[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
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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
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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:]
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