines. So New Hampshire is a small State with a 
lot of State lines: Vermont, Massachusetts, Maine. And I would 
love to get your thoughts on delivering telehealth across State 
lines to some of our most vulnerable, including addiction and 
mental health patients.
    Dr. Mehrotra. Right. So, in New Hampshire--we are very 
close by, obviously, where I am. And it is difficult in many of 
those communities to find an opioid use--to get treatment, and 
providing that flexibility across the Nation. And we do see a 
number of private companies that are providing very innovative 
new models to expand the use of telemedicine, and they can work 
across all 50 States, so people can have that access.
    And, as I articulated before, the keys to providing that in 
New Hampshire and the rest of the Nation are licensure reforms, 
so that we can make that easier for those providers to do so, 
as well as--as I think all of you know, and it is a really key 
aspect of this committee--which is broadband expansion. It is 
very frustrating in 2021 that so many Americans don't have 
access to that necessary technology.
    Ms. Kuster. Well, absolutely. And you have read my closing 
remarks, which are about exactly that. In places like northern 
New Hampshire, my district, Coos County, broadband is very 
limited in the western part of our State, and the successes of 
telehealth are only as great as the access to the digital 
infrastructure.
    And so, lastly, I just want to submit for the record a 
recent report from Dartmouth-Hitchcock on telehealth as a tool 
for rural health equity.
    [The information appears at the conclusion of the hearing.]
    Ms. Kuster. And with that, I will yield back. And, as 
chair, I will now recognize Representative Dunn for 5 minutes 
of questioning.
    Representative Dunn?
    Mr. Dunn. Thank you very much, Chairwoman. I appreciate 
that. Let me say I am enjoying this discussion about the future 
of telehealth, and I appreciate hearing all of the thoughtful 
views of our panel of witnesses.
    You know, among the myriad ways which COVID-19 pushed the 
limits of our health system, telehealth expansion was a bright 
spot in that mess. Obviously, it means treating our patients 
and meeting our patients where they are. And I too have a large 
rural district, Florida 2, and telehealth expansion during the 
public health emergency enormously facilitated access to care 
for some of my most vulnerable constituents. Telehealth is 
helping Americans stay in touch with their healthcare, while so 
many other aspects of life have been put on hold.
    I do think audio-only telehealth has to remain a backup 
option. Many of the most rural of my constituents lack reliable 
Internet access or, in some cases, the ability to employ video 
technology. And again, I would say who among us has never 
struggled with video conferencing?
    I continue to be extremely concerned about the medical care 
that was foregone during the pandemic and quarantine, and what 
that is going to mean for everyone and for everything, from 
cancer screening to management of chronic disease. I am 
encouraged that telehealth offers the opportunity to bridge 
some of those gaps that are occurring.
    We had a great case right here at Children's National 
Hospital, a place where I trained many years ago, who was able 
to--they were actually able to virtually see the family a day 
after a very concerning newborn screening. And the family 
didn't have a car, no care for their other children. And 
instead of having to wait for answers, they saw a physician the 
very next day and started to build a care plan--virtually saw a 
physician, and the physician even had a Spanish translator on 
the call. So that is a model for timely care and coordination 
that we absolutely want to continue in the post-COVID world.
    I want to focus my questions and also offer my support for 
exploring ways to expand the use of remote patient monitoring 
technologies. We have made some mention of that during this 
discussion. Remote patient monitoring can offer physicians 
improved abilities in postoperative management, chronic disease 
management, a lot of tertiary benefits there, and even if it 
just triggers a phone call, you know, because something in 
monitoring technology indicates that, or it is not sending 
anything in.
    So, in that vein, Ms. Mitchell, I would like to start with 
you. Remote patient monitoring, I think, can help these issues 
of no-shows, missed appointments. I think it can ultimately 
decrease the cost of chronic disease for--managing that for 
patients. It reduces frequent flyer ER visits, and it is an 
almost office-style care without exposure to communicable 
diseases.
    I know there are detriments in the physical examination and 
testing remotely. Technology continues to get better. But is 
there data now to determine the degree to which remote patient 
monitoring can generate savings?
    And how should we be thinking about accounting for the cost 
and the savings in regard to remote patient monitoring?
    Ms. Mitchell. Well, thank you for the question. I 
completely agree, this--telehealth will enable much more 
innovative and patient-friendly models of care in the home, in 
the community. But we do need to remove the payment barriers to 
that.
    I wanted to add, in our research we survey over 40,000 
patients a year on their patient experience in California. And 
I--to your point about audio versus audio-visual, the 
satisfaction across both methods was the same. People do 
appreciate both, and we can share those results with you if you 
are interested.
    We don't have any data that I am aware of that quantifies 
the savings from telehealth at this point. Again, we do believe 
if it is deployed correctly and, again, used to avoid 
unnecessary hospital visits or ED visits, we believe there are 
significant savings.
    We ran a Federal--federally funded program in California 
with small practices for several years. And we found that, by 
working with those practices, utilizing telehealth, utilizing, 
you know, new methods of monitoring patients, we saw 
significant total cost reductions and better outcomes. So we 
think we can extrapolate that, but we do believe there is more 
research needed on the outcomes and cost.
    Mr. Dunn. So we are running out of time, but I do think 
this is a terrific aid to practice. I think it can--it is a 
leverage for more--access to more patients.
    I am going to be submitting some questions in writing, 
since we are out of time here. And with that, Madam Chair, I 
yield back.
    Ms. Eshoo [presiding]. The gentleman yields back. It is a 
pleasure to recognize the gentlewoman from Illinois, Ms. Kelly, 
for her 5 minutes of questions.
    Ms. Kelly. Thank you, Madam Chair. I thank the committee 
for bringing us together to discuss the future of telehealth. 
And I thank the witnesses for being here today.
    States play an essential role in licensing providers and 
ensuring that providers practicing in the State are in good 
standing. During the pandemic, many areas experienced increased 
demand for providers and, in response, States moved early on to 
loosen or waive licensure requirements so that out-of-State 
providers could support areas overwhelmed by COVID-19.
    However, even prior to the pandemic, many States partnered 
on licensure issues. Dr. Resneck, can you discuss what States 
have done before and during the pandemic to increase care 
across State lines?
    And also, should States improve Medicare plans--should 
States improve Medicare plans--can contribute to creating an 
unequal system in healthcare delivery?
    Dr. Resneck. Congresswoman, thanks for the question, and 
thanks for your leadership in maternal health and health equity 
on that front. We look forward to continuing to work together 
on that.
    Ms. Kelly. Definitely.
    Dr. Resneck. You know, there are a couple of things that 
help us with some of these licensure issues. So one is a thing 
called the interstate compact, which actually makes it easier 
for physicians who are in good standing with their own State 
medical board to get licensed in multiple States. It is a new 
thing and already we have, in the last few years since it has 
gone live, 30 States, the District, and Guam have all signed 
on. We have got six or seven States that are considering 
legislation.
    So it essentially--once you are licensed in one place, you 
can very easily check boxes on a form to get licensed in 
multiple other places. We would like to see the fees go down 
for that. I think that would be an improvement.
    I think I also recognize that State medical boards do need 
some ability to create unique local reciprocity solutions 
around State border areas. And we have supported local 
reciprocity of licensure as long as, again, fundamental 
safeguards are met around the site of service being where the 
patient is located.
    There is one more thing which people may not be aware of, 
which is there are a set of codes that CMS has approved called 
interprofessional codes that also--sometimes when I get 
consulted about a patient in a States where I don't have a 
license, where it wouldn't be responsible for me to take care 
of the patient and assume care and do all the prescriptions and 
everything else, because maybe I wouldn't be available if 
urgent things came up or side effects came up, I do what is 
called an interprofessional consult.
    So there are codes that actually recognize my doing the 
consult with them and their primary care doctor, or them and 
their specialist, where I give advice and thought and consult 
on the case, but the responsibility for the daily care remains 
local. And so that is another opportunity we have to work on 
the interstate issue.
    Ms. Kelly. And let me just ask my question again. Can you 
expound on how our already unequal system is made worse by the 
way these virtual services are provided?
    And how can we address and remedy these inequities in 
virtual services provided through Medicare?
    Dr. Resneck. Oh, so sorry I missed that, the broader issue 
of disparities.
    I mean, I think the last year has actually ameliorated some 
of that. So we have talked about broadband issues today. That 
definitely affects patients of color, low-income patients more 
than others, and that still needs a substantial amount of work.
    But in the old--before, we had this irony where it was 
largely wealthier patients who were able to use the convenience 
of telehealth, where many of our minority and other 
disadvantaged patients weren't. And so, by fixing this Medicare 
issue, I think we will go a long way towards helping us work on 
health equity. Is that what you were asking about? OK.
    Ms. Kelly. And I look forward to continuing to work with 
you. Thanks for all of your partnership. We really appreciate 
it.
    And with that I yield back with an extra minute.
    Dr. Resneck. I hope we can get the MOMS Act passed.
    Ms. Kelly. Yes.
    Dr. Resneck. Mortality issue.
    Ms. Eshoo. Absolutely. The gentlewoman yields back.
    It is a pleasure to recognize the gentleman from Utah, Mr. 
Curtis, for your 5 minutes of questions.
    Mr. Curtis. Thank you, Madam Chairman. And what a very 
interesting hearing. As I have listened, it is clear to me that 
there is broad consensus that we have something very important 
here. I like that it is bipartisan.
    I have been impressed with the depth of knowledge from the 
members who have participated in this community, everything 
from personal experience, Representative Mullin, to our 
constituents. It seems to impact every single one of us. And 
many of us have talked about the impact on rural parts of our 
district.
    We have been fortunate in the sense that we have had this 
opportunity as we have gone through the pandemic to try things 
we might not have otherwise tried. And it occurs to me that 
most of us can see intuitively a lot of good things. But there 
is also a strong sense, as I have listened to the Members, for 
more data, for more information, for worry about abuse, worry 
about fraud.
    And I have introduced a piece of legislation that, Dr. 
Mehrotra, I would like to ask you about. It is called the 
COVID-19 Emergency Telehealth Impact Reporting Act. I am really 
pleased that it has some really good, strong bipartisan support 
from members of this committee. In essence, it would require 
the Federal Government to collect and analyze telehealth data 
from the pandemic.
    And Doctor, it seems, like, almost so obvious that it would 
be a rhetorical question, but I want to ask it, particularly in 
light of other options, which is, How important is it for the 
U.S. Department of Health and Human Services to work with 
Congress to obtain better telehealth data?
    And maybe contrast that to academia or, you know, to 
industry that would be also looking for data. But what is the 
role here for us, here in Congress?
    Dr. Mehrotra. Representative Curtis, as a researcher who 
studies telemedicine and does exactly what you are describing, 
this is obviously of great interest, and I think, really, 
critically important.
    And in terms of--I would definitely agree that we need more 
data, both on what is happening during the pandemic--myself and 
many others are studying that right now--but also in that 
postpandemic period, hopefully very soon, where we can start to 
see how things get into more of a steady state.
    One thing that I might emphasize where I see a real 
weakness and that Health and Human Services could act is in 
Medicaid. It is a real area where it is such a critical aspect 
of the U.S. healthcare system, yet we don't have as much data 
right now that people are looking at, in terms of what has been 
the impact of telemedicine in that patient population.
    Mr. Curtis. So that is great. I would also like to kind of 
get your thoughts on the metrics. What metrics should we be 
using to determine if we make a lot of these things permanent?
    What--you know, in your community, what metrics would you 
like to have available to you that would help us make better 
decisions?
    Dr. Mehrotra. I think the key here is obviously--and the 
thing that we are all hopeful of--is that telemedicine will 
improve health. And so I think that would be the metric that I 
would love to look at.
    In a paper we just looked at yesterday--or published 
yesterday--we found that roughly a third of U.S. hospitals have 
now introduced telestroke, and that is leading to decreased 
mortality. And that is the kind of work that we really want to 
demonstrate across many areas of telemedicine.
    The only other--you know, the similar measures of patient 
satisfaction, and whether physicians and other clinicians are 
following those guidelines is also a really key aspect, as we 
assess the impact of telemedicine across these different areas.
    Mr. Curtis. Could you weigh in on just the little bit of 
time that we have left on not only this, but behavioral 
telehealth and total medication-assisted treatment?
    And how do we, you know, capture this opportunity for cost 
savings?
    Dr. Mehrotra. Yes. No, I think in the area of, say, opioid 
use disorder or other substance use, how long patients are in 
treatment is going to be the key aspect of that.
    And then, in terms of looking at--the hope would be--is 
that if we can control--address the people's substance use 
disorder better, they won't end up in the emergency department 
or will have further complications. And those are the types of 
metrics that we can look at.
    Mr. Curtis. Excellent. Thank you. I have got just a moment 
left and didn't want to ignore some of the other witnesses. I 
don't know if you have any comments. If not, I will yield my 
time back. But do any of the other witnesses want to comment on 
those questions?
    Ms. Mitchell. Hi, I just wanted to let you know that we 
will have early data on patient experience using telehealth for 
the Medicaid population this spring. We are happy to share that 
with you.
    Mr. Curtis. Thank you, that is awesome.
    Madam Chair, I yield the balance of my time.
    Ms. Eshoo. The gentleman yields back. It is a pleasure to 
recognize the gentlewoman from California, Ms. Barragan.
    Ms. Barragan. Thank you, Madam Chairwoman, for this very 
important hearing. It has been really great to hear all the 
conversation about telehealth.
    This is something I am quite new to, and I represent a 
district that is majority minority, very working class, and, 
frankly, hadn't heard a lot about telehealth. And when COVID 
hit, my own mother had to have a telehealth visit.
    Now, the problem was, number one, my mom doesn't have any 
technology that has video. She has a flip phone and can hardly 
answer that phone. And so it became a challenge to make sure 
that somebody either took the day off or was able to go over 
there to make sure that she had video access. And she still has 
an old-fashioned landline. And so, for me, this was happening 
in my backyard with my own mom. I thought to myself, How often 
is this happening to constituents of mine who don't have that 
similar access, or older Americans who are having the same kind 
of access?
    And so I know that community health centers have also moved 
to telehealth to make sure that they are providing safe access 
to care for constituents. And something--in my district 
community health centers are still very key.
    Many of the providers are still offering over 50 percent of 
their care via telehealth. Now, my concern is the equity 
issues, and making sure underserved communities are not left 
behind and having access adequate to technology, and think that 
it is only going to help provide access to care.
    So, Dr. Mahoney, you have discussed this, but I just want 
to, you know, get more of your thoughts on this issue, on what 
we can do to make sure, you know, underserved communities are 
not left behind. There is certainly a benefit here for those 
who don't have access to transportation to be able to get that 
telehealth. But, you know, on the broadband issues and access 
to technology, what you think Congress should be keeping in 
mind when we are doing all we can to keep telehealth but also 
making sure that there are going to be instances where maybe a 
telephone for some time is going to be the only available 
means.
    Dr. Mahoney. Thank you, Congresswoman Barragan, and thank 
you for the question. And also thank you for sharing the story 
about your mother. I think that that scenario does reflect a 
large number of the patients I see. And throughout my career I 
have been a telehealth provider, and I have seen firsthand the 
ways in which we can make tremendous progress using the phone 
alone.
    And so, when we think about the medical decisionmaking that 
is required, the clinical effort on the part of the 
practitioner that is required, that should be reimbursed and 
compensated in the same way as we reimburse and compensate for 
other modalities of care. So I think that that would be 
something that we should keep in mind.
    The other is, as we have already mentioned, is the 
expansion of broadband access to all communities, so that all 
communities can enjoy the benefits that come along with that 
technology. So, in the circumstances where a video is feasible, 
maybe going to that first but having the phone as a vital 
backup so that we can ensure access to care. I think we have--
already have heard from many of our panelists, and I share the 
sentiment as well, that tremendous, high-quality care can be 
provided by audio-only means and should be reimbursed 
accordingly.
    Ms. Barragan. Great. Thank you, Doctor.
    Dr. Resneck, my next question is directed at you. At the 
beginning of this Congress, I reintroduced the Improving Social 
Determinants of Health Act. This is legislation that would 
empower public health departments and community organizations 
to address social, economic, and societal barriers to health 
access in underserved communities. The COVID-19 pandemic has 
underscored that internet connectivity is a social determinant 
of health. Dr. Resneck, can you discuss ways community 
organizations and community healthcare providers are leveraging 
telehealth to address social determinants of health?
    And how can Congress better support these efforts?
    Dr. Resneck. We really need everybody on the team helping 
with particular disadvantaged and minoritized patients that we 
can get involved in their care. And broadband has been an 
issue. Getting the previous grants that were out there for 
broadband expansion renewed would be great.
    You know, I think about the individual patients that I see 
who are coming from those areas with no broadband, and it is--
still, it is unbelievable sometimes to me that--the lack of 
broadband that they face. Last night, after clinic, I was 
talking to some of my colleagues in the hallway and just asking 
them about cases, telling them I was going to be doing this 
hearing.
    And one mentioned a farm worker from rural northern 
California who has a condition called scleromyxedema, where 
their hands and face thickened. This guy could no longer make a 
fist and do his work and could not put the apples that he was 
picking in his own mouth. It is a really terrible condition. We 
admitted him to the hospital, got him treated. He got back 
home. We were able to coordinate a month's worth of his care. 
And using that whole team and his community of local 
physicians, local nurses and PAs and community workers and 
others to help coordinate his care, he is now doing great.
    But we do find ourselves sometimes doing this audio visit 
with a patient who is literally on break in the fields, or who 
is literally a frontline grocery worker between shifts, or who 
lives on an indigenous reservation with no internet, or who has 
to get on a bus in the midst of COVID to come and see us, all 
of which are difficult.
    So the broadband issues are tremendously important for us 
to continue to be able to provide telemedicine to those 
patients.
    Ms. Barragan. Well, thank you, Doctor, for sharing.
    And with that, Madam Chairwoman, I see our time has 
expired. I yield back.
    Ms. Eshoo. The gentlewoman yields back. I really think that 
our--the public healthcare systems, Medicare, Medicaid should 
be sending something to the beneficiaries in both of those 
systems and just ask the simple question, ``Do you have access 
to broadband?''
    We don't even know what we are talking about. We--well, we 
do when we give the stories, as Ms. Barragan did, her own 
mother. That story is replicated in inner cities, in rural 
areas in the country. And--but we have no yardstick by which to 
measure this by. So I--the committee, obviously, is going to 
have to do something about that. But I can't help but think 
these agencies should be informing us so that we can build on 
good data. And it seems to me that Dr. Mahoney and others are 
doing that.
    Wonderful to recognize the only pharmacist--are you still 
the only pharmacist in the House?
    Mr. Carter. No, we have another one now. We have two now.
    Ms. Eshoo. But we don't know who that----
    Mr. Carter. She is much better looking.
    Ms. Eshoo. Let's put it this way. The only pharmacist on 
the Health Subcommittee----
    Mr. Carter. There you go.
    Ms. Eshoo. Yes, the gentleman from Georgia, Mr. Carter.
    Mr. Carter. Thank you, Madam Chair. I appreciate this. And 
I appreciate all the panelists being here today.
    You know, at some point, when this pandemic ends--and it 
will end--at some point, people are going to list the silver 
linings. They are going to list the things that were good that 
came out of all this. And there are good things coming out of 
this. And one of those, at the top of that list, is going to be 
telehealth.
    You know, we have heard that there has been 10 years of 
progress in 1 week in telehealth. In fact, prior to the 
pandemic, there were roughly 13,000 telehealth appointments per 
week. Yet we have seen an increase during the pandemic. And 
even a few months after the pandemic started, we saw it go up 
to over 3,000 percent of that. Unbelievable, what has happened 
with telehealth. We knew it was there, and I had been looking 
at it for years. But this was the opportunity for us to really 
see it flourish. And I just--I think it has been great, and I 
think it is going to be even better and an important part of 
our healthcare delivery system.
    The benefits are endless, there is no questions about it. 
Patients with comorbidities were able to continue to get care 
without having to be physically present with the physicians. 
And we have seen it, and I have seen it work. I saw it work 
even before that, but we have all seen it work now, during this 
pandemic. And it truly has been part of the silver lining, 
again, that we have noticed.
    Dr. Resneck, I wanted to ask you. In your testimony, you 
discussed that Congress should make the telehealth 
flexibilities from the pandemic permanent. But I hear others 
say, well, we need more data, we need more research. Yet we 
have got a year's worth of data collection and tens of millions 
of telehealth visits that provide us the data to review the 
success of expanded telehealth services. In your opinion, is 
that enough, what we have experienced thus far?
    Dr. Resneck. Yes, these are not new services we are 
providing, and the data have accumulated exponentially in the 
last year, thanks to Ateev and other colleagues on this panel. 
So I think we have data to move ahead with making the expansion 
for visits permanent.
    I am all for continuing to study all of the subareas of 
telehealth because we, as physicians, are going to learn from 
that and continue to learn what things are best done by 
telehealth and what things we need to see a patient in person 
for. But that is really at the standard of care level, and not 
the coverage level. So I think we have got a lot of data, and 
we are ready to move forward.
    Mr. Carter. Would you agree that it has increased access to 
care, as well, particularly in minority communities, even?
    I represent south Georgia, which--you know, we struggle a 
lot with rural broadband. And that is certainly something that 
we are addressing in this committee, as well, and certainly 
something that needs to be addressed. And there is no better 
example, obviously, than our educational system, but also with 
our healthcare system, with telehealth.
    But it does--and it also decreases costs. So would you 
agree that it increases access, as well as decreases cost?
    Dr. Resneck. Clearly, it does increase access. There will 
be instances where it is cost effective and reduces costs. 
There are instances.
    You know, when I see a patient who comes to see me from a 
rural area, and they have something that I know I am going to 
need--it is going to be chronic, and I am going to be taking 
care of with them in partnership for quite a while, I feel 
really bad when I tell them they are going to need to sit in 
traffic and miss work and all those things to come back and see 
me.
    So, whether it is your constituents in south Georgia and 
their physicians or my folks in rural California, just having 
the option to know that it is covered for me to be able to pick 
which visits are most appropriate to see them via telehealth is 
a huge improvement to their access.
    Mr. Carter. And not only that, but, just as you are 
pointing out, it decreases health inequities because it 
increases access, it helps people who are disadvantaged--at a 
disadvantage because of various reasons, but some that you just 
stated right there.
    Dr. Resneck. It was this--we were in this very ironic 
situation, prepandemic, where there was a big, like, a growth 
in telehealth. But again, it was mostly--the fastest growth 
were in these direct consumer providers, which were for people 
who had spare money and could go online and just pay for it out 
of pocket. They got access. But people who paid into Medicare 
and had Medicare coverage, or many who had commercial 
insurance, couldn't follow up with their own physicians who 
knew them well.
    So this has been a great improvement, in terms of 
disparities, and in terms of patients'----
    Mr. Carter. So basically----
    Dr. Resneck [continuing]. Telehealth.
    Mr. Carter. Right. So basically, we have got the research 
and the data. We know that it increases access. We know that it 
decreases costs. We know that it decreases health inequities. 
To go back now, I think, would be a disservice to our citizens 
and a disservice to healthcare, in general.
    That is why I have--cosponsored a bill, along with one of 
my Democratic colleagues, the Telehealth Modernization Act, 
that essentially would make the flexibilities from the pandemic 
permanent. Common sense. We got the data, we know that it 
decreases costs. We know that it decreases health inequities. 
We know that it increases compliance and access.
    Dr. Resneck. Yes, we----
    Mr. Carter. A common-sense bill.
    Dr. Resneck. We strongly support it, and I know my Medicare 
beneficiaries that I take care of would be unhappy to have this 
access yanked away from them. So thank you.
    Mr. Carter. And once again, bipartisan that I am 
cosponsoring with another member of the--Lisa Blunt Rochester 
with--on the Energy and Commerce Committee, a bipartisan bill 
that we should all support. And I hope my colleagues will do 
that.
    And thank you, Madam Chair, for your indulgence.
    Ms. Eshoo. I thank the gentleman.
    You know, there is something else that the Members, if you 
don't realize this, when the waivers are no longer in place and 
we don't do something on this issue, it is only Medicare 
Advantage patients that will be able to receive telehealth 
services. Those that are enrolled in just straightaway Medicare 
will not be eligible. So we have got some work to do to make 
sure that no one falls through the cracks.
    Now it is always a pleasure, and we are all, I think--I 
know we are a better committee because she is a part of it, the 
gentlewoman from Delaware.
    Ms. Blunt Rochester, you have 5 minutes for your questions. 
And thank you for being here from the very beginning of the 
hearing.
    Ms. Blunt Rochester. Thank you, thank you, thank you, Madam 
Chairwoman, for the recognition and especially for your 
leadership on a topic that I think is transformational in our 
healthcare system. And because of the telehealth flexibilities 
granted under the COVID-19 public health emergency, physicians 
and health systems across the country have been able to rapidly 
scale up and deploy telehealth services.
    Dr. Resneck, a lot of questions have been asked of you, and 
there has been a lot of conversation with my colleagues Mr. 
Buddy Carter, Robin Kelly, and Nanette Barragan about just the 
waiver itself and the impact that it has had. And I was 
curious, number one, if there is anything else that you want to 
add about making it permanent.
    But also, you hinted at the impact that it would have for 
your patients, those Medicare beneficiaries, if they were 
abruptly to lose access to telehealth services. Can you talk a 
little bit about that?
    Dr. Resneck. Well, they have gotten comfortable with the 
technology. And I think, you know, they have a better 
understanding of when it is appropriate to use it, I have a 
better understanding of when it is appropriate to use it. And 
that partnership and trust has grown between us. So I would 
have a very hard time looking them in the face at the end of 
the public health emergency and saying, ``Sorry, we are done 
with all that. That is going away.'' So I feel really strongly.
    There are--you know, there are just so many side benefits, 
and many of them have come up today. We have talked about a lot 
of them. We haven't talked a lot about social determinants, 
even though we have talked about differences in access. And I 
never cease to be surprised about how much more I learn about 
my patients' lives that they are willing to share when I am on 
a video visit that just might not come up in my office.
    Ms. Blunt Rochester. Yes.
    Dr. Resneck. You know, I have colleagues who--
endocrinologists who take care of diabetes patients, where the 
patient might walk over and open up their fridge and put it on 
the video to say, ``Do you think I am doing the right thing 
with this, Doc, with the way I changed my diet?''
    You know, this is not a social determinants issue, but I 
had a patient with just constant dermatitis that wasn't going 
away, and wasn't going away, and they didn't have any pets, and 
we couldn't figure out what their allergy was. And they showed 
me the lovely foliage all down the side of their house, which 
was poison oak, and we solved their problem.
    So there are just so many things you don't expect for a new 
technology like this to be helpful with that you discover as 
you go. You also discover the situations where it is, like, 
``OK, it is not so helpful for this. You really need to come to 
my office. This is different.'' It has just been a wonderful 
learning year, and I have been so proud of colleagues all over 
the country who have implemented this so quickly and all of 
whom have, I think, learned a great deal.
    Ms. Blunt Rochester. Yes, I appreciate you sharing that. I 
actually have legislation on the social determinants of health, 
as well, and it is a big topic for our committee, and 
bipartisan, as well.
    Buddy Carter, as has mentioned, he and I both reintroduced 
the Telehealth Modernization Act that would permanently waive 
Medicare's geographic and originating site--for telehealth 
coverage for Medicare beneficiaries.
    And what you just talked about, in terms of the social 
determinants of health, goes right into the H.R. 1332, our 
bill, as well as others that we are working on for equity. 
Could you talk about just how this opportunity intersects with 
broadband, transportation challenges, and other things that 
both, whether you are rural or urban, might experience or face?
    Dr. Resneck. Yes, I mean, you have heard from several of my 
colleagues on the panel, this same idea that we just are 
constantly surprised by how many patients struggle with the 
broadband access. And I just was not aware, I think, until this 
year of how widespread an issue that is.
    And I thank you for bringing up the urban issue, because I 
think there is a sense that this is unique to people who live 
very far from an urban area and really is an issue of the rural 
parts of our country, where it is real, and it is a real issue 
for our rural citizens. But I have plenty of urban patients who 
simply can't afford broadband access or the devices that they 
need. And so, again, it is another reason for having backup 
audio-only for them and working to improve affordability for 
broadband access for those patients.
    Ms. Blunt Rochester. I was happy to hear a mention about 
Medicaid, even though it is a--slightly switching gears. But we 
know that close to 40 million children are enrolled in 
Medicare. And in my State of Delaware alone, 39 percent of 
children are in Medicaid or the CHIP program.
    And so Congressman Burgess and I reintroduced the 
Telehealth Improvement for Kids Essential Services Act, which 
is TIKES, H.R. 1397. And I would love to follow up in writing 
and ask the entire panel about how Congress can best support 
State Medicaid programs in their efforts to expand telehealth. 
And are there supports, incentives, and learnings--and I think 
it was Ms. Mitchell who talked about a report that is coming 
out. So we would look forward to hearing about that report, as 
well, and we will follow up in writing.
    And I yield back 1 minute of my time. Thank you, Madam 
Chairwoman.
    Ms. Eshoo. Well done. My goodness. The gentlewoman yields 
back. I now would like to recognize the gentleman from Texas 
for his 5 minutes of questioning, Mr. Crenshaw.
    Mr. Crenshaw. Thank you, Madam Chairwoman, and thank you to 
all of our witnesses for being here. If I am going, it means 
you are near the end, so great.
    This is a great conversation. There is a lot of consensus 
about the benefits of telehealth. And so the question is, How 
do we properly regulate it? I think this body tends to try to 
answer every question with regulation, whether that is through 
mandates, incentives, or punishments, or restrictions. And 
maybe there is a tendency sometimes to have 1,000 of them, 
right, to make sure that we have thought of everything. I tend 
to think that the opposite is true. I tend to think that simple 
rules for complex problems are the best approach. And so I will 
direct this to Dr. Mehrotra.
    What would--if you had to pick maybe a top five, or just 
two or three essential regulatory incentives, restrictions, 
mandates, whatever it is, what do you think we should be 
focusing on, as this body moves forward, to properly regulate 
this?
    Dr. Mehrotra. Yes, so the first part that I want to 
emphasize is that--that you sort of touched upon with your 
question, but I think it is really important--is that one of 
the barriers to providers using telemedicine has been just pure 
confusion. It is a very complicated landscape to try to 
navigate both Medicare, Medicaid, private insurers, State 
medical boards in five different States that you are providing 
care for, and that becomes a real impediment to providing 
telemedicine care. And it becomes, at least in our 
conversations with providers, a real deterrent: ``I just can't 
bother, it is just so confusing. How the heck am I going to do 
this and pay for it?''
    We have seen a lot of change in the last year, but I still 
think that that is a major issue, and something that I hope 
Medicare will kind of simplify a bit to make sure that it is 
easier for providers to bill.
    But you asked the question about--in terms of regulations 
and so forth. I mean, I think here--I think it is a real 
balancing act that we don't want too many different 
regulations. And so I have argued that we should try to limit--
when we are making limitations on telemedicine, to try to only 
focus on one dimension. I focused on the aspects of different 
diagnoses and conditions where there is cost-effectiveness data 
to support it, but I think that would be the place that I would 
focus.
    Mr. Crenshaw. OK, and I appreciate that answer. It is 
helpful, as we all go forward, right? There is always a balance 
of how much risk do you accept in the regulatory world. You 
know, some of us are more risk tolerant than others. I would 
love to dive down that rabbit hole for about an hour.
    But Ms. Mitchell, I want to ask you a question, because you 
mentioned a large employer is projecting 8 percent cost savings 
using telehealth. And if that is just one employer, any idea 
across all of your large members how much we would save in 
telehealth?
    And then the second part of the question would be, What are 
some of the best practices that you might suggest small and 
medium-sized businesses could use to incorporate telehealth 
and, more importantly, pass these savings on to patients?
    Ms. Mitchell. Well, thank you for the question. We haven't 
measured across our other employers, but again, we don't think 
8 to 10 percent is unreasonable. And, when they are 
collectively spending $100 billion a year, that is not an 
insignificant amount.
    I will remind you that our members are mostly self-insured. 
So those savings go back to them fairly immediately. And they 
are looking for ways to reduce the cost of healthcare for 
employees, waiving cost sharing, or lowering premiums, ideally.
    But again, the barriers that we are currently facing are in 
the payment model, and we have not seen commercial health 
insurance companies actually change payment that would enable 
more flexible use of resources, particularly for physicians. So 
we think that there is enormous potential here. We--and we have 
heard it supported by physicians, patients, and employers.
    So we would like to move this forward as quickly as 
possible, and we need both CMS and commercial health plans to 
enable that.
    Mr. Crenshaw. Well, can you expand on that, and on the 
payment models?
    Do you mean moving away from fee-for-service? Is that what 
you are referring to?
    Ms. Mitchell. Yes. And again, more flexible, prospective 
payments, particularly for primary care. We work directly with 
small, primary-care practices. They need to figure out how to 
enable teams to do this work or to connect with some of the 
community health workers. Current payment systems create 
barriers to doing that. They create barriers to giving optimal 
care.
    But right now, most health plans will only pay fee-for-
service. So we really need to move past that.
    Mr. Crenshaw. I am a big fan of direct primary care. I have 
introduced legislation to promote direct primary care, and I 
think direct primary care is deeply intertwined with 
telehealth----
    Ms. Mitchell. Agreed.
    Mr. Crenshaw [continuing]. As well. And it is--I think it 
is a perfect model for this. And I can go down a rabbit hole 
for an hour, but I only have 5 seconds left.
    So I yield back my 3 seconds. Thank you, Madam Chairwoman.
    Ms. Eshoo. Great job, Mr. Crenshaw.
    I am not so sure what the average reimbursement is for an 
appointment online, but I don't--this is not, I don't believe, 
an expensive part of healthcare. I mean, you know, surgeons are 
not operating on people while they are talking to them. So I 
don't think that is something to be really concerned about. 
There has to be a reimbursement, of course, but I don't think 
we need to make a bigger deal out of it than need be. At least 
that is my view.
    A new member to the committee, a wonderful addition, the 
gentlewoman from Minnesota, Ms. Craig, you are recognized for 5 
minutes.
    [Pause.]
    Ms. Eshoo. Are you there, after I said all those wonderful 
things about you? I guess you are not there.
    All right, another new member to our committee. Everyone 
is--each member is value added. It is Dr. Kim Schrier, 
recognized for 5 minutes for her questions.
    [Pause.]
    Ms. Eshoo. Are you there? You need to unmute.
    Ms. Schrier. You would think that, after this long in a 
pandemic, I would know to unmute. Thank you, Madam Chair. Thank 
you for that very warm introduction, and thank you to our 
witnesses.
    Telehealth is definitely here to stay. Docs love it, 
patients love it. And this pandemic has been devastating in so 
many ways. But the silver lining is that we have this real-
world data that shows that telehealth can strengthen provider 
and patient relationships, and maybe even improve care.
    Certainly in my family, my parents are 78 and 82 years old, 
and telehealth, over the last couple of months, has allowed me 
to join their medical visits, remember the things that they 
don't, ask the questions that they might not think of, clarify 
things, and then I even send them an email, summarizing the 
visit, and then giving the plans afterwards. And this has been 
an absolute godsend.
    Then myself, as a patient with type 1 diabetes, access to 
telehealth has been great. My doctor also has type 1 diabetes, 
so it reduces risk for both of us and keeps my health in good 
shape.
    And as a pediatrician, I hear from my colleagues that 
telemedicine has actually strengthened their relationships with 
their patients and enhanced care in many ways, because you can 
see kids kind of in their own--know what the environment is 
like at home, and get a better snapshot of developmental 
issues.
    But there is a lot that you can't do remotely, so I have a 
couple of questions. One--and my first one is for Dr. Mahoney.
    Just as a doc, I would send my patients to specialists. 
They would come back to see me. I would also get a note from 
the specialist. And oftentimes the two stories did not match 
up. And now that I am going through these health issues with my 
parents, I am just curious about whether you could take 
telehealth even a step further and have, say, the primary doc 
and the neurologist and the neurosurgeon and the interventional 
radiologist sort of all in the room together making a decision 
and coming up with a plan so everybody hears the same 
information. And so I was wondering if you could briefly 
comment on how that might improve medicine.
    Dr. Mahoney. Yes, thank you, Dr. Schrier, for the question. 
And as a fellow primary care provider, I really do resonate 
with your stories of the benefits of talking to caregivers who 
are doing heroic work for our senior population, taking into 
account work schedule, child care responsibilities. And then, 
also as a family physician, I do have the benefit of seeing 
children and watching their developmental milestones, and 
observing those within their home environment, which is a lot 
more helpful.
    So I--can you repeat the question, again? I am sorry, I 
lost----
    Ms. Schrier. I guess just, you know, do you see that as a 
possibility, where you could have multiple layers of 
specialists----
    Dr. Mahoney. Oh, right.
    Ms. Schrier [continuing]. In the room, all hearing the same 
story?
    Like, would that improve a care coordination, if you had 
everybody----
    Dr. Mahoney. Right.
    Ms. Schrier [continuing]. There at the same time?
    Dr. Mahoney. Absolutely. So there are models out there, and 
we have experimented with that in the inpatient setting and 
also in the outpatient setting, where we have video conference, 
multiple consultants, family members, also the patient. We do 
this in the inpatient setting when we want to have a family 
conference, if it is an end-of-life discussion, in particular. 
So that has been successful.
    The barrier is the coordination of scheduling of all these 
very busy individuals. And what is also helpful is asynchronous 
communication through the electronic health record. So that 
is--that has also been incredibly helpful, in also----
    Ms. Schrier. Oh, that is great.
    Dr. Mahoney [continuing]. Being able to----
    Ms. Schrier. Can I ask one more question? I wanted to--this 
one is for Dr. Mehrotra about pediatric care.
    You note in your work for the Commonwealth Fund there has 
been a 24 percent decrease in visits. There has been about a 30 
percent decrease in vaccinations. You can do some things really 
great in pediatric care with telemedicine, but other things are 
going to fall through the cracks. And so I was just wondering 
if you could talk about the good, bad, and the ugly with 
pediatric care, specifically. What are the wins? And where are 
the liabilities--we have some improvements?
    Dr. Mehrotra. Yes, one of the things that we--while there 
has been a big resurgence in visits in the United States and 
back to baseline, one big area that we haven't seen that is in 
pediatrics, and I think that is a combination of both good 
things and bad things.
    The good part, and the silver lining, is kids are less 
exposed to illnesses, and so we are seeing a dramatic drop in 
acute respiratory illnesses, colds, gastroenteritis, eye 
infections, and so that is the positive part. But, as you 
highlighted, Dr. Schrier, there is a real concern that there 
has been a real deficit in immunizations and preventive health 
visits. And so that is a key place that, as we come out of the 
pandemic, how do we make sure we catch up with those kids? And 
telemedicine could play a role there.
    Ms. Schrier. Thank you. I am going to add one more thing 
from experience. When Microsoft patients had to pay a copay to 
come see the doctor, they stopped coming in the first time 
their child sneezed. And so, as we talk about overutilization, 
sometimes just a little copay makes a big difference.
    Thank you, I yield back.
    Ms. Eshoo. I think money is always involved in just about 
everything in life.
    The gentleman from Pennsylvania, Mr. Joyce, is recognized 
for his 5 minutes of questioning.
    Mr. Joyce. Thank you, Madam Chair Eshoo and Ranking Member 
Guthrie. This is an important hearing, a topic of telemedicine. 
As a physician myself, I understand the increased telehealth 
services during COVID-19 has spurred substantial changes, 
positive changes in the delivery of healthcare.
    Last year, when in Congress we acted to provide the 
Secretary of HHS with additional flexibility surrounding 
telehealth, I don't think any of us envisioned the full impact 
that this would have. The pivot to telehealth has raised many 
new questions surrounding patient care access, rural 
availability specifically in broadband, and even privacy and 
security issues.
    I want to thank the witnesses for appearing today, and for 
answering our questions.
    Dr. Resneck, as another board-certified dermatologist in 
this conversation, you and I realize that derm is a very visual 
field of medicine, and visual access to patients is sometimes 
all that is necessary for an evaluation, diagnosis, and 
treatment. But this isn't always the case with all 
subspecialties, specifically surgical subspecialties, which our 
Chair Eshoo talked about, that surgeons aren't going to be 
doing these procedures via telemedicine, but also in 
obstetrics. Do you see any long-term consequences for these 
fields, given the shift that we all know is occurring to 
telemedicine?
    Dr. Resneck. Thank you, Doctor, Congressman Joyce. So I 
think every specialty has found its places where telemedicine 
can be useful.
    So you mentioned surgeons. I have surgical colleagues who--
their patient gets discharged from the hospital, lives a couple 
hours away, and maybe they do a post-op visit via telehealth. 
So, you know, every specialty is figuring out this--OK, this is 
where telehealth does not work for me, and this is where it 
does.
    You know, you and I are both dermatologists. Sometimes a 
still image can be way more useful than a blurry video for us. 
So we are--you know, I am grateful that we have a variety of 
codes to use, including the e-visit codes, where a patient can 
upload really high-quality photos into my EHR portal for me to 
look at. So I think having a variety of tools at our 
fingertips, the continuation of every specialty figuring out 
where this is useful and isn't, is going to bring us to a place 
of ongoing progress here.
    Mr. Joyce. I certainly enjoyed hearing about your treatment 
of the patient with scleromyxedema, knowing how complex with 
the cardiac and pulmonary, that you required ultimately that 
that patient be brought in hospital for ultimate care. But your 
ability to keep that patient working is significant.
    I also wanted to address another issue that I think is 
important, and that is the training of residents and medical 
students in telehealth. And I will ask the physicians on the 
table at this conference.
    Dr. Mahoney, do you think that that should be integrated as 
part of training, both to medical students and to residents?
    Dr. Mahoney. Thank you, Congressman Joyce. This is an 
excellent question. I wholeheartedly endorse and am 
enthusiastic about integrating telehealth and more modern 
modalities of care into the training of medical students and 
our residents. We really do need to prepare for the next 
generation of providers, and we need to ensure that they are 
empowered with all of the knowledge to do so effectively.
    We have been training our residents. We have been bringing 
them in, either in the visit that we have with the patient 
directly, so they can observe--they are able to see patients 
directly, we can conference in as attendings and observe--and 
then they can also have one-on-one appointments with their 
patient, and then present to us later, depending on their level 
of training. But absolutely, I endorse that recommendation.
    Mr. Joyce. Dr. Mahoney, do you recommend this as a 
requirement to complete residency training?
    Dr. Mahoney. You know, I am not an expert in that field, 
but I am very enthusiastic about that, that idea, absolutely.
    Mr. Joyce. Dr. Mehrotra, would you weigh in on this, as far 
as medical students and residency requirements in telemedicine?
    Dr. Mehrotra. You know, I think it is a key point, and it 
is already happening--let's be clear--just because all--as you 
know, residency is often an apprenticeship. You follow 
attendings around, and you see their care that is being 
provided. And, as all of healthcare has moved to telemedicine, 
I am seeing so rapidly how education is moving in that 
direction. So I am very enthusiastic and excited about how the 
future will incorporate telemedicine in training.
    Mr. Joyce. Thank you all for being present.
    And Madam Chair Eshoo, I will return my remaining 12 
seconds.
    Ms. Eshoo. Well, I thank you, Doctor. You raised a very 
important, wonderful point, just as we were kind of winding 
down in the hearing and we think that we have covered all the 
corners and then some. And you raised the point about training. 
So good for you. See what each person brings to the committee? 
It is really wonderful.
    I think Ms. Craig--has she returned? Yes.
    It is a pleasure to yield to you 5 minutes for your 
questions, the gentlewoman from Minnesota, Angie Craig.
    Ms. Craig. Thank you so much, Madam Chair and Ranking 
Member, and thank you to all of the panelists who have been 
here for so long today.
    I know that each one of us shares the goal of ensuring that 
our constituents can safely and affordably access healthcare, 
and, of course, virtual care, telehealth, has been just a 
critical, critical piece of this during the COVID-19 pandemic.
    I am particularly encouraged by the potential for 
telehealth and virtual healthcare to expand access to mental 
health services in rural parts of my congressional district and 
to help alleviate a provider shortage for so many communities, 
including my own. In 2017, rural areas in Minnesota had only 
one licensed mental health provider for every 1,960 residents 
while my metro areas had one mental health provider for every 
340 residents.
    As others have noted, one of the silver linings of the past 
year has been the adoption of telehealth, virtual healthcare, 
for mental and behavioral healthcare. One telehealth vendor in 
our State saw an over 300 percent increase in visits to their 
behavioral health platform last year. Telehealth for mental 
healthcare has also shown great promise for, especially, our 
Medicare beneficiary population, who might otherwise feel 
stigmatized or have other limitations preventing them from 
seeking out care in person.
    I want to start with Dr. Mehrotra.
    You have highlighted that telehealth could lead to the 
potential for overuse of care. HRSA has designated the majority 
of the U.S. as health professional shortage areas for both 
primary and--primary care and mental health. And the same, of 
course, is true in my district. In your view, how do we best 
expand the reach of our existing healthcare workforce, 
especially for services like mental health, behavioral 
healthcare, and, at the same time, balance the appropriate use 
of care and guard against overuse?
    Dr. Mehrotra. I think that first, Representative, I just 
want to highlight I think what many of you know, that if we 
were to look at rural areas of the United States versus urban 
areas, and we look at how much care patients are getting, it is 
much lower often in rural areas, in particular for specialty 
care. And that is why there has been so much of a focus on 
telemedicine to increase access there.
    One other point that we haven't really addressed here that 
I thought might be important is that States are also under a 
quandary of how do we address this balance of increasing access 
but addressing this overuse. And so a number of States have 
said, you know what, we don't have enough data from the 
pandemic, it is such an unusual time in our lives, and that 
they will extend temporarily telemedicine expansion for 1 to 2 
years afterwards, and use that as a period of time to try to 
understand what the impact is and whether this overuse concern 
is valid. So I wanted to highlight that point.
    Ms. Craig. It is an incredibly important point, and I think 
you are exactly right. As we look at this, we are going to need 
an additional level of research on what is appropriate and for 
how long for each particular healthcare action.
    My next question is for Mr. Riccardi.
    You discussed the digital divide in your testimony, and 
many of our districts, including mine, lack full access to 
broadband. A recent study published in Health Affairs found 
that telemedicine and overall outpatient access during COVID-
19, of course, were lower in rural than urban areas. The 
authors theorized the difference could potentially be 
attributed to limited broadband availability in rural areas. I 
could tell them that is probably true.
    In expanding access to telehealth, what additional policy 
tools do you think Congress should consider to address this 
digital divide and ensure that health services reach these 
underserved communities?
    Mr. Riccardi. Yes, thanks for your question. I am concerned 
about the regional variation. We still only have early 2020 
Medicare claims data, and that information has not been 
publicly released, and physicians still have additional months 
to submit that data. But early we know that about 30 percent of 
beneficiaries who receive telehealth services were located in 
urban areas, and 22 percent of beneficiaries were in rural 
areas. So there is that discrepancy there.
    Earlier, you know, you had mentioned, you know, concerns 
around affordability. As we think about expanding Medicare 
telehealth going forward, it is also important to consider the 
types of facilities that people can receive care from, 
including community-based clinics is particularly important. 
And, as the CMS releases this data and it is analyzed by 
researchers, we should be looking at what impact the cost-
sharing waivers that have been in place have had on the 
utilization of services. And we recommend that there is 
standard cost-sharing applied both to telehealth services and 
in-person services to create parity, to avoid incentivizing one 
form of care over another.
    And then, as we consider finances, we should look towards 
CMS's current telehealth payment schedule for the starting 
point to determine what is the appropriate payment for 
telehealth versus in-person care, not only looking at the 
emergency waivers.
    Ms. Craig. Thank you so much. And there's about a million 
questions for follow-up that calls for. But, sadly, I am way 
over my time.
    So, Madam Chair, I will yield back.
    Ms. Eshoo. The gentlewoman yields back. Now I would like to 
move to Members that are waiving onto the subcommittee.
    To the witnesses, these are members of the full Energy and 
Commerce Committee, and we always extend the legislative 
courtesy to any of our Members that would like to join our 
subcommittee for questioning. The only thing is that they have 
to be--they have to wait, wait, wait, and be taken toward the 
end of the hearing. Nonetheless, they all count.
    And the Chair is pleased to recognize the gentleman from 
Ohio, Mr. Latta, for 5 minutes of questions.
    Mr. Latta. Well, I thank the chair, my friend, for holding 
this very important hearing today and for allowing me to waive 
onto the subcommittee.
    You know, we are approaching 1 year since the way Americans 
lived, worked, and learned all changed due to the outbreak of 
the COVID-19 global pandemic. We have seen how quickly the 
virus has spread through our communities. The response to the 
pandemic--action was taken by the Trump administration. Thanks 
to the leadership of the President, telehealth services have 
really expanded to provide care and assistance to the most 
vulnerable at a distance.
    Even with these efforts, I have had numerous constituents 
contact me with concerns regarding the lack of access to 
telehealth services. Whether it is related to issues with 
broadband connectivity, electronic appliances, or a lack of 
available care, it is clear that more needs to be done.
    Early in the pandemic, students in my district who were 
receiving higher education were abruptly notified that they be 
required to return home, even if it meant traveling long 
distance in and out of State. This severed relationship with 
campus-based mental health providers during a stressful time.
    In addition, people fighting cancer and other rare 
conditions weren't able to travel safely for care due to 
lockdown protocols.
    Because of the concerns, I introduced the TREAT Act, along 
with my good friend and colleague, the gentlelady from 
Michigan, Mrs. Dingell. This bill would establish temporary 
reciprocity at the State level for a provider in good standing 
to virtually see patients during the COVID pandemic. With 
only--groups representing patients, physicians, universities, 
health systems, employers, and many others, this bill would 
alleviate the overall healthcare professional shortage we are 
facing and provide immediate relief to providers and patients.
    I address my first question to you, Dr. Mahoney. In light 
of the immense stress and pressure that has been placed on our 
hospitals and mental health providers and addictions 
counselors, do you believe that temporarily waiving State 
licensure requirements would help ensure that patients can 
receive the quality care they need?
    Dr. Mahoney. Thank you, Congressman Latta. I--we believe 
the TREAT Act is a step in the right direction that will ensure 
continuity and access to care for patients nationwide during 
this pandemic. The issue of specialty care access and 
behavioral health access across State lines will last beyond 
the pandemic. And so we encourage, as well, the re-evaluation 
of the system with that in mind.
    And so we are excited about potentially enabling providers 
who are licensed in good standing to treat patients at any 
State, and they can require, you know, oral and written 
acknowledgment of services, require notifying State and local 
licensing boards within 30 days of first practicing in another 
State. And many of the other parts of the TREAT Act make a lot 
of sense. We definitely believe this is a step in the right 
direction.
    Mr. Latta. Well, let me follow up. In your experience, 
could you share any examples of licensure challenges faced by 
Stanford's providers and why the current patchwork of State 
laws is making providing care for those patients more 
difficult, especially during the pandemic?
    Dr. Mahoney. Right, right. So, after lockdown, our 
providers received requests for care from all 50 States. And we 
were able to provide that care during this time in States where 
there wasn't a pediatric rheumatologist available in the entire 
State, or a pediatric endocrinologist. Academic medical centers 
are unique in that they are able to provide subspecialty 
services that are not available throughout certain States. And 
so we were very honored and enthusiastic about having that 
ability to do so.
    Mr. Latta. Well, thank you very much.
    Dr. Mehrotra--I hope I pronounced that correctly--in 2018 
Congress allowed clinicians working within the U.S. VA Affairs 
health system to provide care to patients both in person and 
across State lines through telehealth services, due to veterans 
experiencing long wait times. And that emerged into Federal 
action.
    Would you agree that the severity of this crisis also 
demands that Congress address the licensure issue and expand 
deployment of care during the duration of this public health 
emergency?
    Dr. Mehrotra. I definitely agree, Representative Latta, and 
I would say that--two other points there is that I would go 
beyond the TREAT Act and make this--using--under the Medicare 
system, allowing any Medicare beneficiary to receive care from 
a physician who is licensed in the State that he or she is 
located in.
    One nuance that I might bring up is that there was this 
issue of the interstate medical licensure compact as another 
way of improving the ability of providers to get licensure in 
other States. And I think, in theory, it is a great idea. Our 
data highlights that very few providers have used it to do so, 
to provide telemedicine across State lines, simply because it 
has a lot of administrative paperwork, and the cost of it. So I 
would say that that is one thing I wanted to flag.
    Mr. Latta. Well, thank you very much for our witnesses.
    And, Madam Chair, again thank you very much for your 
indulgence and me waiving on to the subcommittee. Thank you 
very much.
    Ms. Eshoo. We are always happy to have you with us, Mr. 
Latta. You are--when we say ``gentleman,'' you are truly a 
gentleman. You are always welcome at the Health Subcommittee.
    Mr. Latta. Thank you, ma'am.
    Ms. Eshoo. Yes. The Chair is pleased to recognize another 
one of our new members to the full committee from 
Massachusetts, the gentlewoman by the name of Ms. Trahan.
    You are recognized for 5 minutes. Thank you for waiving on. 
Oh, no, you are a member of our committee. You don't need to 
waive on.
    Ms. Trahan. I am, but I would have waived on if I wasn't.
    Ms. Eshoo. Right.
    Ms. Trahan. Thank you, Chairwoman Eshoo, Ranking Member 
Guthrie, as well as all the witnesses here today. I really 
appreciate all of your--all of the insight.
    Missed appointments, or no-shows, are a measure of health 
disparity, with low-income, Medicaid, and minority patients 
traditionally having the highest no-show rates. Lack of private 
transportation, access to healthcare, inflexible work schedules 
contribute to higher no-show rates in an already underserved 
community. Given the ability of telehealth to improve patient 
convenience and eliminate barriers to care, I want to just 
discuss how 1 year of accessing telehealth has resulted in a 
decrease in no-show rates for hard-to-reach patients in the 
pandemic.
    Greater Lawrence Family Health Center is a community health 
center in my district that serves a diverse population. 
Approximately 70 percent of patients are non-English-speaking, 
approximately 75 percent have Medicaid. Excluding testing and 
vaccination appointments, this health center has had more 
overall visits at this point this year than they did last year. 
And they have also seen a 10 percent decrease in no-shows, 
which providers at the center attribute to the expansion of 
telehealth services.
    Also, a study was conducted by a member of the 
Massachusetts Medical Society on all patients that completed or 
no-show appointments with the dermatologist at the campus 
during the months of May and June 2019, compared to 2020. And 
the study found that, compared with the clinic visits, 
televisits had significantly lower no-show rates, with the 
greatest reduction seen for Black, Latinx, and primary non-
English-speaking patients.
    So I know that there's limitations to the study, you know, 
with a small sample size, and single institution experience. 
However, the study provides early evidence that teledermatology 
may play an important role in mitigating no-show rates and 
improving access to care for our most vulnerable populations.
    So, Dr. Resneck, are the findings from the study I 
mentioned consistent with your clinical experience? And do you 
believe these findings represent a trend across practices and 
institutions?
    Dr. Resneck. Congresswoman, those findings do not surprise 
me. This is what I am hearing from my colleagues around the 
country and experiencing myself.
    As you sort of highlighted, traditionally--at least in my 
practice and colleagues who work around me--some of the highest 
no-show rates are in patients who already suffer from health 
disparities. Their lives are more complicated, it is harder to 
get out of work, transportation issues, child care issues. And 
the decrease in no-show rates, I think, has had a particular 
impact on improving care for those minoritized and 
disadvantaged populations.
    So I am seeing it in my own practice. I am hearing about it 
from colleagues. And I think, as we see more national data, 
they will confirm what you read from U Mass.
    Ms. Trahan. You know, another opportunity that our 
Chairwoman Eshoo actually brought up in her opening remarks is 
that telehealth creates the opportunity to get Black and Brown 
patients in front of physicians who look like them. Data 
suggests that individuals are more inclined to visit a medical 
professional if they share their same race or ethnicity.
    So, given the historical context that, you know, people of 
color, particularly Black people in our country being 
mistreated and exploited by our healthcare system, it may take 
more time and effort for a provider to build trust with a 
patient of different demographics in a virtual setting.
    So, Dr. Mahoney, I was wondering if you can shed some light 
on the impact telehealth is having on making the case for 
investing in a more diverse medical workforce, including 
physicians, pharmacists, nurses, and medical professionals, and 
how that will help to build trust with patients across 
cultural, ethnic, and racial dimensions.
    Dr. Mahoney. Thank you, Congresswoman Trahan, for that 
excellent question. And I appreciate the acknowledgment of the 
data that is out there, supporting the association between race 
concordance, between patient and provider and clinical outcomes 
along the lines of patient satisfaction, trust, but also 
perhaps even quality of care might be better when there is race 
concordance.
    And some of the studies that I participated in, we found 
that if there is a single team member--it doesn't have to be 
the physician, because we know that we don't have high numbers 
of people of color who become physicians now--hopefully, that 
is something we can work on and improve in the future. But if 
there is a single team member--so I am glad you have 
highlighted the idea of a team member being someone who is 
culturally or racially concordant with the patient, and the 
importance of that.
    Absolutely, access to telehealth, any modality that is 
going to improve access to care, is going to, as a result, 
improve the trust and the connection that a patient will have 
with her providers. It will improve the availability of 
multiple team members to engage with that patient.
    Ms. Trahan. Terrific. Well, thank you. I am out of time. I 
appreciate those answers.
    I yield back.
    Ms. Eshoo. The gentlewoman yields back. Thank you for your 
patience. Thank you for your patience in waiting to be 
recognized.
    The Chair recognizes another wonderful member of the full 
committee that is waiving on, Mr. Johnson of Ohio.
    Thank you for joining us and for, I think, just being with 
us since we started at 10:30 this morning.
    Mr. Johnson. Yes, I have. I have been paying very close 
attention. And Madam Chairwoman, I thank you and Ranking Member 
Guthrie and the subcommittee for allowing me to waive on and to 
try and contribute today.
    As cochair of the House Telehealth Caucus along with my 
colleague, Ms. Matsui, I am delighted that we are taking a 
close look at this. I represent a very rural district, as you 
know, and telehealth plays such an important part of healthcare 
delivery in rural parts of our country. In fact, you know, it 
was about this time last year, as COVID began to spread and the 
shutdowns took hold, that telehealth began playing such a key 
role in protecting vulnerable patients and helping to slow a 
run on our overburdened medical system.
    I was proud to fight for the emergency telehealth waivers 
that gave providers additional tools to make sure millions of 
Americans still receive and are receiving today the healthcare 
they needed. But this emergency will end, thank God. But many 
of these temporary waivers will end with it. And in my view, we 
should make this progress permanent to prevent a telehealth 
cliff, which would reverse the gains that we have made, and 
deny patients the telehealth services that they have grown to 
appreciate and rely upon. I have legislation that will do just 
that, and I look forward to working with my colleagues this 
Congress to make responsible, permanent changes.
    So first, to Dr. Mehrotra, as we have heard today, 
obviously, telehealth isn't appropriate for every type of 
ailment or doctor visit, but it is uniquely positioned to make 
a huge difference in many others. One of those is in accessing 
mental health treatment. In a rural Appalachian district like 
mine, specialists such as counselors and psychiatrists could be 
perhaps hours away, and treatment can be out of reach. 
Telehealth could be a lifeline to someone headed down the path 
to a mental health crisis, and with prompt intervention a 
possible emergency room visit or worse could possibly be 
avoided.
    So, Dr. Mehrotra, in your testimony you mentioned that 
telehealth can be used to prevent more costly care down the 
road. Can you outline why, in your view, it is so important to 
address issues early?
    And can you provide some more examples on how telehealth 
could be used to achieve this?
    Dr. Mehrotra. Representative Johnson, thank you so much, 
and I just do want to emphasize what a key role telemedicine 
has played in rural communities. In some of our work prior to 
the pandemic we found that, in some rural communities, 30 to 40 
percent of the visits for patients with serious mental illness 
were provided via telemedicine. This is, again, in the Medicare 
population before the pandemic. And certainly within the 
pandemic that rate has increased dramatically.
    Though I will emphasize what Representative Craig--she 
cited one of our papers that, unfortunately, during the 
pandemic, rural patients, unfortunately, are using telemedicine 
at a lower rate than people in urban areas. So it has really 
flipped.
    But your question, Representative Johnson, was more about 
how we can address, where we can address--if we can intervene 
early, how can we prevent downstream issues from coming on. And 
one area that I think is very promising, and I think 
Representative Eshoo had mentioned this previously, was in 
skilled nursing facilities, where we see that, if we can 
provide telemedicine coverage for after-hours coverage as well, 
it allows patients to be treated within the skilled nursing 
facility and not be transferred out to the local emergency 
department and be hospitalized.
    And so it is helpful for people to stay within the 
facility, and it also saves money. So that is a really great 
example of where it can be quite cost effective.
    Mr. Johnson. Well, good. Well, good. Well, your point about 
rural Americans being some of the lowest volume of telehealth 
users, I think there is a really good reason for that, and that 
is why I want to go to Mr. Riccardi next.
    If Americans don't have reliable broadband internet, our 
debate over payment models, state licensure, and permitted 
services won't be of any help to people that live in rural 
areas, low-income individuals who would benefit the most from 
telehealth services. So I agree with your testimony that 
closing the digital divide is essential.
    So, as policymakers, why is it so important, as we consider 
permanent telehealth policy changes, that we also keep working 
to build adequate broadband infrastructure, especially in the 
midst of a global pandemic like this, when school work and 
healthcare have moved online?
    Mr. Riccardi. Thank you, Congressman Johnson. I think 
currently, as we consider expanding the Medicare telehealth 
benefit, that we also have to invest in the infrastructure to 
ensure that all communities have access to broadband and the 
technologies that they can use to receive care from home.
    So, as we consider all of this, we--to revisit a point I 
shared earlier, I think it is important that we have a glide 
path in place to ensure that there is no disruption in care 
once this public health emergency ends. And, as we consider 
expanding the benefit, that we consider people living in the 
rural environment who have benefited from telehealth for many 
years but still lack the essential connectivity that is needed 
to maximize the capability of receiving care, and then also 
consider, you know, urban areas and, in particular, the 
necessity for beneficiaries in rural environments and in cities 
to receive care from home, as a supplement to in-person care.
    So I think there is quite a bit of investment that needs to 
be made, both in the--in technology and then also in the 
expansion of the benefit.
    Mr. Johnson. Well, thank you. Madam Chairwoman, thank you 
for the indulgence in letting that answer run a little over. 
Thanks for having me.
    Ms. Eshoo. Oh, absolutely. Well, if we can go all day, what 
is a few more minutes here or there, right?
    I would just add to this that, in the American Rescue Act, 
there is literally billions of dollars directed to build out 
broadband in our country. So everyone should know that. I mean, 
whether you support the whole bill or not, there is significant 
funding in it. And, of course, it is COVID-related. So I just 
wanted to add that.
    So thank you, Mr. Johnson.
    A wonderful new member of our committee, the gentlewoman 
from Texas, Mrs. Fletcher, you are recognized for 5 minutes for 
your questions.
    Mrs. Fletcher. Thank you, Chairwoman Eshoo, and thanks to 
you and Ranking Member Guthrie for holding this hearing on 
telehealth today. Thank you to all of the witnesses for sharing 
your insights, answering our questions.
    As we have discussed throughout the day, the COVID-19 
pandemic has drastically changed the way that we receive care. 
And I agree with my colleagues that telehealth is a silver 
lining of this experience. Even before the pandemic, providers 
in my community were telling me how they were using and hoped 
to expand telehealth. And we have seen that in my district over 
the last year.
    I want to touch on two issues in the time that I have.
    First, another somewhat new area, and I believe it is 
following up on the pediatric issues that Dr. Schrier raised, 
and the issues that Ms. Craig raised. I heard from my 
constituents that the need for pediatric behavioral health is 
both enormous and growing. COVID has increased suicide rates, 
has created isolation from peers and access to adults like 
teachers and coaches and pediatricians who often help spot 
issues or provide help, and that telemedicine has really kept 
the lights on for mental health programs. So my constituents 
working in this area tell me that they have converted their 
evidence-based treatments to things that work for telemedicine.
    Dr. Mahoney, I appreciated that in your written testimony 
you noted the importance of applying virtual care in all areas, 
including physical therapy and speech language pathology, and 
occupational therapy, which are very important in my district, 
as well, and something that I worked on at the beginning of the 
pandemic. These have been critical for my constituents. Can you 
speak a little bit to these behavioral health issues from your 
perspective, especially pediatric behavioral health issues?
    And, while I understand it is a very complicated issue, the 
need or the possibility for reimbursement beyond Medicaid for 
behavioral health, telemedicine.
    Dr. Mahoney. Great. Well, thank you, Congresswoman 
Fletcher, for the excellent question and the attention to this 
important issue, particularly during this pandemic, when 
children are experiencing more isolation and often are 
overlooked and aren't able to get the most evidence-based 
treatments for their conditions.
    And so what I would say related to reimbursement, this is 
primarily a question about Medicaid law, and sort of outside 
of, you know, my expertise. And I am happy to follow up in 
writing with a response.
    But, in general, what I will say is that having the 
interstate restrictions waived has been beneficial in providing 
access to subspecialty services across State lines in order to 
address this demand for behavioral health services among our 
pediatric patients.
    Mrs. Fletcher. Thank you so much for that. And, on a 
slightly different topic, although it certainly applies to 
pediatric patients, as well, but, you know, even without the 
challenges of COVID-19, for people with disabilities or medical 
complexities, just getting to the doctor can be extremely 
burdensome on both the patient and the caregiver. And we have 
certainly heard about some of those challenges earlier today. I 
have heard a lot of stories from my constituents about how 
telehealth has really helped ease some of those burdens. Just 
the other day, I was on the phone with a constituent who has 
epilepsy and can't drive herself to the doctor, has limited 
access to transportation, and basically just lost her reliable 
transportation.
    So, Mr. Riccardi, are there particular issues that we 
should be thinking about to ensure that more people with 
disabilities or complex medical conditions are able to access 
these services?
    Mr. Riccardi. Yes. And, you know, fortunately, the pandemic 
has allowed more people to access these services. And from, you 
know, our help line and our clients, we do see lack of 
transportation or access to facilities that meet ADA compliance 
as an issue.
    So, as we consider moving forward with telehealth, we want 
to make sure that in-person facilities still are meeting these 
requirements and telehealth does not become the barrier for 
people with disabilities that may need followup care, in-person 
care.
    And, as we know, people with chronic conditions have been 
able to receive services through the pandemic, e-visits, and 
others that we would like to see moving forward. But we must 
ensure that access to in-person care is both accessible and 
available.
    Mrs. Fletcher. Thank you so much, Mr. Riccardi. Thanks to 
all of you for your really insightful testimony today.
    And Madam Chairwoman, thank you again for holding this 
hearing. I yield back.
    Ms. Eshoo. The gentlewoman yields back. It is a pleasure 
now to recognize another one of our wonderful Members that is 
waiving on today, the gentleman from Indiana, Mr. Pence.
    You are recognized for 5 minutes for your questions.
    Mr. Pence. Well, thank you, Chair Eshoo. I haven't been 
called wonderful for quite some time. And thank you, Ranking 
Member Guthrie, for holding this hearing. And thank you to the 
witnesses for appearing before us today to discuss the 
advantages of telehealth technologies during the COVID-19 
pandemic and beyond.
    In rural districts like my Indiana 6th district, telehealth 
expansion during the pandemic has been a game changer. 
Countless Hoosiers have benefited from the convenience of 
services that remotely connect patients to doctors, 
specialists, and other healthcare professionals, all from the 
comfort of their own home. Throughout the pandemic, telehealth 
proved that it can provide high-quality, patient-centered care 
that in many instances mirrors the type of care received in 
person.
    Under President Trump's leadership, flexibility in 
telehealth services allowed physicians to stretch their 
resources to meet the diverse needs of disparate communities, 
quite often 2 hours away from healthcare, as mentioned earlier 
in the hearing today.
    In Indiana's 6th district, two hospital systems received 
funding under the FCC's COVID-19 telehealth program to service 
patients' needs with innovative methods of care. Hancock 
Regional Hospital in Greenfield used these grants to develop a 
portable camera system for COVID-19-infected patients to 
connect with infectious disease experts located at neighboring 
hospital systems.
    Beyond the pandemic, the telehealth services will play a 
key role in addressing barriers to care for rural patients, 
especially those that suffer from mobility issues or patients 
with chronic conditions. It is important to recognize, however, 
that these services are rendered useless for Hoosiers and all 
Americans that sit on the wrong side of the digital divide, 
which covers a large portion of my district. Innovative models 
of care will not overcome inadequate internet connections.
    Further, as this committee develops solutions to the future 
development of telehealth technologies, we must remain 
cognizant of the challenges of wasteful spending and fraudulent 
claims that will strain an already bloated healthcare system.
    Dr. Mehrotra, I understand that there are certain 
conditions such as movement disorders which require in-person 
interactions to properly diagnose and treat. In your testimony, 
you also mentioned the limitation of telemedicine visits for 
things like ear infections for infants. This is especially 
difficult for patients in rural America with limited access to 
resources. Doctor, can you expand more on how we could blend 
telehealth services into traditional care to better impact 
rural America and patients with chronic healthcare conditions?
    Dr. Mehrotra. Well, thank you very much for the question, 
Representative Pence. And I might highlight something before I 
turn to your question directly. I do want to emphasize 
something that you brought up earlier in your testimony, when 
you discussed the health systems in your area using 
telemedicine.
    We are also seeing a lot of, in rural communities, 
telemedicine used in emergency departments to try to facilitate 
specialty care being provided within those communities. And the 
one thing I wanted to emphasize there that I am concerned about 
is, while we have evidence that that telemedicine used in 
emergency departments is effective, the smallest and most rural 
hospitals are the least likely to have that technology. And so 
it is a real barrier there. So how do we make sure that those 
hospitals have that technology?
    In regards to your question more directly related to how do 
we incorporate telemedicine care into rural communities, I 
think one of the points that we made earlier in the 
conversation is how do we allow patients in rural communities 
to access the care from anywhere else in the country.
    And I think we heard a story of how, in many cases, 
patients in rural communities don't--it is not someone within 
the State of Indiana, for example, but is in many States away. 
And so we talk a lot about licensure, and being such a critical 
reform to try to allow patients in rural communities to access 
the care that they need.
    Mr. Pence. OK, thank you.
    And thank you for letting me come on, Madam Chair. I yield 
back.
    Ms. Eshoo. The gentleman yields back.
    You are always welcome at the subcommittee.
    And now, last but not least, the gentleman from Arizona, 
Mr. O'Halleran, who is also waiving on today.
    I do believe you are the last one.
    And thank you to the witnesses for this long hearing. But 
Mr. O'Halleran is worth hearing from, and then we will have a 
few closing business things to do.
    Mr. O'Halleran, you have 5 minutes to question.
    Mr. O'Halleran. Well, thank you, Madam Chair, for letting 
me waive on. I always appreciate being last, if I can speak, so 
I appreciate that very much.
    You know, this committee is made up of individuals across 
the whole spectrum of political thought, but they all care 
about one thing, that is the health of the citizens of our 
Nation.
    The COVID-19 pandemic has finally forced Congress--and I 
mean forced us--to look at HHS and CMS to rapidly address some 
of the issues regarding telehealth.
    One of the most significant issues in administering 
telehealth in rural America is the lack of specialists and, for 
that matter, just plain lack of doctors, lack of nurses, lack 
of health professionals that we need.
    Nothing I am going to say is going to be--and talk about--
is new to any of you. It is just, why is it still an issue in 
our country, this great country, decade after decade after 
decade?
    It shouldn't be this way. Our citizens are not expendable. 
We are all--should be treated equally in healthcare also. And 
we have to make these temporary changes, those that are 
adaptable, permanent.
    My district--why I am so passionate about this is that my 
district is larger than the State of Illinois. It is 58,000 
square miles. And so we have got a little bit of room there. 
And I have the same amount, plus or minus, of any other 
congressperson here.
    I have been working on telehealth issues since I was in the 
legislature 20 years ago. And changes have gone in the right 
direction, but not fast.
    I have 12 Tribes in the district, and they include some of 
the largest Tribal lands in the Nation: the Navajo, the Hopi, 
the White Mountain Apache, some in the San Carlos. These are 
Tribes with larger land masses than many of the States in this 
country.
    I go to different areas with Meals on Wheels to make sure I 
get out there and talk--and actually talk to people, not just 
deliver the food, but see the conditions they live in, talk to 
them about what their issues are. It always gets back to 
healthcare, and it always gets back to not only affordability 
but the ability to even get care in a way that they can get to 
the doctor that is even nearby. That is wrong. We have to do 
something differently about that, and telemedicine is only a 
piece of that puzzle.
    The disparities even in urban communities is a problem in 
this country, and we have to address those issues.
    The CMS issues that are critical to being able to get 
reimbursements at the appropriate level are critical in this 
process.
    Rural doctors. I mean, I just watched a caravan going out 
of rural America, not coming into rural America, and we have to 
do that. That is critical, to be able to address the issues 
that we just got done talking about. How do we tell somebody on 
a telemedicine thing to come on down, come on down, we will see 
you down at the VA, or we will see you down at the center, down 
in--or whatever, and it is a 5-hour trip one way and they can't 
afford to stay at a hospital. They need healthcare, they need 
it now, they need to talk to that specialist. If it is not a 
physical examination, then to be able to go over their 
medications and stuff. And that is not always available. I 
can't tell you how many homes I am in where there is no such 
thing as a computer in those homes.
    And the need for additional technology, we shouldn't be--
broadband is something we all want to work on, but we can't 
work out to--and thinking about it today. We have to think 
about it tomorrow, where the technology is going, and have the 
capacity and speed in which to do that.
    And so I just--I want to end there with my comments, but I 
do have a question for--let's see where it is at--Dr. Resneck, 
and I will get to the short end of it.
    Without access to high-speed broadband, are there certain 
specialists who may be difficult to see, treatments that may be 
more difficult to obtain because of these--Americans lack high 
speed broadband?
    And what is the future with broadband, as far as bringing 
care to people and us being able to adapt to it in the 
appropriate way?
    Dr. Resneck. Thank you for all of your comments. You 
brought up a lot of outstanding issues, Congressman.
    And yes, but there is not just a specialty. I mean, there 
are certain things that require more bandwidth than others. But 
I would say all of us and all of our patients need the option 
to be able to communicate with us electronically, and that 
requires broadband access.
    But I am optimistic. I am optimistic that you all are going 
to help solve the Medicare rules problem that we will be facing 
after the pandemic. And I am optimistic that, as a result, for 
rural populations like yours, telehealth will be a big part of 
the answer so that people's life expectancies and their health 
are not so heavily determined by the ZIP code that they live 
in, by their race, ethnicity. I think we are going to make big 
progress, and I think telehealth is going to be a part of it. 
And I agree, we need broadband to be part of it too.
    Mr. O'Halleran. So thank you very much.
    And, Madam Chair, I thank you for the time over which you 
allowed me to go. Thank you.
    Ms. Eshoo. You waited a long time to speak. So, as I said 
earlier to another Member, a couple of minutes here, a couple 
of minutes there--a lot of chairmen have cut me off in the 
middle of a sentence over 28 years, so I find myself being 
generous as a result of that.
    And we have one more Member to recognize. We are glad to 
see him. And he is the gentleman from Maryland, Mr. Sarbanes. 
I--he has been probably on the floor the better part of today.
    So we are glad you made it to our subcommittee hearing, and 
you are recognized for your 5 minutes of questions.
    Mr. Sarbanes. Thanks very much, Madam Chair. I appreciate 
it. And I appreciate you holding this very important hearing.
    We have been hearing from many constituents and provider 
groups in my district--and I know this is the case for my 
colleagues--about how much of a benefit telehealth can offer, 
particularly during this terrible pandemic that we are facing. 
It allows continued access to medical care for patients while 
protecting the health of both the patients and the medical 
staff that are serving them. So it makes eminent sense.
    We know that we took steps to greatly expand telehealth 
under the CARES Act, which now allows federally qualified 
health centers and rural health clinics to utilize those 
services under Medicare. And that is the case across the 
country.
    But in Maryland, there's places like school-based health 
centers that still can't use telehealth to access their student 
populations. And we know that school-based health centers 
provide high-quality, comprehensive primary healthcare, mental 
health services, preventive care, social services, and youth 
development to primarily low-income children and adolescents 
across the Nation. And they play a critical role in helping to 
reach underserved populations and to achieve health equity.
    I will note that the Maryland State Senate actually 
recently passed a bill that would allow school-based health 
centers to provide their services via telehealth. In Congress I 
think we should be looking at similar kinds of things to make 
sure that that opportunity is available.
    Dr. Resneck, how has the experience in telehealth services 
helped doctors and medical staff reach younger patients, 
particularly underserved populations? And what opportunities do 
you see to broaden access that can benefit those populations?
    Dr. Resneck. Yes, I have seen this improvement at both ends 
of the spectrum. It is younger patients, as well. We have a lot 
of pediatric dermatologists on our team here, and you know, the 
issue is getting them into the office. Again, it doubles up. 
You have got them out of school, you have got a parent who has 
to potentially miss work. You have got transportation issues to 
get into the clinic. All those things are still true for kids, 
and sometimes--and in some instances are actually multiplied 
for kids.
    So the other thing is just in terms of social distancing 
with COVID. Sometimes in pediatric visits we have got a kid, 
family member, medical student, multiple people in the room. It 
makes social distancing even more difficult. So very important 
that those in-person visits still be available to kids, when 
they are appropriate, and very important to have that 
telehealth tool as an option, as well.
    Mr. Sarbanes. Thanks very much.
    Dr. Mehrotra----
    Dr. Mahoney. I am sorry, Congressman Sarbanes, can I just 
add a comment about school-based----
    Mr. Sarbanes. Yes, sure.
    Dr. Mahoney. OK, thank you. So, yes, I just wanted to, you 
know, just amplify that point, that school-based health centers 
have the potential to significantly improve telehealth access 
to children, because it helps us overcome this broadband device 
issue, whereas some children would not be able to have access 
to telehealth, and in the school-based systems they would have 
access.
    And so we have been working at Stanford with schools for 
one-off family needs. But it would be tremendously helpful to 
be able to expand that, of course, as a Medicaid issue. But I 
just wanted to add that comment. Thank you.
    Mr. Sarbanes. No, that is an extremely valuable perspective 
to offer.
    I have got about a minute left. Dr. Mehrotra, maybe you 
could just--and this may have been covered already, or talked 
about, but give us your thoughts on what telehealth is going to 
look like on the other side of the pandemic. Because, 
obviously, the radical change here and expansion of it in the 
midst of the pandemic, I think, is probably creating a new 
foundational level of the access to it postpandemic. So can you 
just give us some quick thoughts on that?
    Dr. Mehrotra. Yes. Well, I couldn't resist, but I will just 
make a very quick comment on the school-based health centers, 
that we also see that it allows teachers to get involved with 
things like attention deficit disorder. So it is really another 
value, a key person in a child's life.
    But, in terms of postpandemic, one of the ideas that has 
come up and I think maybe bears emphasizing in terms of where 
telehealth is going is that we are seeing new models of care 
which really push our boundaries on what is a visit. And what I 
mean by that is such as these tele-endocrinology providers, 
where they have continuous glucose monitoring 24 hours a day, 7 
days a week, and they are sending messages to patients several 
times a day--``Adjust your insulin. How are you doing on your 
diet?''--and I think these new models of care, which kind of 
come under remote patient monitoring, are where we are headed 
post the pandemic, but also really complicate how does the 
Medicare program or any other payer pay for a visit.
    Mr. Sarbanes. Thank you.
    We have got our work cut out for us, Madam Chair. I yield 
back.
    Ms. Eshoo. The gentleman yields back.
    Well, we don't have any other Members at this point that 
are coming in to speak.
    I just wanted to give the exact amount for broadband in the 
American Rescue Act. It is $7 billion, with a B. That is going 
to go a long way, because, regardless of what side of the aisle 
or what part of the country, Members have spoken over and over 
and over again the need for broadband, because that is the 
platform that telehealth really rests on. If we don't have 
that, there isn't any telehealth.
    I want to thank each one of the witnesses. You have been 
extraordinary. I think this is one of the best hearings we have 
ever had. And I think one of the reasons for that is that each 
one of you is superb. But you also spoke very directly to the 
American people. Whatever question members asked, you actually 
answered the questions. And that is so welcome. So for 4\1/2\ 
hours, you have met with and answered the questions of 36 
Members of Congress. You saw firsthand that each and every 
Member really cares very deeply about this issue and that it is 
thoroughly bipartisan.
    So that gives me great hope, together with each one of you 
being such a great source of, you know, of not only 
professional advice, but being such a great source of intellect 
for us. And we will continue drawing from you. I would like to 
see one bill, one bill that is comprehensive, and we will keep 
working with you so that the bill that we come up with really 
speaks to not only this moment in time but that it is so 
durable that it will really speak to the future beyond, God 
willing, this pandemic.
    So I can't thank the witnesses enough. Dr. Mahoney, Dr. 
Mehrotra, Elizabeth Mitchell, Dr. Resneck, and Frederic 
Riccardi, you have just been outstanding.
    Now I would like to make a unanimous consent request to 
enter into the record documents. And I want to ask my friend, 
the ranking member, Mr. Guthrie, if you would consent to my 
request that we place these in the record. There are 50. And if 
you would consent, then you don't have to listen to me reading 
50----
    Mr. Guthrie. You have my--I consent. I consent----
    Ms. Eshoo. They are all important, but----
    Mr. Guthrie. You have my consent.
    Ms. Eshoo [continuing]. Thank you very much. Thank you.
    [The information appears at the conclusion of the hearing.]
    Ms. Eshoo. And so these will all be made part of the 
record. Any of the organizations or individuals who are 
listening in, thank you for submitting something for the 
record.
    So, with that, I thank the ranking member too. Four and a 
half hours, it is a long time. But you know what? I think every 
minute was worth it. And I hope that you all feel that way, as 
well. If we can get this done and done well, we will have made 
a major contribution with your extraordinary help and in our 
day and our time for the American people.
    So, with that, we will adjourn the subcommittee hearing for 
today, and everyone stay well. We need you. Thank you.
    [Whereupon, at 2:56 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

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