[Senate Hearing 117-546]
[From the U.S. Government Publishing Office]



 

                                                        S. Hrg. 117-546

                  COVID	19 HEALTH CARE FLEXIBILITIES:
                       PERSPECTIVES, EXPERIENCES,
                          AND LESSONS LEARNED

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

                                HEARING

                               before the

                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 19, 2021

                               __________

                                     






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                          COMMITTEE ON FINANCE

                      RON WYDEN, Oregon, Chairman

DEBBIE STABENOW, Michigan            MIKE CRAPO, Idaho
MARIA CANTWELL, Washington           CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey          JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware           JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland         RICHARD BURR, North Carolina
SHERROD BROWN, Ohio                  ROB PORTMAN, Ohio
MICHAEL F. BENNET, Colorado          PATRICK J. TOOMEY, Pennsylvania
ROBERT P. CASEY, Jr., Pennsylvania   TIM SCOTT, South Carolina
MARK R. WARNER, Virginia             BILL CASSIDY, Louisiana
SHELDON WHITEHOUSE, Rhode Island     JAMES LANKFORD, Oklahoma
MAGGIE HASSAN, New Hampshire         STEVE DAINES, Montana
CATHERINE CORTEZ MASTO, Nevada       TODD YOUNG, Indiana
ELIZABETH WARREN, Massachusetts      BEN SASSE, Nebraska
                                     JOHN BARRASSO, Wyoming

                    Joshua Sheinkman, Staff Director

                Gregg Richard, Republican Staff Director

                                  (ii)  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                            C O N T E N T S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page
Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee 
  on Finance.....................................................     1
Crapo, Hon. Mike, a U.S. Senator from Idaho......................     3

                               WITNESSES

Farb, Jessica, Director, Health Care, Government Accountability 
  Office, Washington, DC.........................................     6
Davis, Kisha, M.D., MPH, FAAFP, member, Commission on Federal and 
  State Policy, American Academy of Family Physicians, Leawood, 
  KS.............................................................     7
DeCherrie, Linda V., M.D., clinical director, Mount Sinai at 
  Home; and professor of geriatrics and palliative medicine, 
  Icahn School of Medicine at Mount Sinai, Mount Sinai Health 
  System, New York, NY...........................................     9
Murali, Narayana, M.D., board member, America's Physician Groups; 
  and executive director, Marshfield Clinic, Marshfield, WI......    11
Berenson, Robert A., M.D., institute fellow, Urban Institute, 
  Washington, DC.................................................    12

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Berenson, Robert A., M.D.:
    Testimony....................................................    12
    Prepared statement...........................................    51
    Responses to questions from committee members................    56
Crapo, Hon. Mike:
    Opening statement............................................     3
    Prepared statement...........................................    60
Davis, Kisha, M.D., MPH, FAAFP:
    Testimony....................................................     7
    Prepared statement...........................................    61
    Responses to questions from committee members................    65
DeCherrie, Linda V., M.D.:
    Testimony....................................................     9
    Prepared statement...........................................    71
    Responses to questions from committee members................    73
Farb, Jessica:
    Testimony....................................................     6
    Prepared statement...........................................    81
    Responses to questions from committee members................    94
Murali, Narayana, M.D.:
    Testimony....................................................    11
    Prepared statement...........................................   101
    Responses to questions from committee members................   107
Wyden, Hon. Ron:
    Opening statement............................................     1
    Prepared statement with attachment...........................   115

                             Communications

Adventist Health.................................................   127
Advocate Aurora Health...........................................   129
Alliance for Connected Care......................................   133
America's Health Insurance Plans.................................   138
American Association of Nurse Practitioners......................   144
American Hospital Association....................................   147
American Medical Association.....................................   151
American Medical Rehabilitation Providers Association............   157
American Occupational Therapy Association........................   161
American Pharmacists Association.................................   165
American Physical Therapy Association............................   168
American Telemedicine Association................................   172
Association for Clinical Oncology................................   174
Association of American Medical Colleges.........................   181
Better Medicare Alliance.........................................   186
Center for Fiscal Equity.........................................   190
ERISA Industry Committee.........................................   193
Healthcare Leadership Council....................................   199
HealthEquity.....................................................   201
Kaiser Permanente................................................   202
Medically Home Group, Inc........................................   205
Moving Health Home Coalition.....................................   207
National Association of Chain Drug Stores........................   209
National Indian Health Board.....................................   212
98point6.........................................................   216
Ochsner Health...................................................   218
Partnership for Employer-Sponsored Coverage......................   226
Premier Inc......................................................   229
Psychiatric Medical Care, LLC....................................   231
TechNet..........................................................   233
Teladoc Health, Inc..............................................   234

 
                  COVID-19 HEALTH CARE FLEXIBILITIES: 
                       PERSPECTIVES, EXPERIENCES, 
                         AND LESSONS LEARNED  

                              ----------                              


                        WEDNESDAY, MAY 19, 2021

                                       U.S. Senate,
                                      Committee on Finance,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10:06 
a.m., via Webex, in the Dirksen Senate Office Building, Hon. 
Ron Wyden (chairman of the committee) presiding.
    Present: Senators Stabenow, Cantwell, Menendez, Carper, 
Cardin, Brown, Bennet, Casey, Warner, Whitehouse, Hassan, 
Cortez Masto, Warren, Crapo, Grassley, Cornyn, Thune, Portman, 
Cassidy, Lankford, Daines, Young, Sasse, and Barrasso.
    Also present: Democratic staff: Joshua Sheinkman, Staff 
Director; and Beth Vrable, Deputy Chief Counsel and Senior 
Health Counsel. Republican staff: Brett Baker, Deputy Health 
Policy Director; and Gregg Richard, Staff Director.

   OPENING STATEMENT OF HON. RON WYDEN, A U.S. SENATOR FROM 
             OREGON, CHAIRMAN, COMMITTEE ON FINANCE

    The Chairman. The Finance Committee will come to order. And 
before we begin today's hearing, I particularly want to thank 
my colleagues on both sides of the aisle for the exceptional 
participation yesterday on the infrastructure hearing, because 
I thought we got a lot of good ideas out, hearing from Senators 
on both sides, and I want to thank my colleagues.
    Today we are going to turn to another important area. And I 
particularly want to thank our Ranking Member Senator Crapo, 
because he and I have been talking about telehealth, talking 
about a variety of ideas that the committee could work on in a 
bipartisan way. And we thought in particular it made some sense 
as part of our duties, from time to time to step back and take 
a look at what happened during the pandemic, areas where we can 
do better, ideas where this committee can lead with bold 
changes, and particularly in the health-care area prevent 
dramatic disruptions of health care in our country.
    We all understand that when COVID hit, it was no longer 
safe to meet face to face, take a bus to the doctor's office, 
even in many instances walk into a hospital for care. So when 
we talk about changes and what ought to stick around and what 
we ought to build on post-pandemic, Senator Crapo and I both 
thought telehealth was an ideal place to start.
    Now the telehealth challenge has always been about 
balancing the speed and efficiency of new technologies with the 
need for health-care quality and accountability. During the 
pandemic, some patients have felt that they had to jump through 
too many hoops, too many bureaucratic challenges, in order to 
get access to telehealth.
    My view, as a general proposition, is that patients ought 
to be able to have more accessible opportunities for 
telehealth. And particularly after they have seen a provider 
for the first time, we ought to be able to work together to 
clear out the bureaucratic hoops so that they can get access to 
telemedicine.
    In some cases, the right approach may in fact be to give 
the green light to telehealth from the get-go, at the very 
beginning. So we are looking forward today to discussing how to 
go about striking that balance, after a year of experience 
during the pandemic.
    Just so we get back to the question of the history here, 
the committee led the effort to shoehorn coverage for 
telehealth in Medicare as part of the CARES package. That was a 
particularly important part of CARES because it allows health-
care providers in Medicare to offer telehealth services to all 
older people, regardless of whether they live in big cities or 
small rural towns.
    And that particularly badly needed health-care measure 
provided care safely into the homes of tens of millions of 
seniors nationwide.
    The CARES Act also allowed Federally Qualified Health 
Centers, including community health centers and Rural Health 
Clinics, to receive Medicare payment for telehealth services, 
which meant that still more health-care providers could be 
involved in stepping up, as they did, to provide assistance, 
particularly for health-care services that would otherwise be 
very remote, and possibly beyond the reach of millions.
    Now again, for just a short bit of history, the Finance 
Committee actually paved the way for a lot of those changes in 
Medicare. Because for years we pressed the case on a bipartisan 
basis to update the Medicare guarantee, and to in effect say 
Medicare was not like it was in the days when I was director of 
the Gray Panthers. It is not primarily an acute care program 
any longer; it is a chronic care program. And so we led the 
effort to update the Medicare guarantee.
    And for too many years, the Congress simply fell behind in 
terms of recognizing the transformation of the flagship health-
care program at the Federal level. And telemedicine exists now 
largely because it was kicked off by work done by the Senate 
Finance Committee. Telehealth is going to be a big part of the 
transformation going forward, moving beyond acute care to 
dealing with chronic disease.
    The CHRONIC Care Act, which was passed by the committee 
when Orrin Hatch was the chair, marked the very first time 
seniors, for example, could get telehealth in-home for kidney 
disease. The law also made it easier to use telehealth to 
diagnose and treat strokes. It allowed more flexibility for 
Medicare Advantage plans and Accountable Care Organizations.
    So when the pandemic hit, because of the work of the Senate 
Finance Committee, the Centers for Medicare and Medicaid 
Services already had a head start for telehealth.
    I would also like to mention, as Senator Crapo knows, we 
have had a number of colleagues in the Senate who have been 
interested in the telehealth issue, and I want to particularly 
commend Senator Schatz and Senator Wicker, who also have spent 
considerable time on this.
    So Federal agencies have taken advantage of existing law to 
allow providers to care for their patients in fresh ways. For 
example, certain hospital doctors and nurses were able to 
travel out into their communities and provide services at home 
that would typically be reserved for inpatient care. Others 
could set up temporary spaces, like tents, near hospitals 
themselves. They were not allowed to do this prepandemic--in 
ordinary times. So these steps to increase capacity kept 
patients safe and helped maintain care.
    Today we are going to hear from physicians and hospitals 
who have been on the front lines, and health-care experts who 
have seen how the fresh approaches I have just mentioned 
transformed care. And as we have indicated, there is bipartisan 
interest in building on these changes that work for seniors and 
providers, and that can allow us to use Medicare, and 
particularly the telehealth breakthroughs, as a model for other 
parts of the health-care system.
    In the last year we also made progress on legislation that 
lets seniors on Medicare receive mental health services via 
telehealth, including at home. My view is, mental health 
services ought to be available via telehealth for all 
Americans. That provision was part of a bill that I authored 
that would also permit telehealth for routine health-care 
visits in Medicare, known as evaluation and management.
    I believe the committee can work together on a bipartisan 
basis to make that and other changes a reality.
    Let me recognize Senator Crapo, and I am again going to 
express my thanks for his partnership in making sure that we 
got this issue front and center, and we are starting to look at 
how to build on the lessons of the pandemic.
    Senator Crapo?
    [The prepared statement of Chairman Wyden appears in the 
appendix.]

             OPENING STATEMENT OF HON. MIKE CRAPO, 
                   A U.S. SENATOR FROM IDAHO

    Senator Crapo. Thank you, Mr. Chairman. Thanks for holding 
this important hearing.
    Congress and the administration provided certain health-
care flexibilities during the pandemic so that patients could 
continue to receive high-quality care. Making permanent changes 
based on these lessons learned is a top priority.
    I shared my interest with President Biden's nominees for 
the key health-care positions that have come before this 
committee, and I appreciate their commitment to work with us on 
this committee. Republicans and Democrats often disagree on the 
best way to achieve our shared health-care goals. This hearing, 
however, highlights an area of common ground. In fact, Senator 
Wyden and I asked the majority and minority staff to jointly 
plan this hearing, demonstrating strong bipartisanship.
    Acting on legislative changes and using administrative 
authority, the Centers for Medicare and Medicaid Services 
waived over 200 payment rules during the pandemic in Medicare 
alone. Needless to say, there is a lot we can learn. Today's 
witnesses will provide insight into our efforts that we need to 
take to evaluate these flexibilities.
    Hearing firsthand about the patient experience during the 
pandemic from providers who overcame challenges to provide care 
will be invaluable. Understanding how the flexibilities are 
used in fee-for-service, Medicare Advantage, and alternative 
payment models will be insightful.
    Much of the hearing will focus on care provided during the 
pandemic through telehealth. Telehealth has been a lifeline for 
patients and providers, especially in the early months of the 
pandemic. The reliance on telehealth increased in rural and 
urban areas alike, allowing patients to receive remote care 
from the safety of their own home.
    Telehealth services have been especially useful for 
Idahoans. According to the Idaho Department of Insurance, 
telemedicine visits went from an average of about 200 
appointments per month to 28,000 telehealth visits in April 
2020 alone.
    To ensure financial stability, providers have been paid at 
the same rate as if the service was furnished in person. This 
has facilitated care that otherwise would be risky or 
unavailable, and patients have appreciated the convenience. It 
has reduced the frequency of missed appointments and assisted 
provider investment in the infrastructure needed for remote 
care.
    This long period of expanded telehealth will help us 
understand the impact on quality of care and program costs. 
This serves as a robust test project on a scale few could have 
imagined. The promise of telehealth is clear, but it is 
important that we gather evidence on its impact on access, 
quality, and cost.
    There are approaches to providing care in the most 
efficient setting that go beyond telehealth. Some hospitals are 
using a waiver that provides flexibility to triage patients who 
present to the hospital to see if they can be best cared for in 
their home. Whether through telehealth, Hospital at Home, or 
other innovative care arrangements, it is important to find 
ways to get patients care that best meets their needs, and at 
the lowest cost possible.
    Congress has taken permanent steps to do just that in 
recent years. Nephrologists can conduct remote evaluations of 
patients receiving home dialysis. Providers can administer 
certain drugs to vulnerable patients in their own homes. 
Hearing from our provider witnesses helps us to continue down 
this path.
    The Government Accountability Office will supplement what 
we hear from our provider experts, offering a perspective on 
how to track and evaluate flexibilities in Medicare and 
Medicaid as we chart the right course forward.
    I fully expect that we will take what we learn from this 
hearing to continue our bipartisan efforts to help providers 
give patients the best care possible. Permanent changes based 
on lessons learned from the pandemic can modernize our Medicare 
payments and systems and lend to the pressing need to address 
Medicare's financial struggles.
    Identifying smart reforms that make Medicare more efficient 
will be better for patients and better for taxpayers. Such 
changes alone will not put Medicare on a sustainable path, but 
they should be a part of that broader conversation. Addressing 
Medicare solvency should be a bipartisan issue, with time best 
spent determining how to shore up the current system instead of 
expanding it to a broader population.
    Finding the right path on these priority issues is 
important to patients and the health programs in the 
committee's jurisdiction. This hearing will help us to 
capitalize on that bipartisan opportunity.
    Thank you again, Mr. Chairman. I yield back.
    [The prepared statement of Senator Crapo appears in the 
appendix.]
    The Chairman. Thank you, Senator Crapo. And I especially 
appreciate the focus on smart reform. And if we tie smart 
reforms to the whole notion of updating the Medicare guarantee, 
then I think we have really done a service in terms of the 
health-care debate, and I thank you for it.
    We have virtually every member of the committee signed up 
to ask questions after we hear from the witnesses, so we are 
going to have a particularly busy morning. And we are just 
going to move ahead, our first witness being Ms. Jessica Farb, 
Director of Health Care at the Government Accountability 
Office. She has an extensive portfolio there.
    Then we will hear from Dr. Kisha Davis, a family physician 
and a member of the American Academy of Family Physicians' 
Commission on Federal and State Policy. She is also a vice 
president of health equity for Aledade and cares for patients 
at a primary care clinic in Baltimore, MD. We thank her.
    We then have Linda DeCherrie, M.D., a geriatrician and 
palliative medicine physician who serves as clinical director 
of Mount Sinai, part of the Mount Sinai Health System in New 
York.
    After that, we will have Dr. Narayana Murali, a 
nephrologist and the executive director of the Marshfield 
Clinic in Wisconsin.
    And finally, we will hear from Dr. Robert Berenson, whom we 
have had a chance to work with often over the years, an 
internal medicine physician and institute scholar at the Urban 
Institute, who is an expert on health policy, particularly 
Medicare.
    So I would also like at this point--and I think we will not 
have any objection to this--to enter into the record, by 
unanimous consent, the statement of the Medicare Payment 
Advisory Commission, or MedPAC, on pandemic flexibilities in 
Medicare. Hearing no objection, we will make that part of the 
record.
    [The statement appears in the appendix on p. 117.]
    The Chairman. We will go right to our witnesses, and then 
today, colleagues, because we have so many Senators who are 
going to be asking questions, we are going to have to stick to 
the 5-minute rule pretty scrupulously or you will be eating 
your corn flakes tomorrow morning when everybody is still 
waiting to ask questions.
    Ms. Farb?

 STATEMENT OF JESSICA FARB, DIRECTOR, HEALTH CARE, GOVERNMENT 
             ACCOUNTABILITY OFFICE, WASHINGTON, DC

    Ms. Farb. Chairman Wyden, Ranking Member Crapo, and members 
of the committee, thank you for the opportunity to discuss 
GAO's ongoing work examining Medicare and Medicaid waivers and 
flexibilities implemented by CMS in response to COVID-19.
    We undertook this work as part of GAO's broader 
responsibility to conduct monitoring and oversight under the 
CARES Act. To increase access to medical services during a 
public health emergency, the Secretary of HHS can use several 
different authorities to temporarily waive or modify certain 
Federal health-care program requirements.
    Since the beginning of the pandemic, CMS has issued over 
230 waivers related to the Medicare program and approved more 
than 600 different Medicaid waivers and other flexibilities. 
Many of the Medicare waivers offer flexibilities for providers, 
hospitals, nursing facilities, and hospices. They generally 
were intended to increase capacity at facilities, expand the 
available workforce and beneficiary access to care, and reduce 
administrative burdens.
    As examples, CMS, one, allowed hospitals to provide patient 
care at non-hospital buildings or spaces, also known as ``a 
hospital without walls;'' two, created an expedited process for 
new provider enrollment, including waiving certain criminal 
background checks; and three, increased flexibility for 
providers to treat beneficiaries through telehealth.
    Similarly, CMS approved Medicaid waivers and flexibilities 
aimed at addressing obstacles that affect beneficiary care, 
provider availability, and program enrollment. For example, CMS 
allowed out-of-State licensed providers to care for Medicaid 
patients across State lines, and permitted virtual patient 
assessments needed to qualify for long-term care services in 
Medicaid.
    The full effects of most of these waivers and flexibilities 
are not yet known, but CMS has reported some data on the use of 
telehealth in both programs. For example, over the first 8 
months of the pandemic, utilization of telehealth services by 
Medicare fee-for-service beneficiaries sharply increased from 
about 325,000 services per week at the start of the pandemic, 
to a peak of about 1.9 million about a month later. Since then, 
utilization has slowly declined, and as of mid-October was 
slightly over 700,000 services per week, still much higher than 
pre-pandemic levels.
    This utilization varies in a number of ways, including by 
service type, provider specialty, and beneficiary demographics. 
For example, telehealth was used more frequently for mental 
health services and by beneficiaries under the age of 65, as 
well as those located in urban areas. CMS has also reported 
variation in the use of telehealth in the Medicaid program 
across the States and across age groups within the States.
    The waivers and flexibilities implemented in Medicare and 
Medicaid during COVID-19 likely benefited providers and 
beneficiaries, yet determining whether and, if so, how to 
continue them post-
pandemic warrants consideration.
    Factors to consider include program spending, program 
integrity, beneficiary health and safety, and health equity. 
Both the Medicare and Medicaid programs are on GAO's high-risk 
list in part due to concerns about fraud, waste, and abuse.
    Telehealth and other waivers pose some risks of unnecessary 
program spending. The lower but stable telehealth utilization 
trend we saw last fall in Medicare suggests that demand for 
telehealth may continue after the pandemic.
    Medicare currently pays the same for telehealth and in-
person services, and one provider group we interviewed 
cautioned that this could create incentives for specialties 
that can provide and be paid for both in-person and additional 
telehealth services to generate telehealth visits without 
obvious clinical benefit.
    In addition, the lack of complete data for oversight and 
suspension of some program safeguards may have increased 
program risks. For example, CMS lacks complete data to 
determine the telehealth modality being used, audio-only or 
audio-video, or where the services are originated--important 
information to consider, given payment incentives and the lack 
of evidence so far about the quality of telehealth services in 
Medicare.
    Extending or ending waivers and flexibilities may affect 
beneficiary health and safety in unknown ways. For example, 
expedited processes for provider enrollment in both programs, 
including waivers of normal screening and criminal background 
checks, could affect the quality and safety of care provided to 
beneficiaries.
    And finally, the health disparities we have observed during 
the pandemic also extend to beneficiaries' access to services 
and may be exacerbated by differences in access to things such 
as technology used to support telehealth in rural areas. Thus, 
health equity may be an important factor in decisions about the 
continuation of these flexibilities.
    Careful contemplation of the benefits and risks of 
continuing these waivers and flexibilities will be key to 
determining the path forward. We look forward to working with 
Congress and this committee as we continue our oversight of the 
Federal response to the COVID-19 pandemic.
    Chairman Wyden, Ranking Member Crapo, and members of the 
committee, this completes my prepared statement. I would be 
pleased to respond to any questions that you may have.
    [The prepared statement of Ms. Farb appears in the 
appendix.]
    The Chairman. Thanks very much, Ms. Farb.
    We go now to Dr. Davis.

STATEMENT OF KISHA DAVIS, M.D., MPH, FAAFP, MEMBER, COMMISSION 
    ON FEDERAL AND STATE POLICY, AMERICAN ACADEMY OF FAMILY 
                    PHYSICIANS, LEAWOOD, KS

    Dr. Davis. Good morning, Chairman Wyden, Ranking Member 
Crapo, and members of the committee. I am Dr. Kisha Davis, a 
member of the American Academy of Family Physicians' Commission 
on Federal and State Policy, and I am honored to be here today 
representing over 133,000 physician and student members of the 
AAFP.
    I am a practicing family physician providing primary care 
to patients in Baltimore, MD, and I also serve as vice 
president of health equity at Aledade, working to reduce health 
disparities in physician-led ACOs across multiple States.
    I have experienced the impact of COVID-19 and resulting 
Federal policy changes first-hand, as well as through the 
shared experiences of the physicians that I support. I am 
appreciative of the flexibilities granted due to the public 
health emergency. These have allowed all patients, especially 
some of the most vulnerable, isolated, elderly, and 
disadvantaged patients, to maintain their relationship with 
their trusted primary care physician, while many offices had to 
close or severely limit in-person visits due to social 
distancing restrictions.
    They have also allowed these practices to remain 
financially solvent, whereas their mass closure would have been 
devastating at a time when medical care was needed most.
    Lastly, the ability to connect with one's trusted primary 
care physician via telehealth helped to alleviate the burden on 
emergency rooms and hospitals.
    As a physician myself, I want telehealth to be a tool in my 
toolbox that I can deploy based on a clinical judgment, not 
based on whether I get paid. As Congress considers whether to 
extend these flexibilities beyond the public health emergency 
and how to build upon recent advances, it is vital that 
Medicare and Medicaid policy changes are designed to advance 
health equity, protect patient safety, and enable clinicians to 
provide the right care at the right time.
    To this end, I suggest the following four recommendations 
regarding telehealth flexibilities.
    First, Congress should permanently remove the section 
1834(m) geographic and originating site restrictions, to ensure 
that all Medicare beneficiaries can access care at home. 
Expanded access to telehealth visits has allowed me to observe 
my patient's home or work environment, identify factors that 
may be affecting their health, and develop more personalized 
treatment plans. While some worry that telehealth will cause 
patients to become disconnected from their doctor, I have seen 
just the opposite. For patients, telehealth enables timely 
first contact access to care, while building and maintaining 
long-term trusting relationships. I have numerous examples of 
physicians ensuring patients were still getting the preventive 
care they needed by conducting annual wellness visits via 
telehealth, the monitoring and treatment of chronic diseases 
such as diabetes and hypertension, addressing acute concerns, 
and most notably conducting transitional care management 
visits--visits done post-hospital discharge aimed at preventing 
readmission.
    Prior to COVID, coming into the doctor's office after being 
hospitalized was often a barrier. Providing these services for 
patients in their home increases accessibility for patients who 
may be homebound or lack transportation, and creates 
opportunities to engage distant family and caregivers. 
Eliminating geographic and originating site requirements is 
essential and improves utilization of high-value care and 
patient outcomes.
    Second, Congress should require Medicare to cover audio-
only E&M services beyond the public health emergency. It is 
vital to ensure equitable access to telehealth services for 
patients who may lack broadband access or be uncomfortable with 
video visits. For many of our patients, especially rural, low-
income, elderly, and non-English speakers, voice calls are 
simply the most accessible option. Payments should support 
patients' and physicians' ability to choose the most 
appropriate modality of care, whether it be telephone, audio-
video, or in-person, and ensure appropriate payment for care 
provided.
    Third, Congress should ensure the permanent equitable 
coverage and payment of telehealth services provided by 
community health centers, and modify existing payment 
methodologies to provide timely, appropriate payment for 
telehealth. Community health centers have been stalwarts during 
the COVID-19 pandemic, providing testing services, remaining 
open during staffing shortages, and now leading in vaccine 
distribution, while ensuring quality of care for millions of 
low-income persons.
    Fourth, policymakers should monitor the impact of 
telehealth on access and equity, and invest in infrastructure 
to promote digital health equity. While the rapid expansion of 
telehealth has yielded many benefits for patients and 
clinicians, not everyone has benefited equally. To achieve the 
full promise of telehealth, Congress must proactively address 
structural barriers to virtual care. Additional studies to 
inform the direction of permanent telehealth policies should 
include the collection and reporting of data stratified by 
race, ethnicity, gender, language, and other key factors.
    Thank you for the opportunity to discuss with this 
committee the impact of these flexibilities on family 
physicians and the AAFP's recommendations for permanent 
policies to advance accessible, equitable, high-quality health 
care beyond the pandemic.
    [The prepared statement of Dr. Davis appears in the 
appendix.]
    The Chairman. Dr. Davis, thank you. You said so many 
sensible things, but I especially appreciate your bringing up 
and advocating for the voice calls, because I heard that 
repeatedly again and again. Thank you.
    Our next witness will be Dr. Linda DeCherrie, a 
geriatrician.

STATEMENT OF LINDA V. DeCHERRIE, M.D., CLINICAL DIRECTOR, MOUNT 
   SINAI AT HOME; AND PROFESSOR OF GERIATRICS AND PALLIATIVE 
MEDICINE, ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI, MOUNT SINAI 
                  HEALTH SYSTEM, NEW YORK, NY

    Dr. DeCherrie. Thank you.
    The Chairman. There she is. Good.
    Dr. DeCherrie. Chairman Wyden, Ranking Member Crapo, and 
the members of the Senate Finance Committee, it is my distinct 
pleasure on behalf of the Icahn School of Medicine at Mount 
Sinai, and the Hospital at Home Users Group, to be part of this 
panel to discuss Hospital at Home, specifically extending the 
current acute hospital care at home flexibilities being offered 
under the public health emergency.
    Hospital at Home is patient-centered model of care which 
provides hospital-level care at home for patients with select 
acute illnesses who would otherwise be hospitalized. Multiple 
Hospital at Home studies have demonstrated improved patient 
safety, reduced mortality, enhanced quality, and reduced costs.
    It was a model that many Medicare Advantage commercial and 
Medicaid Managed Care plans already covered before the 
pandemic. Adding the rest of the Medicare beneficiaries allows 
equitable care and has been extremely helpful since November 
2020 when the Acute Hospital Care at Home waiver was approved.
    I believe the coverage of Acute Hospital Care at Home 
should be covered beyond the pandemic, preferably as a 30-day 
bundle of care. In 2014, Mount Sinai applied and received a 
Center for Medicare and Medicaid Innovation award to develop 
and test Hospital at Home for the fee-for-service Medicare 
population. From this work, we submitted a proposal to the 
Physician-Focused Payment Model Technical Advisory Committee.
    The PTAC recommended our proposal in 2018 to the Secretary 
of the Department of Health and Human Services for 
implementation. The Secretary expressed interest in testing 
home-based 
hospital-level care models, but no payment model was advanced 
for beneficiaries in fee-for-service Medicare.
    In 2017, when our CMMI award was finished, our Hospital at 
Home program was no longer able to provide care for fee-for-
service Medicare patients, as there was no reimbursement, and 
the program shifted to focus on Medicare Advantage commercial 
and Medicaid Managed Care plans.
    We believe congressional action to extend the current 
waivers and flexibilities is necessary and particularly 
valuable for patient care. During the initial surge of COVID-19 
in March of 2020, we were an important part of helping the 
Mount Sinai health system open up more capacity for patients 
needing higher levels of care, such as ICU, by completing Acute 
Hospital Care at Home for patients already hospitalized.
    However, we were still unable to admit fee-for-service 
Medicare patients from the emergency departments. We were very 
excited to be part of the original group of hospitals approved 
for the Acute Hospital Care at Home waiver in November 2020. In 
addition, we formed a Hospital at Home Users Group with support 
from the John A. Hartford Foundation, which provides technical 
assistance and office hours to other hospitals seeking to 
respond to the waiver.
    To date there have been 129 hospitals approved for the 
Acute Hospital Care at Home waiver, with 56 health systems in 
30 States, all since November. This shows that there is great 
interest. However, it does take significant start-up resources 
and time, and many hospitals are not planning to launch until 
this summer.
    I believe even more hospitals would implement Hospital at 
Home if they knew this program would be extended or made 
permanent.
    Therefore, we request Congress and HHS to consider a 
permanent extension of Acute Hospital Care at Home waivers 
beyond the PHE to mitigate the residual impacts of COVID-19 on 
the public health, and to encourage broader adoption of 
providing patient-
centered health-care services in the home.
    Thank you for the opportunity to present today.
    [The prepared statement of Dr. DeCherrie appears in the 
appendix.]
    The Chairman. Thank you very much, Dr. DeCherrie.
    Next will be Dr. Murali.

  STATEMENT OF NARAYANA MURALI, M.D., BOARD MEMBER, AMERICA'S 
 PHYSICIAN GROUPS; AND EXECUTIVE DIRECTOR, MARSHFIELD CLINIC, 
                         MARSHFIELD, WI

    Dr. Murali. Thank you, Chairman Wyden, Ranking Member 
Crapo, and members of the committee. I serve as the executive 
vice president of care delivery and chief strategy officer of 
the Marshfield Clinic Health System. I also serve as the 
executive director. What I am advocating for, and strongly 
believe, is that permanently supporting the flexibilities 
created in response to the COVID-19 pandemic, and broadband, 
particularly in middle America, will combat the rising cost of 
health care in America and its economic impact on both patients 
as well as their employers.
    The potential that telehealth infrastructure has advanced 
in the American health-care system in enhanced equity, access 
to health care, as well as prosperity for all Americans, cannot 
be overstated.
    It is my honor and privilege to testify on behalf of 
America's Physician Groups. APG is a national professional 
association representing 300 physician groups and their members 
with approximately 195,000 physicians who provide care to 
nearly 45 million patients from coast to coast.
    Our vision is to transition from legacy transaction fee-
for-service reimbursement to a capitated value-based system, 
where physician groups are held accountable for the total cost 
of care, the quality of care that they provide for their 
patients, and are incentivized to innovate to provide the best 
possible care.
    Marshfield Clinic Health System is one of the Nation's 
largest fully integrated systems, serving a predominantly rural 
population in the State of Wisconsin. Our 1,400 primary care 
and specialty providers provide approximately 3.5 million 
encounters annually.
    Our primary service area encompasses over 80 percent of 
Wisconsin's rural population. In fact, over half of our 60-plus 
facilities serve populations of less than 2,000 people. We have 
more cars than people. Our mission to provide health care for 
the large area greater than the State of Maine led to the 
genesis of our telehealth program in 1997, where we performed 
heart and lung exams over the Internet.
    Today we use telehealth for Hospital at Home care, acute 
care, arterial care, dental screenings in schools, and much 
more. We were one of the first hospitals in the country granted 
a Hospitals Without Walls waiver by CMS; this, because we were 
already providing hospital-level care in the comfort of our 
patients' homes since 2016, using telehealth even when there 
was no formal incentive to do so. We knew that for a subset of 
our population, there is no place like home for inpatient 
recovery.
    Compared to matched hospital cohorts, we saw our patient 
satisfaction increased by 22 percent, hospital readmission 
decreased by 44 percent, length of stay decreased by 37 
percent, and ER visits halved.
    Together, this created a 15-percent cost savings per 
episode per patient for the health plan. Since the onset of the 
pandemic, APG physicians have adopted a lifeline of telehealth, 
ensuring access to care for all patients who were terrified to 
leave their homes.
    In 2020, MCH provided a quarter of a million telehealth and 
telephone encounters. Presently, they average about 15 percent 
of all encounters. Telehealth is here to stay. It is convenient 
and economically beneficial for patients, as well as employers. 
Our patients are older, sicker, and poorer than average in the 
State of Wisconsin, as well as in the Nation.
    Almost half our children are eligible for reduced or free 
lunches. Public transportation is virtually nonexistent. Our 
patients are geographically isolated, and travel 2 hours in 
treacherous winter weather to come and get essential care. Such 
obstacles deny care. Telehealth addresses these disparities, 
ensuring proactive care that reduces ER visits, as well as 
enhancing equity and access to health care and stabilizing the 
economy.
    My heart tugs at the story of a 67-year-old diabetic woman 
whom I had managed for heart failure as well as kidney disease 
back in 2007. Since then, we managed her care virtually, except 
for one visit in a year. For the last 13 years, every year she 
has sent me a Christmas card.
    Telehealth has the power to become the norm of this 
country. We are at a critical juncture at this point. Here are 
some obstacles.
    First, given our experience with the current waivers, the 
site visit restrictions are no longer justifiable. The location 
for a physician or a patient should not deny care for a 
patient.
    Second, the greatest obstacle for patient satisfaction is 
access to broadband or Internet that is stable. Our patient 
appointments are taken by patients at schools, as well as 
library parking lots. It would be important for us to focus, at 
least as a stopgap, on using phone care for increasing access 
for Medicare Advantage people. Our members agree with that, 
that restricting care denies care.
    Finally, and most importantly, permanently reviewing and 
renewing the waivers, including acute care without walls, will 
trigger commercial investments to go faster. I thank you for 
your service, as well as your support.
    I would like to share this in the historical context. The 
U.S. Congress has acted decisively in the past, creating great 
infrastructure like the Hoover Dam, the Tennessee Valley 
Authority, and the highway system. We look forward to working 
with you in advancing America's health care Thank you.
    [The prepared statement of Dr. Murali appears in the 
appendix.]
    The Chairman. Thank you, Dr. Murali. I can tell you, 
millions of Americans would be clapping for your proposition 
that, with respect to health care, there is no place like home. 
So thank you very much for your valuable testimony.
    Dr. Berenson?

             STATEMENT OF ROBERT A. BERENSON, M.D.,
       INSTITUTE FELLOW, URBAN INSTITUTE, WASHINGTON, DC

    Dr. Berenson. Thank you very much, Chairman Wyden, Ranking 
Member Crapo, and members of the committee.
    Telehealth offers the promise of an important disruptive 
innovation in health-care delivery, improving access and 
quality, while reducing spending. However, decisions on how to 
pay for expanded use of telehealth will determine whether that 
promise is achieved.
    As a practicing internist, the government official in 
charge of Medicare payment policy at CMS, and now as a policy 
researcher at the Urban Institute, I have spent much of my 
professional life exploring better ways of paying health 
professionals. I have also worked on Medicare payment issues as 
the Vice Chair of MedPAC, and as an initial member of the PTAC, 
which was established under the MACRA legislation.
    On PTAC, I often argued for a straightforward fee schedule 
change, rather than the proposed alternative payment model, to 
achieve the purpose sought. My objections to some alternative 
models are that they are not operationally feasible. The 
converse is the case for telehealth. Fee-for-service for 
telehealth is not operationally feasible as long-term payment 
policy. I will briefly outline three major reasons.
    First, fee schedules function reasonably well when the code 
descriptions are concise and clinically relevant, producing 
reliable and accurate coding. Codes for telehealth services are 
anything but concise. Telehealth code descriptions specify the 
specific modality employed, the patient's location during the 
communication, which party initiated the service, the duration 
of the virtual encounter, and a range of other specifications 
for each code that was described as part of the telehealth 
expansion.
    These coding parameters were established for payment 
purposes alone. They are not useful clinically. Using the 
standard fee schedule to pay for telehealth services would 
likely produce a quagmire of confusion, inadvertent or 
intentional miscoding, and lots of clinician and patient 
complaints about burden and counterproductive rules.
    Second, for many telehealth services, fee-for-service 
payments generate high billing costs relative to the payment 
actually received. A recent study found that the cost for 
billing and related documentation for an office visit was more 
than $20. And that is just the billing cost for the first 
submitted claim from the practice. A typical claim bounces 
between the practice, the Medicare contractor, the supplemental 
insurer, back to the practice, and then to the patient for 
applicable cost-sharing. Proper and fair payment levels will 
often be lower than the billing cost. So they either will not 
be billed or, even worse, they will not be provided post-COVID.
    Yet, raising the fee to make it financially worthwhile, as 
under pay parity, would ignore the 30-year process for setting 
relative values in Medicare. Paul Ginsburg, who is the current 
Vice Chair of MedPAC, and I wrote that that process needs to be 
changed, but it should not be changed on an ad hoc, one-off 
basis just for telehealth.
    Third, patients face substantial time costs and 
inconvenience in traditional travel, waiting rooms, and actual 
time with the clinician. I recently waited 20 minutes after my 
annual wellness visit just to check out. My time commitment for 
the visit was 3 hours. Patients will often prefer virtual 
visits, but there should be brakes on demand and spending, 
especially if paying for fee-for-service at parity.
    RAND researchers found in the pre-COVID period that 90 
percent of telehealth services were additional services, rather 
than substitutes for in-person services. Used properly, 
telehealth services often should be add-ons, such as for 
chronic care managers but also for lots of other sound clinical 
reasons, and those communications can certainly be done by 
telephone calls in many cases. But those add-on services need 
to be managed by the practice, within a spending constraint, to 
help assure that virtual visits are used appropriately.
    CMMI has developed a primary care alternative payment model 
called ``Primary Care First.'' The approach needs to be tested 
in an expedited fashion on a regional, mandatory basis, in my 
opinion. It has the potential to be the permanent payment model 
for primary care practices generally, while also addressing 
payment for telehealth services. My written testimony also 
provides initial thoughts on using lump sum payments to 
practices for specialists' use of telehealth, rather than fee-
for-service.
    So in conclusion, I would just suggest that this is an 
important time and a real opportunity to fundamentally examine 
how Medicare pays physicians and other health professionals, 
and it should not be just sort of a default ``let's just 
continue the current payment flexibilities and high payment 
levels'' without full consideration.
    Thank you very much.
    [The prepared statement of Dr. Berenson appears in the 
appendix.]
    The Chairman. Doctor, thank you. And we have virtually 
every member participating, so we are going to have to stay 
pretty close to the 5-minute rule today, colleagues.
    My first question really speaks to the question of balance. 
We love the speed and efficiency of new technologies like 
telehealth, and at the same time, as Dr. Berenson just 
mentioned, we have to ensure quality care and accountability. 
And he described this horror story of bills just bouncing from 
place to place to place. So we are going to have to move 
around.
    In terms of questions, I think I will start with our GAO 
person, and Dr. Berenson, on this. What are the lessons learned 
from how we did telehealth during the pandemic in striking this 
balance that I described as speed and efficiency and quality 
and accountability? Why don't we start with the GAO person, and 
then we will go to you, Dr. Berenson.
    Ms. Farb. Sure. Thank you, Chairman Wyden. I think what we 
have learned so far is that we do not have the complete 
information that we need to study what we need to study in 
order to make some determinations about some of the issues that 
Dr. Berenson was raising.
    I believe that is why MedPAC actually recommended that some 
of these flexibilities continue with some guard rails in place 
so that we can study the effects of these issues on the quality 
of care, which is still not quite known in Medicare at this 
point, and on sort of program spending and provider and 
beneficiary behavior.
    The Chairman. Dr. Berenson?
    [Pause.]
    The Chairman. You are muted, Doctor.
    Dr. Berenson. Okay, I am on. I will make two points. One is 
that we learned that if you simply pay what the sort of process 
is for generating relative values and fees that has been used 
in Medicare, you will not get the services you are desiring.
    In 2019, Medicare, CMS, put into effect something called a 
check-in visit, which was a payment to physicians to call their 
patients to discuss whether they needed to come in for an in-
person visit. The payment by the traditional method was about 
$14 and change. And guess what? Nobody did the visits. It was 
less. The practices are not stupid, so they may have made the 
call but they sure did not bill for it, and I would suspect 
that many practices did not even do it because of the 
inadequate payment.
    And within 2 weeks of announcing that there would be a 
whole new list of telehealth services, CMS raised that payment 
level from $14 and change to $56. And guess what? Doctors did 
it. And I think it was a very smart move by CMS to get money 
out the door to beleaguered practices that suddenly saw their 
revenues decrease dramatically and patients who could not get 
care. So the payment level matters a lot. And so that is one 
point.
    The second point I want to make is that--actually I am 
blanking on what my second point is, and so I will move on.
    The Chairman. Thank you.
    Let's go to the equity question. And by the way, all of you 
can give us additional information for the record. I just felt 
that this question of striking a balance is what practitioners 
and patients are always asking me. They want the speed. They 
like the efficiency. But they want the quality, and they want 
answers to these kinds of questions. So apropos of what we 
heard from GAO, we will be interested in more information, for 
example, on your work apparently in the guard rail kind of 
area.
    A question for you, Dr. Davis. We have said in our work on 
this committee, every single time out, we are going to focus on 
equity issues, because we know in America much of health care 
is really a desert for vulnerable people. If you are affluent, 
and you are white, and you are in the suburbs, you have the 
world in front of you. If you are in the BIPOC community, very 
often these options just pass you completely.
    So our first work was on maternal mortality, but we want to 
make sure that the principles of fairness extend to new 
technology as well. Wave your wand and tell us a couple of 
things you think you would be doing if you were on the Finance 
Committee to promote racial equity in telehealth.
    Dr. Davis. Thank you, Senator Wyden. That is a great 
question, and it is a concern that we have as well. What we 
have seen from the pandemic is that there has been unequal 
access, and the communities that have been most likely to 
access telehealth have been whiter, richer, more urban, and 
with more access.
    And so I think the first thing is--really as we are 
exploring and expanding telehealth--really being sure to make 
sure that the data that we collect is stratified by race, 
ethnicity, gender, language, and other key factors, making sure 
that we are taking customer and patient reviews into account as 
we are expanding outward. And then also, continuing to invest 
in infrastructure, in broadband for our rural communities, for 
our underserved communities, making sure that they continue to 
have access so that we are not inadvertently creating a two-
tiered system where all have access to in-person and only some 
have access to telehealth.
    The Chairman. Good. I am over my time.
    Senator Crapo?
    Senator Crapo. Thank you very much, Mr. Chairman.
    I will start with you, Ms. Farb. The waivers have clearly 
been successful in increasing patient access. The impact of 
telehealth on the quality and cost of care is more complicated 
to measure, as you have indicated.
    Focusing on the quality part of the equation, what metrics 
do you use to measure the quality of telehealth services, 
including in comparison to in-person care?
    Ms. Farb. Well, Chairman Crapo--Senator Crapo, sorry--thank 
you for that question. Organizations like the NCQA and AQF have 
been working during the past year to retool their quality 
measurement sets and the frameworks that they use to develop 
quality metrics specifically for telehealth.
    The key areas that AQF has noted include things like the 
timeliness of care--and obviously, telehealth may have an 
advantage in that regard--how well it encourages care 
coordination, and patient empowerment and engagement.
    So there are a number of different metrics and sort of 
categories of metrics along which the quality organizations are 
suggesting telehealth be measured. We at GAO have not yet 
looked into specific quality measures for telehealth yet. We 
have been asking about those as part of our ongoing work to try 
to understand how providers and others are viewing that.
    Senator Crapo. All right; thank you.
    And, Dr. Murali, it seems the ideal way to deploy 
telehealth is for a physician working with the patient to 
decide which care modality works best for each patient visit. 
But payer policies related to billing, documentation, and 
payment play a large role in the extent to which providers 
offer telehealth.
    Understanding that physicians provide the same level of 
patient care regardless of the type of insurance, is telehealth 
more feasible in a capitated payment arrangement?
    [Pause.]
    Senator Crapo. You are muted. There you go.
    Dr. Murali. Senator Crapo, thank you very much. Absolutely. 
Transactional fee-for-service does not help people to innovate 
because it is transactional. If you need transformation, you 
need prospective payments. Capitated payments allow the 
physician groups to focus on what is important as well as 
invest in the infrastructure required to provide optimal 
telehealth that is integrated in the electronic medical 
records.
    As I shared in my documentation, presently physicians have 
worked as heroes. They do the video chats, the e-coms, as well 
as all the transactions while they are doing telehealth, but 
the systems are not optimally designed to get at patient care. 
So if you want to get the efficient care and adoption at a much 
higher rate, that is absolutely necessary, and you are right 
on.
    Senator Crapo. Well, thank you.
    And, Dr. Berenson, could you comment on the same question?
    You are muted.
    Dr. Berenson. I don't know who is muting me. In any case, I 
agree very much with Dr. Murali. Capitation does not--the 
problems that I described in fee-for-service where you have all 
these rules and requirements as to the circumstances that you 
have to follow and on which you can bill, in my practice I have 
found often a 2- or 3-minute phone call follow-up the week 
after I either made a tentative diagnosis or changed the 
medication, was the proper way to follow up with a patient. 
Yet, that would not qualify for payment under fee-for-service.
    With capitation, you have essentially an account that can 
be deployed to appropriately use capitation without artificial 
rules and regulations, to use telehealth without artificial 
rules and regulations. So I think that is the way to go.
    CMMI has actually developed a model which is sort of half 
fee-for-service and half capitation. It seems like with 
expedited testing it could, within a couple of years, become a 
national model for moving primary care practices. It is a 
little trickier to figure out how to pay specialists for their 
telehealth because, with capitation, it is not easily done for 
specialty services.
    Senator Crapo. All right; thank you.
    And back to you, Dr. Murali. We have talked about broadband 
and some of the infrastructure aspects of getting this issue 
resolved. You stated that telehealth was a fundamental element 
of caring for patients in rural Wisconsin, even before the 
pandemic. And can you speak to how Marshfield Clinics made the 
necessary investment in infrastructure and physician training 
to make that possible?
    Dr. Murali. Yes; some before the pandemic, some during the 
pandemic. Before the pandemic, we invested in optic fiber 
cables, along with our community of three-quarters of a million 
in Marshfield, to expand the capacity to provide that service; 
invested in a stand-alone data warehouse; as well as focused on 
trying to get the intelligence required for providing good care 
with quality outcomes that are measured.
    In addition to what needs to be done--so if you want to 
provide telestroke coverage or ER coverage, or you want to do 
Hospital at Home, you need to invest in equipment and platforms 
that translate to roughly about $4\1/2\ million a year for us 
as a health system.
    And so we have been doing that without any concern, because 
there is no other way to optimize labor and recruit physicians 
to provide the care in populations that are less than 2,000 in 
a 45,000 square mile geography.
    Senator Crapo. Thank you very much.
    The Chairman. Doctor, thank you.
    With 26 Senators waiting to ask questions, we are going to 
move quickly.
    Senator Stabenow?
    Senator Stabenow. Well, thank you very much, Mr. Chairman. 
And you know, I have been smiling this morning as I am thinking 
back to when so many of us pulled together before the CARES Act 
was put together. At the time, Senator Thune and I were charged 
with getting together to make some recommendations, bipartisan 
recommendations on Medicare. And we quickly came together 
around telehealth. And of course the committee embraced those 
recommendations.
    And I am just so pleased that we were, all of us together, 
willing to move forward on telehealth. And I support yours and 
the ranking member's desires to make these things permanent, 
certainly dealing with the issues around accountability that we 
need to do.
    So when we look at the issues around telehealth, I wanted 
to specifically ask about mental health and addiction services. 
We did include these areas for behavioral health clinics to be 
able to use telehealth, as well as community health centers and 
others.
    And while we are seeing that there has been dramatically 
expanded access to telehealth--CMS reported a 2,700-percent 
increase in telehealth utilization for Medicaid and children's 
health insurance beneficiaries. That is amazing.
    But in behavioral health treatment for Medicaid and for 
CHIP, actually at the same time, it dropped dramatically 
overall during the pandemic--22 percent for adults, and 34 
percent for children. So we definitely want to move ahead and 
do what we need to do to strengthen all these policies. But I 
do want to ask, Dr. Davis, if you could speak to the mental 
health addiction services piece of this, and what we need to do 
to be able to make sure we are reaching out to everyone who 
needs help, because obviously in this space, we are not 
reaching people.
    Dr. Davis. Thank you, Senator Stabenow. Yes, telehealth for 
mental health and behavioral care is so important, and it 
really can help remove barriers to access, to stigma in terms 
of patients who may be hesitant to get out and meet somebody in 
person--and being able to see them face to face makes a huge 
difference.
    In the practice that I work in, we have a strong connection 
with mental health. And so it has been absolutely beneficial to 
our patients to be able to provide them with behavioral health 
services through telehealth.
    We also provide addiction services. And so being able to 
provide substance use disorder and MAT treatment through 
telehealth has been essential for our patients. I cannot 
explain why we have not seen the increase that we might have 
expected, but I can tell from patient experience that it is an 
essential service.
    Senator Stabenow. Thank you.
    And let me take my last moments just to ask Dr. DeCherrie 
about home health, more about home health, because we know that 
as we were expanding eligibility for more people to get care at 
home during COVID-19, how important that was. And many Medicare 
beneficiaries can now receive that care at home that they would 
previously have had to travel, or risk exposure, to be able to 
receive. And we know that home health care helps in many 
different ways.
    But, Dr. DeCherrie, could you discuss the benefit to 
meeting patients' needs in their communities, including at 
home, when medically appropriate? Just a little bit more about 
why you think it is important that we focus on that.
    Dr. DeCherrie. Yes. Thank you for that great question. So 
yes, I provide care both in Hospital at Home--home-based 
primary care, home-based palliative care--so I believe in 
multiple models of home-based care. They all have their place, 
and we have seen increased need during this pandemic, where 
patients want to be home and get that care at home.
    So yes, I think all of those are things that we should 
think about how to expand.
    Senator Stabenow. Thank you. Thank you, Mr. Chairman. I am 
going to yield back 30 seconds, for the good of order.
    The Chairman. Thank you for your good work.
    Senator Grassley is next.
    Senator Grassley. Thank you, Mr. Chairman. I am glad to be 
with you for a very important issue of lessons learned from the 
pandemic, but we are still going to continue to learn a lot. 
Thank you very much.
    So I am going to ask questions of all the panelists, pretty 
much, so if you can save some time by not repeating each other, 
I would appreciate it.
    So my first question to the panel is, while the pandemic 
has shown many flexibilities in health care take place without 
compromising patient safety and quality, there are still areas 
in health care that are restricted by Federal laws and 
regulations. I sponsored the Pharmacy and Medically Underserved 
Areas Enhancement Act with Senators Casey and Brown. This bill 
would let pharmacists operate in a medically underserved area, 
offer health services like wellness screening in diabetes 
management, and be paid by Medicare.
    For each of the panelists, which additional flexibilities 
should Congress consider, to improve patient access and remove 
Federal red tape?
    Dr. Murali. Senator Grassley, if I may, at this point in 
time in the Marshfield Clinic Health System, we do about 53,000 
to 55,000 telepharmacy visits using the pharmacist at one 
center to help with respect to mixing in a sterile environment 
all the medications that are required across the large 
geography. So promoting programs that will help, like you have, 
is going to be very, very valuable in this space.
    Senator Grassley. Is there anybody else who wants to add, 
although you do not all have to speak if you do not have 
something to add.
    Dr. Davis. Sure. This is Dr. Davis. I will say, I 
appreciate the extension of pharmacy, and as long as that is 
done as part of the medical home, I think that is important.
    Speaking of other flexibilities beyond telehealth that 
should be considered, one is Medicare and Medicaid coverage for 
all AAFP- and also ACIP-required recommendations, not just the 
COVID-19 vaccines, but access without cost sharing beyond the 
public health emergency.
    In addition, allowing physicians to provide direct 
supervision and teaching services via real-time two-way audio/
video communication, which would expand access to primary care 
and increase training opportunities. This is already being done 
in rural areas, but extending that to all communities.
    And then permanently removing or reducing the volume of 
prior authorizations, step therapy, and other administrative 
requirements, and allowing those to be done via telehealth or 
in person.
    Senator Grassley. Okay. Since you brought up telehealth, I 
am going to go to my next question. It is really a positive 
thing, I think, that has resulted from the pandemic, if you 
want to say anything good can come out of a pandemic. The 
public health emergency permitted more than 140 services to be 
administered through telehealth. Last Congress, we made mental 
services by telehealth a permanent Medicare benefit.
    For each of the panelists who are physicians, telehealth 
was widely adopted throughout the pandemic, with its current 
utilization greater than pre-pandemic but less than its peak 
last spring. What type of medical services are most utilized 
today through telehealth? And which ones are most effective for 
patients and providers? And maybe the last half of that 
question is the most important part of it.
    Dr. Murali. Senator Grassley, so from the standpoint--I 
heard Senator Stabenow's comment. In the Marshfield Clinic 
Health System, the number of behavioral and psychological 
consults that go through telehealth has more than doubled 
compared to the average.
    So more than 30 to 40 percent of home visits are actually 
for behavioral visits, for substance abuse, as well as with 
other elements. So that is an important factor from the 
standpoint of telehealth. I leave it to the others to comment.
    Dr. Berenson. I will just make a brief comment on that as 
well. I am going to agree again with Dr. Murali about the role 
of behavioral health by telehealth. I was involved with 
interviewing primary care physicians, nearly 20, and they all 
said, even though they are not specifically behavioral health 
physicians, that that has been the biggest uptake and the most 
valuable thing that has occurred.
    The only issue that I can raise there is that, in some 
families there may be a confidentiality issue, where we are 
doing the telehealth when the patient is at their home. But 
that can usually be worked around.
    I do not think there is a comprehensive analysis yet of 
which services--we heard anecdotally, for example, that 
hypertension was good to manage by telehealth because patients 
had their own blood pressure machines and could take their 
blood pressure, whereas for diabetes the patient needed to come 
in for a blood test to check the hemoglobin A1C. And this will 
evolve over time.
    I think, however, that for the most part virtually all, 
sort of general medical and--not surgical, which needs a 
procedure in many cases--but general medical issues can be 
dealt with with telehealth being a central part of the 
management strategy.
    Senator Grassley. Thank you, Mr. Chairman. I am going to 
submit other questions for answers in writing.
    The Chairman. That will be fine.
    Senator Cantwell, chair of the Commerce Committee, and an 
expert, is next.
    Senator Cantwell. Thank you, Mr. Chairman. Thanks for 
having this hearing.
    If I could just get a quick ``yes'' or ``no'' answer from 
all the witnesses, do you think we need more affordable health-
care options for people in America?
    Dr. Davis. Yes.
    Dr. DeCherrie. Yes.
    Ms. Farb. Yes.
    Dr. Murali. Yes.
    Dr. Berenson. Yes.
    Senator Cantwell. Thank you.
    Ms. Farb, one plan that is out there that could help reduce 
the cost is the Essential Plan in New York, or better known as 
the Basic Health Program from the legislation. It has allowed 
people under 200 percent of the Federal poverty line to see a 
huge savings in their costs.
    Should we be doing more to drive the value of expansion of 
this program to other States?
    Ms. Farb. Senator Cantwell, thank you for the question. We 
have not done any work looking at that plan in New York at GAO, 
so I cannot really comment on whether or not it should be 
expanded. I defer to my colleagues.
    Senator Cantwell. Yes, Dr. DeCherrie, you are a New Yorker. 
What do you think?
    Dr. DeCherrie. That is also not in my area of expertise, so 
I do not have anything to add to that.
    Senator Cantwell. Okay. Anybody else?
    [No response.]
    Senator Cantwell. Okay, so I guess we have a mystery here 
that maybe I can try to illuminate for the future. But I can 
tell you this. My constituents are tired of subsidizing 
expensive health insurance plans when we do not have to. If 
there are ways to buy in bulk, which New York and Minnesota 
have done, and bundle up a large percentage of the population, 
then, yes, they believe they should get discounts. That is what 
is happening.
    So, Mr. Chairman, mark me down as someone who is not going 
to go along, even if it is a Democratic proposal, not going to 
go along until we do something about lowering the investments 
we are making in expensive subsidies to insurance companies for 
health care.
    This plan has worked in two States, and we should be using 
it as a way to save dollars and expand coverage to more people. 
Americans cannot, even with our tax subsidies, continue to have 
expensive health insurance costs.
    Okay, great discussion on telehealth. I really appreciate 
all of that. The University of Washington has gone from doing 
about 20,000 people a year to 20,000 a month. And I am curious, 
Dr. DeCherrie or Dr. Berenson, what do you think that--what 
else do we need to do to change the actual reimbursement rate? 
Does it have to be on exact parity? Can it be a little off of 
parity? What do we need to do to make sure the reimbursement 
rate is fair? Or is there something else we need to do to 
differentiate?
    Dr. DeCherrie. I think that is probably Dr. Berenson's 
field to answer.
    Dr. Berenson. Again, my compulsion would be that we 
continue fee-for-service as an interim strategy. I do not have 
the magic number for you. If we pay based on the traditional 
resource-based relative value scale approach, the payments for 
the low end of telehealth would be too low to actually have 
them perform.
    Pay parity, where we are now paying three times what that 
sort of proper amount should be, is too high. So I think some 
smart people could get into a room and come up with some middle 
ground so that it was high enough that physicians and practices 
would actually bill it. But RAND has pretty well demonstrated 
in a prior study, and I have not seen it challenged, that the 
costs for telehealth are less than the costs for in-person. It 
just makes sense. And telehealth becomes sort of standard in 
most practices. They will--practices will reduce some of their 
infrastructure, and maybe work with less space, and their costs 
may come down. But in the interim, I think we can find some 
middle ground. But it should be in the context that we are 
moving to something different at some date, if not certain----
    Senator Cantwell. Thank you for that honest answer. Do you 
think that is rocket science? Or do you think that is just 
coming to terms on numbers--and yes, people will obviously have 
strong opinions. But do you think that is something we could 
achieve in the next several weeks?
    Dr. Berenson. The next several months. I think we have seen 
surveys of practices to get some answers.
    Senator Cantwell. Thank you so much. I do not know if I 
have any time left, Mr. Chairman. I cannot see the clock here, 
so----
    The Chairman. You are pretty much on the line, but do you 
have one other one you want to ask?
    Senator Cantwell. I just want to say that I hope that Dr. 
DeCherrie could answer some questions in writing about--
MultiCare got a CMS waiver on helping integrate doctor care and 
home care. So it is basically better ways for the home health-
care programs to work with health-care providers, and I hope 
that we could look at that also as a cost savings in keeping 
patients in their homes longer.
    So thank you very much, and we will write something for the 
record on that.
    The Chairman. Great. And, Senator Cantwell, I want 
everybody to know I am with you all the way on this proposition 
that States ought to be given the opportunity to be able to do 
more to hold down health-care costs. And I think you said it 
very well.
    Senator Cantwell. Thank you.
    The Chairman. Senator Cornyn is next.
    Senator Cornyn. Well, thank you, Mr. Chairman. We all know 
that in an effort to maintain adequate capacity in our 
hospitals and doctors' offices, we limited the amount of 
elective procedures that were performed to deal with the 
potential surge of COVID-19 patients. And as a result, a lot of 
health-care screenings, colonoscopies, other life-saving 
diagnostics, dropped dramatically.
    We know that about a third of adults have not received 
recommended screenings for age-associated risks during the 
pandemic, and 43 percent of patients have missed routine 
preventative health appointments as a consequence of these 
precautions.
    Fortunately, now that more people are being vaccinated, 
hopefully those numbers will improve. But I want to add my 
voice to the chorus, I guess, here today of advocating the 
enhanced use of telehealth. I tell my friends and constituents 
back in Texas there are only two good things that came out of 
COVID-19. One is telehealth, and the second is margueritas to 
go. Those are the only two good things I can think of.
    So let me ask. We are all very familiar with the digital 
divide. And this is very true, particularly of big States like 
mine, and we are working on that diligently. Senator Manchin 
and I have a Digital Divide Act which would provide grants to 
Governors to help them work with Internet service providers to 
connect underserved areas.
    But I want to ask the panel about audio telehealth. It 
seems to me that this could be an interim solution to make sure 
that low-income earners could get access to a doctor or health-
care advice over the telephone. So maybe starting with Ms. Farb 
and Dr. Davis, could you explain how telehealth services 
furnished by audio-only communications could increase access to 
care, particularly in rural and underserved areas?
    Ms. Farb. Sure. I'll start, and then I think Dr. Davis can 
speak more fully to this. But what we have observed--and even 
talking to some of the provider groups you have spoken with--is 
not only the beneficiaries not having access, but providers not 
having access is also an issue. And so a lot of providers 
initially started off using audio-only telehealth services, 
especially for the office visits, the evaluation and management 
codes. And that has probably continued throughout the pandemic.
    But in the early days, that was definitely a source of 
modality that really was working for a number of groups that we 
have spoken to.
    Senator Cornyn. Dr. Davis?
    Dr. Davis. Thanks for that question. I would also echo that 
the need for audio-only is essential, both for our under-
represented communities and under-serviced. We realize that 
sometimes broadband is just not there, and we will try and try 
to connect with patients via video, and the resource is just 
not there. The patient is not comfortable with it. They cannot 
get their smartphone or device to work, or they just do not 
have one. And as we build infrastructure, we should build it in 
a way that is mindful of that.
    I also want to call out specifically around translation 
services for our non-English-speaking patients. And being able 
to get that language translation is often easier through an 
audio-only visit than it is through an audio-video visit.
    Senator Cornyn. So, Dr. Murali, I saw you nodding when I 
asked about audio-only telehealth. What is your view?
    Dr. Murali. Well, out of the quarter-million or so 
encounters that we have in Wisconsin, more than 50 percent of 
the visits are by audio only. Unfortunately, even Medicare 
Advantage does not consider it for risk evaluation or 
adjudication, and that is a bad deal for patients because it 
increases disparities. And I think when you think about the 
digital divide, as well as racial disparities, we also need to 
think about the fact that even white people in rural America 
are poor. They basically do not have access to care. And there 
is also the question of literacy that needs to increase.
    So all of those are disparities that we have to keep in 
mind. So, right on.
    Senator Cornyn. I have time for one more question. You 
know, one of the concerns we have is about security of, 
specifically, personal health information. Obviously HIPAA 
provides that generally speaking, but as we continue to provide 
more telehealth, I am worried about the protection of the 
privacy of the doctor/patient relationship.
    In closing here, do any of you have any particular 
observations or experience about how we can make sure that that 
is preserved?
    Dr. Murali. Yes. So I think it is important to invest in 
the infrastructure for security breaches. What is happening in 
Ireland right now with Conti is a good example of a security 
breach. And that can be addressed by infrastructure.
    And then from the psychiatric care side, patients actually 
prefer to do that from home because it gives them the 
psychological safety of having that discussion in the comfort 
of the home, as opposed to sitting in a public health waiting 
room.
    So those are all factors that should be factored in, and 
that is why payment parity is necessary to get us moving 
forward on this.
    Senator Cornyn. Thank you very much, Mr. Chairman.
    The Chairman. Thank you, Senator Cornyn. And we are with 
you on the audio question, particularly if the take-up rate is 
as low as Dr. Murali said; it is probably even worse when you 
are talking about traditional Medicare. If the take-up rate is 
low on MA, think about what it is like on traditional Medicare. 
So we are going to follow that up. Thank you.
    Our next questioner is Senator Menendez.
    Senator Menendez. Thank you, Mr. Chairman.
    Dr. Davis and Dr. Murali, in your testimony you both 
highlight the importance of audio-only telehealth. Can you tell 
the committee a little bit more about why coverage of audio-
only telehealth services is so critical to ensure that we do 
not further fall behind on health-care equity?
    Dr. Murali. Senator Menendez, I would like to invite you to 
visit us in Marshfield. You can go from one location to any of 
our 60 locations for 2 hours without having access to the 
Internet. And the only thing that works is the old-fashioned 
telephone network.
    So if we are really trying to address geographic isolation, 
that phone call is the most critical piece. In the Hospital at 
Home program that we started, we were trying to work those 
pieces back in 2016, and we were looking for one bar out of 
five to make sure that we could provide some kind of virtual 
help.
    So it is not just the access to broadband, it is also the 
degree to which broadband is available in these rural areas 
that causes the disparity. So I hope that answers your 
question.
    Senator Menendez. Dr. Davis?
    Dr. Davis. And I would second everything that Dr. Murali 
just said. The extension to rural areas is so important, and 
really investment in primary care is helpful in bridging that 
digital divide so that patients have timely access to in-person 
care and audio-video telehealth.
    But the audio-only is really just essential for getting 
past some of those barriers. And we do not want to create a 
two-tiered system, so we need to make sure that payment is 
adequate to support the flexibility and modalities of care.
    Senator Menendez. Thank you.
    Dr. DeCherrie, building on the previous question, the 
COVID-19 pandemic did not create inequity in our health-care 
system. Inequity is in fact a hallmark of American health care.
    What role can telehealth play in addressing longstanding 
health disparities in our health-care system?
    Dr. DeCherrie. Yes. I mean, I witnessed this firsthand in 
my home-based primary care program where, again, most patients 
did not own a cellphone and had no ability to do any video 
visits. And we, like Dr. Murali mentioned, did everything by 
telephone those first couple of months.
    In my Hospital at Home program, we actually provide every 
patient with a telehealth kit. And even here in New York City, 
one kit that is set up with Verizon does not always work when 
they switch to the AT&T one. You know, even here in New York 
City we have these issues.
    So, to be able to provide care for patients in their homes, 
we need to think through these things and make sure we have all 
options available.
    Senator Menendez. Ms. Farb, data collection has been an 
ongoing issue throughout this pandemic. I sent letters to the 
administration, as well as the last one, about the need for 
better data collection during the pandemic.
    I am disappointed that HHS has still not consolidated data 
collection into one site with standardized reporting 
requirements. What data is needed about the flexibilities 
extended during this public health emergency to show the 
committee the impact of these flexibilities? And what, if any, 
flexibilities should be made permanent?
    Ms. Farb. We do not have any recommendations yet on any 
flexibilities that should be made permanent. One thing I did 
want to point out that might be worth considering as the 
committee undertakes some of this work is ensuring that some of 
the program requirements between both Medicare and Medicaid--
you know, looking at how well they align and what are some of 
the differences. Because I think the providers on the panel 
probably agree that having two very different sets of rules 
around how telehealth works can make it difficult for them to 
operate in that environment where they are dealing with that.
    As far as data collection goes, yes, we have made a number 
of recommendations during the pandemic around providing better 
data, as well as ensuring that the data are contained in a site 
that is publicly accessible on cases, hospitalizations, et 
cetera.
    For flexibilities, I think what we do not have is some of 
the information we need about differences between different 
telehealth modalities and some of the patient information 
demographics that we need and the sites of care so that we can 
look at quality and other things that would be important to 
measure.
    Senator Menendez. Thank you.
    Finally, Mr. Chairman, I know we are all committed to 
building back a stronger health system, ensuring our Nation is 
ready for the next pandemic, and dealing with the inequities in 
our system, but if we are going to do that, I think one of the 
most effective and informed ways that we can come together on a 
nonpartisan basis is to conduct a thorough examination of the 
United States' COVID-19 response. What went right? What went 
wrong? How can we do it better? That is why we have a 
bipartisan, bicameral National Coronavirus Commission Act that 
my friend and colleague, Susan Collins, has joined me on. I 
appreciate your support as well, Mr. Chairman, as well as 
Senator Brown and Senator Kaine. And the House has 
Representatives Malinowski and Diaz-Balart on a bipartisan 
basis leading an effort. And I hope we can get that, because I 
think that would provide us an unvarnished and fair process of 
understanding what went right and what went wrong. Thank you.
    The Chairman. We will be supporting you. Thank you.
    Senator Cardin is next.
    Senator Cardin. Well, thank you, Mr. Chairman, and I want 
to thank all of our witnesses. And I want to just join the 
overwhelming number of our members on lessons learned from 
COVID-19 about telehealth. But I just really want to follow up 
with Senator Menendez.
    It also shows the inequities in our health-care system. And 
those communities that do not have the same degree of 
infrastructure, health infrastructure, or access to 
infrastructure, health care, were the ones who suffered the 
most during COVID-19. There is no question about that.
    So it means we have to strengthen that. So as we look at 
telehealth--which was critically important for mental health--I 
hope we go forward with permanent changes in our reimbursement 
structures and in the reciprocal regulatory issues among States 
so that we can expand telehealth, because I think it gives 
timely access to care for so many individuals.
    I just really want to underscore the point that Senator 
Menendez made about not developing a two-tiered system. It is 
very clear to me that, as a practical matter, having audio-only 
is better than not having any care. But if we set up a 
structure that has a two-tier system, those who have access to 
high-speed Internet or have the ability to access providers 
that can provide a much more comprehensive telehealth service, 
and other communities that do not have that same degree given 
only audio, we run the risk of a two-tier system. And if the 
reimbursement structure incorporates that, it then becomes also 
a two-tier system.
    So I guess my question to all of you is, as we look at the 
reciprocal regulations, as we look at the reimbursement 
structures, as we look at access to broadband, and not just 
access to high-speed but the capacity to be able as an 
individual person to properly access that--some of our elderly 
have difficulty with this--what steps should be our top 
priority to make sure that, as we expand telehealth, which we 
all agree needs to be done, we do it in a way that does not set 
up a two-tier system?
    Dr. Berenson. I would be glad to start with----
    Senator Cardin. Jessica Farb, do you want to start? Or 
whoever wants to start?
    Ms. Farb. I think one option that has been suggested, 
although it does not sort of completely align with what the 
panel has been talking about, is to make sure to cover audio-
only where there is a documented barrier to audio-visual 
visits, and look at that for a brief period of time so that 
data could be collected to study the quality of care and 
determine the comparability to in-person visits.
    And as I said earlier, we have heard from providers--and we 
have already heard from this panel--that they have had to 
resort to audio-only when the patient did not have access. And 
as you pointed out, Senator Cardin, just having something is 
better than nothing.
    So trying to do some kind of targeted study of differences 
would be one way to try to make sure that we are giving 
comparable care.
    Senator Cardin. Dr. Davis?
    Dr. Berenson. If I could go next?
    Senator Cardin. Sure.
    Dr. Berenson. I have not had a chance to say this yet, but 
I will take this opportunity. I actually got interested in how 
to pay for telehealth after our Professor Ed Wagner at the 
University of Washington--who I am sure the chairman and 
Senator Cantwell know--proposed his chronic care model. And the 
chronic care model included--this was in 2003--it called for 
robust use of telephones, before we had video. I see video as 
being hyped a little too much here.
    In many situations such as chronic care management, you 
only need a few minutes with a patient. You have already seen 
them, either in person or through a video conference, and you 
want to be checking on how they are doing. We have created in 
Medicare a chronic care management code, but that is for very 
sick people who need really intensive care management.
    Most patients with hypertension or diabetes or congestive 
heart failure will benefit from a follow-up phone call. And so 
my view is that the phone calls are the encounters that take 
place for minutes. The video visit is for something longer, 
like an annual visit, or for something that really requires 20 
or 25 minutes, and where visual contact is necessary.
    And that would, I think, help a lot on the equity issue. I 
think that phones, audio-only as it is being called, should be 
equal. And that was one of my points, that the coding is sort 
of arbitrary. So I will pose the question, is the Zoom call 
with the video off, is that an audio-only? Or is that a 
defective video call?
    Senator Cardin. I think I will just underscore Ms. Farb's 
point. It would be good to have a study as to how audio works. 
Obviously follow-up conversations with health-care providers 
are one thing. But to do a diagnostic-type of interview is a 
lot of times easier and more effective with video.
    Anyway, I look forward to that study, and thank you, Mr. 
Chairman; an excellent hearing.
    The Chairman. Thank you, Senator Cardin. And I will tell 
you, Dr. Berenson, you are spot-on with respect to the history 
on chronic care. Senator Hatch and I always conceded that there 
would be a significant audio/phone component of it, and that is 
what we really envisioned in the first part of the bill.
    Okay. Senator Portman, I believe, is next, if he is there.
    [Pause.]
    The Chairman. Senator Portman, are you out in cyberspace 
somewhere?
    [No response.]
    The Chairman. Senator Brown?
    [No response.]
    The Chairman. Senator Cassidy, a physician?
    [No response.]
    The Chairman. Senator Bennet?
    [No response.]
    The Chairman. Senator Lankford?
    [No response.]
    The Chairman. I do see Senator Whitehouse on the screen, 
and he is not even on our list, but we have no other Senators, 
so let's have Senator Whitehouse, who is a very knowledgeable 
person on health care.
    Senator Whitehouse?
    Senator Whitehouse. Thank you, Mr. Chairman. Every once in 
a while, you get lucky and can jump the queue. I just wanted to 
pass along to the panelists the success that Rhode Island has 
had with these waivers during the COVID pandemic.
    We have made very good use of the Hospitals Without Walls 
program, and I would love to see that continued. We kind of 
broke the back of opposition to telehealth generally, and I do 
not think there is really any going back on that. It has been 
particularly welcome in the behavioral health, mental health, 
addiction area, where practitioners report to me not only 
better compliance with showing up and participating, but also 
better substantive content.
    It is hard for them to quantify that, but it is a repeated 
theme that there is something about being able to talk from 
your own home, from a comfortable place, rather than having to 
drive across town and fill out the clipboard and sit in 
somebody else's office. It just seems better.
    And the medication-assisted treatment element, and allowing 
access to buprenorphine, for instance, with telehealth, has 
been a godsend for that population.
    And the last thing I will mention is that I have been 
working for a long time to try to get CMMI to sign off on a 
bunch of waivers to deal with people who are nearing the end of 
life, for whom a lot of waivers make a lot of sense. It does 
not make any sense to fuss too much on how home-bound somebody 
is at that stage of their life. Home health services, waivers 
that we have seen through COVID, are very helpful.
    Respite care is not ``respite'' if you have to stuff granny 
in the hospital and not get help to come to her in the house. 
And the whole 3-day/2-night rule is ridiculous for those 
patients. And those waivers, I hope we can extend.
    I would ask Director Farb, with respect to the homebound 
and home health service and 3-day/2-night waivers, has GAO seen 
any evidence of heightened utilization as a result, heightened 
cost?
    Ms. Farb. Senator Whitehouse, no, we have not examined that 
directly. We also tried to look to see what CMS has been 
reporting, and so far they have created an accomplishment 
report sort of describing effects of many of the waivers.
    They have not included anything thus far in their 
reporting, but it is something that we are going to be tracking 
going forward, as we start to work on the additional waiver 
study that we are planning to do.
    Senator Whitehouse. Good. It is particularly important to 
me for people nearing the end of their lives, because it just 
does not make any sense. It is kind of cruel to the family to 
deny them those supports because of some funding requirement 
that is not even designed for that population but has terrible 
effects on families and their access to care.
    Dr. DeCherrie, are you familiar with the Hospitals Without 
Walls program? And would you like to comment on the wisdom of 
extending that?
    Dr. DeCherrie. Yes, and it is specifically the Hospital at 
Home portion of that that we made use of during this pandemic. 
I want to also go back to one thing that you mentioned earlier 
about the comfort of someone in their home. You mentioned it in 
the context of behavioral health, but I would broaden that.
    When we are in the home--and that could be either in person 
for the Hospital at Home, the nurses in person in the home, or 
through the video when a provider might be doing a video 
visit--seeing someone in their own context, to see what they 
are actually eating, might actually have long-term real impacts 
in their lives. And so these little snippets of getting into 
someone's home have really improved health for people long-
term.
    So I just wanted to make sure that that was understood.
    Senator Whitehouse. Let me close out with a little brag on 
Rhode Island ACOs. We have two--Rhode Island Primary Care 
Physicians, which operates an Integra ACO, and Coastal Medical 
in Rhode Island--and both of them are absolutely top-performing 
ACOs nationally. I mean they are right up in the upper corner 
of savings, and quality of outcome, and patient satisfaction.
    And part of what they have done is to engage with patients 
in their home in order to get better information, and that is 
part of what has made it work so well. I will go as far as you 
want to go, Dr. DeCherrie, on this. My problem is, I have been 
jammed up in CMMI for 10 years trying to get it just for those 
patients. So that is our beachhead. But I do think a lot more 
can be done, and the ACOs have shown a lot of good results on 
that.
    So I will yield back, because I think I am probably out of 
time, but I really appreciate this conversation. There is a lot 
to be done, and if people at CMMI are listening, I think we 
gave them these powers for a reason. Let's use them.
    The Chairman. Well said.
    Senator Brown?
    Senator Brown. Thank you, Mr. Chairman. I appreciated the 
comments of my friend from Rhode Island, and I know that 
Senators Cornyn and Menendez asked about audio health, audio-
only telehealth. So I would like to follow up with a couple of 
questions, particularly about folks who live in more urban and 
suburban settings who may not have access to video conferencing 
or Internet capabilities to access video telehealth.
    So my question is starting with Dr. Murali. Speak briefly, 
if you would, about the increased reimbursement for audio-only 
telemedicine, how it helped you stay connected with hard-to-
reach populations throughout the pandemic, both in underserved 
urban areas and underserved rural areas, if you would, Dr. 
Murali.
    Dr. Murali. Thank you, Senator Brown. So as I said 
previously, out of the quarter-million visits that we did at 
the Marshfield Clinic Health System, greater than 50 percent of 
those visits were done by audio visits. So what it allowed us 
to do is manage patients with heart failure. In fact, we had 
studies that demonstrated that we were able to save close to 
$2.7 million while managing 600 patients. Just imagine the 
power of that if you were to take that across the entire 
country.
    From the standpoint of behavioral health, I have already 
made my point about audio, because it gives you pretty much all 
of what you need to know from the standpoint of that care. So 
there are several benefits, but that is just a snippet of what 
audio can do.
    Senator Brown. Thank you, Dr. Murali----
    Dr. Murali. The other piece is----
    Senator Brown. Sorry.
    Dr. Murali. The other piece is that it is extremely 
difficult to get broadband access in rural Wisconsin. And so, 
if you do not provide that support on the audio side, you are 
geographically isolating these patients from seeking the care 
that they need, and therefore you are not being proactive. And 
that will increase your emergency care visits, as well as your 
urgent care visits, and overall costs from the standpoint of 
care.
    Senator Brown. Thank you.
    Dr. DeCherrie, I appreciated your comments about nutrition 
and what the window into the home can provide.
    Dr. Davis, my questions, my next couple of questions are 
for you. You recommend Congress act to require Medicare to 
cover audio-only evaluation and management services beyond the 
public health emergency to ensure equitable access to care. 
Talk, if you would, about two questions: how audio-only 
telemedicine services could help reduce disparities in access 
to care, and how should CMS monitor the impact of telehealth, 
including audio-only telehealth, in access inequity?
    Dr. Davis. Sure. Thanks, Senator Brown. You know, as a 
primary care provider and also working in an Accountable Care 
Organization, we have lots of experience with this. And audio-
only care, when used appropriately, is high-quality care. And 
so I want to make sure that we note that distinction, that 
studies comparing telephone-only visits to telehealth visits 
conducted prior to the pandemic found no significant difference 
in health outcomes or patients' reported satisfaction.
    And so it certainly is an additional tool in the toolbox in 
order to be able to provide equitable care for patients, 
regardless of whether patients are rural or suburban. I have 
provided care for those patients; the docs I work with have 
provided care for those patients; and across the board, we have 
had challenges when they are restricted to only video services.
    And so being able to interact with our elderly patients who 
may have trouble connecting and not have a family member close 
by who can help, or our non-English speakers who may have 
trouble connecting and using translation services, and for 
those who do not have access to broadband in a robust way, 
audio-only is essential for providing good care for them.
    Senator Brown. And CMS can monitor the impact of that?
    Dr. Davis. Yes. I mean, I think we have coding and an 
ability to do that, paired with patient satisfaction, paired 
with care outcomes, the ability to collect data. Now I feel 
like, as a physician, my quality is monitored in many different 
ways and getting back to health outcomes. And I think it is 
important to distinguish that telehealth audio-only and with 
video should be differentiated between what happens in the 
primary care patient-centered medical home, versus a vendor 
that is providing just that service.
    And so audio telehealth is provided best when it is part of 
the care continuum that a primary care provider is providing. 
You have the background and the history on the patient, the 
access to their chart, and that long-term trusting 
relationship.
    Senator Brown. Thank you, Dr. Davis.
    I am on my last 30 seconds, Mr. Chairman, and thank you for 
your indulgence. I wanted to bring up another issue--no 
question, just an issue. Senator Capito and I have proposed, 
related to Medicare's hospice respite benefit, the COVID-19 
Hospice Respite Care Relief Act of 2020, giving the Secretary 
of HHS the authority to allow hospice patients to receive 
respite care at home, and for longer periods of time during any 
public health emergency, including obviously the one we are in. 
It was not able to make a difference for family caregivers over 
the past year. So I hope the committee, Mr. Chairman, can 
consider ways to strengthen the hospice respite benefit moving 
forward.
    So thank you, and thanks to the witnesses today for their 
insight.
    The Chairman. We will follow up with you, Senator Brown, 
and Senator Capito. Very important.
    Senator Lankford is next.
    Senator Lankford. Mr. Chairman, thank you, and thanks to 
all of our witnesses and the insight that you are bringing, and 
for all your work during the pandemic. There is a great deal of 
work that was done and a lot of innovation that happened at 
your places to be able to actually take care of people. So 
thanks for that level of engagement that you have as we work 
our way through this.
    There were over 200 flexibilities that were given by CMS 
during this time period. Congress is obviously very engaged. My 
office was engaged, as well as all the other offices here in 
this hearing today, trying to be able to go back and forth on 
it. We have talked a lot about telehealth, and I want to 
mention some of those things in a moment.
    But, Dr. Berenson, I do want to be able to bring up an 
issue about the 3-day rule for skilled nursing facilities. When 
I called back to touch base with a lot of our hospitals and 
facilities and such and ask, of all the flexibilities that are 
there, which one really stands out as one that needs to last, 
everyone brought up telehealth, but then this 3-day rule for 
the skilled nursing facilities came up.
    Can you talk about that a little bit?
    [Pause.]
    Senator Lankford. You are on mute, still.
    Dr. Berenson. I apologize for forgetting that I am on mute. 
It has been around since the beginning of the program, 
basically, because of the concern that Medicare would be turned 
into a long-term care program if you did not have a requirement 
that skilled nursing was associated with an inpatient 
hospitalization.
    It is clear that an MA functions very well without the 3-
day rule. There are exceptions for ACOs, and there is sort of 
general agreement that it has a perverse incentive, and it 
involves a lot of gaming, in fact. I have been involved with a 
family member who was kept an extra day just to qualify for the 
3-day rule.
    So for me, if we can figure out a way to sort of eliminate 
it without running into the concern that we have created a 
long-term care benefit, I think we should do so. And the more 
we sort of move towards risk-taking and capitated type of 
arrangements where the organization itself has an incentive not 
to abuse the hospitalization, I think we can make good 
progress.
    But I agree with you completely that it is very 
frustrating. It even affects the observation stay rule in 
Medicare where beneficiaries do not qualify because they 
actually were not on an inpatient stay, they were just in an 
observation stay, and therefore they do not get the same access 
to skilled nursing. It really is a problem that deserves real 
attention.
    Senator Lankford. It is a serious issue. I would be 
interested in any other practitioners who have had observations 
on this 3-day rule.
    Dr. Davis. Sure. This is Dr. Davis with AAFP. I would like 
to second that AAFP would be in favor of reducing that. And 
just to share an example from a patient that I had, a patient 
that I was actually doing home visits on, which is rare, but we 
still do home visits. And we could see in his home that he 
needed a higher level of care. He did not need to go to the 
emergency room or hospital. He just needed to be at a skilled 
nursing facility to receive some rehab. But in order to get him 
there, he had to go to the hospital.
    He developed an infection in the hospital, which lengthened 
his length of stay and raised his Medicare costs. He eventually 
did end up in the nursing home, but the relationship that I had 
with that patient--I knew his history. I knew what the 
appropriate next level of care was, and it just created 
barriers and increased costs that were unnecessary.
    Dr. Murali. Senator Lankford, at Marshfield in 2014 we 
started our process for creating comfort and recovery suites, 
got skilled nursing facility bed licenses, and did all of our 
orthopedic surgery, our gall bladder surgery, our gynecological 
surgery, thyroid surgeries, and kept them in the SNF a little 
longer than 24 hours, and then we could send them home. 
Phenomenal cost savings that can be achieved on the commercial 
side as well as in Medicare Advantage, which we have shown in 
our data. And so I think it is an archaic rule that needs to be 
looked at, because its costs are wastefully spent.
    The other piece is in the Hospital at Home. When somebody 
comes into the ER, you wind up putting them in an observation 
bed from the standpoint of 24 hours or whatever duration of 
time. If you have the skilled nursing facility option 
available, if somebody comes in the middle of the night and 
cannot go back home, you prop them up in the skilled nursing 
facility bed for 12 hours and then make arrangements for 
Hospital at Home care at home.
    So that is what we do in the rural environment. Because, 
when you have the little old lady who is 84 years old come into 
the ER at midnight, you cannot possibly arrange for oxygen. It 
is easier to deliver pizza in Manhattan at midnight than it is 
to get oxygen delivered to a home at midnight.
    So I think for all of those reasons, thinking about skilled 
nursing facilities differently and creatively is important on a 
risk basis model. So I will rest there.
    Senator Lankford. All right; thank you.
    Mr. Chairman, thank you very much.
    The Chairman. Thank you very much.
    And, Doctor, you really highlighted the importance of care 
over some other things people are thinking about sometimes.
    Senator Casey?
    Senator Casey. Mr. Chairman, thanks very much for having 
this hearing. It is critically important, the number of issues 
that we are learning so much about in the last more than a year 
now.
    I will have a question for Dr. DeCherrie and Dr. Davis. The 
question for Dr. Davis will be about mental health for children 
and teens. But I wanted to ask you, Dr. DeCherrie, about the 
PACE program and the expansion of it.
    We are learning so much and exploring today innovative 
models of care. I think if there is one thing we have learned 
over the course of the pandemic, it is the importance of 
services that allow seniors and people with disabilities to 
remain in their homes, in their communities, as we have heard 
over and over again today.
    And that is of course the setting that they would prefer. 
They prefer to get care in the home, or in the community. And 
like the Hospital at Home model, which provides hospital-level 
care for people with acute illnesses, the PACE program, or the 
so-called Program of All-Inclusive Care for the Elderly--we 
refer to it in Pennsylvania by a different acronym, the LIFE 
program--is similarly a way that seniors and people with 
disabilities can receive wraparound care while remaining at 
home.
    So I think we have to take the lessons we learned in the 
last year to improve and expand upon services like PACE to 
ensure that seniors and people with disabilities have access to 
the supports that they require.
    I have introduced the PACE Plus Act just last month. This 
would provide funding for existing PACE programs to service 
more people. And it would allow these specialized programs to 
expand into areas that do not currently offer PACE as a long-
term care option.
    So, Doctor, I would ask for your perspective on what is the 
value of expanding programs like PACE that provide these 
wraparound services for seniors and people with disabilities?
    Dr. DeCherrie. Thank you for that excellent question. I 
have not worked at a PACE program since my residency. I was 
fortunate enough to get that opportunity to work at a PACE 
program for an entire year during my residency, and so I have 
familiarity with the model. But it is very much like home-based 
primary care, which I do every day. And so I do believe that 
expanding access for home-based programs, Hospital at Home, 
Home Based Primary Care, and PACE, is very important.
    We have seen here in the pandemic that patients absolutely 
want that type of care, and we should act to expand it.
    Senator Casey. Doctor, I appreciate that.
    I want to ask a question for Dr. Davis, as I mentioned 
earlier, about children. We know that if there was one problem 
that was terribly, terribly exacerbated by the pandemic, it was 
the crisis in mental health, especially for children and teens.
    Some of the most horrific stories and some of the numbers 
that are so horrific, I think will stay with us a long time. We 
are told, for example, of a 24-percent increase in emergency 
room visits for mental health crises among children ages 5 to 
11, increased wait times to access inpatient mental health 
treatment, and so much else. And as we recover from the 
pandemic and the restrictions are lifted, children with mental 
and behavioral health needs, of course, are not going to be 
going away.
    We have to make sure that we have programs in place and 
strategies to make sure we have the appropriate care for them. 
We need to make sure that they have the appropriate treatment 
in the appropriate setting at the appropriate time.
    So, Dr. Davis, are there ways and existing tools or options 
in both Medicaid and CHIP that can be used to address mental 
and behavioral health needs of children and teens?
    Dr. Davis. Thank you, Senator Casey. You know, as a mom of 
three school-aged sons, this is acutely aware to me, in the 
challenges that they have had in virtual schooling and not 
being able to connect with their friends. And I see it in my 
patients as well.
    So, one, the expansion of telehealth for mental health is 
crucial for children. One of the biggest barriers as a primary 
care physician is just being able to find a therapist, or a 
psychologist, or psychiatrist in the area to be able to treat 
children. And so being able to expand that treatment network is 
really huge.
    I think the second is creating parity in payment with 
Medicaid, continuing that. And we especially see low 
reimbursement for mental health providers who are offering 
Medicaid services. And so, if we really are trying to address 
that divide, we need to make sure that Medicaid is having 
reimbursement for mental health services, especially for 
children.
    Senator Casey. Doctor, thank you.
    Mr. Chairman, thank you.
    The Chairman. Thank you, Senator Casey.
    Next is Senator Thune.
    Senator Thune. Thank you, Mr. Chairman and Ranking Member 
Crapo. I think if we can find a bright spot from this pandemic, 
the embrace of telehealth across the Nation is certainly one. 
For four Congresses, the Senate Telehealth Working Group has 
advocated for increased access to telehealth, and working with 
this committee, many provisions from past versions of our 
group's CONNECT for Health Act have become law. In fact, 
CONNECT informed a lot of our discussions on the CARES Act, 
which Senator Stabenow already mentioned.
    So that bring us to where we are today. And I think the 
question is, what have we learned?
    Dr. Murali, you represent a health system that utilized 
telehealth long before the pandemic, like many of the systems 
in South Dakota have. Do you support the CONNECT Act? And which 
provisions, in your view, are most important to improve access 
for rural and urban patients?
    Dr. Murali. First, I thank you for cosponsoring the CONNECT 
Act. It is one of the most important acts, especially in the 
space of rural health care, particularly the provision to waive 
the requirements of geographic restrictions to allow FQHCs and 
RHCs to do the work that they need to do. It is one of the 
craziest rules.
    For instance, you have a physician who can see say 20 
patients a day. They are in a rural center as part of an FQHC 
or RHC, and they only have four patients to see that day. If 
they need to provide that service in some of the remote areas, 
they could not do it if not for the Act. So that is a wonderful 
piece of what that act has achieved, at least in remote and 
rural parts of Wisconsin.
    So I hope I have answered your question as to the value of 
the CONNECT Act. And I think Sanford, which is in your State, 
has some of the same issues, and they are part of the Clinic 
Club, and we spent a lot of time trying to see how we can 
provide service.
    So that is my response.
    Senator Thune. In your testimony, you discussed what could 
be the, quote, ``new norm'' with telehealth and phone. You 
predict that 15 or 16 percent of all appointments per month may 
be handled this way moving forward. Could you talk to us a 
little bit more about how you came to that conclusion, and if 
your data includes both Medicare and commercially insured 
patients?
    Dr. Murali. As to the last question, our answer is ``yes,'' 
for both commercial as well as Medicare patients at this point 
in time for that calculation.
    So let me just make a quick illustration. My wife is a 
pediatric neurologist. She is one of three pediatric 
neurologists in the 45,000 square miles where we provide care. 
If a mother has to bring her child for general epilepsy care, 
which is a 30-minute visit, she needs to bundle those kids in 
winter gear, in the peak of winter, and travel 2 hours, and 
then back 2 hours, for a 30-minute visit. This can be done 
through telehealth.
    Like that, there are lots of established visits that can be 
done through telehealth, once you have had the first physical 
visit, and can be done efficiently. Think about the impact of 
that to the employer; think of the impact to the mother; the 
cost of driving these kids, paying for their lunches, paying 
for the gas, and losing 1 day's work. That is happening all 
across rural America. So that is the number one point.
    You can extend that to E&M visits for dermatology. You can 
do that for pretty much all specialties in terms of how you can 
manage that care. And that number is about 15 to 16 percent in 
our present numbers, and could go up to 20 percent if we are 
actually allowed to adopt these services in a creative manner. 
And that is confirmed by my colleagues in APG who also do some 
of that same work, and further confirmed--when the pandemic 
happened, when we shut down all services, 22 percent of all 
care, even by physicians who were unwilling to do telephone or 
telehealth visits, was the number that we had in our 
institution.
    So it is a phenomenal step if we can go down that 
direction.
    Senator Thune. So as Congress continues to discuss which of 
these pandemic flexibilities should be made permanent, there 
have been discussions about whether increased program integrity 
measures are needed. And some have suggested a requirement for 
a face-to-face encounter.
    Concerning this from a health disparity standpoint, I think 
we have to be careful about a one-size-fits-all approach that 
could prevent rural patients in particular from taking the 
first step to seek care.
    So as things stand today, is there any reason that a 
clinician could not tell their patient that an in-person visit 
is needed, without having a mandate to do that?
    Dr. Murali. Yes; so all clinicians will do the right thing 
for their patients. If we believe a physical visit is required, 
we will do it, because we have signed the Hippocratic Oath and 
we want to provide the best care for our patients. And we carry 
the burden of their sickness or outcomes.
    So I do not think that that is a concern at all. Like I 
said in my testimony, I manage a 67-year-old lady for complex 
heart failure at a distance of 200 miles, and she came to visit 
me once a year for 4 years, and she is well even now 13 years 
after the episode. She still sends me a Christmas card. A lot 
can be done from the standpoint of how care is provided.
    Senator Thune. Good. Thank you, Mr. Chairman.
    The Chairman. Senator Carper? Senator Carper, I think you 
are out there somewhere?
    [No response.]
    The Chairman. Okay, we are missing Senator Carper. Let's 
see; yes, Senator Daines would be next, and then Senator Warner 
and Senator Hassan.
    Senator Daines?
    Senator Daines. Yes.
    The Chairman. All right.
    Senator Daines. Thank you, Mr. Chairman. I appreciate it.
    Well, I appreciate this hearing today. We are a rural State 
in Montana, and we have faced the access challenge to health 
care before the pandemic. And so when folks were told to stay 
home to prevent the spread of COVID and avoid exposure to the 
virus, virtual care became even more important. It was a 
lifeline in many cases for Montana patients.
    Montanans now are telling me that that test drive of COVID 
health-care flexibilities was a success, especially when it 
comes to expanded access to telehealth. I believe we need to do 
what we can to make expanded access to telehealth permanent for 
Montanans and all Americans, especially in rural areas, and not 
cut access back once we are in the post-pandemic period.
    Back in March of last year, I introduced the Telehealth 
Expansion Act to allow American workers and families to access 
virtual care without the burden of first meeting their 
deductible. My bill was signed into law as part of the CARES 
Act, allowing these high-deductible health plans with Health 
Savings Accounts to offer cost-free telehealth services. This 
ensures patient access to critical care during the pandemic.
    Today I am teaming up with my colleague Senator Cortez 
Masto, and we are introducing legislation to make this policy 
permanent. One of the lessons certainly we learned from the 
pandemic is the value of leveraging telehealth to meet rising 
demand for health-care services.
    Access to virtual care should not solely be considered a 
COVID-19 policy. Our legislation, entitled The Telehealth 
Expansion Act of 2021, will meaningfully expand access to care 
by permanently allowing first-dollar coverage of virtual care 
under high-deductible health plans.
    My question for Dr. Murali is, practicing in Wisconsin, you 
are all too familiar with rural health-care challenges. Could 
you speak to the value of reducing barriers to telemedicine, 
and specifically the advantage of making this particular policy 
permanent?
    Dr. Murali. We actually strongly support that policy. I 
think you are talking about your first-dollar policy with 
respect to high-
deductible health plans, and we believe that that brings 
immense value to our communities. And if that is expanded to 
behavioral health and other pieces, I think it is a wonderful 
thing.
    I have discussed this with our health plan CEO, as well as 
our folks who are on the ground, and the information I received 
from them is, it will be extremely well received from the 
standpoint of care, and for providing access to care, which is 
critical in rural Wisconsin.
    Senator Daines. Thank you, Doctor.
    When it comes to accessing telehealth in Montana, our 
people in rural communities who lack sufficient broadband 
Internet connectivity do not have the option of that face-to-
face virtual care. In some cases, audio telehealth using a 
phone is the only option.
    In fact, I just met with some of my primary care docs from 
Montana this morning. They talked about being forced to audio 
telehealth when we sometimes do not have the visual option. And 
that is why I worked with my colleagues last year to ensure 
payment parity for audio-only telehealth, ensuring that rural 
Montanans can access telehealth no matter where they live, and 
no matter what access they might have.
    Dr. Murali, how important is payment parity when it comes 
to ensuring that folks in rural communities can access care?
    Dr. Murali. I think, as I have said before, there is a lot 
of investment that goes into infrastructure to maintain that 
ability to provide telehealth and actually lower the cost of 
care. So payment parity is absolutely important from that 
standpoint.
    Senator Daines. So expanded access to telehealth services, 
including physical therapy, has helped our seniors in Montana 
and around our country who have been the most vulnerable to the 
virus. It also helped demonstrate that therapy needs to be, and 
can be met with the use of technology, and that patients can 
have improved access in rural areas particularly.
    Ms. Farb, what has GAO found when it comes to the value of 
expanded telehealth, including physical therapy, during this 
pandemic? And is there evidence that using telehealth has 
helped remove delays, or perhaps barriers to people accessing 
preventive services that have helped to prevent the 
deterioration of a patient's condition?
    Ms. Farb. So, Senator Daines, we are still working on our 
study looking at the effects of telehealth on the beneficiaries 
who have received it. I can say from some of the interviews we 
conducted with beneficiary advocacy organizations that much of 
what you just said in terms of serving as a lifeline, and 
serving as a way for beneficiaries to access services that they 
otherwise would not have been able to do--we definitely have 
heard that.
    We will be breaking out some of the utilization both pre-
pandemic and during the pandemic in terms of looking at some of 
the data by various demographic characteristics, including 
urban areas, as well as particular services, as you mentioned, 
such as physical therapy and other services that were 
available.
    So I do not have any preliminary data yet to share on that, 
but that is what we are currently working on in our study that 
we are doing right now.
    Senator Daines. Thank you, Ms. Farb.
    Mr. Chairman, thank you.
    The Chairman. Thank you, Senator Daines.
    Senator Crapo is going to help us keep this going. So I 
believe our next three will be Senator Carper, Senator Warner, 
and Senator Hassan. We can get all three in before the vote.
    Senator Carper?
    Senator Carper. Thanks, Mr. Chairman. I was out during our 
last recess, Mr. Chairman and colleagues, I was out in the Bay 
Area and visited a number of technology companies. Some of them 
were startups, some have been around for a while. One of the 
companies I visited--I think her name was, I want to say 
Ginger--and they are involved in behavioral science. And they 
work with helping people who have behavioral science challenges 
in their lives, mental health and so forth, and it is a company 
that uses telemedicine to try to bring some help to more people 
early on in their illnesses.
    So for me it is something in real life, and I saw it for 
myself, and it is, I think, another way to get results, and 
hopefully better results, for less money in helping people who 
are dealing with those kinds of challenges in their lives.
    But I very much welcome this hearing today. During the 
pandemic, telehealth has been an essential, and is becoming a 
more essential, tool in our toolbox to try to make sure that 
not just adults, but children receive the care that they need, 
while minimizing risk.
    And although telehealth in Medicare has been a focus, close 
to 40 million children, I am told, are enrolled in Medicaid or 
the Children's Health Insurance Program--close to 40 million. 
And across our Nation, families experience barriers that 
prevent them from accessing routine health services, like a 
limited availability of providers, or long lead times for an 
appointment.
    And for many in Medicaid and the Children's Health 
Insurance Program, increased access to telehealth services can 
mitigate those barriers to improve the timeliness and 
convenience of care delivery, while also improving health-care 
outcomes, and do so at reduced cost.
    I have a question for Dr. Berenson, if I could. What are 
the main policy changes, Dr. Berenson, that we need to ensure 
the broader use of telehealth can be continued for children 
beyond the pandemic? Dr. Berenson?
    Dr. Berenson. Well, I--there is an echo--it tends to be a 
Medicare effort, and I am not a CHIP expert, but I think 
basically States need to have generous telehealth policies. But 
I am not the person who really can tell you precisely what we 
should do for children in this area.
    Senator Carper. Okay; thank you. Anybody else among the 
panelists who would like to take a shot at that, please?
    Dr. Davis. This is Dr. Davis. Again, Medicaid payments for 
children are really important [much echoing] to ensure they 
have access.
    Senator Carper. All right; thank you. Anyone else, please?
    [No response.]
    Senator Carper. All right; let me move to the next 
question. This is my follow-up question that deals with 
guidance for State Medicaid and CHIP programs. And during the 
COVID-19 public health emergency--which we are still struggling 
to get out of, but making progress--a wide variety of policy 
waivers have been put in place across our country to expand 
access to telehealth services, unleashing the power and 
potential of telehealth to safely and effectively provide care 
to children and to their families.
    However, there is a wide variation in telehealth policies 
among State Medicaid programs. And as States consider how to 
expand coverage of telehealth services, there is limited 
guidance or information to aid in their planning.
    Moreover, there are limited comprehensive studies 
specifically looking at the impact of telehealth on the 
Medicaid population, including during national public health 
problems.
    And if I could, Dr. Davis and Ms. Farb, according to 
MACPAC's March 2018 report on telehealth in Medicaid, States 
looking to expand telehealth in their Medicaid and CHIP 
programs would benefit from additional research and a more 
robust understanding of the impact of telehealth.
    My question of Dr. Davis and Ms. Farb: do you believe that 
further study in this space is still needed? And do you think 
the real-world evidence gathered during the pandemic could 
provide further insights that support the expansion of 
telehealth for our children? Dr. Davis, Ms. Farb, please.
    Dr. Davis. Thank you, Senator Carper. There has been a lot 
of study already, and I think from MACPAC's work and work that 
we have seen, we can start to move forward and recognize the 
importance of Medicaid, especially for the benefit of our 
children who are participating in the CHIP program and in the 
Medicaid program.
    Ms. Farb. And I will just add, we are actually studying 
telehealth and the Medicaid program as we speak, as well. My 
statement today has been based on the ongoing work that we are 
doing both in Medicare and Medicaid. So we are looking at the 
effects of the use of telehealth during the pandemic and trying 
to garner some lessons learned.
    As far as guidance from CMS, we understand that they are 
planning to issue some additional guidance to States, but some 
of that guidance is still in review within the agency. So, in 
our ongoing work, we have talked to CMS about what plans they 
have to provide that guidance, especially in looking at sort of 
program integrity types of things that they need to be aware 
of.
    But we are doing work. So it is hard for me to say we 
should not study it more, I think, given where I sit at GAO, 
but I definitely think there is a lot of evidence out there, as 
Dr. Davis pointed out.
    The Chairman. There is an important vote, and let us get 
Senator Warner and Senator Hassan in before we have to run. And 
we are going to keep this going.
    Senator Warner?
    Senator Warner. Thank you, Mr. Chairman. I will try to make 
sure I address the quick timelines.
    First, I think we all know that obviously COVID exposed 
some of the racial disparities we see in health-care coverage. 
I think this committee and others have tried to do a better job 
of making sure we get good data on some of those racial 
disparities.
    One of the things that I have worked with the chairman and 
others on is making sure that we encourage States to go ahead 
and expand Medicaid, and that we increase our premium payments. 
I actually hope on the ACA, I hope we can make some of those 
things permanent.
    But, Dr. Berenson, do you want to weigh in on this issue of 
whether the expansion of Medicaid in States that were not 
covered, whether the ACA additional premium payments support 
that we put in place in some of the legislation recently will 
actually start to help diminish some of the racial disparities 
that were exposed by COVID-19?
    [Pause.]
    Senator Warner. I think you are on mute, Dr. Berenson.
    Dr. Berenson. Sorry about that. Again, I am not a Medicaid 
expert, but my understanding of the results from Oregon, which 
had that study where they sort of randomly selected people into 
Medicaid, demonstrated better access when people did get 
Medicaid. And I think that the outcomes were a little mixed, 
but the study was not conducted long enough to be able to 
demonstrate those.
    So I basically agree with the premise of your question 
there. There need to be incentives for all States without 
Medicaid as an expansion.
    Senator Warner. Well, thank you. I think I am going to, 
obviously, continue working with the chairman and others on 
this.
    Let me move to a slightly more probing question for Dr. 
Davis and Ms. Farb. You know--and let me preface this question 
with, obviously we all realize the opioid abuse and substance 
abuse issues are a huge challenge, and this committee again, 
with folks like my friend Senator Portman, has been grappling 
with that for some time.
    On the other hand, I have been trying to get the DEA, 
literally for close to 10 years, to allow for physicians to--
and frankly, for the DEA to promulgate rulemakings, which they 
were supposed to have done by law, to allow certain physicians 
to prescribe certain controlled substances via telehealth. We 
have made sure to make this happen in legislation called The 
SUPPORT Act last Congress. But the DEA continues to refuse to 
take up this rulemaking.
    I have reached out to them multiple times on this. I do 
believe that the Biden administration is trying to work in good 
faith, but with the importance of telehealth being accentuated 
by COVID, by this panel, Dr. Davis, I would like to hear from 
you, given your experience with patient care, and, Ms. Farb, 
maybe GAO may have taken a look this issue as well.
    I know we want to make sure there is not abuse, 
particularly when it comes to controlled substances, but I do 
think we have been waiting 10 years. It is in the law. And 
while we need to put appropriate protections in place, we need 
to let physicians have these tools.
    So, Dr. Davis and Ms. Farb, will you comment on that 
subject?
    Dr. Davis. Sure. Thank you, Senator Warner.
    I do also want to go back to your previous question. As 
Vice Chair of MACPAC, I do want to echo that we have already 
started to see a reduction in health disparities in those 
States that have expanded Medicaid. And we need to continue to 
study that and look and see those drivers.
    In terms of substance abuse treatment, as a buprenorphine 
provider myself, I have seen the benefit, especially throughout 
COVID-19, of being able to conduct those services by 
telehealth. Being able to prescribe remotely and 
electronically, being able to keep patients from relapsing, has 
been essential, especially with all of the stresses that have 
happened over the last year.
    And so I encourage continuation of, as well as passing new 
legislation getting us further along to be able to conduct that 
service electronically, both in terms of prescription and in 
terms of the visit by telehealth or audio.
    Senator Warner. Thank you, Doctor. I agree with you. And 
again, DEA, on some of this rulemaking, has just been dragging 
its feet.
    Ms. Farb, do you want to make a comment?
    Ms. Farb. Sure. So GAO does have prior work kind of looking 
at some of the barriers to medication-assisted treatment for 
opioid use disorder. And we have noted that some of what you 
are discussing did occur, in terms of prior authorization 
requirements, and restrictions on distribution, and just the 
Federal waiver that providers need to prescribe or administer 
some of the prescriptions that are needed.
    So we did not make any recommendations out of that study, 
but we definitely did enumerate all the barriers that are being 
faced by providers and various health-care programs.
    Senator Warner. Well, I hope we can keep working on this. I 
think I will turn it back now to, I guess, Senator Crapo, you 
are filling in. Thank you.
    The Chairman. Thank you, Senator Warner. This is great.
    We are--let's see. It is Senator Hassan there, and Senator 
Crapo is back, and I will run and vote and come right back. But 
Senator Hassan is up now, Senator Crapo.
    Senator Hassan. Well, thank you so much, Chairman Wyden and 
Ranking Member Crapo, for this hearing. I want to echo what 
Senator Warner was just talking about when it comes to 
facilitating medication-assisted treatment, and I look forward 
to working with colleagues on both sides of the aisle on that.
    And before I get to my questions, I also want to reinforce 
my colleagues' calls to continue to expand telehealth access, 
including in rural communities. The dramatic expansion in 
telehealth services during the pandemic has benefited a large 
number of patients, including in my home State of New 
Hampshire.
    I want to turn now to Dr. Davis. The news that there could 
be an authorized COVID-19 vaccine for all children by the end 
of this year is truly an exciting development for many 
families. However, I am very concerned that over the past year 
routine child wellness visits and pediatric vaccinations have 
declined significantly, particularly for children enrolled in 
Medicaid and the Children's Health Insurance Program.
    Telehealth expansions have improved access to many routine 
primary care services, but unfortunately you cannot get a 
vaccination over Zoom.
    So, Dr. Davis, as telehealth becomes more integrated into 
primary care services, how can we ensure that children will 
continue to attend routine, in-person wellness visits that help 
ensure that children are receiving lifesaving vaccinations, as 
well as critical developmental and physical screenings? And how 
do we get children who missed their routine vaccinations over 
the past year back on track?
    Dr. Davis. Thank you, Senator Hassan. The answer is, you 
know it is very important, and I do worry about the kids who 
are delayed in their vaccines because of hesitancy in going 
into care. But I have seen the resilience of our family 
physicians and pediatricians, especially at our community 
health centers, in getting creative and innovative and making 
sure that kids are getting their vaccines in terms of drive-up 
clinics, parking lot operations, and being able to make sure 
that they are getting them.
    I am not worried that telehealth is going to replace what 
we do as physicians. And in combination with the primary care 
relationship, doctors are going to make sure that their kids 
are coming in for their vaccines, and I have really seen them 
being stalwarts and champions in continuing that.
    I think that there are other things that we can do to 
encourage vaccines, requirements that happen at schools, you 
know, to make sure that kids are getting the vaccines. But I am 
not worried that--there is a lot of catch-up to do, but I think 
that we can get there.
    Senator Hassan. Thank you so much for that.
    To Dr. DeCherrie, I want to talk with you a little bit 
about home and community-based services. The American Rescue 
Plan increases Federal funding for home and community-based 
Medicaid services. However, while this initial investment is an 
important step, we need to do more to ensure that older adults 
and individuals with disabilities have access to this care.
    Many of us on the committee are continuing to work towards 
some long-term solutions here, but what changes do you believe 
are needed to expand the home health workforce and improve the 
quality and accessibility of home and community-based services?
    Dr. DeCherrie. Thank you so much for this question. We 
cannot--you know, in geriatrics we cannot do what we do without 
the family support, without the aides who are there to care for 
our patients. Our work is like one-tenth of the daily work that 
these people do to help support our patients. And it is so 
important that we are able to support the caregivers.
    So I agree with you that we need to think about how to 
expand that workforce, how to make sure that patients are able 
to get quality care through that workforce. And it could be 
through family caregivers or paid caregivers.
    Senator Hassan. Thank you. Is it fair to say that families 
who can get some support and relief from home care health 
aides, for instance, often are able to support their loved ones 
better at home than when they try to do it all by themselves?
    Dr. DeCherrie. Yes. Definitely.
    Senator Hassan. Thank you.
    Dr. Davis, one more question. The COVID-19 pandemic has 
demonstrated the value of providing critical vaccines to 
vulnerable populations at no cost. Women covered through 
Medicaid are less likely to receive the tetanus and influenza 
vaccines during pregnancy than those who have commercial 
insurance.
    Earlier this year, Senator Cassidy and I reintroduced the 
Maternal Immunization Coverage Act to help address this 
disparity. This is a bipartisan bill that would ensure that 
State Medicaid programs cover ACIP-recommended vaccines for 
pregnant beneficiaries at no cost.
    Dr. Davis, how should we parlay the lessons that we have 
learned from this public health emergency about the benefits of 
providing vaccines to vulnerable populations at no cost in 
order to ensure that all Americans have access to life-saving 
vaccinations?
    Dr. Davis. You know, we have really learned from the COVID-
19 vaccination that when you are able to offer it without cost, 
that removes a significant barrier. And the AAFP agrees that we 
should expand access to all ACIP-recommended vaccines at no 
cost through Medicare and Medicaid, CHIP, and all other 
commercial insurers.
    Senator Hassan. Thank you very much.
    And thank you, Senator Crapo.
    Senator Crapo [presiding]. Thank you.
    And Senator Young is next on the list, but I do not see him 
on the screen. Is Senator Young with us?
    [No response.]
    Senator Crapo. All right, Senator Warren, I see you. Go 
ahead, please.
    Senator Warren. Thank you, Mr. Chairman.
    So when coronavirus hit, patients still needed access to 
basic health services like primary care and mental health 
visits, but COVID made it harder for patients to get the care 
that they needed. On top of the usual struggles like taking off 
time from work, people now had to keep themselves safe from 
infection. Services that were already difficult to manage even 
in the best of times became much harder to get.
    Take hearing loss, which affects 48 million Americans. On 
average, it takes 7 years for patients to seek treatment for 
hearing issues, even when we are not in a global pandemic. And 
COVID-19 only added additional burdens.
    So that is a key reason why the Centers for Medicare and 
Medicaid Services made it easier for providers like 
audiologists to offer hearing services remotely during the 
pandemic.
    Ms. Farb, what steps has CMS taken to make it easier for 
patients to access care from audiologists through telehealth 
during this pandemic?
    Ms. Farb. Well, Senator, as you pointed out, CMS initially 
expanded the types of providers that could furnish telehealth 
services to include all those eligible to bill, which included 
physical therapists and speech language pathologists, as well 
as audiologists.
    At the beginning, they were able to bill for certain codes 
starting in March of 2020, and some of those codes are not 
typically the codes that are billed by audiologists, but CMS 
added additional codes to the list at the end of March of 2021. 
And that coverage is effective retroactively back to January of 
2021. The list included services such as tone decay tests and 
assessments of tinnitis. And so that expanded sort of the 
ability for audiologists to provide those services.
    We spoke with ASHA, the association that covers speech 
language pathologists as well as audiologists, and they were 
very supportive of those changes.
    Senator Warren. So, Ms. Farb, if I can just summarize, CMS 
considered all the audiologists to be important enough to 
include in the response to the pandemic, but audiologists 
usually are not treated equally in the Medicare program. 
Despite their years of schooling and training, audiologists are 
considered, quote, ``suppliers'' not, quote, ``practitioners'' 
in the program. And outdated Medicare rules require patients to 
get their doctor's permission to see an audiologist rather than 
letting patients make the decisions they need to improve their 
hearing.
    So let me ask, Dr. DeCherrie, why is it so important that 
seniors with hearing loss can access the providers they need, 
including audiologists, without bureaucratic limitations that 
make it harder for them to get care?
    Dr. DeCherrie. Thank you for that question. Yes, I mean 
being able to hear is so important, especially for our elderly 
patients. I mean, there have been numerous studies that have 
shown reduced risk of falls, improved mood, improved memory, 
all by being able to hear better. I mean, we see this every day 
on home visits now when we are trying to do something by video. 
If they cannot hear, just turning up the volume does not work.
    So these patients really do need their hearing assessed, 
and then potentially a hearing aid or whatever is needed.
    Senator Warren. In other words, audiologists provide 
critical services to people with hearing loss. That is why I am 
joining Senator Paul and Senator Grassley in reintroducing the 
Medicare Audiologist Access and Services Act. This is a bill 
that would expand seniors' access to hearing services by 
reclassifying audiologists as practitioners in the Medicare 
program. And that will allow them to bill for services without 
a physician referral, and to provide patients with both the 
diagnostic and treatment services that are within an 
audiologist's scope of practice.
    It seems to me that the COVID-19 pandemic has forced us all 
to reconsider bureaucratic limitations to health care, 
including hearing care. So I believe that the Senate should 
prioritize the passage of our bill to help seniors get the care 
that they need.
    Thank you, Mr. Chairman.
    Senator Crapo. Thank you, Senator Warren.
    And I see Senator Cortez Masto, so, Senator, you may 
proceed.
    Senator Cortez Masto. Senator Crapo, thank you. And thank 
you to the panelists. This has been a very, very informative 
conversation. And let me echo and agree with my colleagues. I 
think making telehealth permanent is so important for the 
reasons that we are discussing today. But I also recognize and 
really appreciate the challenges that we still need to 
understand, the data. We need to capture the accurate data, the 
diversity in the data. We need to make sure we put up guard 
rails but still to study it. But for the many reasons we have 
talked about, I think it is so important.
    I have seen the benefits in Nevada alone, but here is one 
thing--and we have talked about this already this morning--
which is audio-only diagnostic information. I absolutely have 
concerns that we are not allowing the diagnostic information 
for audio-only to occur. This is information that I have been 
talking to CMS about.
    And so, because I think it is so important that we address 
this--and clearly my colleagues feel the same way after 
listening to the conversation this morning--Senator Tim Scott 
and I introduced a bill, the Ensuring Parity in Medicare 
Advantage for Audio-Only Telehealth Act.
    It would really require CMS to include diagnosis obtained 
via an audio-only telehealth visit in a Medicare Advantage risk 
adjustment program. And it is so important for the very reasons 
that you talked about.
    So I want to get that out there. But let me also--Dr. 
Davis, let me ask you this. In your experience, are patients 
with high-
deductible health plans more or less likely to seek regular 
treatment?
    Dr. Davis. Pre-public health emergency, I certainly saw 
patients who were hesitant to come in because of the high-
deductible health plans, and just not being able to afford it.
    The AAFP supported temporarily waiving the deductible for 
telehealth visits, because the investment was necessary for 
providers to really be able to make that investment in 
telehealth. We are concerned, though, with the permanent waiver 
of that and the possibility of creating a two-tiered system 
where low-income enrollees are only able to afford virtual 
care.
    And so we recommend that the committee pass legislation to 
allow high-deductible health-care plans to waive the deductible 
for primary care and mental health services, both in person and 
telehealth, to promote timely access to high-value care and 
preserve patients' freedom to choose the most appropriate 
modality of care.
    Senator Cortez Masto. Yes, I could not agree more. And I 
thank you for that.
    And so let me jump to Ms. Farb. There was conversation 
about identifying the quality of telehealth health services. 
And I know you were asked what were the metrics that GAO was 
looking at. And you said that GAO had not defined yet the 
metrics for identifying the quality of telehealth services.
    Can you give me a timeline? Is this something that is a 
priority now for GAO? And is this something you will be further 
looking into, or GAO will, in identifying those metrics?
    Ms. Farb. Yes, Senator. So, as far as identifying and 
creating the metrics, that is a role that GAO does not play. We 
rely on the institutions that are sort of responsible and 
contracted with HHS, such as the National Quality Forum, to 
develop consensus-based quality metrics.
    And as I mentioned earlier, both the NCQA, another quality 
organization, and NQF have been working this past year to sort 
of adapt some of the metrics and frameworks that they use to 
incorporate telehealth, the concept of telehealth, and focusing 
it on things that are clinically meaningful for patients and 
providers to measure quality.
    So that is sort of what we are waiting on: to see what 
these other institutions are going to do in terms of how they 
are going to define quality. There are ways to compare 
particular end points and outcomes where you could compare 
telehealth to in-person care. But that is still a ways away for 
us in terms of our work that we are doing right now.
    Senator Cortez Masto. Well, thank you. And so then, let me 
jump to Dr. DeCherrie, because I think it is important. In your 
testimony you really talked about the acute Hospital at Home 
waivers, and particularly the front-end costs of getting things 
started, whether it is telehealth, acute Hospital at Home 
waivers, whatever is needed--that the hospitals were not making 
some of these investments long-term because they were not sure 
if the waivers would become permanent.
    And I guess my question to you is, what is it that you need 
from us on a Federal level, or you would think that the 
hospitals need, to really be thinking long-term that we want to 
move in this direction, short of passing legislation?
    Dr. DeCherrie. Yes, well, the Hospital at Home waiver came 
about last November. Obviously we do not know exactly when the 
public health emergency is going to end, but it is tied to the 
public health emergency. Right now, that date is July. And so, 
making an investment now for a program that might end in July, 
that is a big decision for a hospital.
    So making the waiver permanent for another year, or another 
2 years, or extending the waiver while things are being 
analyzed, I think that that would be one way that would entice 
the hospitals to apply for it.
    Senator Cortez Masto. Thank you. Thank you again.
    Thank you to the panel members.
    The Chairman. Thank you, Senator Crapo, for filling in. It 
has gotten to be a tradition. We juggle all of this.
    Senator Young, I believe, is next. We are moving into the 
home stretch, colleagues, if members have not gotten a chance 
to ask questions. We are putting out the word that we are 
almost done.
    Senator Young?
    Senator Young. Thank you, Mr. Chairman.
    Well, I welcome our panelists, and I will begin with the 
topic of telehealth. Even prior to the pandemic, I heard from 
my constituents in Indiana, particularly those in rural areas, 
about the ways in which telehealth can both increase access to 
underserved Americans and reduce health-care costs.
    Since the start of the public health emergency, the 
telehealth flexibilities provided by Congress and the 
Department of Health and Human Services have been a lifeline 
for vulnerable seniors. I have seen it up close and personal. 
It is amazing how we have been able to leverage telehealth to 
provide vital services, to our seniors in particular.
    But others have taken advantage of this as well to access 
all manner of care from the safety of their own homes. 
Currently, authorizations are included in the CARES Act to 
create additional flexibility for patients and providers using 
telehealth that only extend through the pandemic.
    So I will ask some questions of Dr. Murali. The Federal 
Government has relaxed, waived, or changed many regulations to 
extend access to telehealth during COVID-19. What regulatory 
flexibilities are key to providing telehealth today and should 
be made permanent after COVID-19?
    Dr. Murali. So I personally think that all the telehealth 
waivers that came in during the pandemic need to be extended. 
The particular focus on behavioral health is something that you 
have been a strong proponent of, and looking at what is 
happening in the rural geography. And I heard a story of a 63-
year-old farmer who had to sell all his cows and would not come 
in to our institution for psychiatric care if telehealth was 
not available. So it is fundamentally important to extend that.
    In terms of the acute care without walls, that is something 
that we are all invested in, and we know it works very well. 
The outcomes from the standpoint of fall prevention, the 
outcomes from the standpoint of reducing infections, length of 
stay, cost of care, safety, patient satisfaction, patient 
acceptance rates, are all phenomenal and off the charts. And 
that is something that should be extended beyond the pandemic. 
So those are two things.
    And then in terms of the geographic site requirements, I 
think that that also has to be remote because the geographic 
site requirements restrict care. So it does not make sense that 
a Medicare Advantage patient can go to an MSA and seek care, 
when the Medicare fee-for-service patient cannot go to the same 
location and seek care. So it works for one, but it does not 
work for the other.
    So there are several of these waiver programs that just 
need to be disposed and done with. And if there are prospective 
payment mechanisms for groups that are taking risk or 
capitation, they will figure a way of how to manage the cost of 
health care within the budget that they are allocated. But 
actually making sure that outcomes and quality are tied to the 
provider who is providing care is important. So you want to 
take the middle man out of the equation and say, physician 
groups, care delivery groups, you are responsible for 
delivering on this, and this is the expectation, and they will 
telework. Because if you have front-end money to invest on 
that, we can provide care creatively, just as we did during the 
pandemic.
    And so those are things we would support.
    Senator Young. So you just provided a very concise and 
compelling tutorial on the extension, I think, of these 
waivers. I appreciate that.
    Just from personal experience--I visited mental health 
providers, and they have indicated to me that not only have 
they seen an increase in the rate of maintaining appointments, 
which increases their efficiencies, but there are certain 
individuals, for private reasons, who would prefer to have 
their initial consultation, or in some instances all their 
consultations, through telehealth, irrespective of the public 
health condition at a particular period of time.
    The providers are generally very happy with the ability to 
provide telehealth. It took a period of time for many of them 
to become used to it, but one could envision hybrid services, 
here again even for those who have access to or are able to 
physically go into the office. But there are just so many 
efficiencies, conveniences to the consumer as well as to the 
provider, that can be realized here.
    And as we talk about bending the cost curve down--actually 
we stopped talking about that, because we have utterly failed, 
for a number of reasons. Number one, I do not think we have 
invested enough in prevention across a number of different 
areas. But this is another area where I see just sort of a 
fertile opportunity to reduce the actual cost of care, and 
therefore reduce the cost of insurance for my constituents and 
others.
    So it is very important. Thank you for your quick summary.
    How much time do I have left, Mr. Chairman? It looks like 
30 seconds. And so, for that reason, I will yield back the 
balance of my time.
    The Chairman. All right. If my colleague, because he is the 
last one, has a last question, I do not want to see him 
stifled.
    Senator Young. I have a vote to cast, but thank you for 
your time, Mr. Chairman.
    The Chairman. Great. Thank you.
    All right, I believe we have heard from all of our members. 
I have a brief closing statement, and I always like Senator 
Crapo to have a chance to do one as well.
    Senator Crapo, would you like to go now?
    Senator Crapo. Well, certainly. I will be very brief, Mr. 
Chairman. I again thank you for holding this hearing, and I 
thank our witnesses. I think we have had a very strong support 
for a number of the provisions that you and I, Mr. Chairman, 
think we need to address on a permanent basis, particularly 
telehealth. I appreciate your helping us confirm what the 
issues are, and what the benefits are of making that loop.
    And, Mr. Chairman, I turn it back to you.
    The Chairman. Okay. Let me say ``thank you'' to all our 
witnesses.
    Back in the days when I was director of the Gray Panthers, 
we dreamed of being able to tap the technology treasure trove 
that exists today. It is extraordinary what can be 
accomplished. And you all made so many important points. 
Certainly this question of equity is fundamental.
    I would probably say telemedicine during the pandemic was a 
godsend for people who could get access to it. And you all have 
made a compelling case that a number of people could not. We 
started, I guess, 3 hours ago.
    Dr. Davis, you and I were talking about the importance of 
making sure that audio-only telehealth is expanded. I also 
share your view about the fact that it ought to be accessible 
in other languages as well. And you could hear the strong 
sentiment from my colleagues of both political parties on that. 
Because you know, audio-only can be a lifeline in rural 
communities and communities of color where access to telehealth 
is limited at best.
    We also got a lot of good recommendations. Dr. DeCherrie 
made the recommendation to allow permanent waivers for Hospital 
at Home. It strikes me as a very good suggestion.
    I think several of you made the point that it was time for 
Congress to remove geographic site restrictions on telehealth. 
I think you, Dr. Davis, and maybe the good souls at GAO 
recommended that, but several of you said that there really was 
not a substantive case for doing that.
    And Dr. Murali, off on the corner of my screen, really 
brought it home when he said there is no place like home for 
American health care, and probably if Americans could have 
heard the news you were giving, you would have gotten a digital 
standing ovation for that one.
    Now in terms of the challenges, I was really struck when 
Dr. Berenson described, several hours ago, the process of 
billing and approval bouncing from office to office to office, 
leaving both patients and providers in something resembling a 
bureaucratic Never-Never Land.
    And, Dr. Berenson, you and I have known each other for a 
lot of years. We have appreciated your good work. But we would 
like to conscript all of you good people into this question of 
sorting out the bureaucracy. And Senator Crapo and I have made 
this kind of a special priority, because if we are really going 
to get it right and squeeze out every bit of value for both 
patients and providers, as well as taxpayers, we have to sort 
this out. And I will tell you, Dr. Berenson, you brought it 
home, because I have been hearing that at home too about 
billing and approval and the like. Because this was something 
that was put together so quickly--and that is another story, 
because then-Chairman Hatch and I thought it would have been 
done well before the pandemic, because the CHRONIC Care Act was 
passed in 2017. It was stood up very quickly. And when you 
painted that picture of billings and approvals, it was almost 
like the days when I ran the legal aid office for the elderly 
and we just bounced bill after bill after bill, and program 
after program from office to office, and eventually they said, 
``Well, Ron is going to run it down.''
    Well now, Senator Crapo and I are going to do this 
together. We are going to sort this bureaucracy challenge out, 
and we are going to conscript all of you. But it has been a 
terrific panel. In my time in public service, we have had a 
chance to talk to a lot of thoughtful people, and we managed to 
get everybody together who was thoughtful this morning. So a 
big thanks, and with that the Senate Finance Committee is 
adjourned--excuse me. One bit of business. For members, all 
questions in writing for our guests are due a week from today.
    And with that, the Finance Committee is adjourned, and we 
thank you all.
    [Whereupon, at 12:45 p.m., the hearing was concluded.]

                            A P P E N D I X

              Additional Material Submitted for the Record

                              ----------                              


           Prepared Statement of Robert A. Berenson, M.D.,* 
                   Institute Fellow, Urban Institute
---------------------------------------------------------------------------
    * The views expressed are my own and should not be attributed to 
the Urban Institute, its trustees, or its funders.
---------------------------------------------------------------------------
    Chairman Wyden, Ranking Member Crapo, and members of the committee, 
telehealth offers the promise of an important disruptive innovation in 
health-care delivery. With broad adoption, the approach could 
simultaneously (1) increase access to care for the American public, (2) 
raise the quality of that care, and (3) substantially reduce spending 
growth. However, decisions on how to pay for expanded use of 
telehealth--decisions that need to be made in the near future--will 
determine whether that promise is achieved or, alternatively, whether 
telehealth adoption will raise spending substantially without 
corresponding benefits to patients or society.

    I have spent a good part of my professional career, first as a 
practicing, general internist in a Washington, DC, group practice; then 
as a government official in charge of Medicare payment policy at the 
Centers for Medicare and Medicaid Services (CMS) in the Clinton 
administration; and for nearly 20 years as a policy researcher at the 
Urban Institute, exploring better ways of compensating physicians and 
other health professionals. (The views expressed here are my own and 
should not be attributed to the Urban Institute, its trustees, or its 
funders.) I have focused both on making improvements to the predominant 
fee schedule method of paying practitioners and on seeking workable 
payment alternatives to fee-for-service. I have also worked on these 
payment method issues as vice chair of the Medicare Payment Advisory 
Commission, better known as MedPAC, and more recently as an initial 
member of the Physician-Focused Payment Model Technical Advisory 
Committee, or PTAC, which was established under the Medicare Access and 
CHIP Reauthorization Act of 2015, or MACRA.

    Payment reform has not been easy or particularly successful. Over 
the past 40 years, ``alternative payment models'' (APMs) have come and 
gone as clinicians and hospital providers have continued to battle more 
for their share of the fee-for-service pie rather than embrace 
alternatives that in the long run would enhance their own practice 
environment and sense of professionalism, provide economic stability to 
practices, and better serve their patients.

    Although I am sure that with so many other issues to address 
following the COVID-19 pandemic, there is temptation to simply ratify 
as permanent what were intended to be temporary policies during this 
public health emergency. But Congress needs to recognize that it has a 
unique (though maybe short-lived) opportunity to act decisively to move 
away from nearly complete dependence on the Medicare Physician Fee 
Schedule (MPFS) to more successful, alternative payment approaches that 
will open the door to further APM development and adoption. In my view, 
making permanent the temporary public health emergency work-arounds 
could be a years-long setback to the compelling need for fundamental 
provider payment reform for Medicare and, because Medicare typically 
establishes the model for other payers, the entire health-care system.

    The committee should understand that over the past decade as public 
policy has encouraged the development of so-called ``value-based 
payment,'' I have been something of a contrarian, pointing out that all 
payment methods have strengths and weaknesses, including fee-for-
service. Accordingly, I argue that the legacy payment models (for 
physicians, the MPFS) need attention to improve value and to better 
complement proposed APMs. I have also argued that many proposed APMs, 
although conceptually compelling, are operationally challenged if not 
impossible, yet they consume a lot of what economists call 
``opportunity costs.'' The result is that I sometimes defend the MPFS 
and point to recent improvements that have clearly added to the value 
produced by the MPFS (i.e., that improve access and quality at an 
acceptable cost). But as I will try to make clear in this testimony, 
fee-for-service is a particularly inappropriate payment method for most 
telehealth services.

    My interest in finding a payment method appropriate for what we are 
calling virtual care (i.e., not in person, using a growing range of 
communication technologies) is not new. I co-authored a paper in 2003 
commenting on the Chronic Care Model, which had been recently developed 
by Edward Wagner and colleagues at the University of Washington.\1\ 
Besides advocating for other innovative approaches to caring for the 
increasing number of individuals living with one or more chronic 
condition, the Wagner Model called for robust communications with 
patients outside of the occasional in-office visit (largely by 
telephone at the time). In the paper, I explained why payment for what 
should be high-frequency communications should not be through fee 
schedules; instead I called for telehealth payment primarily through 
per person per month (PPPM) payments. In essence, these would be 
telehealth accounts that would provide practices a lump sum that 
patients spend down to support virtual care. It is fair to say that 
that paper was thoroughly ignored. However, the urgency and interest in 
finding an alternative to fee schedule payments for telehealth has now 
increased substantially. In this testimony I will expand on that 
perspective, laying out the main barriers to fee schedule payment for 
telehealth services and suggesting alternatives.
---------------------------------------------------------------------------
    \1\ Berenson, RA and Horvath J. ``Confronting the Barriers to 
Chronic Care Management in Medicare,'' Health Affairs, 22, Suppl 1 
(2003): W3-1--W3-14.

    Last year, CMS acted with decisive speed to provide a safety net 
for practices and ongoing access for patients during the public health 
emergency. CMS (1) introduced flexibility in the requirements for a 
qualifying telehealth video visit by permitting the patient's home 
(rather than only a medical facility) to be an accepted telehealth 
originating site; (2) reversed a long-standing policy, now designating 
phone calls as short as 5 minutes as a reimbursable service; (3) 
softened security and privacy requirements to permit usage of a broad 
range of communication devices and methods; and as I will discuss in 
more detail below, (4) raised fees substantially, in the process 
ignoring the resource-based relative value scale approach that the 
organization has followed since 1992, however imperfectly. The public 
health emergency modifications also expanded the range of clinicians, 
---------------------------------------------------------------------------
such as physical therapists, eligible to bill telehealth services.

    I will identify three major reasons why maintaining most of these 
rule flexibilities and increased payments should not be maintained over 
the long term. Adele Shartzer (an Urban Institute colleague) and I 
outlined these concerns in a recent paper in JAMA Forum.\2\
---------------------------------------------------------------------------
    \2\ Robert Berenson and Adele Shartzer, ``The Mismatch of 
Telehealth and Fee-for-Service Payment,'' JAMA Health Forum 1, no. 10 
(2020): e201183.
---------------------------------------------------------------------------
                      1. administrative complexity
    Fee schedules can function reasonably well when code descriptions 
are concise and specific, thereby producing reliable and accurate 
coding. For example, there are about 20 different payment codes for 
colonoscopies, with each one detailing whether there was a polyp 
removed, a biopsy taken, or some other distinctive feature of the 
procedure. Colonoscopies represent a clearly defined procedure. 
Operationally, it is easy to bill for and receive fee schedule payment 
for a colonoscopy. Most procedures, tests, and imagings lend themselves 
operationally to payment by fee schedule. But codes for telehealth 
services are not concise; indeed, CMS telehealth codes attempt to 
delineate the specific communication technology employed, the patient's 
location during the communication, which party initiated the service, 
the duration of the virtual encounter, the time interval from prior and 
subsequent office visits, the frequency of allowed billing for the 
service, and other characteristics specific to the particular 
telehealth services. Importantly, these coding parameters were 
established for payment purposes alone: they do not provide useful 
clinical distinctions. Given rapidly evolving technological 
capabilities, telehealth codes will quickly become outdated. The tangle 
of telehealth codes (now numbering about 250 and counting in the MPFS), 
combined with lots of code requirements, will lead to fraud in some 
cases, but also more commonly to ``gaming behavior'' by provider 
practices. For example, if a phone call needs to last at least 5 
minutes to qualify for payment, how will Medicare ferret out 4-minute 
calls that were billed (many of which will be as clinically important 
as calls lasting a minute longer). Will the agency require use of 
timing devices on phones?

    Especially if overly generous payments are made through pay parity 
for telehealth visits and phone calls, CMS will feel compelled to 
impose additional burdensome (and ultimately ineffective) documentation 
requirements as these telehealth services proliferate. In short, 
following the COVID-19 pandemic, using the standard MPFS to pay for 
telehealth services would likely produce a quagmire of confusion, 
inadvertent or intentional miscoding, and lots of clinician and patient 
complaints about burden and counterproductive rules.
             2. billing costs in relation to payment levels
    For reasons that practices and hospitals know well but policymakers 
rarely acknowledge, fee-for-service payments can generate high billing 
costs relative to the payment sought and received. The result is that 
it is imprudent to pay for high-frequency, low-payment services by fee 
schedule, at least when the low-priced service is the only service 
billed rather than one line on a larger claim. A recent study from an 
academic health center found that the cost for billing and related 
documentation activities for an office visit was $20.49, including 13 
minutes of work for various individuals, including clinicians.\3\ There 
is no obvious reason why billing and documentation costs for submitting 
telehealth services would be much less than that. Indeed, studies have 
documented that the costs of billing and related functions make up 10 
to 15 percent of operating revenue for practices.\4\ In short, because 
a major portion of billing costs are fixed and apply to any service 
regardless of the payment level, practices would bear transaction costs 
approaching or exceeding the payment they would receive.
---------------------------------------------------------------------------
    \3\ Phillip Tseng, Robert S. Kaplan, Barak D. Richman, Mahek A. 
Shah, and Kevin A. Schulman, ``Administrative Costs Associated with 
Physician Billing and Insurance-Related Activities at an Academic 
Health Care System,'' JAMA 319, no. 7 (2018): 691-97.
    \4\ Bonnie B. Blanchfield, James L. Heffernan, Bradford Osgood, 
Rosemary R. Sheehan, and Gregg S. Meyer, ``Saving Billions of Dollars--
and Physicians' Time--by Streamlining Billing Practices,'' Health 
Affairs 29, no. 6 (2010): 1248-54; James G. Kahn, Richard Kronick, Mary 
Kreger, and David N. Gans, ``The Cost of Health Insurance 
Administration in California: Estimates for Insurers, Physicians, and 
Hospitals,'' Health Affairs 24, no. 6 (2005): 1629-39; Julie Ann 
Sakowski, James G. Kahn, Richard G. Kronick, Jeffrey M. Newman, and 
Harold S. Luft, ``Peering into the Black Box: Billing and Insurance 
Activities in a Medical Group,'' Health Affairs 28, no. 4 (2009): w544-
54.

    And that is just the billing cost for the first submitted claim 
from the practice. A typical claim for a MPFS service is generated by 
the practice and sent to a Medicare administrative contractor, which 
adjudicates the claim and makes a payment to the practice for 
Medicare's portion. The contractor passes the claim to a supplemental 
insurer, such as a Medigap carrier, which determines its portion and 
informs the practice what it can bill the patient for applicable 
beneficiary cost-sharing, at which point the practice generates another 
bill for the patient. Even with electronic transfer, this cycle of 
claiming and paying requires many manual steps, and the cumulative 
---------------------------------------------------------------------------
costs clearly exceed the $20 for the initial claim.

    Practices understand this billing reality. CMS adopted a ``virtual 
check-in'' code in the 2019 MPFS for short (5- to 10-minute) phone 
calls with patients to sort out whether patients needed to come in for 
an office visit. The ``correct'' national fee according to usual 
relative cost determination was about $15. Although the check-in call 
may make good clinical sense in some situations, it failed from a 
financial point of view. Not surprisingly, practices rarely billed for 
the service, suggesting that practices considered the relatively meager 
payment too little to justify the even higher billing costs. The result 
was that Medicare allowed less than $200,000 for this code in 2019 
(compared with total spending under the MPFS of more than $90 billion.)

    Perhaps CMS learned the lesson of payment levels below billing 
costs. Within a few weeks of adopting payment for phone calls during 
the public health emergency, CMS raised the payment for a 5- to 10-
minute phone call from $15 to a more acceptable $46--the rate for a 
level 2 office visit. It made perfect policy sense during the public 
health emergency to get money out to financially strapped practices 
while also facilitating needed access for beneficiaries to their 
practitioners. However, retaining this three-fold increase in the 
proper fee (indeed, adopting complete pay parity) presents an 
unresolvable dilemma for policymakers. Using standard, relative cost 
calculations, the fees for many desirable ``small-ticket'' items would 
be too low to justify practices performing them and/or billing for 
them. Yet raising the fees to make it financially worthwhile for the 
practices would create a major precedent for ignoring relative values 
based on relative resources, thereby opening up the fee schedule to 
special pleadings from many stakeholders.

    Paul Ginsburg (the Vice Chair of MedPAC) and I wrote a paper in 
2019 arguing that it is time for the MPFS to move off of strict 
adherence to relative costs to determine fees (Berenson and Ginsburg 
2019).\5\ This could be accomplished by both (1) altering fee levels 
for likely overpriced services by examining service volume changes that 
occur in response to initial fee changes, usually fee reductions, and 
(2) seeking to accomplish specific policy objectives that could be 
supported by fee changes, usually providing increases in underpriced 
services, such as to increase the attractiveness and supply of primary 
care health professionals. Pay parity for telehealth services in the 
face of research that shows substantially lower production costs \6\ 
should not be adopted as a policy ``one-off'' under the current 
pressure to generously expand telehealth. Rather, such parity should be 
considered only as part of a more comprehensive approach to modifying 
how MPFS fees are determined. Doing otherwise could lead to a policy 
free-for-all in which plausible (but self-interested) pleadings are 
advanced outside of a disciplined process for weighing the merits of 
fee changes. Dr. Ginsburg and I argued that CMS, under the guidance of 
a formal Federal Advisory Committee Act--compliant committee, should 
have the authority to change fees considering factors other than 
relative costs.
---------------------------------------------------------------------------
    \5\ Robert A. Berenson and Paul B. Ginsburg, ``Improving the 
Medicare Physician Fee Schedule: Make It Part of Value-Based Payment,'' 
Health Affairs 38, no. 2 (2019): 246-252.
    \6\ J. Scott Ashwood, Ateev Mehrotra, David Cowling, and Lori 
Uscher-Pines, ``Direct-to-
Consumer Telehealth May Increase Access to Care but Does Not Decrease 
Spending,'' Health Affairs 36, no. 3 (2017): 485-491.
---------------------------------------------------------------------------
                    3. increased volume and spending
    I anticipate that patients and their families will love the 
alternative of video-based telehealth and much greater use of phone 
communications with their practitioners and primary care team members. 
Patients face substantial time costs and inconvenience in traditional 
travel, waiting rooms, and actual time with the practitioner. I 
recently waited 20 minutes after my visit just to check out. The 
routine annual wellness visit took about three hours altogether 
(admittedly with some delays created by COVID-19 concerns).

    I would reiterate that telehealth should be advanced substantially 
as a potential game-changer in how care is delivered. My objection lies 
in using fee schedule payments as the way to compensate the practices 
when alternatives exist that can be adopted and adapted over time. 
Without the constraints of consumer time and inconvenience, the 
potential for a spending explosion is real, especially if policymakers 
resolve the pricing dilemma posed above by paying far above production 
costs, as pay parity would do. Furthermore, important work by 
researchers at RAND (performed before the COVID-19 pandemic) found that 
90 percent of telehealth services were additional services rather than 
substitutes for in-person services.\7\
---------------------------------------------------------------------------
    \7\ Ashwood et al., ``Direct-to-Consumer Telehealth May Increase 
Access to Care but Does Not Decrease Spending.''

    Clearly, that has not been the case during the public health 
emergency, during which virtual visits became the only way for patients 
to receive timely care for a period of time. Nevertheless, used 
properly, telehealth very often should be an add-on to often 
insufficient in-person care, especially for chronic care management but 
also, for example, to clarify whether a tentative diagnosis was 
correct, to monitor the effect of adding a medication or changing a 
dosage, or for myriad other potential clinical reasons. But those add-
on, virtual services need to be managed by the practice within a 
spending constraint to help assure that virtual visits are used 
appropriately.
             4. alternative payment methods for telehealth
    Fee schedule payments should be limited to virtual visits 
equivalent to high-level office visits and paid somewhat less than 
office visits, in line with relative cost calculations as usual. There 
may be compelling reasons to pay fee-for-service for unique provider 
types. A challenging issue is whether Medicare should routinely pay for 
telehealth vendors that do not have established relationships with 
beneficiaries as do many private insurers (but not Medicare). Younger 
patients often do not have established relationships such that an 
occasional telehealth vendor encounter can make good clinical sense as 
a reasonable convenience for patients. But for Medicare beneficiaries, 
policy in general should encourage continuous, established 
relationships, not occasional telehealth vendor visits supported 
through fee-for-service.

    Assuming established relationships between clinicians and patients, 
telehealth is best paid through PPPM payments to cover the costs of 
robust telehealth. Currently, CMS is working to test various forms of 
hybrid payment models that would pay partly by fee schedule and partly 
by a monthly PPPM, called capitation. The latter approach pays the 
practice for patients who are expected to seek care initially from 
their chosen or assigned practice (but remain free to seek care 
elsewhere). The payment is adjusted for the person's underlying health 
risks and represents an average amount for the population of 
beneficiaries with similar health risks.

    Capitation incentives are fundamentally different from fee-for-
service: the practice receives the funds regardless of how many 
services they provide an individual for whom payment is received. The 
incentives are reversed--the practice is rewarded for keeping patients 
healthy and not in need of health services.And the approach should 
reward broad use of telehealth when a virtual visit or phone call 
suffices without need for an in-office visit. There would be no billing 
costs associated with the telehealth provision, and, indeed, 
beneficiary cost-sharing for the capitation portion of the hybrid 
payment could be waived altogether under a well-functioning hybrid 
model. Initially, maintaining fee schedule payments for some services 
(including in-office visits) would help mitigate the expressed concern 
about stinting on care (i.e., accepting the PPPM payments but stinting 
on actually providing care).

    In my view, the compelling need to find an alternative to fee 
schedule payments for telehealth calls for expediting the design and 
testing of the Center for Medicare and Medicaid Innovation's (CMMI) 
model called Primary Care First on a regional and mandatory basis. It 
has the potential to be the alternative permanent payment model for 
primary care practices while also addressing payment for telehealth 
services.

    Paying for telehealth for specialists presents a different 
challenge, because many specialists do not and should not have 
continuous, established relationships. Based on analyzing the use of 
telehealth by specialty during the public health emergency, specialty 
practices that provide a large amount of telehealth services could 
receive lump sum, monthly payments that they control and use for 
appropriate application of virtual care. The practices would allocate 
the funds for telehealth services as they deem appropriate and not have 
to submit claims for each instance. Some accounting would be necessary 
to ensure that the telehealth services were actually provided.
                             5. conclusion
    Congress and CMS face an urgent need to adequately fund telehealth 
services as an essential component of 21st-century health-care 
delivery. However, payment should not simply continue public health 
emergency-based flexibilities and generous payments that are important 
to allow during the COVID-19 pandemic. It would be a policy mistake not 
to use this unique opportunity not only to provide a better payment 
method to support virtual health care and other evaluation and 
management services, including in-office services, but also to reform 
how Medicare Physician Fee Schedule fees are determined in the first 
place.

    Telehealth should not be supported primarily through fee-for-
service, but rather through hybrid payment methods that should include 
capitation for primary care practices and periodic lump sum payments 
for specialists. The latter approach has not been tested and will need 
immediate development and pilot testing. Continued fee schedule 
payments for telehealth should be limited to lengthy, virtual care 
encounters and for particular clinicians and other providers that do 
not have continuous, established relationships with patients. Policy 
should encourage development of established relationships, especially 
for the Medicare population, who often have multiple, interacting 
chronic conditions.

    Admittedly, pursuing these recommendations would be challenging; it 
would be easier politically and operationally to simply ratify the PHE 
changes going forward, as many stakeholders advocate. That would be a 
mistake both because it could produce sustained increases in Medicare 
spending for years to come and because of the missed opportunity 
presented by telehealth to adopt alternative payment models that would 
produce greater value than even improved fee-for-service is able to 
produce. True value-based payment, although aspirationally worthy, has 
been difficult to accomplish. Telehealth provides a ready opportunity 
to make a virtue of necessity. Congress should not allow the 
opportunity to pass by.

                                 ______
                                 
     Questions Submitted for the Record to Robert A. Berenson, M.D.
           Questions Submitted by Hon. Catherine Cortez Masto
    Question. More than a quarter of Medicare beneficiaries lacked 
digital access at home in 2018, a figure that is higher among those 
with low socioeconomic status, those 85 years or older, and in 
communities of color. States have just received unprecedented funding 
from the American Rescue Plan to support COVID-19 response and recovery 
efforts, including expanding digital infrastructure that communities 
need to get up and running again.

    What could be done at the State level to leverage the funding 
provided in the American Rescue Plan to close the gap in access to 
telehealth services?

    What more could be done at the Federal level to support 
communities?

    Answer. The prospects for passage of the American Rescue Plan are 
uncertain at this time. I suggest that a large portion of unspent funds 
from the Provider Relief Fund of the CARES Act be reprogrammed for the 
purpose of building comprehensive, national digital infrastructure. On 
June 21, 2021, The Washington Post again documented that many large 
non-profit health systems actually improved their financial margins in 
2020. In addition, research work that I have helped lead and is now in 
the process of journal peer review, when published, will demonstrate 
that many health systems have many billions of dollars readily 
available as cash and marketable securities and have no need for 
additional CARES Act bailout. They have substantial surpluses as days 
cash on hand to meet their expenses, even if they had no new revenues 
at all, in some cases exceeding 365 days. Building up digital 
infrastructure to support telehealth and for a range of other purposes 
should take priority over further funding of already flush health 
systems.

    In the longer term, Federal and State action to increase antitrust 
scrutiny of mergers and acquisitions and of anticompetitive behavior 
from extant health system oligopolies would reduce health-care spending 
increases, again freeing up funds to support access to basic health-
care services in all communities.

              Questions Submitted by Hon. Thomas R. Carper
    Question. During the pandemic, telehealth has been an essential 
tool to get children the care that they need while minimizing risk. 
Although telehealth under Medicare has been a focus, close to 40 
million children are enrolled in Medicaid.

    What are the main policy changes we need to ensure this broader use 
of telehealth can continue beyond the pandemic for children?

    Answer. I have limited expertise on Medicaid and CHIP issues and, 
so, will not respond.

    Question. During COVID-19, many States adopted temporary changes to 
their telehealth policies, such as expanding the scope of services and 
providers able to furnish telehealth, relaxing of licensure 
requirements and modifying reimbursement policies. Many States 
legislatures have also begun the work to adopt more permanent 
telehealth policy changes.

    How can the Federal Government best support State Medicaid programs 
in their efforts to expand telehealth?

    Are there Medicaid supports, incentives, and learnings that Federal 
policymakers could provide?

    Answer. I have limited expertise on Medicaid and CHIP issues and, 
so, will not respond.

    Question. COVID-19 has introduced additional stress and trauma for 
children and families. Telehealth, and particularly audio-only 
telehealth has been a crucial tool to connect children and adolescents 
to needed mental health-care services.

    How can telehealth be best utilized to meet kids' mental health-
care needs, and can you speak to the use of audio-only telehealth 
specifically?

    Answer. I will repeat two points I emphasized in my testimony and 
in response to questions raised by Senators at the hearing. One, fee-
for-service is a particularly poor payment method for telehealth. 
Public and private payers need to promptly move away from total 
dependence on fee schedule payments to health professionals in include 
a substantial amount of lump sum payments that allow clinicians to 
deploy telehealth appropriately, rather than be dependent on incomplete 
and changing code-level descriptions of fee schedule services. Two, 
audio-only services (which used to be called phone calls) should be 
considered an essential, ``must include,'' component of telehealth 
services. When patients are well known to their clinicians, video-based 
calls in health-care delivery often is needed only for group 
conversations or for visual display of clinically-relevant physical 
appearance and data transfer. In many situations, the phone can be as 
effective and certainly more efficient than a video visit, assuming 
appropriate attention to security and confidentiality. At the same 
time, fee-for-service payment for audio-only services would be 
particularly challenging in the long term and would likely generate 
intrusive and ultimately counterproductive compliance requirements. The 
solution, again, is moving telehealth payment to lump sum payments, 
such as primary care capitation (per person month payments for patients 
empaneled with a primary care practice).

    Question. As State Medicaid programs look at expanding their use of 
telehealth, it is particularly important that vulnerable populations 
like children are not negatively impacted. Policies must be looked at 
through a health equity lens, considering access to reliable and 
affordable broadband services, access to devices that support HIPAA-
compliant telehealth platforms and coverage policies.

    How can Medicaid programs work to ensure telehealth policies are 
equitable for children and mitigate potential inequities that may 
arise?

    Answer. Again, given my lack of expertise on Medicaid, I will not 
respond to this question.

                                 ______
                                 
              Question Submitted by Hon. Patrick J. Toomey
    Question. In your testimony, you cited pre-pandemic research 
undertaken by RAND that found 90 percent of telehealth services were 
additional services rather than substitutes for other in-person 
services and consultations. Moreover, other witnesses' testimony 
clearly demonstrates that telehealth utilization in Medicare and 
Medicaid has increased over the past year in light of the COVID-19 
pandemic.

    Given the unsustainable fiscal trajectory of the Medicare program 
and the need for payment reforms, what types of tools exist or may be 
needed in the Medicare fee-for-service program or Medicare Advantage 
program that will ensure appropriate utilization management of 
telehealth services?

    Answer. In my writing and speaking on Medicare, I do not refer to 
the ``Medicare fee-for-service program,'' for the simple reasons that 
most of the payment methods in this program are no longer fee-for-
service and calling it fee-for-service supports an inaccurate, negative 
caricature of the program. For example, the inpatient prospective 
payment system in 1984 abandoned fee-for-service by adopting case rate 
payment, known as diagnosis-related groups (DRGs). Nearly two dozen 
other countries have now adopted various versions of DRGs, precisely 
because this payment method is not fee-for-service. The Medicare 
Physician Fee Schedule stands out as true fee-for-service and in need 
of reform.

    It is true, however, that most Medicare payment methods, remain 
volume-based, if not fee-for- service. That is total payment depend on 
the number of payment units generated and billed for, whether at the 
individual service level or whether bundled into larger payment units. 
Many payment policy experts are currently recommending that the 
traditional Medicare program adopt a hybrid payment model for primary 
care practices, consisting of a hybrid of equal parts fee schedule and 
capitation relying on patient empanelment with their preferred primary 
care practice. Such a payment system would substantially restrain the 
potential explosion of telehealth services; telehealth services would 
be covered under the capitation portion of the hybrid paymemt. Limited 
exceptions to permit fee schedule payments for telehealth should be 
considered, e.g., for other categories of health professionals, such as 
physical therapists, or for especially long and unusual telehealth 
visits. Nevertheless, I strongly recommend that Medicare generally 
should not pay mainstream physician practices for telehealth through 
the fee schedule payments.

    Medicare Advantage plans are in a position to pioneer the use of 
innovative payment methods. They need not--and sometimes do not--adopt 
traditional Medicare's payment methods for various reasons. 
Unfortunately, MA plans have tended to be followers rather than 
innovators, perhaps because of their limited market shares compared to 
traditional Medicare's. Ideally, payment reform would occur as a 
collaboration between traditional Medicare, Medicaid agencies and MCOs, 
and both MA plans and commercial insurers. That kind of collaboration 
has not been very successful over the past decade, but needs to be 
reinvigorated, with CMS taking the lead.

                                 ______
                                 
               Questions Submitted by Hon. Chuck Grassley
    Question. Throughout the public health emergency, the Centers for 
Medicare and Medicaid Services (CMS) issued over 200 waivers under 
Medicare and approved more than 600 waivers and other flexibilities 
under Medicaid. While some of the regulations waived are specifically 
for responding to a pandemic, ensuring patient safety, controlling 
costs, and maintaining program integrity its clear innovation and 
common sense ideas in our health-care system have been stifled too 
often by Federal regulations. For example, CMS permanently added 
certain new services (including mental health and care planning 
services) that it had temporarily added to the approved list of 
Medicare telehealth services during the pandemic. Some regulations play 
an important role in protecting safety and maintaining program 
integrity but others may stifle good ideas.

    Is health care too regulated that it's stifling good ideas?

    Should executive agencies sunset regulations in the future to 
enable more innovation in health care?

    Answer. Unfortunately, a primary reason for relative lack of 
innovation in health-care results from fee-for-service and other 
volume-based payment incentives. Providers with well-established, 
profitable revenue streams typically are not eager to consider 
disruptive innovation that might undermine these streams. Both 
horizontal and vertical integration based around hospitals has resulted 
to a significant extent in non-responsive, health systems that dominate 
health delivery to the detriment of independent practitioners and 
patients. The Nation has needed more and more creative antitrust 
enforcement. Although some deride assertive antitrust enforcement as 
``over-regulation,'' antitrust serves to preserve competition and 
choice, which is where innovation takes place.

    Currently, in the face of increasingly non-competitive health 
provider markets, policy is needed to actively regulate the ``monopoly 
prices'' that health systems demand of commercial insurers. Indeed, 
regulated, rather than market- determined, prices have allowed Medicare 
Advantage plans to thrive as a choice that 40 percent of Medicare 
beneficiaries have exercised. In short, regulating prices now would 
allow markets to work better to reward innovation rather than preserve 
what economists call ``monopoly rents.'' Regulations can have negative 
effects on innovation, but in my opinion are not a major source of the 
current high spending, poor quality health system the U.S., regrettably 
now exhibits. And, as I emphasized in my testimony and in other 
responses here, paying telehealth through fee-for-service would 
undoubtedly produce substantially increased, intrusive and 
counterproductive regulation to try to protect against the inevitable 
fraud and abuse that telehealth would spawn if paid for that way.

               Questions Submitted by Hon. John Barrasso
    Question. Before coming to the Senate, I had the privilege of 
practicing medicine in Wyoming. Rural health care faced challenges 
prior to the pandemic. In particular, we know since 2010 more than 135 
rural hospitals have closed.

    In the Senate, I am proud to help lead the bipartisan Rural Health 
Caucus. This group is committed to ensuring patients in rural America 
can get access to the care they need.

    Can you specifically discuss the changes in Federal health-care 
policy that you believe have helped rural providers the most during 
this pandemic?

    Can you please discuss any specific changes that Congress should 
consider to better support rural health-care providers?

    Answer. The Affordable Care Act authorized creation of a Workforce 
Commission, which was constituted with appointments of commissioners 
but never met because of the absence of the requisite appropriation. 
Workforce policy is desperately needed to address access to basic 
health services for rural populations, which now face a drastic 
shortage of health professionals. Medicare Graduate Medical Education 
policy needs overhaul to redistribute funds to primary and preventive 
care education and to require academic health centers to better educate 
and provide ongoing educational support to rural practitioners. The 
workforce issues have mostly been ignored over the past decade, partly 
because the Workforce Commission has not been able to carry out its 
legislated mission.

    Telehealth provides a new opportunity to reconfigure workforce 
needs for rural communities, once the requisite electronic 
infrastructure is deployed, Again, there is need for a dedicated 
commission to present a set of comprehensive recommendations for 
congressional consideration.

    Question. Prior to the pandemic, I introduced bipartisan 
legislation with Senator Tina Smith, which among other things, would 
allow Rural Health Clinics (RHCs) to provide more telehealth services.

    I was pleased that Congress through the CARES Act authorized both 
Rural Health Clinics and Federally Qualified Health Centers to furnish 
telehealth services to Medicare beneficiaries during the public health 
emergency.

    Can you discuss the importance of Rural Health Clinics and 
Federally Qualified Health Centers continuing to provide telehealth 
services after the public health emergency has ended?

    Answer. RHCs and FQHCs are crucial for access to basic health 
services in rural areas and underserved urban areas. As I emphasized in 
my testimony, fee-for-
service is a poor way to compensate for telehealth services, even if 
based on costs, as in these two programs. Both RHCs and FQHCs receive 
cost-based per visit payments subject to limits relying on rates from 
2000 trended forward 20 years. That method will not work to encourage 
telehealth services. There has been interest in moving payment for RHCs 
and FQHCs away from per visit rates. Telehealth can be a catalyst for 
moving to a population-based payment method for these important 
centers.

    Question. My wife Bobbi and I are passionate about improving access 
to mental health services. This pandemic has clearly impacted the 
mental, as well as the physical health of our Nation.

    For people living in rural America, getting help from a mental 
health provider was challenging before the pandemic. This is why 
Senator Stabenow and I have long supported professional counselors and 
marriage and family therapists participating in Medicare. We believe 
that increasing the number of mental health providers able to care for 
our Nation's seniors is an important priority.

    Please discuss how telehealth has impacted the ability of patients 
to receive mental health services during the pandemic.

    Can you please identify ways Congress can improve access to mental 
health services, including expanding the number of providers that can 
participate in Medicare?

    Answer. I have no expertise in provision of mental health and other 
behavioral health services. However, in interviews with primary care 
physicians and other discussions I have participated in, I have heard a 
consensus viewpoint expressed that mental health services are 
particularly amenable to telehealth interactions with health 
professionals, who do not have to reside in the community. An 
operational issue that needs ongoing attention is the need to assure 
confidentiality and security of the telehealth services. But that is a 
soluble problem.

    Question. I agree telehealth is transforming the way we are 
providing care. However, in Wyoming, most of our providers are part of 
smaller hospitals and practices. We need to make sure government 
regulation is not making it more difficult for these providers to serve 
their patients.

    Can you discuss specific ways Congress can reduce the 
administrative burden in providing care through telehealth?

    Answer. One of the responses to the telehealth imperative for 
adoption use during the public health emergency was the relief 
expressed by clinicians to the lessened administrative burden that 
disappeared because of the regulatory waivers. That said, maintaining 
the flexibility waivers and continuing to pay fee-for-service is a 
dangerous mix and likely to encourage even more fraud and abuse. To 
avoid that outcome I called for prompt adoption of new payment 
methods--capitation for primary care physicians, and telehealth-based, 
lump sum payments for specialists--as substitutes for fee schedule 
payments for telehealth services. Doing so should substantially reduce 
administrative burden for providing care through telehealth while also 
reducing the likelihood of fraud and abuse. There surely will need to 
be accountability for the telehealth services provided when using these 
alternative payment methods, but such accountability would likely 
require much less burden for practices than what would be required 
under standard fee schedule payments.

    Question. Wyoming has many passionate advocates supporting both 
hospice and palliative care. These folks are committed to ensuring 
patients have the highest quality of life and are able stay out of the 
hospital and with their families. This is why I help lead the 
bipartisan Comprehensive Care Caucus. Our mission is to improve both 
palliative and hospice care for patients.

    Can you please discuss how telehealth flexibilities have impacted 
access to palliative care and how we can continue making progress in 
this area?

    Answer. I have no knowledge about impact of telehealth 
flexibilities on the provision of palliative care.

                                 ______
                                 
                Prepared Statement of Hon. Mike Crapo, 
                       a U.S. Senator From Idaho
    Thank you, Mr. Chairman, for holding this important hearing.

    Congress and the administration provided certain health-care 
flexibilities during the pandemic so that patients could continue to 
receive high-quality care. Making permanent changes based on lessons 
learned is a top priority.

    I have shared my interest with President Biden's nominees for the 
key health-care positions who have come before this committee, and I 
appreciate their commitment to work with me and this committee. 
Republicans and Democrats often disagree on the best way to achieve 
shared health-care goals. This hearing, however, highlights an area of 
common ground.

    In fact, Senator Wyden and I asked the majority and minority staff 
to jointly plan this hearing, demonstrating strong bipartisanship. 
Acting on legislative changes and using administrative authority, the 
Centers for Medicare and Medicaid Services waived over 200 payment 
rules during the pandemic in Medicare alone.

    Needless to say, there is a lot we can learn.

    Today's witnesses will provide insight to guide our efforts in 
evaluating these flexibilities. Hearing firsthand about the patient 
experience during the pandemic from providers who overcame challenges 
to provide care will be invaluable. Understanding how the flexibilities 
are used in fee-for-service, Medicare Advantage, and in alternative 
payment models will be insightful.

    Much of the hearing will focus on care provided during the pandemic 
through telehealth. Telehealth has been a lifeline for patients and 
providers, especially in the early months of the pandemic. The reliance 
on telehealth increased in rural and urban areas alike, allowing 
patients to receive remote care from the safety of their home. 
Telehealth services have been especially useful for Idahoans.

    According to the Idaho Department of Insurance, telemedicine visits 
went from an average of about 200 appointments per month to 28,000 
telehealth visits in April 2020 alone. To ensure financial stability, 
providers have been paid at the same rate as if the service was 
furnished in-person. This has facilitated care that otherwise would be 
risky or unavailable, and patients have appreciated the convenience. It 
has reduced the frequency of missed appointments, and assisted provider 
investment in the infrastructure needed for remote care.

    This long period of expanded telehealth will help us understand the 
impact on quality of care and program costs. It serves as a robust test 
project on a scale few could have imagined. The promise of telehealth 
is clear, but it is important that we gather evidence on its impact on 
access, quality, and cost.

    There are approaches to providing care in the most efficient 
setting that go beyond telehealth. Some hospitals are using a waiver 
that provides flexibility to triage patients who present to the 
hospital to see if they can be best cared for in their home.

    Whether through telehealth, Hospital at Home, or other innovative 
care arrangements, it is important to find ways to get patients care 
that best meets their needs, and at the lowest cost possible. Congress 
has taken permanent steps to do just that in recent years.

    Nephrologists can conduct remote evaluations of patients receiving 
home dialysis. Providers can administer certain drugs to vulnerable 
patients in their own homes.

    Hearing from our provider witnesses helps us to continue down this 
path. The Government Accountability Office will supplement what we hear 
from our provider experts, offering a perspective on how to track and 
evaluate flexibilities in Medicare and Medicaid as we chart the right 
course forward. I fully expect we will take what we learn from this 
hearing to continue our bipartisan efforts to help providers give 
patients the best care possible.

    Permanent changes based on lessons learned from the pandemic to 
modernize Medicare payment systems lend to the pressing need to address 
Medicare's financial struggles. Identifying smart reforms that make 
Medicare more efficient will be better for patients and better for 
taxpayers. Such changes alone will not put Medicare on a sustainable 
path, but they should be part of that broader conversation.

    Addressing Medicare solvency should also be a bipartisan issue, 
with time best spent determining how to shore up the current system 
instead of expanding it to a broader population. Finding the right path 
on these priority issues is important to patients and the health 
programs in the committee's jurisdiction.


    This hearing will help us to capitalize on the bipartisan 
opportunity.

    Thank you, Mr. Chairman. I yield back.

                                 ______
                                 
Prepared Statement of Kisha Davis, M.D., MPH, FAAFP, Member, Commission 
   on Federal and State Policy, American Academy of Family Physicians
    Chairman Wyden, Ranking Member Crapo, and members of the committee, 
I am Dr. Kisha Davis, a member of the American Academy of Family 
Physicians (AAFP) Commission on Federal and State Policy, and I am 
honored to be here today representing the 133,500 physician and student 
members of the AAFP.

    I am a practicing family physician and the vice president of health 
equity at Aledade. In addition to seeing patients in Baltimore, MD, 
through my role at Aledade, I support physicians in private practices 
and community health centers across the country. I have experienced the 
impact of the COVID-19 pandemic and resulting Federal policy changes 
firsthand as a front-line physician, and I have had the opportunity to 
observe them on a broader scale.

    Many of the emergency flexibilities that the Centers for Medicare 
and Medicaid Services (CMS) made available during the COVID-19 pandemic 
have improved patients' access to primary and preventive care, 
bolstered the physician workforce in rural and underserved communities, 
and alleviated administrative burdens on clinicians, enabling us to 
focus on patient care. As Congress considers whether to extend these 
flexibilities beyond the public health emergency and how to build upon 
recent advances, it is vital that Medicare and Medicaid policy changes 
are designed to advance health equity, protect patient safety, and 
enable clinicians to provide the right care at the right time.

    The AAFP offers the following recommendations.

        Adopt telehealth policies that enhance the physician-patient 
relationship rather than disrupt it, and incentivize coordinated, 
continuous care provided by the medical home.

        Adopt payment models that support patients' and clinicians' 
ability to choose the most appropriate modality of care and ensure 
appropriate payment for care provided.

        Permanently remove geographic and originating site 
restrictions to ensure that all Medicare beneficiaries can access 
telehealth care at home.

        Require Medicare to cover audio-only evaluation and management 
services beyond the public health emergency to ensure equitable access 
to care.

        Permanently cover telehealth services provided by Federally 
Qualified Health Centers (FQHCs) and rural health clinics and ensure 
adequate payment.

        Monitor the impact of telehealth on access and equity by 
ensuring that data collection and evaluation include race, ethnicity, 
gender, language, and other key factors.

        Invest in infrastructure to promote digital health equity.

        Mandate Medicaid coverage of all Advisory Committee for 
Immunization Practices (ACIP)--recommended vaccines for all adults.

        Permanently allow physicians to provide direct supervision and 
teaching services via telehealth to expand access to primary care 
services and increase training opportunities.

        Reduce the volume of prior authorization requirements to 
decrease unnecessary administrative burden on physicians.

        Grant HHS the authority to waive reporting and other 
administrative requirements for the Quality Payment and Medicare Shared 
Savings programs in future public health emergencies without rulemaking 
to enable physicians to focus on patient care during emergencies.

        Restore Medicare and Medicaid physician supervision 
requirements to safeguard patient safety and maintain access to 
appropriate, high-quality care.

    Over the last year, family physicians rapidly changed the way they 
practice to meet the needs of their patients amid a global pandemic. 
Arguably, the most dramatic shift was the unprecedented uptake and 
increase of telehealth services. Last spring, out of necessity, 
physicians quickly pivoted from providing a majority of care in-person 
to caring for their patients virtually to promote social distancing and 
infection control. This would not have been possible without the swift 
legislative and regulatory action that expanded coverage, increased 
payment, and added flexibility for telehealth services.

    Prior to COVID-19--due in large part to Medicare restrictions and 
inadequate reimbursement--fewer than 15 percent of family physicians 
were providing virtual visits to their patients, and during the public 
health emergency that number surged to more than 90 percent. Despite 
technical challenges on the part of patients and physicians, both 
quickly came to realize the value of virtual care. According to a 
recent survey of AAFP members, seven in ten family physicians want to 
continue offering more virtual visits in the future.

    Telehealth benefit expansions must increase access to care and 
promote high-quality, comprehensive, continuous care. Telehealth, when 
implemented thoughtfully, can improve the quality and comprehensiveness 
of patient care and expand access to care for under-resourced 
communities and vulnerable populations. As outlined in our Joint 
Principles for Telehealth Policy,\1\ in partnership with the American 
Academy of Pediatrics and the American College of Physicians, the AAFP 
strongly believes that the permanent expansion of telehealth services 
should be done in a way that advances care continuity and the patient-
physician relationship. Expanding telehealth services in isolation, 
without regard for previous physician-
patient relationship, medical history, or the eventual need for a 
follow-up hands-on physical examination, can undermine the basic 
principles of the medical home, increase fragmentation of care, and 
lead to the patient receiving suboptimal care. In fact, a recent 
nationwide survey found that most patients prefer to see their usual 
physician through a telehealth visit, feel it is important to have an 
established relationship with the clinician providing telehealth 
services, and believe it is important for the clinician to have access 
to their full medical record.
---------------------------------------------------------------------------
    \1\ https://www.aafp.org/dam/AAFP/documents/advocacy/health_it/
telehealth/LT-Congress-TelehealthHELP-070120.pdf.

    Telehealth can enable timely, first-contact access to care and 
supports physicians in maintaining long-term, trusting relationships 
with their patients, both of which are central to continuity of care. 
Allowing physicians to provide telehealth services from their home 
enables them to extend their availability beyond traditional office 
hours for patients who, due to work or childcare constraints, are 
unable to take time off work for an appointment. This not only advances 
equitable access to care but also can prevent unnecessary trips to 
urgent care or the emergency room. Telehealth can also be a tool to 
help alleviate physician burnout by facilitating better work-life 
balance. One example: Some employers allow physicians to be on 
``telehealth duty'' in the period leading up to and following their 
---------------------------------------------------------------------------
maternity leave.

    Given these benefits, patients and physicians agree that some 
current telehealth flexibilities should continue beyond the public 
health emergency.

    Congress should permanently remove the section 1834(m) geographic 
originating site restrictions to ensure that all Medicare beneficiaries 
can access care at home. The COVID-19 pandemic has demonstrated that 
enabling physicians to virtually care for their patients at home can 
not only reduce patients' and clinicians' risk of exposure and 
infection but also increase accessibility for patients who may be 
homebound or lack transportation. It can also offer opportunities to 
engage distant family members and caregivers. Telehealth visits allow 
physicians to get to know their patients in their home and observe 
things they normally cannot during an in-office visit. This helps us to 
identify environmental factors that may be affecting their health, and 
to develop more personalized treatment plans.

    Transitional care management (TCM) services are another example of 
how permanently eliminating geographic and originating site 
requirements could improve utilization of high-value care and 
ultimately improve care coordination and patient outcomes. TCM services 
are provided after a patient is discharged from a hospital stay, with 
the goal of ensuring care continuity once they return home. Prior to 
the public health emergency, patients were hesitant to come into the 
office after just being discharged from the hospital. Once TCM services 
were available to all Medicare patients via telehealth, many more 
received TCM services, allowing me as their primary care physician to 
check on them, update their medications, schedule follow-up visits with 
specialists, and prevent hospital readmissions.

    There are many more examples of how telehealth visits can be used 
to promote prevention through conducting Medicare Annual Wellness 
visits as well as for monitoring and treatment of chronic diseases such 
as diabetes and hypertension for patients in their home thereby 
increasing accessibility for patients who may be homebound or lack 
transportation and create opportunities to engage distant family and 
caregivers.

    Require Medicare to cover audio-only Evaluation and Management (E/
M) services beyond the public health emergency. Coverage of audio-only 
E/M services is vital for ensuring equitable access to telehealth 
services for patients who may lack broadband access or be uncomfortable 
with video visits. In September, after using telehealth for several 
months due to the pandemic, more than 80 percent of family physicians 
responded to an AAFP survey indicating they were using phone calls to 
provide telehealth services. Together with ongoing reports from 
physicians that phone calls are vital to ensuring access for many 
patients, this survey data indicate that phone calls are more 
accessible for many patients than video visits. This may be 
particularly true for Medicare beneficiaries. According to the Pew 
Research Center, only about 53 percent of patients over the age of 65 
own smartphones, while 91 percent own any type of cell phone. Recent 
studies of telehealth utilization by patients with limited English 
proficiency show that non-English speakers have used telehealth far 
less than English-speakers. Many physicians routinely use telephone 
translation services to provide linguistically appropriate care, and 
these services can be more seamlessly integrated into telephone visits, 
whereas integrating translation services into audio-video platforms can 
be costly and complex. Outside of the PHE, Medicare allowed physicians 
to bill for brief phone calls as ``virtual check-ins.'' During the PHE 
we conducted telephone visits, realizing that we would not get 
reimbursed appropriately, but did so because it was the right thing for 
our patients. Unfortunately the payment rate for those services does 
not adequately reflect the level of time and effort required, and often 
the cost to bill the services exceeds that amount.

    Payment should support patients' and clinicians' ability to choose 
the most appropriate modality of care (i.e., audio-video, audio-only or 
in-
person) and ensure appropriate payment for care provided. Some patients 
and some cases are better suited to virtual care, and others require 
in-person care; some issues can be effectively treated through a phone 
call, whereas others require a visual examination. As a physician, I 
want telehealth to be a tool in my toolbox, and I want to choose when 
and how to deploy it based on my clinical judgment, not based on 
whether I will get paid.

    Permanently ensure that beneficiaries can access telehealth 
services provided by Federally Qualified Health Centers (FQHCs) and 
Rural Health Clinics (RHCs). FQHCs and RHCs serve as the primary source 
of care for millions of low-income and underserved patients across the 
country. In order to promote care continuity and ensure that 
beneficiaries have access to affordable, comprehensive care, Medicare 
should permanently cover telehealth services provided by these health 
centers. Medicare and Medicaid payment methodologies should also be 
modified to provide appropriate and timely payment to community health 
centers for telehealth services.

    In order to make long-term investments in telehealth platforms and 
workflow modifications, physician practices need advanced notice of 
changing Medicare and Medicaid telehealth policies. While more data 
will be needed to make determinations on whether to permanently 
continue certain telehealth services, temporary policies should be 
avoided for well-established, high-value telehealth services such as E/
M office visits and mental health services.

    The AAFP is supportive of broadly expanding access to telehealth 
services. However, we recognize that Congress and CMS are concerned 
about preventing waste, fraud, and abuse and considering policy options 
to reduce those risks. In addition to promoting the use of telehealth 
within the medical home, we also recommend relying on existing Medicare 
policies to minimize confusion and administrative burden imposed on 
physician practices. For example, Medicare defines an established 
patient as one that has received professional services from a clinician 
in the same practice and of the same medical specialty within the last 
3 years. This definition should be repurposed in any new telehealth 
policies, instead of creating a new definition for an established 
patient that could conflict with current coding guidelines.

    While the rapid expansion of telehealth has yielded many benefits 
for patients and clinicians, not everyone has benefited equally. 
Without sufficient investment and thoughtful policies, telehealth could 
actually worsen health disparities. Prior to the COVID-19 pandemic, 
evidence suggests that telehealth uptake was higher among patients with 
higher levels of education and those with access to employer-sponsored 
insurance. Another study found that patients with limited English 
proficiency utilized telehealth at one-third the rate of proficient 
English speakers. Anecdotes from family physicians suggest that the 
same trend may hold true for the past year--that those benefitting most 
from telehealth are those who already had better access to care. As the 
committee seeks additional studies to inform the direction of permanent 
telehealth policies, you should ensure the collection and reporting of 
data stratified by race, ethnicity, gender, language, and other key 
factors.

    One in three households headed by someone over the age of 65 do not 
have a computer, and more than half of people over age 65 do not have a 
smartphone. Children in low-income households are less likely to have 
access to a computer, and 30 percent of black or Hispanic children do 
not have a computer, compared to 14 percent of whites. Digital literacy 
also varies with age, income, and ethnicity. In order to achieve the 
full promise of telehealth, Congress must act to address these 
structural barriers to virtual care. The AAFP supports the creation of 
a pilot program to fund digital health navigators; development of 
digital health literacy programs; and deployment of digital health 
tools that provide interpretive services at the point of care, are 
available in non-English languages, easily and securely integrate with 
third-party applications and include assistive technology. Such a pilot 
should include a robust evaluation to demonstrate how the interventions 
addressed gaps in care or increased access for underserved populations.

    Beyond telehealth, CMS implemented several other flexibilities to 
facilitate access to care and prevent the spread of COVID-19. We 
recommend making several of these flexibilities permanent, while others 
should remain in place only during this and future public health 
emergencies.

    Congress took several actions to secure access to the COVID-19 
vaccine for free for most Medicare, Medicaid, and CHIP beneficiaries. 
We recommend that Congress explore further actions to facilitate 
affordable, equitable coverage of routine adult immunizations. 
Currently, only 43 percent of State Medicaid agencies cover all 
recommended adult vaccines, and overall adult utilization remains low. 
The AAFP believes \2\ that all public and private insurers should 
include as a covered benefit immunizations recommended by the ACIP 
without co-payments or deductibles.
---------------------------------------------------------------------------
    \2\ https://www.aafp.org/about/policies/all/immunizations.html.

    CMS should allow physicians to provide direct supervision and 
teaching services via synchronous audio/video communication nationwide. 
During the public health emergency, CMS allowed this to improve access 
to care in areas with physician shortages and prevent the transmission 
of COVID-19. The flexibility to provide these services virtually had 
clear benefits, as evidenced by CMS's recent decision to permanently 
allow virtual teaching and supervision in rural areas. If made 
permanent nationwide, it would increase training opportunities in rural 
and other underserved communities and improve patients' access to 
---------------------------------------------------------------------------
comprehensive, continuous care.

    A similar permanent policy was finalized for all levels of E/M 
office visits provided at a primary care center during the PHE: 
Teaching physicians can permanently use video conferencing to supervise 
residents providing primary care in rural areas. The AAFP is supportive 
of this policy being made permanent, and we believe that, applied 
nationwide, it would bolster primary care training opportunities and 
improve access to primary care in other underserved areas. The rural 
designation may not capture many areas of the country that are 
experiencing primary care shortages.

    Medicare and Medicaid both waived prior authorization requirements 
for durable medical equipment (DME) and other services early on during 
the public health emergency. While these requirements have since been 
reinstated, Congress should permanently reduce the volume of prior 
authorization requirements across Medicare and Medicaid payers. Prior 
authorization requirements delay care for patients and contribute to 
alarming rates of physician burnout. Commonsense solutions are needed 
to preserve and strengthen our physician workforce. For example, prior 
authorization should not be required for most DME ordered by a primary 
care physician for an established patient, regardless of whether it is 
ordered during a telehealth or in-person visit.

    Family physicians were relieved when CMS took swift action to delay 
and/or waive reporting requirements for the Quality Payment Program, 
Medicare Shared Savings Program, and other programs. However, many 
practices were frustrated that CMS delayed the implementation of the 
extreme and uncontrollable circumstances policy for the 2020 
performance year. This policy, along with other waivers, should be 
quickly applied in future PHEs so physicians can focus on providing 
patient care with minimized administrative tasks without fearing 
negative financial repercussions. The AAFP also has urged CMS to update 
measure benchmarks used across various programs to account for changes 
in utilization of health-care services during the pandemic.

    CMS waived requirements for physician supervision, including 
requiring certain services to be ordered by a physician, in Medicare, 
Medicaid, and the VA system. To safeguard patient safety and maintain 
access to appropriate, high-quality care, these waivers and 
flexibilities should not be made permanent, because patients are best 
served by a physician-led care team. Family physicians are particularly 
qualified to lead the health-care team because they possess distinctive 
skills, training, expertise and knowledge that allow them to provide 
medical care, health maintenance and preventive services for a range of 
medical and behavioral health issues. While certain flexibilities 
during the PHE addressed the historic nature of the pandemic, 
flexibilities to loosen supervision requirements should be restricted 
by Congress to ensure continuity of care and high-quality, accessible 
health care for all patients.

    Thank you for the opportunity to discuss with this committee the 
impact of health care regulatory flexibilities made available during 
the current public health emergency on family physicians and the AAFP's 
recommendations for permanent policy to advance accessible, equitable, 
high-quality health care beyond the pandemic.

                                 ______
                                 
  Questions Submitted for the Record to Kisha Davis, M.D., MPH, FAAFP
              Questions Submitted by Hon. Thomas R. Carper
    Question. During the pandemic, telehealth has been an essential 
tool to get children the care that they need while minimizing risk. 
Although telehealth under Medicare has been a focus, close to 40 
million children are enrolled in Medicaid.

    What are the main policy changes we need to ensure this broader use 
of telehealth can be continued beyond the pandemic for children?

    Answer. Telehealth, when implemented thoughtfully, can improve the 
quality and comprehensiveness of patient care and expand access to care 
for vulnerable populations, including children enrolled in Medicaid. 
Children have unique medical needs and the appropriateness of virtual 
care can differ between children and adults and based on the amount of 
information that the treating clinician has about the patient. Family 
physicians and pediatricians form long-term, trusting relationships 
with their patients and parents, which not only enables them to provide 
personalized care but also to assess and recommend the optimal mode of 
care. Some care such as treatment for mild illness, follow-up care and 
behavioral health services may be well-suited for telehealth; whereas 
other health needs require hands-on examination or treatment, and 
essential preventative services such as immunizations and health 
screenings must be done in-person. In most instances children can 
benefit from a hybrid of in-person and virtual care, which is optimized 
when all care is coordinated through the patient's medical home. The 
AAFP joined with the American Academy of Pediatrics to develop these 
joint principles \1\ for permanent telehealth policy that support the 
medical home. Congress should support coverage and payment models that 
enable primary care clinicians to provide virtual care to their 
patients and discourage the proliferation of direct-to-consumer, 
virtual-only telehealth vendors as a substitute for primary care.
---------------------------------------------------------------------------
    \1\ https://www.aafp.org/dam/AAFP/documents/advocacy/health_it/
telehealth/LT-Congress-TelehealthHELP-070120.pdf.

    The AAFP also encourages Congress to invest in initiatives to 
bridge the digital divide including expanding broadband coverage and 
subsidizing access, providing lower-income individuals with end devices 
(i.e., tablets, laptops, remote monitoring tools) and/or access points 
and ensuring that digital health platforms and tools are culturally and 
linguistically appropriate and accessible for vision and hearing 
---------------------------------------------------------------------------
impaired.

    Question. During COVID-19, many States adopted temporary changes to 
their telehealth policies, such as expanding the scope of services and 
providers able to furnish telehealth, relaxing of licensure 
requirements and modifying reimbursement policies. Many States 
legislatures have also begun the work to adopt more permanent 
telehealth policy changes.

    How can the Federal Government best support State Medicaid programs 
in their efforts to expand telehealth?

    Are there Medicaid supports, incentives, and learnings that Federal 
policymakers could provide?

    Answer. States have adopted a broad range of telehealth 
flexibilities during the pandemic, including waiving restrictions on 
distant and originating sites, adjusting provider reimbursement rates, 
and issuing guidance on the use of telehealth in particular areas 
(behavioral health, reproductive health, physical therapy). Most 
flexibilities expire with the end of the public health emergency and 
coverage of particular services provided via telehealth is inconsistent 
across the States. With information and data on the most effective and 
beneficial State policies during the pandemic, incentives and guidance 
on best policies would be helpful to facilitate information sharing 
among States who wish to make changes permanent.

    Federal financial support to States is critical in increasing both 
provider and patient access to telehealth technologies, starting with 
the need for investment in broadband Internet for rural areas across 
the country and additional funding for telehealth technologies for 
underserved areas and populations. There is a significant digital 
divide that is even more visible in the context of telehealth. Adults 
in rural areas lack access to broadband Internet and are more likely to 
be covered by Medicaid than those in other areas. Expanded broadband 
can lead to increased access to telehealth, giving adults in rural 
areas the access to care they need, especially those living in health 
professional shortage areas.

    The AAFP encourages Federal policymakers to provide clear guidance 
to States on ways to adopt alternative payment models that provide 
sustainable funding for clinicians to incorporate telehealth into the 
medical home. The AAFP also encourages CMS and States to provide 
guidance and oversight to Medicaid managed care plans to ensure 
coverage and payment policies are not inappropriately steering patients 
toward one modality of care or limiting their choice of provider.

    Question. COVID-19 has introduced additional stress and trauma for 
children and families. Telehealth, and particularly audio-only 
telehealth has been a crucial tool to connect children and adolescents 
to needed mental health-care services.

    How can telehealth be best utilized to meet kids' mental health-
care needs, and can you speak to the use of audio-only telehealth 
specifically?

    Answer. Telehealth has been shown as highly effective mode of 
delivering mental health care and can reduce access barriers and 
stigma. One model for expanding access to mental health services that 
the AAFP supports is the Collaborative Care Model (CCoM) for 
integrating behavioral health into primary care, and services provided 
virtually could extend the benefits of CCoM.

    The AAFP strongly supports extending coverage of audio-only 
telehealth services beyond the PHE to ensure that patients in rural 
areas and who lack access to broadband or technology devices can access 
services.

    Question. As State Medicaid programs look at expanding their use of 
telehealth, it is particularly important that vulnerable populations 
like children are not negatively impacted. Policies must be looked at 
through a health equity lens, considering access to reliable and 
affordable broadband services, access to devices that support HIPAA-
compliant telehealth platforms and coverage policies.

    How can Medicaid programs work to ensure telehealth policies are 
equitable for children and mitigate potential inequities that may 
arise?

    Answer. Prior to the COVID-19 pandemic, evidence suggests that 
telehealth uptake was higher among patients with higher levels of 
education and those with access to employer-sponsored insurance. 
Another study found that patients with limited English proficiency 
utilized telehealth at one-third the rate of proficient English 
speakers. Anecdotes from family physicians suggest that the same trend 
may hold true for the past year--that those benefitting most from 
telehealth are those who already had better access to virtual care. At 
a minimum, Congress, CMS, and State Medicaid programs should ensure the 
collection and reporting of data on telehealth utilization by Medicaid 
beneficiaries is stratified by race, ethnicity, gender, language, and 
other key factors. Such data will be critical for identifying access 
disparities and informing equitable policy decisions.

    The AAFP also encourages Congress to invest in initiatives to 
bridge the digital divide including expanding broadband coverage and 
subsidizing access, providing lower-income individuals with end devices 
(i.e., tablets, laptops, remote monitoring tools) and/or access points 
and ensuring that digital health platforms and tools are culturally and 
linguistically appropriate and accessible for vision and hearing 
impaired. In the interim, the AAFP also supports Medicaid coverage for 
audio-only services to ensure all patients can access virtual care.

    Medicaid coverage and payment for telehealth should promote virtual 
care that is connected to patients' medical home and should support 
physicians and patients' freedom to choose the most appropriate 
modality of care--video, telephone, asynchronous, in-person, etc.

                                 ______
                                 
             Questions Submitted by Hon. Benjamin L. Cardin
    Question. We have seen licensure limits substantially restrict 
access to cross-State medical care during this unprecedented COVID-19 
emergency period. To maximize the utility of telehealth options and 
ensure provider accountability, some experts have suggested that States 
should do more to ensure mutual licensing reciprocity in the post-
pandemic environment.

    I am a cosponsor of Senator Murphy's Temporary Reciprocity to 
Ensure Access to Treatment Act (TREAT Act, S. 168/H.R. 708)--a narrowly 
tailored bill to enable providers licensed in good standing in one 
State to treat patients in any State for the duration of the COVID-19 
Public Health Emergency.

    In 2018, Congress allowed clinicians working within the U.S. 
Veterans Affairs 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. Congress did the same thing for Homeland 
Security providers in the CARES Act last year.

    Would the American Academy of Family Physicians support a 
temporary, time- limited reciprocity proposal like that in the TREAT 
Act given the extraordinary public health crisis?

    How should Congress help remove licensure barriers caused by the 
current patchwork of State laws in the post-pandemic environment?

    Answer. State-based licensure is part of the larger State-based 
infrastructure to ensure patient safety. Monitoring medical practice 
and performing disciplinary actions is performed by State medical 
boards. Removing State licensure would bypass that consumer protection 
performed by State medical boards. As well, the standard of care and 
the practice of medicine does vary across States to support the varied 
needs of individuals in the different States. We recommend that 
Congress should look at options that strengthen and ease participation 
in the Interstate Medical Licensure Compact \2\ by both physicians and 
States.
---------------------------------------------------------------------------
    \2\ https://www.imlcc.org/.

    To prepare for the next public health crisis, Congress should look 
to support research of the varied approaches that were performed by 
States during the COVID-19 public health emergency with the goal of 
providing States with analysis of potential best practices. This would 
inform State Governers and Legislators on how best to prepare their 
State for the next public health emergency. Such research could also 
inform the Federal Government on best practices for their action in the 
---------------------------------------------------------------------------
next public health emergency.

                                 ______
                                 
               Questions Submitted by Hon. Chuck Grassley
    Question. Throughout the public health emergency, the Centers for 
Medicare and Medicaid Services (CMS) issued over 200 waivers under 
Medicare and approved more than 600 waivers and other flexibilities 
under Medicaid. While some of the regulations waived are specifically 
for responding to a pandemic, ensuring patient safety, controlling 
costs, and maintaining program integrity its clear innovation and 
common-sense ideas in our health-care system have been stifled too 
often by Federal regulations. For example, CMS permanently added 
certain new services (including mental health and care planning 
services) that it had temporarily added to the approved list of 
Medicare telehealth services during the pandemic. Some regulations play 
an important role in protecting safety and maintaining program 
integrity but others may stifle good ideas.

    Is health care too regulated that it's stifling good ideas?

    Answer. Family physician practices continue to be deeply 
overburdened by administrative functions at the point of care and after 
patient care hours, which hinders their ability to provide high-quality 
care and contributes to physician burnout. The AAFP and other frontline 
physician organizations developed joint principles \3\ on reducing 
administrative burden in health care.
---------------------------------------------------------------------------
    \3\ https://www.aafp.org/dam/AAFP/documents/advocacy/legal/
administrative/ST-Group6-AdministrativeBurden-061118.pdf.

        The AAFP urges CMS to adopt our recommendations \4\ on prior 
authorization (PA) and step therapy to promote efficiency, reduce 
administrative complexity and improve patient access to treatment 
including exempting physicians participating in financial risk-sharing 
agreements from PA, exempting generic medications from PA, and not 
requiring step therapy for patients already on a course of treatment.
---------------------------------------------------------------------------
    \4\ https://www.aafp.org/dam/AAFP/documents/advocacy/legal/
administrative/BKG-PriorAuthorization.pdf.
---------------------------------------------------------------------------
        The AAFP has called on CMS to simplify Medicare rules 
surrounding prescription of diabetic supplies and other DME ordered by 
a primary care physician for an established patient for the treatment 
of ongoing health conditions.
        The AAFP remains concerned that Medicare Incentive Payment 
System (MIPS) reporting requirements necessitate expanded human and 
technological infrastructure that many smaller physician practices 
cannot afford. To reduce reporting burden for all MIPS clinicians, CMS 
should provide scoring flexibility through multi-category credit. There 
should be a single set of performance measures across all payers that 
are universal, meet the highest standards of validity, reliability, 
feasibility, importance, and risk-adjustment. The measures should focus 
on outcomes that matter most to patients and that have the greatest 
overall impact on better health of the population, better health care, 
and lower costs.
        The AAFP calls on Congress and CMS to work together to repeal 
Meaningful Use requirements for physicians' utilization of health IT 
and reform the MIPS promoting interoperability measure category. Health 
IT vendors should be held accountable for interoperability before 
physicians are measured on EHR use. Health IT should be a means to 
achieving desirable outcomes such as improved quality of care and 
reduction of health disparities. Health IT utilization is not an end 
goal in and of itself.
        The AAFP urges \5\ Congress to delay implementation of the 
Medicare Appropriate Use Criteria (AUC) program. Physicians led the way 
in development of AUC for diagnostic imaging and use it, but the AUC 
program as authored by Congress is outdated and, if implemented, would 
add regulatory and financial burden to practices.
---------------------------------------------------------------------------
    \5\ https://www.aafp.org/dam/AAFP/documents/advocacy/coverage/
medicare/LT-Congress-AUCProgram-110720.pdf.

    The AAFP calls on Federal agencies to provide financial, time and 
quality-of-care impact statements for new regulations and 
administrative tasks and to revise regulations or administrative tasks 
that negatively affect the ability to provide timely, appropriate, 
---------------------------------------------------------------------------
high-value patient care.

    Question. Should executive agencies sunset regulations in the 
future to enable more innovation in health care?

    Answer. While the AAFP supports efforts to reduce the regulatory 
burdens on physicians, we believe that automatically sunsetting 
regulations would increase regulatory complexity and lead to 
disruptions for a myriad of health-care stakeholders. States, insurance 
issuers, physicians, and other health-care professionals all rely on 
existing regulations and the regulatory process in order to serve 
patients. Patients themselves also rely on clear regulatory guidance on 
the safety of food and medications, as well as health care coverage 
programs. Sunsetting these regulations would undermine safety standards 
and could result in barriers to accessing essential health services. 
Further, we are concerned that sunsetting regulations would interfere 
with agencies' ability to perform their essential functions and 
promulgate important new regulations to implement legislation passed by 
Congress. To ensure agencies can focus on administering vital health 
care and public health programs that advance the health of our Nation, 
we recommend against sunsetting regulations. However, we look forward 
to working with Congress to find other legislative solutions for 
reducing physicians' administrative burdens.

                                 ______
                                 
               Questions Submitted by Hon. John Barrasso
    Question. Before coming to the Senate, I had the privilege of 
practicing medicine in Wyoming. Rural health care faced challenges 
prior to the pandemic. In particular, we know since 2010 more than 135 
rural hospitals have closed.

    In the Senate, I am proud to help lead the bipartisan Rural Health 
Caucus. This group is committed to ensuring patients in rural America 
can get access to the care they need.

    Can you specifically discuss the changes in Federal health-care 
policy that you believe have helped rural providers the most during 
this pandemic?

    Can you please discuss any specific changes that Congress should 
consider to better support rural health-care providers?

    Answer. Rural physicians have benefited from nearly all telehealth 
changes during the pandemic including removal of geographic and 
originating site restrictions and coverage of audio-only E/M services. 
The AAFP has advocated for CMS to permanently cover audio-only E/M 
services to ensure access to virtual care for patients in rural areas 
who lack access to reliable broadband.

    The Teaching Health Center Graduate Medical Education (THCGME) is 
one of the most successful, efficiently run programs in the country. 
Since its inception, this program has trained 1,148 primary care 
physicians and dentists, and evidence suggests that physicians who 
train in community-based underserved settings are more likely to 
practice in those settings. Data from the American Medical Association 
Physician Masterfile show that the majority of family medicine 
residents will stay within 100 miles of where they train, which often 
includes rural areas. Congress reauthorized the THCGME program in 2020 
for 3 years and should permanently reauthorize and expand the program 
by passing the Doctors of Community (DOC) Act (S. 1958).

    In the FY 2022 Inpatient Prospective Payment System (IPPS) proposed 
rule, CMS laid out a proposed methodology for distributing one thousand 
new Medicare GME residency positions that were enacted by Congress in 
December. This is the first increase to the number of available 
positions under the Medicare GME program in nearly 25 years. The same 
legislation also allowed for the creation of new rural training track 
sites. While the AAFP was largely supportive of CMS's proposals to 
allow for the creation of new rural training track sites, we strongly 
recommend that CMS allow existing rural track sites to increase the 
number of physicians they are able to train. These existing sites are 
successfully training rural physicians and addressing physician 
maldistribution and CMS should invest in their expansion.

    Specifically for rural areas, Congress should consider the impact 
of low patient volumes on physician payment. As payment transitions 
from volume to value, physicians are being increasingly held 
accountable for quality and utilization performance. A physician's 
performance is more easily skewed by outliers when they have a lower 
patient volume. Congress should ensure value-based payment models make 
appropriate adjustments on quality and utilization assessment for rural 
practices. Practices should not be assessed on measures unless the 
measure is both valid and reliable for low patient volumes, and payers 
should consider the high resource burden associated with quality 
reporting.

    Increased funding for the National Health Service Corps (NHSC) 
primary care physicians would allow more rural Health Professions 
Shortage Areas (HPSAs) to qualify for family physician placements. 
Primary Care HPSA scoring prioritizes population-to-provider ratio over 
travel time to the nearest source of care. This leaves rural 
communities at a disadvantage when there is not adequate funding of the 
National Health Service Corps (NHSC) to provide a family physician for 
areas with lower HPSA scores. Those areas need physicians, but the 
funding does not extend far enough to provide a NHSC clinician.

    The rising cost of liability insurance premiums contributes to the 
growing loss of obstetrical services in rural communities. Higher 
premiums threaten the viability of some rural hospitals and make it 
difficult for rural areas to recruit or retain an adequate number and 
mix of physicians. Through the Federal Tort Claims Act (FTCA), the 
Federal Government offers a way for certain rural health centers to 
lower their malpractice insurance costs. FTCA expansion could help 
rural communities struggling to provide high-risk services due to the 
increasing cost of private medical malpractice insurance.

    Physicians utilizing J-1 visa waivers play an important role in 
addressing the current physician shortage in rural areas. Conrad 30 has 
been a highly successful program, enabling underserved communities to 
recruit both primary care and specialty physicians after they complete 
their medical residency training. The AAFP recommends streamlining the 
green card program for the J-1 visa program.

    Question. Prior to the pandemic, I introduced bipartisan 
legislation with Senator Tina Smith, which among other things, would 
allow Rural Health Clinics (RHCs) to provide more telehealth services.

    I was pleased that Congress through the CARES Act authorized both 
Rural Health Clinics and Federally Qualified Health Centers to furnish 
telehealth services to Medicare beneficiaries during the public health 
emergency.

    Can you discuss the importance of Rural Health Clinics and 
Federally Qualified Health Centers continuing to provide telehealth 
services after the public health emergency has ended?

    Answer. FQHCs and RHCs must continue to be allowed to be the 
distant site in telehealth encounters beyond the PHE. This has improved 
health-care access for historically marginalized populations and will 
be beneficial as we continue to strive for health equity.

    Question. My wife Bobbi and I are passionate about improving access 
to mental health services. This pandemic has clearly impacted the 
mental, as well as the physical health of our Nation.

    For people living in rural America, getting help from a mental 
health provider was challenging before the pandemic. This is why 
Senator Stabenow and I have long supported professional counselors and 
marriage and family therapists participating in Medicare. We believe 
that increasing the number of mental health providers able to care for 
our Nation's seniors is an important priority.

    Please discuss how telehealth has impacted the ability of patients 
to receive mental health services during the pandemic.

    Answer. Often, the only access rural patients have to mental health 
providers is through telehealth. It is not unusual for a family 
physician to be the only health-care provider in the county or in 
several counties driving distance. The pandemic has opened access to 
mental health providers that were previously not accessible due to 
Medicare's arbitrary geographic and originating site restrictions, 
which previously only exempted certain substance use disorder 
treatment.

    Question. Can you please identify ways Congress can improve access 
to mental health services, including expanding the number of providers 
that can participate in Medicare?

    I agree telehealth is transforming the way we are providing care. 
However, in Wyoming, most of our providers are part of smaller 
hospitals and practices. We need to make sure government regulation is 
not making it more difficult for these providers to serve their 
patients.

    Can you discuss specific ways Congress can reduce the 
administrative burden in providing care through telehealth?

    Answer. We encourage Congress to adopt and support policies that 
streamline coverage and payment for telehealth services across public 
and private payers. Variations in coverage and coding requirements add 
undue complexity that is especially burdensome for small and solo 
physician practices. Telehealth services provided by a primary care 
physician to an established patient should not be subject to different 
oversight than comparable in-person services.

                                 ______
                                 
  Prepared Statement of Linda V. DeCherrie, M.D., Clinical Director, 
    Mount Sinai at Home; and Professor of Geriatrics and Palliative 
 Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Health 
                                 System
    Chairman Wyden, Ranking Member Crapo, and members of the Senate 
Finance Committee, it is my distinct pleasure on behalf of the Icahn 
School of Medicine at Mount Sinai and Hospital at Home Users Group to 
submit this testimony in support of Hospital at Home, specifically 
extending the current Hospital Without Walls and Acute Hospital Care at 
Home flexibilities currently being offered under the public health 
emergency (PHE).

    The Mount Sinai Health System is New York City's largest academic 
medical system, encompassing eight hospitals, a leading medical school, 
and a vast network of ambulatory practices throughout the greater New 
York region. Mount Sinai is a national and international source of 
unrivaled education, translational research and discovery, and 
collaborative clinical leadership ensuring that we deliver the highest 
quality care--from prevention to treatment of the most serious and 
complex human diseases. The Health System includes more than 7,200 
physicians and features a robust and continually expanding network of 
multispecialty services, including more than 400 ambulatory practice 
locations throughout the five boroughs of New York City, Westchester, 
and Long Island. The Mount Sinai Hospital is ranked No. 14 on U.S. News 
and World Report's ``Honor Roll'' of the Top 20 Best Hospitals in the 
country and the Icahn School of Medicine as one of the Top 20 Best 
Medical Schools in the country. Mount Sinai Health System hospitals are 
consistently ranked regionally by specialty and our physicians in the 
top 1 percent of all physicians nationally by U.S. News and World 
Report.

    The Hospital at Home Users Group is a dynamic collaborative of 
Hospital at Home programs around the United States and Canada. We are 
sharing resources and best practices, working together to expand the 
reach of our programs, and developing the program and policy standards 
to inform regulatory and reimbursement policies necessary to spread 
this hopeful model broadly throughout North America.

    Hospital at Home (HaH) is a patient-centric model of care which 
provides 
hospital-level care at home for patients with select acute illnesses 
and acuity level who would otherwise be hospitalized. The traditional 
hospital can be dangerous for older adults with resultant functional 
decline, iatrogenic illnesses, and other adverse events. Multiple HaH 
studies have demonstrated improved patient safety, reduced mortality, 
enhanced quality, and reduced cost. This was a model that many Medicare 
Advantage, commercial, and Medicaid managed care plans already covered 
before the pandemic. Adding the rest of Medicare beneficiaries allows 
equitable care and has been extremely helpful since November 2020, when 
the Acute Hospital Care at Home waiver was approved. I believe the 
coverage of Hospital at Home or Acute Hospital Care at Home should be 
covered beyond the pandemic as a 30-day bundle of care.

    Typically, HaH starts in the emergency departments where a patient 
is evaluated by the emergency physicians and staff and if they are 
determined to need inpatient care they are screened for HaH. This 
screening first starts with a clinical screen to see if the conditions 
and treatment plan can be effectively delivered in the home, then the 
patients home environment is screened through a bedside survey. Common 
diagnoses are Pneumonia, Congestive Heart Failure (CHF), Chronic 
Obstructive Pulmonary Disease (COPD), and Cellulitis. The patient then 
is offered the opportunity to participate in the program and consents. 
Other physicians see the patient and write admission orders. Patients 
go home with an IV in place, in an ambulance, with a telehealth kit and 
potentially with oxygen. The ambulance staff sets them up in the home 
and within a couple of hours, a nurse arrives at the home and further 
assesses the home for safety and starts the treatment plan. Multiple 
deliveries typically occur such as IV and oral medications, equipment, 
and supplies. In the subsequent days, nurses come twice a day (some 
programs use mobile integrated health paramedics), and a physician or 
nurse practitioner sees the patient daily (in person or via video 
visit). They have access to other services such as physical therapy, 
occupational therapy, speech therapy, social work, and nutrition--all 
as needed based on the patient's individualized care plan. Patients 
usually require frequent blood draws, IV fluids, antibiotics, x-rays, 
or oxygen, all of which can be done in the home. Teams will round a 
couple times a day to review the care plan. There is 24/7 immediate 
availability of the team, including in person within 30 minutes if 
needed. This care is inclusive, patient centric, and equitable, as 41 
percent of our patients have some form of Medicaid. Once a clinician is 
in the home many additional barriers to improved health care, including 
health literacy, food insecurity, nutritional misinformation, and 
medical equipment needs are all readily identifiable, allowing our 
social worker to get involved, and referrals to be made to help improve 
the patient's health longer-term.

    There are other pathways into Hospital at Home, such as from a 
patient's outpatient doctors' offices, urgent care, or from the 
inpatient floors as long as the patient requires inpatient level care 
and would otherwise have been admitted to the hospital.

    The model of Hospital at Home has existed for several decades 
internationally with Australia, France, Spain, and Israel being some of 
the early adopters. In the mid-1990s the first trials of Hospital at 
Home were performed in the U.S. at Johns Hopkins. It was shown to be 
safe, efficacious and the patients desired this type of care. Never the 
less, no payment was available and existing payment structures did not 
adequately cover the costs of the program. Between the mid-1990s and 
2014, a number of veterans' hospitals developed similar programs as 
they had payment flexibilities. One integrated health system in New 
Mexico with their own Medicare Advantage plan has offered a HaH program 
since 2008. In 2014, we at Icahn School of Medicine at Mount Sinai in 
New York City applied and received a Center for Medicare and Medicaid 
Innovation (CMMI) award to develop and test Hospital at Home for a fee-
for-service Medicare population. We did one thing differently than 
previous iterations of Hospital at Home, we cared for the patients for 
30 days. It was split into two phases--the acute phase where the 
patient would have been in the hospital and a transitional phase for 
monitoring and ensuring the patient was stable and back under the care 
of their primary care provider and outpatient specialists.

    From our CMMI period, we examined more than 500 fee-for-service 
Medicare beneficiaries who received HaH care. We received additional 
funding from The John A. Hartford Foundation, and were able to compare 
care to a group of patients who received traditional inpatient care. 
For both groups of patients, the full 30 days of care were examined, 
and more than 65 Diagnosis-Related Groups (DRGs) were included in this 
analysis. Length of stay was reduced from 5.5 days to 3.2 days, 30-day 
readmissions were reduced from 15.6 percent to 8.6 percent, and Skilled 
Nursing Facility transfers on discharge were reduced from 10.4 percent 
to 1.7 percent with a resultant higher use of Certified Home Health for 
this HaH cohort. With regards to patient satisfaction, 45.3 percent of 
traditionally hospitalized patients were highly satisfied with care, 
while with HaH it increased to 68.8 percent.

    While some programs may start with a limited number of DRGs for 
which they can provide HaH care, we currently believe there are more 
than 150 DRGs that HaH can serve, and believe this is probably a 
conservative estimate. As many programs expand into oncology and 
surgical cases, the number will increase.

    From this work, we submitted a proposal to the Physician-Focused 
Payment Model Technical Advisory Committee (PTAC)--``HaH Plus'' 
(Hospital at Home Plus)--Provider-Focused Payment Model. Moreover, 
after evaluation, PTAC recommended two separate HaH proposals in 2018: 
(1) our proposal, the Hospital at Home Plus Model (HaH-Plus); and (2) 
the Home Hospitalization: An Alternative Payment Model for Delivering 
Care in the Home (HH-APM), to the Secretary of the Department of Health 
and Human Services for implementation. The Secretary expressed interest 
in testing home-based, hospital-level of care models and agreed with 
the PTAC that these models hold promise for testing. The agency has the 
authority to further refine the recommended PTAC models; however, to-
date, they have not utilized this authority. While we recognize the 
broader need for a refined HaH model, and we look forward to working 
with the agency to advance such a model to ensure greater availability 
of hospital care in the home to all patients, we believe congressional 
action to extend the current waivers and flexibilities is necessary and 
particularly valuable for patient care in the immediate and near term.

    We believe these regulatory flexibilities should be made permanent 
beyond the PHE and will be an effective foundation for establishing 
Medicare reimbursement that is specific to Hospital at Home services. 
We applaud The United States Department of Health and Human Services 
(HHS) for providing these flexibilities to ensure hospital services in 
the home during the PHE, and we encourage Congress and HHS to consider 
extending these flexibilities as a new model of care that prioritizes 
the patient's safety and care needs.

    In 2017 when the CMMI award was finished, our Hospital at Home 
program no longer provided care for fee-for-service patients as there 
was no fee-for-service reimbursement and the program shifted to focus 
on Medicare Advantage, commercial, and Medicaid managed care plans. We 
created a joint venture with Contessa Health and together have 
negotiated contracts with most of the major insurance providers in our 
area.

    During the initial surge of COVID-19 in March 2020 we were an 
important part of helping the Mount Sinai Health system admit both 
COVID negative and positive patients to open up more capacity for 
patients needing higher levels of care like ICUs, but were still unable 
to admit a fee-for-service Medicare patient from the emergency room. 
The PHE has demonstrated the need to have Hospital at Home accessible 
to fee-for-service Medicare patients.

    We were very excited to be part of the original group of hospitals 
approved for the Acute Hospital Care at Home waiver in November 2020. 
Despite having operated since 2014, we still needed some time to set up 
and meet the new requirements. We are appreciative that CMS made this 
available to fee-for-service Medicare patients. My colleagues and I 
have been happy to engage with CMS as stakeholders in this process. In 
addition, we formed the Hospital at Home Users group with funding from 
The John A. Hartford Foundation, which provides technical assistance, 
office hours and a member community which has engaged in multiple work 
groups. To date, there have been 129 hospitals approved for the Acute 
Hospital Care at Home waiver, with 56 health systems in 30 States since 
November. This shows that there is great interest. It does take 
significant start up resources and time and many are not planning to 
launch until this summer. I believe even more hospitals would apply if 
they knew this program would be made permanent. This waiver allowed 
many hospitals to jump start a program in the pandemic, which has been 
helpful in many communities for the provision of high quality and safe 
patient hospital inpatient care.

    Having a payment model for Hospital at Home/Acute Hospital Care at 
Home is needed to serve Medicare beneficiaries beyond the pandemic and 
especially if an emergency of this type ever happens again. These 
programs are complex to start, and many places could not start 
instantaneously; therefore, if the flexibilities continue beyond the 
PHE, I believe many additional hospitals will join. There is a strong 
interest in the community of Hospital at Home programs to continue 
this.

    Due to the regulatory barriers outlined above, hospitals have been 
wary about and disincentivized from implementing the innovations of 
providing acute level care in the home. Therefore, we request Congress 
and HHS to consider a permanent extension of the Hospital Without Walls 
and Acute Hospital Care at Home waivers beyond the PHE to mitigate the 
residual impacts of COVID-19 on public health and encourage broader 
adoption of providing patient centered health-care services in the 
home. Thank you for the opportunity to provide this testimony to the 
committee. My colleagues and I look forward to continuing to work with 
Congress and HHS on this important issue.

                                 ______
                                 
     Questions Submitted for the Record to Linda V. DeCherrie, M.D.
                 Questions Submitted by Hon. Mike Crapo
    Question. Mount Sinai health system was one of the first group of 
hospitals that CMS approved for the Acute Hospital Care at Home waiver 
last year. Medicare pays hospitals participating in the program at the 
same reimbursement rate that the facility otherwise would have received 
if the beneficiary had been admitted to the hospital. In your 
testimony, as well as during interviews with my staff, you indicated 
that the Mount Sinai Hospital at Home program has demonstrated improved 
patient outcomes, increased quality of care, enhanced patient safety, 
reduced mortality, and lowered costs. This committee wants to identify 
smart Medicare payment reforms that show the greatest potential to 
ensure beneficiaries get the right care, in the right setting, at the 
right time, and in a cost-efficient manner. Not only do Medicare 
beneficiaries deserve high-quality care, but any innovative payment 
arrangements that we consider implementing beyond the PHE, must also 
help put Medicare on a more sustainable fiscal path.

    If it was less expensive for Medicare to furnish certain acute 
inpatient services in the home during the pandemic, and beneficiaries 
saw better health outcomes, then how do you think these efficiencies 
should be factored into the Medicare hospital inpatient payment rates?

    Answer. In my opinion, the services provided by Hospital at Home 
(HaH) programs should be billed as a DRG based 30-day bundled value-
based payment to better manage the care of HaH patients, which was 
studied through our CMMI Innovation Grant from 2014-2017. It is our 
belief that this is the most cost effective and appropriate manner to 
bill these services going forward. While this value-based payment model 
is built, the current Acute Hospital Care at Home waiver should extend 
to enable programs, like Mount Sinai, to continue providing and being 
paid for hospital inpatient care in the home. I do not believe the two 
offerings and approaches to hospital care in the home are mutually 
exclusive, and do believe they collectively benefit patients, 
providers, and the Medicare program.

    Question. Should CMS calculate separate Medicare claims codes in 
order to reimburse for these specific services?

    Answer. No, it is not necessary to create separate Medicare claims 
codes to reimburse for Hospital at Home specific services. The services 
provided through HaH are indeed the same level of services provided in 
an acute care setting for patients. Creation of a new set of Medicare 
claims code would add unnecessary burden to providers needing to learn 
a new set of codes for the same set of services. Importantly, the 
patients seen under HaH receive higher quality, lower cost care, and 
have a higher patient satisfaction scores than patients receiving the 
same level of care in an acute care setting.

    Question. The Congressional Budget Office (CBO) would analyze and 
provide a cost-estimate for any legislative proposal seeking to make 
the Acute Hospital Care at Home program permanent once the PHE expires. 
CBO has previously indicated that Medicare fee-for-service programs are 
generally subject to unnecessary utilization as well as potential 
fraud, waste, and abuse.

    What specific policies do you recommend in order to minimize these 
risks?

    Answer. HaH allows for treatment of patients that meet Milliman 
Care Guidelines or other equivalent guidelines for medical necessity 
for hospital admission by a qualified team of care providers. In order 
to qualify for HaH, we advise that patients and their homes meet a 
strict set of screening criteria, as per our study at Mount Sinai, 
before being deemed eligible for HaH. Additionally, we believe based on 
our experience with the HaH plus model that home-based acute care 
services resulted in less waste than traditional hospital inpatient 
care. Further studies could be conducted to confirm these findings and 
expand upon the work previously done.

                                 ______
                                 
              Questions Submitted by Hon. Thomas R. Carper
    Question. During the pandemic, telehealth has been an essential 
tool to get children the care that they need while minimizing risk. 
Although telehealth under Medicare has been a focus, close to 40 
million children are enrolled in Medicaid.

    What are the main policy changes we need to ensure this broader use 
of telehealth can be continued beyond the pandemic for children?

    Answer. Telehealth and audio-only telehealth need to continue to be 
reimbursed as they were during the Public Health Emergency. Allowing 
the continuation of these services for Medicaid beneficiaries is an 
important step to improving access to care and health equity for 
children. During the PHE, Mount Sinai used grant funding from the 
Federal Communications Commission (FCC) to provide 700 devices to 
children and their families requiring telehealth monitoring and care, 
on a rotating basis, in addition to another 150 tablets for homebound 
adults in the Mount Sinai Visiting Doctors Program. Through innovative 
partnerships, telehealth was provided to thousands of patients by 
removing obstacles to receiving health-care services. This model could 
be expanded upon to the larger population in order to provide 
convenient, cost-efficient, high-quality home-based health-care 
services to children and adults.

    Question. During COVID-19, many States adopted temporary changes to 
their telehealth policies, such as expanding the scope of services and 
providers able to furnish telehealth, relaxing of licensure 
requirements and modifying reimbursement policies. Many States 
legislatures have also begun the work to adopt more permanent 
telehealth policy changes.

    How can the Federal Government best support State Medicaid programs 
in their efforts to expand telehealth?

    Answer. The Federal Government can help support State Medicaid 
programs by ensuring telehealth and audio only telehealth continue to 
be reimbursed for the care provided to beneficiaries. In addition, the 
Federal Government can help support State Medicaid to cover Hospital at 
Home (Acute Hospital Care at Home) services. HaH can provides acute 
levels of care to all adults, and during the pandemic that has included 
patients within the Medicare and Medicaid population, who often 
struggle with access to convenient health-care services. Additionally, 
the lifting of geographic restrictions for providers of health-care 
services is another important step that will allow telehealth to be 
provided across State lines and fill gaps of care where access is 
limited. Lastly, enhancing the rollout of broadband Internet to rural 
communities will ensure everyone has access to telehealth services.

    Question. Are there Medicaid supports, incentives, and learnings 
that Federal policymakers could provide?

    Answer. Federal policymakers could help State Medicaid programs by 
continuing to rollout access to broadband Internet services across the 
country and subsidizing affordable technology provided to Medicaid 
patients to allow telehealth and audio-only telehealth visits. 
Extending the Acute Hospital Care at Home waiver beyond the PHE is an 
additional step that should be taken to support the Medicaid 
population. These supports and incentives would greatly improve access 
to care and allow for continued innovation in how cost-efficient care 
is delivered to Medicaid (and all) patients.

    Question. COVID-19 has introduced additional stress and trauma for 
children and families. Telehealth, and particularly audio-only 
telehealth has been a crucial tool to connect children and adolescents 
to needed mental health-care services.

    How can telehealth be best utilized to meet kids' mental health-
care needs, and can you speak to the use of audio-only telehealth 
specifically?

    Answer. Telehealth effectively increases access to mental health 
services for kids. It is a cost-efficient, barrier removing (i.e., 
travel, parent/guardian time, access) solution to provide much needed 
mental health services to children in need. As we have seen during the 
public health emergency, mental health in our country is at an 
inflection point and desperately needs to be addressed. The CDC found 
that suicide rates among teenagers increased by more than 50 percent 
during the PHE, worsening mental health issues long ignored. As such, 
audio only telehealth reimbursement needs to continue, as it provides 
additional coverage to children without the financial and technological 
capabilities to engage in video enabled telehealth visits and provides 
further options of convenient, cost-effective care.

    Question. As State Medicaid programs look at expanding their use of 
telehealth, it is particularly important that vulnerable populations 
like children are not negatively impacted. Policies must be looked at 
through a health equity lens, considering access to reliable and 
affordable broadband services, access to devices that support HIPAA-
compliant telehealth platforms and coverage policies.

    How can Medicaid programs work to ensure telehealth policies are 
equitable for children and mitigate potential inequities that may 
arise?

    Answer. Subsidizing access to affordable technological resources to 
engage in video enabled telehealth, like the grant funding Mount Sinai 
received from FCC to provide children and their families devices, will 
help to improve equity of telehealth policies. Reimbursement should 
also be allowed to continue for audio-only telehealth services and HaH 
post-PHE. Additionally, Medicaid programs should enable providers to 
treat patients across State lines in order to improve access to care 
for States that do not have enough health services providers. Lastly, 
it is crucial to fill the gap in rural broadband service to ensure 
rural populations have the same access to telehealth services as other 
populations.

             Questions Submitted by Hon. Benjamin L. Cardin
    Question. We have seen licensure limits substantially restrict 
access to cross-State medical care during this unprecedented COVID-19 
emergency period. To maximize the utility of telehealth options and 
ensure provider accountability, some experts have suggested that States 
should do more to ensure mutual licensing reciprocity in the post-
pandemic environment.

    I am a cosponsor of Senator Murphy's Temporary Reciprocity to 
Ensure Access to Treatment Act (TREAT Act, S. 168/H.R. 708)--a narrowly 
tailored bill to enable providers licensed in good standing in one 
State to treat patients in any State for the duration of the COVID-19 
Public Health Emergency.

    How have health systems and patients benefited from State licensing 
reciprocity during the COVID19 public health emergency?

    Answer. This allows providers to treat their patients regardless of 
what State they are currently in. Patients have benefited from being 
able to access the providers of their choice. If a patient is traveling 
and needs their care managed by their PCP who is in another State, they 
should be able to receive that care telephonically and by video and be 
managed by the physician that knows them and their specific health 
status best.

    Question. I recently reintroduced the Home Health Emergency Access 
to Telehealth Act (HEAT) Act with Senators Collins and Shaheen. This 
bill would allow Medicare home health providers to be reimbursed for 
the telehealth services during a public health emergency. I also have 
heard from other home-based care providers, like hospice and palliative 
care as well as home-based primary care about the importance of 
telehealth during the emergency and into the future as services in the 
home and community continue to grow.

    Could you talk about your experiences using telehealth to 
supplement care for the populations you take care of?

    Answer. We have learned to be creative in this pandemic. In March 
2020 a small portion of our home-based primary care patients were able 
to access telehealth, mostly those who lived with their adult children. 
However, with a grant from the FCC where we provided tablets to some 
patients and working with other patients who had consistent home health 
aides who had smart phones we were able to expand those we could use 
video visit. However, it still did not reach all patients, and regular 
telephone was utilized instead.

    When a patient is able to use video technology it is tremendously 
helpful to us, when the call with an urgent complaint such as leg 
swelling, a new rash or ulcer, our nurses can immediately get a visual 
on the issue and provide that to the provider who can decide how 
urgently and in what way a patient needs to be seen. In the past we 
would do that telephonically only and then next day send a provider out 
to the home.

    In our Hospital at Home program (Acute Hospital Care at Home) we 
also heavily utilize video technology, which allows the provider and 
care coordinator to participate in all visits to the home.

    Question. What lessons from the pandemic would you like to see 
brought forward into the future of care for home health, hospice, 
palliative, and other home-based care providers?

    Answer. The need for patient-centered, acute level care that can be 
furnished in a patient's home is the biggest lesson from the PHE that 
needs to be brought forward into the future of care. We learned that a 
decades old model of care, Hospital at Home, which provided value pre-
pandemic despite lack of a Medicare payment structure could bring value 
during the PHE by providing payment for and access to hospital 
inpatient services. Moreover, this model can and should carry beyond 
the PHE. While we recognize the broader need for a refined HaH model as 
part of the shift to a value-based payment system, we believe 
congressional action to extend the current Acute Hospital Care at Home 
waiver and associated telehealth flexibilities is necessary and 
particularly valuable for patient care in the immediate and near term. 
We believe these regulatory flexibilities should be made permanent 
beyond the PHE and will be an effective foundation for establishing 
Medicare reimbursement that is specific to HaH services. We look 
forward to working with Congress and the agency to advance such a model 
to ensure greater availability of hospital care in the home to all 
patients.

                                 ______
                                 
               Questions Submitted by Hon. Chuck Grassley
    Question. Throughout the public health emergency, the Centers for 
Medicare and Medicaid Services (CMS) issued over 200 waivers under 
Medicare and approved more than 600 waivers and other flexibilities 
under Medicaid. While some of the regulations waived are specifically 
for responding to a pandemic, ensuring patient safety, controlling 
costs, and maintaining program integrity its clear innovation and 
common-sense ideas in our health-care system have been stifled too 
often by Federal regulations. For example, CMS permanently added 
certain new services (including mental health and care planning 
services) that it had temporarily added to the approved list of 
Medicare telehealth services during the pandemic. Some regulations play 
an important role in protecting safety and maintaining program 
integrity but others may stifle good ideas.

    Is health care too regulated that it's stifling good ideas?

    Answer. In the case of the Hospital Without Walls and Acute 
Hospital Care at Home waivers, policymakers have lifted critical 
regulatory barriers that have prevented or at minimum dissuaded 
hospitals and health systems from investing in Hospital at Home. 
Specifically, these waivers have allowed the home to be a permissible 
site for acute level care and allowed section 482.23 of the Medicare 
Conditions of Participation for 24-hour nursing services to be 
fulfilled virtually. These waivers have allowed for necessary 
innovations to maintain patient safety, and we need to continue to 
foster this innovation after the end of the PHE. This should be 
extended as a distinct hospital program of hospital inpatient care as 
an integrated model of hospital services, separate and distinct from 
home care services.

    Due to the pre-pandemic aforementioned regulatory barriers, 
hospitals and health systems have been unable to receive Medicare fee-
for-service reimbursement. Hospitals and health systems need time, 
funding, and predictability beyond 90-day intervals to build the 
necessary infrastructure to administer Hospital at Home. Without the 
continuation of these waivers, these regulatory barriers will resume 
and innovations like the Hospital at Home program (Acute Hospital Care 
at Home) will not be adopted across health systems and hospitals.

    Question. Should executive agencies sunset regulations in the 
future to enable more innovation in health care?

    Answer. Prior to the public health emergency, Hospital at Home was 
only reimbursed in certain circumstances under commercial arrangements. 
With traditional Medicare covering 15 percent of the population, it is 
vital that executive agencies consider a formal payment model for fee-
for-service patients. Having a payment model for Hospital at Home is 
needed to serve Medicare beneficiaries beyond the pandemic and 
especially in the event of a future public health emergency.

    Moreover, executive agencies should allow a reinterpretation of 
section 482.23 of the Medicare Conditions of Participation to allow 
nursing services to be fulfilled virtually for Hospital at Home 
programs. Agencies should also sunset regulations that limit the home 
as an originating site for acute level services and telehealth.

    Question. In March 2020, CMS announced an effort known as Hospitals 
Without Walls designed to rapidly increase hospital capacity at the 
start of the pandemic. In November 2020, CMS established the Acute 
Hospital Care at Home demonstration model. This model allows approved 
hospitals to deliver home-based care and meet patients' needs with 
quality, convenience, and comfort. The model has proven to be effective 
in better quality outcomes, shorter lengths of stay, and higher patient 
satisfaction all while lowering overall cost of care. The UnityPoint at 
Home, an Iowa health-care provider, was one of the first providers to 
be approved by CMS and the first in the Nation in February 2021 to 
admit and bill for patients. Hospitals under Medicare FFS were not 
previously allowed to offer this type of care that is more intensive 
than home health. This model was already utilized by Medicare 
Advantage, commercial, and Medicaid managed care plans. I have 
supported similar innovations for hospitals in rural areas. Last 
Congress, we passed the Rural Emergency Hospital Designation (REH) that 
will let rural hospitals right-size their infrastructure while 
maintaining essential medical services in their communities like 24/7 
emergency care and outpatient care.

    Should CMMI extend the current waiver for the Medicare FFS program 
to exist into the future?

    Answer. Yes, the coverage of Hospitals Without Walls and Acute 
Hospital Care at Home should be covered permanently beyond the PHE. 
Multiple studies on the Hospital at Home program have demonstrated 
improved patient safety, reduced mortality, enhanced quality, and 
reduced cost. We applaud the Department of Health and Human Services 
for providing these flexibilities to ensure hospital services in the 
home during the PHE, and we encourage Congress and HHS to also consider 
a CMMI model that allows a reimbursement pathway for a new Hospital at 
Home 30-day bundle value-based model of care that reduces costs of care 
and prioritizes the patient's safety and care needs.

    Question. What efforts can be made to improve the model?

    Answer. The shift of care in the community will require further 
training of providers, alignment with community partners, and shifting 
the current framework that usually results in hospitalization. 
Successful treatment in the home of individuals with acute illness 
requires a skill set that includes hospital care, home-based care, and 
a strong focus on coordination of care and transitions. Hospital at 
Home programs require home inspections and patient safety protocols 
that can respond to abrupt changes in clinical status and needs when 
certain clinical resources are not readily available. Leveraging the 
experience of a home-based primary or palliative care program can help 
create that infrastructure. While we recognize the broader need for a 
refined Hospital at Home value-based model of care, and we look forward 
to working with the agency to advance such a model to ensure greater 
availability of hospital care in the home to all patients, we believe 
congressional action to extend the current waivers and flexibilities is 
necessary and particularly valuable for patient care in the immediate 
and near term.

    Question. What similar cost-effective innovations are being stifled 
by Federal law and regulations?

    Answer. Value-based arrangements have historically been stifled by 
regulatory barriers. Cost-saving innovations such as care coordination 
services have been difficult to implement with Federal laws restricting 
information sharing and access to data between providers. Recently, CMS 
published the Modernizing and Clarifying the Physician Self-Referral 
Final Rule, which mitigated some of these barriers by giving greater 
flexibility to providers to participate in value-based care delivery 
models and provide coordinated care or patients. While this rule offers 
exciting new opportunities for providers, payers, and others to 
innovate, there are still limitations. The safe harbors and exceptions 
in the Final Rule are highly prescriptive so existing value-based 
arrangements will likely not satisfy all AKS or Stark Law value-based 
requirements without review and amendment.

                                 ______
                                 
               Questions Submitted by Hon. John Barrasso
    Question. Before coming to the Senate, I had the privilege of 
practicing medicine in Wyoming. Rural health care faced challenges 
prior to the pandemic. In particular, we know since 2010 more than 135 
rural hospitals have closed.

    In the Senate, I am proud to help lead the bipartisan Rural Health 
Caucus. This group is committed to ensuring patients in rural America 
can get access to the care they need.

    Can you specifically discuss the changes in Federal health-care 
policy that you believe have helped rural providers the most during 
this pandemic?

    Answer. During COVID-19, CMS allowed many evaluation and management 
codes to be furnished via telehealth. Telehealth has become an 
essential service for patients and primary care providers have led the 
charge in its use. Telehealth has allowed providers to maintain, and in 
certain cases expand, the reach of their medical services to 
populations in need. Many provider practices and the patients they 
serve will remain reliant on telehealth services as a care tool for the 
immediate future, if not longer.

    Waiving originating and distant site requirements, allowing 
Medicare reimbursement for audio-only, and increased funding for 
broadband infrastructure have all helped rural health-care providers 
and contributed to increased access for patients.

    Question. Can you please discuss any specific changes that Congress 
should consider to better support rural health-care providers?

    Answer. There are a few avenues Congress can consider to better 
support rural health-care providers:

        Support extending the Acute Hospital Care at Home waiver: 
There are already many rural hospitals participating, and this will 
allow rural providers options of site of care for their patients. 
Simultaneously or subsequently encourage and work with the Secretary to 
finalize a 30-day bundle value-based payment model for HaH as proposed 
to the PTAC in 2017.
        Increase funding for telecommunications services and connected 
devices for provider practices and patients: Small practices in rural 
areas often do not have the upgraded technological platforms needed to 
provide telehealth services for their patients. Additionally, funding 
opportunities for these services and devices have been limited for 
independent provider practices. Applications for additional funding 
should be streamlined as much as possible to preclude any unnecessary 
administrative burden for independent practices that may lack some of 
the support services and administrative staff that larger entities can 
take advantage of.
        Increase support for broadband infrastructure: The expanded 
use of telehealth, including video visits and remote patient 
monitoring, require the use of broadband which many patients in rural 
and underserved areas do not have. Congress should consider the needs 
of this population and commit to providing universal broadband to all 
who need it.
        Permanent removal of originating and distant site 
requirements: This ensures that providers can provide needed care for 
patients without regulatory barriers and patients themselves have 
continued access to telehealth services beyond the PHE when they need 
it.
        Permanently implement a separate payment for telephone-only 
services: Post COVID-19, many physician practices and the patients they 
serve will continue to rely on telehealth services for the foreseeable 
future. Not covering these codes post-PHE will disproportionally put 
patients without the means or access to technology and the Internet at 
risk of not having access to care.

    Question. Prior to the pandemic, I introduced bipartisan 
legislation with Senator Tina Smith, which among other things, would 
allow rural health clinics (RHCs) to provide more telehealth services.

    I was pleased that Congress through the CARES Act authorized both 
Rural Health Clinics and Federally Qualified Health Centers to furnish 
telehealth services to Medicare beneficiaries during the public health 
emergency.

    Can you discuss the importance of Rural Health Clinics and 
Federally Qualified Health Centers continuing to provide telehealth 
services after the public health emergency has ended?

    Answer. As you know, Rural Health Clinics and health centers are 
required to offer comprehensive services in areas of high need, and 
many are using telehealth to address geographic, economic, 
transportation, and linguistic barriers to health-care access. During 
the PHE, Medicare and Medicaid adopted policies that have allowed 
health centers to provide primary and preventive care virtually. These 
policies allow health centers to ensure their patients continue to 
receive the care they rely on, often from the comfort and safety of 
their own homes. Disparities will not disappear after the PHE, rather 
they will be exacerbated as a result. It is vital now more than ever 
that Rural Health Clinics and FQHCs continue to provide telehealth 
services after the PHE has concluded.

    Question. My wife Bobbi and I are passionate about improving access 
to mental health services. This pandemic has clearly impacted the 
mental, as well as the physical health of our Nation.

    For people living in rural America, getting help from a mental 
health provider was challenging before the pandemic. This is why 
Senator Stabenow and I have long supported professional counselors and 
marriage and family therapists participating in Medicare. We believe 
that increasing the number of mental health providers able to care for 
our Nation's seniors is an important priority.

    Please discuss how telehealth has impacted the ability of patients 
to receive mental health services during the pandemic.

    Answer. Telehealth has greatly increased access to mental health 
services during the pandemic. COVID-19 has far reaching mental health 
implications for a large proportion of the US population. Prior to the 
pandemic, nearly one in five U.S. adults reported living with a mental 
illness, but only half received treatment. Many obstacles remain in 
place for those living with a mental illness, including stigma and lack 
of mental health services in urban and rural areas. With digital tools 
and access to broadband Internet, patients can now consult with a 
mental health professional remotely using live video. Patients living 
in ``mental health professional shortage'' areas can use these tools to 
speak with a licensed professional without driving long distances. They 
can also receive care discretely if their loved ones or colleagues 
perpetuate stigmas about receiving care. A large body of evidence has 
demonstrated that telemental health programs help increase access to 
care in areas with limited mental health resources, provide effective 
treatment for mental health conditions, and improve medication 
adherence.

    Question. Can you please identify ways Congress can improve access 
to mental health services, including expanding the number of providers 
that can participate in Medicare?

    Answer. There are multiple ways in which Congress can improve 
access to mental health services, including:

        Implementing a Federal statute permanently requiring payers to 
reimburse telehealth encounters at the same rate as in-person or to 
generally cover telehealth as parity remains an issue for widespread 
implementation of telemental health.
        Revision to section 123 of the Consolidated Appropriations Act 
passed in December 2020, which expanded telehealth mental services but 
imposed a requirement that the patient must be seen in person within 6 
months of the telehealth visit and periodically in person thereafter. 
This has imposed unnecessary obstacles to a service that is well suited 
for telehealth.
        Improving care reimbursement rates by enforcing parity laws 
and developing new payment models for services such as telehealth group 
therapy.
        Increasing funding to train and develop more behavioral health 
professionals.
        Removing regulatory impediments to care coordination and 
information sharing.
        Partnering with community organizations, patients, and 
caregivers to identify and expand programs that reduce stigma and 
combat barriers to care.
        Ensuring sufficient coverage for behavioral health services.
        Increasing funding to schools to ensure administrators and 
teachers have the tools and funding to help students deal with mental 
health issues and promote wellness.

    Question. I agree telehealth is transforming the way we are 
providing care. However, in Wyoming, most of our providers are part of 
smaller hospitals and practices. We need to make sure government 
regulation is not making it more difficult for these providers to serve 
their patients.

    Can you discuss specific ways Congress can reduce the 
administrative burden in providing care through telehealth?

    Answer. It is critical that Congress remove originating and distant 
site requirements to increase access for patients and reduce 
administrative burden for providers. CMS added a few evaluation and 
management codes to Category 1 of the Medicare telehealth list for the 
CY 2021 Medicare Physician Fee Schedule and omitted many others. 
Category 1 codes are considered permanently payable under the Medicare 
Physician Fee Schedule. CMS notes that while the home is generally not 
a permissible telehealth originating site, certain services could be 
billed as telehealth only for treatment of a substance use disorder or 
co-occurring mental health disorder under the flexibility afforded by 
the SUPPORT for Patients and Communities Act. This rule is limiting as 
many other patients with serious conditions also highly benefit from 
telehealth visits. The home needs to be a permissible telehealth 
originating site to ensure that patients have continued access to 
telehealth services beyond the PHE.

    Question. Wyoming has many passionate advocates supporting both 
hospice and palliative care. These folks are committed to ensuring 
patients have the highest quality of life and are able stay out of the 
hospital and with their families. This is why I help lead the 
bipartisan Comprehensive Care Caucus. Our mission is to improve both 
palliative and hospice care for patients.

    I was particularly impressed with your background in palliative 
care.

    Can you please discuss how telehealth flexibilities have impacted 
access to palliative care and how we can continue making progress in 
this area?

    Answer. Telehealth flexibilities have created greater access to 
palliative care for many patients, particularly with the reimbursement 
of audio-only codes. In response to COVID-19, CMS permitted certain 
services to be furnished using audio only telehealth. In the CY 2021 
Medicare Physician Fee Schedule Final Rule, CMS noted that audio-only 
evaluation and management codes will not be reimbursed after the end of 
the PHE and proposed an interim final rule on coding and payment for 
virtual check-in services to support reimbursement for lengthier audio-
only services outside of the PHE. However, these audio-only services 
can only be used to determine whether the beneficiary requires an in-
person services and are not services that can be provided in lieu of 
in-person services.

    Many physician practices, and the patients they serve will continue 
to remain reliant on telehealth services for the foreseeable future. 
Discontinuing the use of these codes will disproportionally put 
patients without a means to technology or access to the Internet at 
risk of not having access to care. Many complex palliative care 
patients are without Wi-Fi, computers, or smart devices and may be 
cognitively or physically impaired in using video technology. 
Therefore, they require medical intervention and guidance via audio-
only telephone calls when they are not receiving in-
person care. Congress needs to permanently implement a separate payment 
for telephone-only services that specifies what is included in the 
visit.

    In our Home-based Primary Care and our Home-based Palliative Care 
practices we utilized the telehealth flexibilities heavily during the 
pandemic. We were able to quickly take patients from the emergency room 
home under palliative care where we provided both video and audio only 
telehealth to work with patients and their families.

                                 ______
                                 
      Prepared Statement of Jessica Farb, Director, Health Care, 
                    Government Accountability Office
                         why gao did this study
    Medicare and Medicaid--two federally financed health insurance 
programs--spent over $1.5 trillion on health-care services provided to 
about 140 million beneficiaries in 2020. Recognizing the critical role 
of these programs in providing health-care services to millions of 
Americans, the Federal Government has provided for increased funding 
and program flexibilities, including waivers of certain Federal 
requirements, in response to the COVID-19 pandemic.

    The CARES Act includes a provision for GAO to conduct monitoring 
and oversight of the Federal Government's response to the COVID-19 
pandemic. In response, GAO has issued a series of government-wide 
reports from June 2020 through March 2021. GAO is continuing to monitor 
and report on these services.

    This testimony summarizes GAO's findings from these reports related 
to Medicare and Medicaid flexibilities during the COVID-19 pandemic, as 
well as preliminary observations from ongoing work related to 
telehealth waivers in both programs. Specifically, the statement 
focuses on what is known about the effects of these waivers and 
flexibilities on Medicare and Medicaid, and considerations regarding 
their ongoing use.

    To conduct this work, GAO reviewed Federal laws, CMS documents and 
guidance, and interviewed Federal and State officials. GAO also 
interviewed six provider and beneficiary groups, selected based on 
their experience with telehealth services.

    GAO obtained technical comments from CMS and incorporated them as 
appropriate.
                             what gao found
    In response to the COVID-19 pandemic, the Centers for Medicare and 
Medicaid Services (CMS), the Federal agency responsible for overseeing 
Medicare and Medicaid, made widespread use of program waivers and other 
flexibilities to expand beneficiary access to care. Some preliminary 
information is available on the effects of these waivers. Specifically:

    Medicare. CMS issued over 200 waivers and cited some of their 
benefits in a January 2021 report. For example, CMS reported that:

        Expansion of hospital capacity. More than 100 new facilities 
were added through the waivers that permitted hospitals to provide care 
in non-hospital settings, including beneficiaries' homes.
        Workforce expansion. Waivers and other flexibilities that 
relaxed certain provider enrollment requirements and allowed certain 
nonphysicians, such as nurse practitioners, to provide additional 
services expanded the provider workforce.
        Telehealth waivers. Utilization of telehealth services--
certain services that are normally provided in-person but can also be 
provided using audio and audio-video technology--increased sharply. For 
example, utilization increased from a weekly average of about 325,000 
services in mid-March to peak at about 1.9 million in mid-April 2020.

    Medicaid. CMS approved more than 600 waivers or other flexibilities 
aimed at addressing obstacles to beneficiary care, provider 
availability, and program enrollment. GAO has reported certain 
flexibilities such as telehealth as critical in reducing obstacles to 
care. Examples of other flexibilities included:

        Forty-three States suspended fee-for-service prior 
authorizations, which help ensure compliance with coverage and payment 
rules before beneficiaries can obtain certain services.
        Fifty States and the District of Columbia waived certain 
provider screening and enrollment requirements, such as criminal 
background checks.

    While likely benefiting beneficiaries and providers, these program 
flexibilities also increase certain risks to the Medicare and Medicaid 
programs and raise considerations for their continuation beyond the 
pandemic. For example:

        Increased spending. Telehealth waivers can increase spending 
in both programs, if telehealth services are furnished in addition to 
in-person services.
        Program integrity. The suspension of some program safeguards 
has increased the risks of fraud, waste, and abuse that GAO previously 
noted in its High-Risk report series.
        Beneficiary health and safety. Although telehealth has enabled 
the safe provision of services, the quality of telehealth services has 
not been fully analyzed.
_______________________________________________________________________

    Chairman Wyden, Ranking Member Crapo, and members of the committee, 
thank you for the opportunity to discuss flexibilities related to 
Medicare and Medicaid that were made available during the current 
public health emergency. More than a year after the Secretary of the 
Department of Health and Human Services (HHS) first declared a public 
health emergency for the U.S. and the World Health Organization 
characterized the Coronavirus Disease 2019 (COVID-19) as a pandemic, 
COVID-19 continues to result in catastrophic loss of life and 
substantial damage to the global economy, stability, and security.\1\
---------------------------------------------------------------------------
    \1\ On January 31, 2020, the Secretary of HHS declared a public 
health emergency for the U.S., retroactive to January 27th. 
Subsequently, on March 13, 2020, the President declared COVID-19 a 
national emergency under the National Emergencies Act and a nationwide 
emergency under section 501(b) of the Robert T. Stafford Disaster 
Relief and Emergency Assistance Act (Stafford Act). See 50 U.S.C. 
Sec. 1601 et seq. and 42 U.S.C. Sec. 5121 et seq. The President has 
also approved major disaster declarations under the Stafford Act for 
all 50 States, the District of Columbia, and five territories.

    In response to COVID-19, the Centers for Medicare and Medicaid 
Services (CMS), the Federal agency responsible for overseeing Medicare 
and Medicaid, provided increased Federal funding and made widespread 
use of program waivers and other flexibilities to expand the 
availability of services, maintain access for beneficiaries, and give 
providers more flexibility in treating beneficiaries. For example, CMS 
issued waivers to expand telehealth services in Medicare fee-for-
service (FFS).\2\ Many of these waivers and flexibilities CMS granted 
were to States, which administer their Medicaid programs within broad 
Federal rules and according to State plans that CMS approves.
---------------------------------------------------------------------------
    \2\ Medicare FFS consists of two separate parts: Medicare Part A, 
which primarily covers hospital services, and Medicare Part B, which 
primarily covers outpatient services. Medicare FFS beneficiaries may 
also enroll in Medicare Part D, which offers prescription drug 
coverage. Telehealth services include certain clinical services that 
are typically furnished in person but are instead provided remotely via 
telecommunications technologies. By law, Medicare FFS generally only 
pays for these services under limited circumstances; such as when the 
patient is located in certain health-care settings and certain (mostly 
rural) geographic locations.

    The CARES Act includes a provision for us to conduct monitoring and 
oversight of the Federal Government's efforts to prepare for, respond 
to, and recover from the COVID-19 pandemic.\3\ In response, we issued 
government-wide reports on the Federal efforts, have examined and 
reported on Medicare and Medicaid flexibilities during the pandemic, 
and we have ongoing work examining related topics such as Medicare and 
Medicaid telehealth waivers.\4\
---------------------------------------------------------------------------
    \3\ Pub. L. No. 116-136, Sec. 19010(b), 134 Stat. 281, 580 (2020).
    \4\ GAO, COVID-19: Opportunities to Improve Federal Response and 
Recovery Efforts, GAO-20-625 (Washington, DC: June 25, 2020); GAO, 
COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal 
Response, GAO-21-191 (Washington, DC: November 30, 2020); GAO, COVID-
19: Sustained Federal Action Is Crucial as Pandemic Enters Its Second 
Year, GAO-21-387 (Washington, DC: March 31, 2021).

    My testimony today will summarize key findings from issued reports 
as well as preliminary observations from our ongoing work related to 
expanded telehealth services in the Medicare and Medicaid programs and 
flexibilities related to the provision of Medicaid home- and community-
based services during the COVID-19 pandemic.\5\ In particular, my 
statement will address: (1) what is known about the effects of Medicare 
waivers on the Medicare fee-for-service program; (2) what is known 
about the effects of Medicaid waivers and flexibilities on the Medicaid 
program; and (3) considerations for the ongoing use of these waivers 
and flexibilities for Medicare and Medicaid.
---------------------------------------------------------------------------
    \5\ Medicaid home- and community-based services cover a wide range 
of services and supports to help individuals remain in their homes or 
live in a community setting, such as personal assistance with daily 
activities, assistive devices, and case management services to 
coordinate services and supports that may be provided from multiple 
sources.

    In developing this statement, we relied primarily on reports we 
issued from June 2020 to March 2021. For our previously issued reports 
on which my comments are based, we reviewed applicable Federal laws; 
CMS documents, including guidance on program waivers and guidance to 
States on resuming normal operations after the end of the public health 
emergency; CMS written responses to questions regarding Medicare 
waivers; and our prior work related to Medicare and Medicaid. We also 
interviewed Medicaid officials from selected States regarding 
flexibilities they requested during the COVID-19 pandemic.\6\ More 
detailed information on the scope and methodology for our past work can 
be found in these published reports.
---------------------------------------------------------------------------
    \6\ For more information about the scope and methods for our past 
work, please see our enclosures on Medicaid Enrollment, Spending, and 
Flexibilities; Medicaid Spending; Medicaid Financing, Waivers, and 
Flexibilities; Medicare Telehealth Waivers; and Medicare Waivers.

    My comments also include preliminary observations from ongoing 
work, including interviews with CMS officials and representatives from 
six beneficiary advocacy and provider groups, selected based on their 
experience with telehealth services and Medicare telehealth waivers, as 
well as Medicaid waivers and flexibilities.\7\ We reviewed CMS 
documents and other published research on the effects of Medicare 
telehealth waivers on these types of services during the pandemic. In 
particular, we reviewed a January 2021 report from CMS on the 
preliminary effects of some Medicare and Medicaid waivers on both 
programs--including the effect of telehealth waivers on Medicare 
utilization of services.\8\ We also reviewed data from the Kaiser 
Family Foundation on Medicaid waivers and flexibilities.\9\ We reviewed 
the utilization data and Medicaid waivers and flexibilities data for 
any obvious errors and determined these data were sufficiently reliable 
for the purpose of our objectives.
---------------------------------------------------------------------------
    \7\ The provider groups included umbrella organizations 
representing four broad specialty types--primary care, medical, 
surgical, and mental and behavioral health specialties. We also 
interviewed two beneficiary advocacy groups with knowledge of Medicare 
beneficiaries' experience with Medicare telehealth.
    \8\ See Centers for Medicare and Medicaid Services, Putting 
Patients First: The Centers for Medicare and Medicaid Services' Record 
of Accomplishments from 2017-2020 (January 13, 2021). We refer to this 
report as the CMS ``Accomplishment Report'' throughout this report.
    \9\ See Kaiser Family Foundation, Medicaid Emergency Authority 
Tracker: Approved State Actions to Address COVID-19, accessed May 10, 
2021, https://www.kff.org/coronavirus-covid-19/issue-brief/medicaid-
emergency-authority-tracker-approved-state-actions-to-address-covid-
19/.

    We shared our preliminary observations from this ongoing work with 
CMS officials to obtain their views. CMS officials provided us with 
---------------------------------------------------------------------------
technical comments, which we incorporated as appropriate.

    We conducted the work upon which this statement is based in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives.
                               background
Medicare Waivers and Flexibilities
    In 2020, Medicare--the federally financed health insurance program 
for persons aged 65 or over, certain individuals with disabilities, and 
individuals with end-stage renal disease--spent about $910 billion on 
health-care services provided to about 62.8 million Medicare 
beneficiaries.\10\ Providers and suppliers furnishing services to 
beneficiaries must comply with Medicare requirements and conditions of 
participation that are set in statute and regulations. In response to 
COVID-19, CMS expanded the availability of Medicare services through 
widespread use of program waivers. Specifically, section 1135 of the 
Social Security Act authorizes the Secretary of HHS to temporarily 
waive or modify certain Federal health-care requirements, including in 
the Medicare program, to increase access to medical services when both 
a public health emergency and a disaster or emergency have been 
declared.\11\ The Administrator of CMS typically implements section 
1135 waivers for Medicare.
---------------------------------------------------------------------------
    \10\ Total Medicare spending is for fiscal year 2020 and from the 
Centers for Medicare and Medicaid Services' Office of Financial 
Management. Count of Medicare beneficiaries is for calendar year 2020 
and from the Centers for Medicare and Medicaid Services' Medicare 
Enrollment Dashboard. See https://www.cms.gov/Research-Statistics-Data-
and-Systems/Statistics-Trends-and-Reports/CMSProgramStatistics/
Dashboard; accessed May 12, 2021.
    \11\ See 42 U.S.C. Sec. 1320b-5 (authority to waive requirements 
during national emergencies).

    The president authorized HHS to issue waivers under section 1135 
beginning March 1, 2020. This authority will end no later than the 
termination of one of the underlying emergencies or 60 days from the 
date the waiver is published, unless the Secretary extends it for 
---------------------------------------------------------------------------
additional periods of up to 60 days.

    There are two types of Medicare 1135 waivers:

        Blanket waivers apply automatically to all applicable 
providers and suppliers in the emergency area, which encompasses the 
entire United States in the case of the COVID-19 pandemic. Providers 
and suppliers do not need to apply individually or notify CMS that they 
are acting upon the waiver. They are required to comply with normal 
rules and regulations as soon as it is feasible to do so.

        Provider/supplier individual waivers may be issued upon 
application for States, providers, or suppliers only if an existing 
blanket waiver is not sufficient.

    Congress also enacted legislation to expand the Secretary's 
authority to temporarily waive or modify application of certain 
Medicare requirements, such as the geographic restrictions on where 
telehealth services can be provided. The Coronavirus Preparedness and 
Response Supplemental Appropriations Act, 2020, amends section 1135 of 
the Social Security Act to allow the Secretary to waive certain 
Medicare telehealth payment requirements during the emergency 
period.\12\ The CARES Act further expands the Secretary's authority to 
waive telehealth requirements during the emergency period.\13\
---------------------------------------------------------------------------
    \12\ Pub. L. No. 116-123, Div. B, Sec. 102, 134 Stat. 146, 155-157 
(adding 42 U.S.C. Sec. 1320b-5(b)(8)).
    \13\ Pub. L. No. 116-136, Sec. 3703, 134 Stat. 281, 416 (2020) 
(amending 42 U.S.C. Sec. 1320b-5(b)(8)).
---------------------------------------------------------------------------
Medicaid Waivers and Flexibilities
    Medicaid is one of the Nation's largest sources of funding for 
health-care services for low-income and medically needy individuals, 
covering an estimated 77 million people and spending an estimated $673 
billion (total Federal and State) in fiscal year 2020. Medicaid allows 
significant flexibility for States to design and implement their 
programs. For example, States can request waivers of certain Federal 
requirements to target certain populations or to test new or innovative 
approaches for managing the health-care needs of beneficiaries. In 
addition to its normal authority to approve these State waiver 
applications, CMS has additional authorities to waive Medicaid 
requirements to help ensure the availability of care in certain 
emergency circumstances.

    Since the beginning of the COVID-19 pandemic, CMS has issued 
guidance to States on implementing various flexibilities and on 
resuming normal activities once the public health emergency has ended. 
(See fig. 1.)

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    For example, CMS created and released four templates to help 
States receive Federal waivers and assist them in identifying other 
authorities to implement program flexibilities more efficiently. 
Specifically, CMS issued templates for four authorities for the 
following purposes:

        Medicaid disaster State plan amendments: To revise or 
implement new policies in Medicaid State plans related to eligibility, 
enrollment, benefits, premiums and cost sharing, or payments in 
response to a public health emergency or disaster.

        Section 1115(a) demonstrations: To furnish medical assistance 
in a manner intended to protect, to the greatest extent possible, the 
health, safety, and welfare of individuals and providers who may be 
affected by COVID-19.\14\
---------------------------------------------------------------------------
    \14\ Under section 1115 of the Social Security Act, the Secretary 
of HHS may waive certain Federal Medicaid requirements and approve 
expenditures that would not otherwise be eligible for Federal Medicaid 
funds for certain experimental, pilot, or demonstration projects that, 
in the Secretary's judgment, are likely to promote Medicaid objectives.

        Section 1135 waivers: To temporarily waive or modify certain 
Medicaid requirements to ensure that sufficient health-care items and 
services are available to meet the needs of individuals enrolled in the 
respective programs and that health-care providers that furnish such 
items and services in good faith, but are unable to comply with one or 
more of such requirements as a result of the COVID-19 pandemic, may be 
reimbursed for such items and services and exempted from sanctions for 
---------------------------------------------------------------------------
such noncompliance, absent any determination of fraud or abuse.

        Section 1915(c), Appendix K waivers: To request amendment to 
an approved section 1915(c) home and community-based waiver authority 
to respond to an emergency, for example, expanding the pool of 
providers authorized to provide waiver services such as personal 
care.\15\
---------------------------------------------------------------------------
    \15\ Under section 1915(c) of the Social Security Act, the 
Secretary of HHS may waive requirements that States offering home- and 
community-based services offer comparable benefits statewide and to all 
eligible beneficiaries, and that they use a single standard for 
eligibility.
---------------------------------------------------------------------------
 full effects of medicare waivers not yet known; preliminary analysis 
    indicates medicare fee-for-service telehealth waivers increased 
                         utilization and access
CMS Has Issued Hundreds of Medicare Waivers During the COVID-19 
        Pandemic
    According to the CMS Accomplishment Report, as of January 2021, CMS 
had issued over 130 blanket Medicare waivers nationwide since the start 
of the pandemic. The blanket waivers cover flexibilities for hospitals, 
skilled nursing facilities, home health agencies, and hospices, among 
others. They also cover flexibilities for providers, including 
licensing and enrollment, to the extent these flexibilities are 
consistent with applicable State laws, State emergency preparedness 
plans, and State scope of practice rules. For example, CMS waived or 
modified certain telehealth provisions to increase access to services 
and give providers more flexibility in treating beneficiaries.

    In addition to blanket waivers of statutory requirements, CMS also 
reported that as of January 2021, it had issued over 100 Medicare 
waivers under its authority to waive or modify its policies or 
regulations in response to the pandemic. CMS has since made some of 
these waivers permanent.\16\ Table 1 provides examples of changes that 
CMS approved, including under blanket waivers.\17\
---------------------------------------------------------------------------
    \16\ For example, in December 2020, CMS announced it was 
permanently adding certain new services (including mental health and 
care planning services) that it had temporarily added to the approved 
list of Medicare telehealth services during the pandemic.
    \17\ For more information on all COVID-19 related waivers approved 
by CMS, see Centers for Medicare and Medicaid Services, Coronavirus 
Waivers and Flexibilities, accessed May 11, 2021, https://www.cms.gov/
about-cms/emergency-preparedness-response-operations/current-
emergencies/coronavirus-waivers.


  Table 1: Examples of Medicare Waivers CMS Approved, PSince March 13,
                                  2020
------------------------------------------------------------------------
         Waiver                               Changes
------------------------------------------------------------------------
Increased capacity         Expand hospital capacity--for example,
                           hospitals may provide patient care at
                           nonhospital buildings or spaces provided that
                           the location is approved by the State, and
                           hospitals may treat patients in their own
                           homes.a
                           Allow hospitals to set up alternative
                           screening sites on campus to perform medical
                           screening examinations as a triage function.b
                           Waive sanctions for certain referrals that
                           would otherwise violate the Physician Self-
                           Referral law that generally prohibits a
                           physician from making referrals for certain
                           health-care services to an entity with which
                           the physician (or an immediate family member)
                           has a financial relationship, unless an
                           exception applies.c
------------------------------------------------------------------------
Workforce expansion        Expedite process for provider enrollment in
                           Medicare, including expediting pending or new
                           applications and waiving certain criminal
                           background checks.
                           Allow physicians whose privileges to
                           practice at a hospital will expire to
                           continue practicing at the hospital and
                           allowing new physicians to begin practicing
                           before full approval.
------------------------------------------------------------------------
Reducing administrative    Temporarily eliminate certain reporting and
 burdens                   other paperwork requirements that providers
                           must complete to be paid by Medicare, such as
                           program audits that may require additional
                           information from providers.
------------------------------------------------------------------------
Expansion of telehealth    Allow telehealth services to be provided
 services                  nationwide, rather than only in certain
                           locations.
                           Allow beneficiaries to receive, and
                           providers to furnish, telehealth services
                           from any setting, including beneficiaries'
                           and providers' homes.
                           Allow additional types of providers, such as
                           physical and occupational therapists, to
                           furnish telehealth services.
                           Temporarily add over 146 new telehealth
                           services.
                           Allow certain services to be furnished using
                           audio-only technology such as telephones,
                           instead of interactive systems involving
                           video technology.
------------------------------------------------------------------------
Source: GAO analysis of Centers for Medicare and Medicaid Services (CMS)
  information. | GAO-21-575T
 
a Hospitals typically must meet certain requirements to participate in
  Medicare, including providing services within their own buildings.
b By law, any Medicare-participating hospital with a dedicated emergency
  department must provide a medical screening examination and, if
  necessary, stabilizing treatment to any individual who arrives in its
  emergency department for examination or treatment, regardless of the
  ability to pay for the services.
c Entities that submit claims for services furnished pursuant to a
  prohibited referral are subject to financial sanctions.

Full Effects of Medicare Waivers Are Not Yet Known
    Information on the full effects of Medicare waivers and 
flexibilities is not yet available. However, in its Accomplishment 
Report, CMS provided information on certain flexibilities in January 
2021. For example:

        Expansion of hospital capacity. CMS reported that the waiver 
permitting hospitals to use non-hospital buildings and spaces to be 
used for patient care and quarantine sites (subject to State approval), 
has expanded access to care during the pandemic. For example, according 
to CMS, as of January 2021, 116 facilities in Texas were enrolled as 
hospital sites under a waiver that allowed ambulatory care centers and 
freestanding emergency centers to enroll as hospitals--thus increasing 
access to care. Additionally, CMS reported as of January 7, 2021, it 
had approved 63 hospitals in 21 States nationwide to participate in the 
waiver that allowed hospitals to treat patients in their own homes.\18\
---------------------------------------------------------------------------
    \18\ These include six health systems with extensive pre-pandemic 
experience providing acute hospital care at home--Brigham and Women's 
Hospital (Massachusetts); Huntsman Cancer Institute (Utah); 
Massachusetts General Hospital (Massachusetts); Mount Sinai Health 
System (New York City); Presbyterian Healthcare Services (New Mexico); 
and UnityPoint Health (Iowa).

        Workforce expansion. CMS reported that the removal of certain 
barriers regarding licensure and scope of practice has expanded the 
provider workforce enabling health professionals to provide services 
they were otherwise not eligible to provide, subject to State law. For 
---------------------------------------------------------------------------
example,

            Certain non-physician practitioners such as nurse 
practitioners and physician assistants can supervise the performance of 
diagnostic tests, subject to State law.

            Occupational therapists from home health agencies can now 
perform initial assessments on certain homebound patients, allowing 
home health services to start sooner and freeing home- health nurses to 
do more direct patient care.

    However, the Accomplishment Report did not contain information on 
the extent to which these added flexibilities have resulted in greater 
access to services for Medicare beneficiaries.

    CMS's Accomplishment Report also did not contain information on the 
effects of other flexibilities--including waivers granting provider 
enrollment flexibilities or waivers that reduced administrative 
burdens--on Medicare services during the pandemic. In future work, we 
will examine the impact of these and other waivers and flexibilities 
that HHS issued in response to the pandemic.
Medicare Telehealth Waivers Increased Utilization and Access
    As we reported in November 2020, Medicare telehealth waivers 
resulted in increased utilization of telehealth services, and provided 
beneficiaries access to services that would not have otherwise been 
available during the early days of the COVID-19 pandemic. However, the 
long-term effect of these waivers on spending and quality of care is 
not yet known.\19\ In addition, we reported that careful monitoring and 
oversight is warranted to prevent potential fraud, waste, and abuse 
that can arise from these new waivers. Existing research and 
preliminary observations from our ongoing work indicate the following 
effects of telehealth waivers on service utilization and access to 
care.
---------------------------------------------------------------------------
    \19\ See GAO-21-191.

    Available analysis from the CMS Accomplishment Report indicates 
that over the first 8 months of the pandemic, utilization of telehealth 
services in Medicare FFS sharply increased from about 325,000 services 
in mid-March to a peak of nearly 1.9 million services in late-
April.\20\ Utilization then dropped to about 1.3 million services by 
the beginning of June, and generally continued to slowly drop through 
mid-
October, as shown in figure 2.\21\
---------------------------------------------------------------------------
    \20\ The data for this analysis are based on Medicare FFS claims 
submitted through November 13, 2020. These figures include telehealth 
services as well as other services such as virtual check-ins and e-
visits, which collectively CMS defines as telemedicine. Virtual check-
ins are short patient-initiated communications with a health-care 
practitioner through different technologies including by phone or 
video. E-visits are non-face-to-face patient-initiated communications 
through an online patient portal. Medicare covered and paid for virtual 
check-ins and e-visits prior to the pandemic.
    \21\ CMS did not provide data on corresponding utilization of in-
person services for all services furnished via telehealth during this 
time. An analysis of telehealth utilization of primary care services 
from the Department of Health and Human Services' Office of the 
Assistant Secretary for Planning and Evaluation showed similar trends 
in telehealth utilization. Their analysis also showed that while 
telehealth primary care services were peaking from mid-March through 
mid-April, in-person services were precipitously dropping during this 
time, and that the peak in telehealth services was not sufficient to 
offset the drop in in-person services. See Department of Health and 
Human Services, Assistant Secretary for Planning and Evaluation, 
Medicare Beneficiary Use of Telehealth Visits: Early Data from the 
Start of COVID-19 Pandemic (Washington, DC: July 28, 2020).

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    This utilization varied by the type of service, the specialty 
of the provider, and the telehealth modality (audio-video or audio 
only). For example, CMS reported that nearly 40 percent of 
beneficiaries receiving office visits received them through telehealth 
compared to nearly 60 percent for mental health services. CMS also 
reported that internists and family practitioners furnished about one-
quarter of their services through telehealth compared to virtually none 
for other specialties. In addition, CMS reported that many (89 out of 
146) of the newly available types of telehealth services could be 
---------------------------------------------------------------------------
furnished through landline phones.

    Moreover, CMS reported that telehealth waivers played a critical 
role in maintaining access to services when beneficiaries and providers 
were concerned about the transmission of COVID-19. For example, before 
the pandemic, approximately 13,000 beneficiaries in Medicare FFS had 
received telehealth services in a week, compared to almost 1.7 million 
in the last week of April. CMS also reported that there was some 
variation in the levels of access among various groups of beneficiaries 
utilizing telehealth services. For example, a slightly higher 
proportion of beneficiaries below the age of 65 received a telehealth 
service, compared to groups aged 65 and over; the proportion of 
beneficiaries receiving telehealth services in urban areas was slightly 
higher than in rural areas; but the proportion of beneficiaries 
utilizing telehealth was similar across racial and ethnic groups. (See 
fig. 3.)

    Preliminary observations from our interviews with groups 
representing providers and beneficiaries confirmed flexibilities 
enabled beneficiaries to continue accessing care. Specifically, 
representatives we interviewed from two provider groups said providers 
quickly adopted and furnished telehealth services in the early days of 
the pandemic, but as patients became more comfortable coming into the 
office or clinic, in-person appointments resumed. Representatives from 
one provider group also told us that they relied more heavily on audio-
only or phone visits rather than video visits in the early days of the 
pandemic and switched later on to offering only in-person or video 
visits. Interviews with two groups representing beneficiaries indicated 
that telehealth flexibilities have enabled beneficiaries to access care 
from home during the pandemic, as well as the ability to seek care in a 
timely manner, reduce travel time, and triage their health issues to 
determine if an in-person visit is needed.

    However, as we noted in our June 2020 report, telehealth waivers 
may not alleviate all access concerns.\22\ Further, a recent study 
found that more than 26 percent of Medicare beneficiaries lack digital 
access at home in 2018, making it unlikely that they could have video-
based telehealth visits with clinicians.\23\ The proportion of 
beneficiaries in this study who lacked digital access was higher among 
those with low socioeconomic status, those 85 years or older, and in 
communities of color. Preliminary observations from our beneficiary and 
provider group interviews is consistent with these findings. For 
example, representatives from the two beneficiary groups and three 
groups representing providers told us that some beneficiaries were 
unable to access telehealth services due to lack of technology or 
broadband needed for a telehealth visit or they did not understand how 
to use the technology.
---------------------------------------------------------------------------
    \22\ See GAO-20-625.
    \23\ Eric Roberts and Ateev Mehrotra, ``Assessment of Disparities 
in Digital Access Among Medicare Beneficiaries and Implications for 
Telemedicine,'' The Journal of American Medical Association Internal 
Medicine, vol. 180, no. 10 (2020): pp. 1386-1389.

    Furthermore, the quality of telehealth services provided to 
Medicare beneficiaries has not yet been fully analyzed, and evidence 
from the few existing studies is inconclusive. According to MedPAC, 
some researchers have concluded that, in addition to increasing access 
to care, telehealth can also improve the quality of care.\24\ Other 
researchers caution that the convenience of telehealth could harm the 
quality of patient care.\25\ CMS officials told us in February 2021 
that they are still exploring how to measure the quality of care when 
services are delivered via telehealth.
---------------------------------------------------------------------------
    \24\ For example, in 2018 MedPAC reported that telestroke services 
both expanded access to care and likely improve the quality of care 
because the timeliness of stroke treatment could be improved. MedPAC, 
Report to Congress: Medicare Payment Policy (March 2018): 496.
    \25\ For example, a 2015 study of patients receiving treatment for 
acute respiratory infections found that physicians providing care 
through telehealth prescribed more expensive antibiotics that could 
increase antibiotic resistance in patients than antibiotics prescribed 
by physicians providing in-person care. See L. Uscher-Pines, et al., 
``Antibiotic Prescribing for Acute Respiratory Infections in Direct-to-
Consumer Telemedicine Visits,'' JAMA Internal Medicine, vol. 175, no. 7 
(2015).

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

 NOTE: THESE FIGURES INCLUDE TELEHEALTH SERVICES AS WELL AS OTHER 
                    SERVICES SUCH AS VIRTUAL CHECK-INS AND E-VISITS, 
                    WHICH COLLECTIVELY CMS DEFINES AS TELEMEDICINE. 
                    VIRTUAL CHECK-INS ARE SHORT PATIENT-INITIATED 
                    COMMUNICATIONS WITH A HEALTH-CARE PRACTITIONER 
                    THROUGH DIFFERENT TECHNOLOGIES INCLUDING BY PHONE 
                    OR VIDEO. E-VISITS ARE NON-FACE-TO-FACE PATIENT-
                    INITIATED COMMUNICATIONS THROUGH AN ONLINE PATIENT 
                    PORTAL. MEDICARE COVERED AND PAID FOR VIRTUAL 
                    CHECK-INS AND E-VISITS PRIOR TO THE PANDEMIC.

 temporary state medicaid flexibilities aimed to address obstacles to 
   beneficiary care, provider availability, and program enrollment; 
                        effects not fully known
    CMS-approved Medicaid waivers and flexibilities in all States were 
aimed at addressing obstacles that affect beneficiary care and provider 
availability, among other areas. In December 2020, CMS reported that 
the agency had approved more than 600 different Medicaid waivers, State 
plan amendments, and other flexibilities to offer States flexibility in 
responding to the COVID-19 pandemic. Some of the Medicaid flexibilities 
focused on facilitating beneficiary access to care and beneficiary 
safety. For example, CMS approved flexibilities regarding the provision 
of long- term services and supports to beneficiaries who receive care 
in facilities or in their homes and who were particularly vulnerable to 
exposure and disease. Other flexibilities focused on ensuring provider 
availability, such as allowing licensed out-of-State providers to 
enroll in a State's Medicaid program. (See table 2.)


 Table 2: Examples of State Medicaid Waivers and Flexibilities Approved
                     by CMS, March 2020 to May 2021
------------------------------------------------------------------------
          Focus                Specific State Flexibilities Approved
------------------------------------------------------------------------
Beneficiary care and       Forty-three States suspended fee-for-service
 safety                    prior authorizations, which are used to
                           demonstrate compliance with coverage and
                           payment rules before beneficiaries can obtain
                           certain services, rather than after the
                           services have been provided.a
                           Forty-nine States extended the dates for
                           reassessing and reevaluating beneficiaries'
                           needs, which are normally required for
                           beneficiaries to retain eligibility for some
                           home- and community-based services.b
                           Fifty States permitted virtual evaluations,
                           assessments, and Pperson-centered planning
                           for beneficiaries receiving long-term
                           services and supports normally conducted in
                           person.b
                           Fifty-one States issued program guidance to
                           expand coverage and access to telehealth
                           services.c
                           Nine States allowed early refills for most
                           medications.c
------------------------------------------------------------------------
Provider availability      Fifty-one States waived some requirements to
                           allow licensed out-of-State providers to
                           enroll in their programs to maintain provider
                           capacity.a, d
                           Twelve States modified facility requirements
                           to allow services to be provided from
                           practitioner's location via telehealth.c
                           Fifty-one States waived certain provider
                           screening and enrollment requirements during
                           the pandemic.
------------------------------------------------------------------------
Source: GAO analysis of Centers for Medicare and Medicaid Services (CMS)
  information complied by Kaiser Family Foundation, Medicaid Emergency
  Authority Tracker: Approved State Actions to Address COVID-19,
  accessed May 10, 2021, https://www.kff.org/coronavirus-covid-19/issue-
  brief/medicaid-emergency-authority-tracker-approved-state-actions-to-
  address-covid-19/. | GAO-21-575T
 
Note: For purposes of the table, States include the 50 States and the
  District of Columbia.
a States received approval under section 1135 of the Social Security
  Act, which authorizes the Secretary of Health and Human Services to
  temporarily waive or modify certain Federal health-care program
  requirements, including Medicaid requirements, to ensure that
  sufficient health-care items and services are available to meet the
  needs of enrollees when both a public health emergency and a disaster
  or emergency have been declared.
b States received approval to make changes to their section 1915(c) home-
   and community-based services waivers under an Appendix K amendment in
  order to respond to the emergency.
c States received approval to revise policies in their Medicaid State
  plan related to eligibility, enrollment, benefits, premiums and cost
  sharing, and payments. To make these changes, States must submit a
  State Plan Amendment to CMS for approval.
d States approved to temporarily enroll licensed out-of-State providers
  must follow certain requirements, which include screening providers to
  ensure they are enrolled in the Medicaid program and licensed in the
  State relating to their Medicaid enrollment. Waiver of these Federal
  requirements does not affect State or local licensure requirements.

    Among these flexibilities, we have reported that efforts to remove 
obstacles to beneficiary access to care, such as the use of telehealth, 
were among the most important during the COVID-19 pandemic.\26\ A 
Medicaid official we interviewed in one State said that flexibilities 
permitting virtual evaluations provided Medicaid beneficiaries with an 
added sense of security and safety while providing needed care. We have 
ongoing work examining States' experiences using waivers to maintain 
safe access to home- and community-based services. To reduce in- person 
contact between beneficiaries and providers, CMS has approved waivers 
allowing family to become paid caregivers. In addition, waivers have 
been used to make retainer payments to certain providers to support and 
maintain the provider network.
---------------------------------------------------------------------------
    \26\ See GAO-21-387.

    In addition to waivers, recent statutory changes have aimed at 
maintaining Medicaid enrollment. For example, the Families First 
Coronavirus Response Act provided a temporary increase in the Federal 
Government's matching rate for States' and territories' spending for 
Medicaid services for all qualifying States through the end of the 
quarter in which the public health emergency, including any extensions, 
ends. To receive the increased matching rate, States and territories 
were required to meet certain conditions, such as maintaining Medicaid 
enrollment for certain beneficiaries through the end of the month in 
which the public health emergency ends.\27\ In March 2021, we reported 
that from February 2020 through August 2020, Medicaid enrollment 
increased by 5.6 million, or 9 percent.\28\
---------------------------------------------------------------------------
    \27\ Specifically, States must provide continuous coverage to 
Medicaid beneficiaries who were enrolled in Medicaid on or after March 
18, 2020, regardless of any changes in circumstances or 
redeterminations at scheduled renewals that otherwise would result in 
termination, through the end of the month in which the public health 
emergency ends, among other requirements. States may terminate coverage 
for individuals who request a voluntary termination of eligibility, or 
who are no longer considered to be residents of the State.
    \28\ See GAO-21-387.

    Some preliminary effects of CMS-approved waivers and flexibilities 
and other flexibilities States permitted through law are known. CMS has 
reported an increase in telehealth utilization since the pandemic 
began--in particular, soon after the national emergency was declared. 
CMS has also reported variation in the use of telehealth across States 
and across ages within States.\29\ As an example of this variation, in 
January 2021, a North Carolina Medicaid official reported that 
beneficiaries in urban geographies were more likely to use services 
delivered via telehealth than beneficiaries in rural geographies.
---------------------------------------------------------------------------
    \29\ See CMS, Medicaid and CHIP COVID-19 Summaries, Preliminary 
Medicaid and CHIP Data Snapshot of Services through July 31, 2020, 
accessed May 10, 2021, https://www.medicaid.gov/state-resource-center/
downloads/covid19-data-snapshot.pdf.
---------------------------------------------------------------------------
program integrity, beneficiary health and safety, and equity are among 
   considerations for the continued use of waivers and flexibilities 
                    implemented during the pandemic
    The waivers and flexibilities implemented in Medicare and Medicaid 
during the COVID-19 pandemic likely benefited providers and 
beneficiaries, yet determining whether--and if so, how--to continue 
them post-pandemic warrants consideration. CMS has made some Medicare 
waivers permanent, and, based on interest from policymakers and 
stakeholders, is considering doing so for other waivers. With respect 
to Medicaid, CMS has set an end date for some of the waivers and 
flexibilities and has issued guidance to States in December 2020 on 
resuming normal Medicaid operations after the end of the public health 
emergency.\30\ In light of these impending decisions, our past work and 
the work of others suggest there are several issues, including program 
integrity, beneficiary health and safety, and equity, to consider.
---------------------------------------------------------------------------
    \30\ See CMS, RE: Planning for the Resumption of Normal State 
Medicaid, Children's Health Insurance Program (CHIP), and Basic Health 
Program (BHP) Operations Upon Conclusion of the COVID-19 Public Health 
Emergency (Baltimore, MD: December 22, 2020).

    Potential for increased spending. As we have previously reported, 
telehealth and other waivers pose risks of increased spending in both 
---------------------------------------------------------------------------
programs. Specifically,

        Recent data from the CMS Accomplishment Report indicates 
telehealth services continued as in-person visits began to ramp up in 
the third quarter of 2020. This suggests that increased demand for 
telehealth may continue even after the pandemic--an important 
consideration given payment incentives that may result from paying the 
same for telehealth and in-person services. One provider group that we 
interviewed also noted that these incentives may be particularly 
relevant for specialties that can provide and be paid for both in-
person and additional telehealth services they generate compared to 
other procedure-based specialties that receive more global payments 
regardless of the number of visits they generate.

        The temporary waiver of sanctions for certain referrals that 
would otherwise violate the Physician Self-Referral Law may increase 
the potential for increased spending in both programs given our prior 
work indicating that providers who self-refer tended to use more 
health-care services.\31\
---------------------------------------------------------------------------
    \31\ GAO, Medicare Physical Therapy: Self-Referring Providers 
Generally Referred More Beneficiaries but Fewer Services per 
Beneficiary, GAO-14-270 (Washington, DC: April 30, 2014); GAO, 
Medicare: Higher Use of Costly Prostate Cancer Treatment by Providers 
Who Self-Refer Warrants Scrutiny, GAO-13-525 (Washington, DC: July 19, 
2013); GAO, Medicare: Action Needed to Address Higher Use of Anatomic 
Pathology Services by Providers Who Self-Refer, GAO-13-445 (Washington, 
DC: June 24, 2013); GAO, Medicare: Referrals to Physician-Owned Imaging 
Facilities Warrant HCFA's Scrutiny, GAO/HEHS-95-2 (Washington, DC: 
October 20, 1994).

    Program integrity. Both the Medicare and Medicaid programs are on 
GAO's High-Risk List, in part due to concerns about fraud, waste, and 
abuse.\32\ Increased program spending, the lack of complete data, and 
suspensions of some program safeguards increase these risks. For 
example:
---------------------------------------------------------------------------
    \32\ GAO, High-Risk Series: Dedicated Leadership Needed to Address 
Limited Progress in Most High-Risk Areas, GAO-21-119SP (Washington, DC: 
March 2, 2021).

        CMS lacks complete data to determine the telehealth modality 
being used (audio only or audio-video technology) or if services are 
originating from providers' and beneficiaries' homes, important 
information to consider in light of the aforementioned payment 
incentives and that the quality of telehealth services has not yet been 
---------------------------------------------------------------------------
fully analyzed.

        The non-enforcement of certain privacy and security rules to 
allow for telehealth flexibility raises concerns about the transmission 
of medical information over potentially insecure systems.\33\
---------------------------------------------------------------------------
    \33\ The HHS Office of Civil Rights (responsible for enforcing 
certain regulations relating to privacy and security of protected 
health information) stated that it would exercise enforcement 
discretion and not impose penalties for noncompliance with regulatory 
requirements during the pandemic.

    In our ongoing work, CMS officials have noted oversight activities 
---------------------------------------------------------------------------
related to program integrity. As examples:

        CMS is using its Fraud Prevention System to identify 
potentially inappropriate Medicare claims for telehealth services prior 
to payment and to flag providers with suspicious billing patterns 
through post- payment screens.

        CMS is conducting and updating program integrity risk 
assessments for all Medicaid waivers and flexibilities issued as a 
result of the pandemic.

    Beneficiary health and safety. Providing services while limiting 
beneficiary exposure to COVID-19 has been a difficult balance for CMS 
and states--and telehealth has been a large part of these efforts. The 
pandemic has also given rise to new levels of need for behavioral 
health care--both mental health and substance use disorders--while 
behavioral health service providers reported increasing demand and 
decreasing staff size.\34\ Extending or ending waivers and 
flexibilities may affect beneficiary health and safety in unknown ways.
---------------------------------------------------------------------------
    \34\ GAO, Behavioral Health: Patient Access, Provider Claims 
Payment, and the Effects of the COVID-19 Pandemic, GAO-21-437R 
(Washington, DC: March 31, 2021).

        In Medicare, we have previously reported that the effect of 
COVID-19 related waivers on quality of care is not yet known. We also 
noted earlier that the quality of telehealth services has not been 
fully analyzed, and evidence from the few existing studies is 
---------------------------------------------------------------------------
inconclusive.

        In Medicaid, preliminary data from CMS show outpatient mental 
health services for adults age 19 to 64 declined starting in March and 
continuing through July--despite CMS approving waivers and 
flexibilities to help ensure the availability of care.

        Expedited processes for provider enrollment, including waivers 
of normal screening and criminal background checks, could affect the 
quality of care provided to beneficiaries in both programs.

    Issues of equity. We have previously reported that communities of 
color have been disproportionately affected by COVID-19 in terms of 
cases reported, hospitalizations, deaths, and rates of testing and 
vaccinations.\35\ Disparate effects from COVID-19 extend to 
beneficiaries' receipt of services, as well. As we noted earlier, 
beneficiaries in urban areas received or were more likely to use 
telehealth services than beneficiaries in rural areas both in Medicare 
and in one State's Medicaid program. To ensure that all beneficiaries 
receive the best care possible, how waivers and flexibilities in both 
programs account for equity is an important consideration.
---------------------------------------------------------------------------
    \35\ For example, Non-Hispanic black persons were hospitalized at 
almost 3 times the rate of non-Hispanic white persons when adjusting 
for age, and their death rates were 1.4 times higher than non-Hispanic 
white persons. See GAO-21-387.

    In summary, my testimony highlighted the various flexibilities and 
waivers implemented during the COVID-19 pandemic and provided 
preliminary information on how these flexibilities have likely 
benefitted providers and beneficiaries. Continuing these flexibilities 
after the public health emergency declarations end could increase 
certain risks to the Medicare and Medicaid programs. Careful 
consideration of these benefits and risks will be key to determining 
the path forward, especially given that both programs are on GAO's 
High-Risk List. We look forward to working with Congress as we continue 
---------------------------------------------------------------------------
our oversight of the Federal response to the COVID-19 pandemic.

    Chairman Wyden, Ranking Member Crapo, and members of the committee, 
this completes my prepared statement. I would be pleased to respond to 
any questions that you may have at this time.

                                 ______
                                 
           Questions Submitted for the Record to Jessica Farb
           Questions Submitted by Hon. Catherine Cortez Masto
    Question. In your written testimony, you noted that the quality of 
telehealth services has not been fully analyzed.

    What kind of information does GAO or CMS need to paint a complete 
picture of care quality when it comes to telehealth?

    Answer. We will report on CMS's progress on this topic in our 
ongoing work on Medicare and Medicaid telehealth services, which we 
expect to issue in late 2021 and early 2022, respectively. As we 
reported in our testimony, CMS officials told us in February 2021 that 
they are still exploring how to measure the quality of telehealth 
services. Several organizations have been involved in developing 
quality measures for services delivered via telehealth. For example, in 
2017 the National Quality Forum (NQF) developed a framework for 
measuring the quality of telehealth services, through a project funded 
by CMS. In January 2021, NQF announced that CMS had tasked it with 
updating the framework in light of the recent uptick in telehealth use.

    Question. In your written testimony, you noted a couple of 
instances where the COVID-19 flexibilities benefit different 
populations disproportionately. Telehealth, for example, was utilized 
more by urban populations than their rural counterparts. One of the 
flexibilities enabled providers to deliver services within their scope 
of practice that they're normally not eligible to provide to Medicare 
beneficiaries. Typically, we see these scope expansions as 
disproportionately benefitting rural areas where provider shortages are 
more acute.

    Has GAO found any patterns in the benefits of these scope 
expansions?

    Answer. As we reported in our testimony, CMS provided certain 
Medicare scope of practice flexibilities during the pandemic to allow 
health professionals to provide services that they were not otherwise 
permitted to provide. For example, CMS allowed certain nonphysicians to 
supervise the performance of diagnostic tests that they were otherwise 
not eligible to provide, as permitted under State law. CMS data show 
that the proportion of beneficiaries in rural areas using telehealth 
significantly increased from October 2019 through June 2020. It is not 
clear how much of this increase was due to expansion of scope of 
practice versus lifting of other restrictions, such as allowing 
beneficiaries to receive services at home. In our ongoing work, we will 
report how these flexibilities affected beneficiary access to services 
in rural areas during the public health emergency.

              Questions Submitted by Hon. Thomas R. Carper
    Question. During the pandemic, telehealth has been an essential 
tool to get children the care that they need while minimizing risk. 
Although telehealth under Medicare has been a focus, close to 40 
million children are enrolled in Medicaid.

    What are the main policy changes we need to ensure this broader use 
of telehealth can be continued beyond the pandemic for children?

    Answer. We have not done work specific to the broader use of 
telehealth for children. CMS-approved Medicaid waivers and 
flexibilities in all States were aimed at addressing obstacles that 
affect beneficiary care and provider availability, among other areas. 
Among these flexibilities, we have reported that efforts to remove 
obstacles to beneficiary access to care, such as the use of telehealth, 
were among the most important during the COVID-19 pandemic. The 
temporary authorities CMS has approved will terminate based on the 
conclusion of the public health emergency unless the States make 
certain temporary changes permanent, for example, by submitting a State 
plan amendment for CMS's review and approval. We will continue to 
monitor CMS and State actions on temporary authorities, including in 
our ongoing work examining telehealth in Medicaid during COVID-19, 
which we expect to issue in early 2022.

    Question. During COVID-19, many States adopted temporary changes to 
their telehealth policies, such as expanding the scope of services and 
providers able to furnish telehealth, relaxing of licensure 
requirements and modifying reimbursement policies. Many States 
legislatures have also begun the work to adopt more permanent 
telehealth policy changes.

    How can the Federal Government best support State Medicaid programs 
in their efforts to expand telehealth?

    Are there Medicaid supports, incentives, and learnings that Federal 
policymakers could provide'?

    Answer. Medicaid allows significant flexibility for States to 
design and implement their programs. For example, States have the 
option to determine: whether to cover services provided through 
telehealth; which types of services provided through telehealth to 
cover, as long as such telehealth providers are recognized and 
qualified according to Medicaid statute and regulation; and how much to 
pay providers for services delivered through telehealth, as long as 
such payments do not exceed other program requirements.

    Since the beginning of the COVID-19 pandemic, CMS created and 
released four templates to help States obtain Federal waivers and 
assist them in identifying other authorities to implement program 
flexibilities more efficiently. In our ongoing work examining 
telehealth in Medicaid during COVID-19, CMS officials have described 
efforts to share practices with States, for example through technical 
advisory group calls and Medicaid Integrity Institute offerings. We 
will continue to monitor these efforts through our ongoing work.

    Question. COVID-19 has introduced additional stress and trauma for 
children and families. Telehealth, and particularly audio-only 
telehealth has been a crucial tool to connect children and adolescents 
to needed mental health-care services.

    How can telehealth be best utilized to meet kids' mental health-
care needs, and can you speak to the use of audio-only telehealth 
specifically?

    Answer. We have not reviewed how telehealth can best be utilized to 
meet children's mental health needs. According to preliminary data from 
CMS, through October 31, 2020, primary, preventive, and mental health 
service use declined among children under age 19 starting in March 
2020. The agency also noted that of all services examined in their 
analysis, the smallest rebound between March and October 2020 has been 
the mental health service use rates. Our ongoing work examining 
telehealth in Medicaid during COVID-19 will review selected States' 
considerations for delivering services via telehealth after the end of 
the public health. emergency, including via audio-only telehealth 
modality. As part of that ongoing work, CMS officials told us that the 
agency is monitoring services delivered via telehealth by modality, and 
that for services delivered via live audio/video, the agency is also 
examining monthly utilization of certain behavioral health services.

    Question. As State Medicaid programs look at expanding their use of 
telehealth, it is particularly important that vulnerable populations 
like children are not negatively impacted. Policies must be looked at 
through a health equity lens, considering access to reliable and 
affordable broadband services, access to devices that support HIPAA-
compliant telehealth platforms and coverage policies.

    How can Medicaid programs work to ensure telehealth policies are 
equitable for children and mitigate potential inequities that may 
arise?

    Answer. We have not conducted work on how to ensure telehealth 
policies are equitable for children and mitigate potential inequities 
across the Medicaid beneficiary population. However, as part of our 
ongoing work examining telehealth in Medicaid during COVID-19, we will 
continue to monitor CMS and State telehealth policies. As noted in the 
testimony statement, to ensure that all beneficiaries receive the best 
care possible, how waivers and flexibilities account for equity is an 
important consideration.

                                 ______
                                 
              Questions Submitted by Hon. Elizabeth Warren
    Question. The COVID-19 pandemic laid bare the deep systemic 
inequities that exist in our Nation's health system. Telehealth creates 
opportunities to combat racial disparities. But, if policymakers fail 
to center health equity in their discussions around expanding 
telehealth and making pandemic-era flexibilities permanent, future 
telehealth policies could exacerbate inequity.

    Ensuring that patients receive health services in a language they 
can understand is critical to maximizing health outcomes, and studies 
show that language-concordant care ``enhances trust between patients 
and physicians, optimizes health outcomes, and advances health equity 
for diverse populations.''\1\
---------------------------------------------------------------------------
    \1\ BMC Medical Education, ``The power of language-concordant care: 
A call to action for medical schools,'' Rose L. Molina and Jennifer 
Kasper, November 6, 2019, doi: 10.1186/s12909-019-1807-4.

    What specific steps, if any, did CMS take to ensure that telehealth 
services provided during the pandemic were offered in languages that 
---------------------------------------------------------------------------
patients could understand?

    Were these steps sufficient in ensuring that patients with limited 
English proficiency could access high-quality care during the pandemic?

    What information, if any, exists on improvements that could be made 
to telehealth regulations (both generally and regarding flexibilities 
offered during the pandemic) to improve patient access to language-
concordant services?

    Answer. During the pandemic, CMS compiled a variety of resources on 
telehealth for minority populations, including individuals with limited 
English proficiency. For example, CMS developed a telehealth guide for 
health-care providers that included considerations for providing 
telehealth to special populations, including non-English speakers.\2\ 
We have not assessed the effectiveness of these resources in ensuring 
access to care for these individuals, but equitable access to care will 
continue to be an important consideration in our work on delivery of 
services to Medicare and Medicaid beneficiaries during the pandemic, 
which we expect to report on in late 2021 and early 2022, respectively.
---------------------------------------------------------------------------
    \2\ See, U.S. Department of Health and Human Services, Stay Safe: 
Getting the Care You Need at Home, Woodlawn, MD: revised May 2020, 
accessed June 9, 2021, available at https://www.cms.gov/About-CMS/
Agency-Information/OMH/equity-initiatives/c2c/consumerresources/c2c-
covid-19-resources; and U.S. Department of Health and Human Services, 
Telehealth for Providers: What You Need to Know, Woodlawn, MD: revised 
March 2021, accessed June 14, 2021, available at https://www.cms.gov/
files/document/telehealth-toolkit-providers.pdf.

    Question. The COVID-19 pandemic exacerbated substance use disorder 
across the country, with impacts disproportionately felt by communities 
of color.\3\ In your testimony, you noted that preliminary Medicaid 
data ``show outpatient mental health services for adults age 19 to 64 
declined'' from March through July 2020, ``despite CMS approving 
waivers and flexibilities to ensure the availability of care.'' 
Medicare data on behavioral health was not yet fully analyzed or 
conclusive.
---------------------------------------------------------------------------
    \3\ Mass.gov, ``Opioid-related overdose deaths rose by 5 percent in 
2020,'' May 12, 2021, https://www.mass.gov/news/opioid-related-
overdose-deaths-rose-by-5-percent-in-2020.

    What information, if any, exists explaining why Medicaid (and to 
the extent data has become available, Medicare) mental health visits 
declined, despite efforts to expand access to services via telehealth 
---------------------------------------------------------------------------
and other flexibilities?

    What lessons should policymakers take from this episode to app y to 
future efforts to expand access to mental health services during public 
health crises?

    Answer. We do not have information explaining why Medicaid mental 
health visits declined for either population during this time frame. As 
you noted, preliminary CMS data show that Medicaid outpatient mental 
health services for adults age 19 to 64 declined from March through 
July 2020. In addition, preliminary CMS data through October 31, 2020 
show that mental health service use also declined among children under 
age 19 starting in March 2020.

    Some of our ongoing work could also provide additional information 
about efforts to expand behavioral health services to Medicaid 
beneficiaries. In addition to our work examining Medicaid telehealth 
services during COVID-19, we are also examining State demonstrations 
that have established certified community behavioral health clinics, 
including steps States have taken to assess the effects of the 
demonstration on the health outcomes of beneficiaries, including 
beneficiaries with substance use disorders.

    With respect to Medicare, telehealth for mental health care may be 
showing promise for beneficiaries. Specifically, CMS data show that 60 
percent of beneficiaries receiving mental health services received them 
through telehealth between March 17th and June 13, 2020. In our ongoing 
work, we are examining trends in beneficiary use of Medicare services 
in 2019 and 2020, including by service type, such as mental and 
behavioral health services.

                                 ______
                                 
             Questions Submitted by Hon. Patrick J. Toomey
    Question. The improper payment rates in Medicare (6.27 percent in 
FFS, 6.78 percent in MA) are the lowest in nearly a decade, whereas the 
Medicaid improper payment rate has ballooned (21.36 percent).\4\ 
Bringing the Medicare improper payment rate down over the years was 
surely not an easy feat. Given the propensity for our Federal health-
care programs to be susceptible to waste, fraud, and abuse, 
policymakers and Federal agencies must continue to take action to 
safeguard these programs. The Medicare Payment Advisory Commission 
(MedPAC) previously noted that telehealth could enhance risks for 
fraud, waste, and abuse in Medicare, and the Commission recommended 
that the Centers for Medicare and Medicaid Services (CMS) implement 
additional safeguards to curb the potential for telehealth-related 
fraud and waste following the public health emergency.\5\
---------------------------------------------------------------------------
    \4\ ``2020 Estimated Improper Payment Rates for Centers for 
Medicare and Medicaid (CMS) Programs,'' CMS, November 16, 2020, https:/
/www.cms.gov/newsroom/fact-sheets/2020-estimated-improper-payment-
rates-centers-medicare-medicaid-services-cms-programs.
    \5\ ``Telehealth in Medicare After the Coronavirus Public Health 
Emergency,'' Medicare Payment Advisory Commission (MedPAC), http://
www.medpac.gov/docs/default-source/reports/
mar21_medpac_report_ch14_sec.pdf?sfvrsn=0.

    What features of the Medicare and Medicaid programs make telehealth 
services susceptible to fraud, waste, and abuse? Which feature has the 
---------------------------------------------------------------------------
greatest potential for such behavior?

    Does CMS have the tools and resources necessary to expand 
telehealth services or provide flexibilities in a manner that does not 
exacerbate existing vulnerabilities in the Medicare and Medicaid 
programs?

    Answer. With respect to telehealth in the Medicare program, as we 
reported in our testimony, the suspension of some program safeguards-
such as the non-enforcement of certain privacy and security rules to 
allow for telehealth flexibility-can increase these vulnerabilities. 
Telehealth waivers can also increase spending if these services are 
furnished in addition to in-person services. As noted in our testimony, 
assessing the impact of some flexibilities will be challenging because 
CMS lacks complete data--for example, with respect to the telehealth 
modality being used (audio-only or audio-video technology). In the 
Medicaid program, one-third of improper payments are related to States' 
noncompliance with provider screening and enrollment requirements-an 
area where flexibilities have been increased, and oversight 
decreased.\6\
---------------------------------------------------------------------------
    \6\ GAO, High-Risk Series: Dedicated Leadership Needed to Address 
Limited Progress in Most High-Risk Areas, GAO-21 119SP (Washington, DC: 
March 2, 2021).

    Question. Your testimony noted that CMS is conducting program 
integrity risk assessments for all of pandemic-related waivers and 
---------------------------------------------------------------------------
flexibilities in the Medicaid program.

    Has the Department of Health and Human Services established a 
timeline or plan for the completion of these integrity risk 
assessments?

    Answer. According to CMS officials, the risk assessments are an 
ongoing process and may be updated, for example, when certain risk 
mitigation strategies are implemented. In April 2021, CMS officials 
said that the agency was developing a webinar and toolkit for States to 
conduct risk assessments. We will continue to monitor these actions as 
part of our ongoing work examining telehealth in Medicaid during COVID-
19.

    Question. Your testimony also noted that CMS currently lacks data 
on certain aspects of telehealth visits that could be important in 
determining the quality outcomes of telehealth services.

    What data is needed in order to measure the effects of telehealth 
services on patient outcomes? Has the Department of Health and Human 
Services established a timeline or plan for developing these type of 
measures?

    Answer. As reported in our testimony, regarding Medicare, CMS lacks 
complete data to determine the telehealth modality being used (audio-
only or audio-video technology) or if services are originating from 
providers' and beneficiaries' homes--important information to consider 
in light of the fact that the quality of telehealth services has not 
yet been fully analyzed. As part of our ongoing work examining 
telehealth in Medicaid during COVID-19, CMS officials told us that the 
agency is monitoring services delivered via telehealth by modality, and 
that for services delivered via live audio-video, the agency is also 
examining monthly utilization of certain services.

    Several organizations have been involved in developing quality 
measures for services delivered via telehealth. For example, in 2017, 
the National Quality Forum (NQF) developed a framework for measuring 
the quality of telehealth services through a project funded by CMS and 
was tasked with updating this framework in January 2021, in light of 
the recent uptick in telehealth use. As we reported in our testimony, 
CMS officials told us in February 2021 that they are still exploring 
how to measure the quality of telehealth services. We will report on 
CMS's progress on this topic in our ongoing work on Medicare and 
Medicaid telehealth services, which we expect to issue in late 2021 and 
early 2022, respectively.

                                 ______
                                 
               Questions Submitted by Hon. Chuck Grassley
    Question. Throughout the public health emergency, the Centers for 
Medicare and Medicaid Services (CMS) issued over 200 waivers under 
Medicare and approved more than 600 waivers and other flexibilities 
under Medicaid. While some of the regulations waived are specifically 
for responding to a pandemic, ensuring patient safety, controlling 
costs, and maintaining program integrity its clear innovation and 
common sense ideas in our health-care system have been stifled too 
often by Federal regulations. For example, CMS permanently added 
certain new services (including mental health and care planning 
services) that it had temporarily added to the approved list of 
Medicare telehealth services during the pandemic. Some regulations play 
an important role in protecting safety and maintaining program 
integrity but others may stifle good ideas.

    Is health care too regulated that it's stifling good ideas?

    Should executive agencies sunset regulations in the future to 
enable more innovation in health care?

    Answer. CMS issued hundreds of waivers in the Medicare and Medicaid 
programs to ensure beneficiary access to services during the pandemic. 
We reported in our testimony that telehealth waivers in particular were 
instrumental in providing safe access to services that beneficiaries 
would otherwise not have had. In addition to implementing rapid 
innovations through waivers and flexibilities, as we reported in March 
2018, CMS is also testing new approaches to health-care delivery and 
payment in both programs through its Center for Medicare and Medicaid 
Innovation Center, and, as of March 1, 2018, had implemented 37 models 
to reduce spending and improve the quality of care.\7\
---------------------------------------------------------------------------
    \7\ GAO, CMS Innovation Center: Model Implementation and Center 
Performance, GAO-18-302 (Washington, DC: March 26, 2018).

    Our prior work examining States' views on the impact of Federal 
Medicaid policies on their programs also highlights key considerations 
with respect to any potential changes to program oversight. In this 
work, States identified a range of Federal laws, regulations, and 
procedures that affected their ability to efficiently administer their 
Medicaid programs. In considering potential Federal actions to address 
these challenges, we identified a series of tradeoffs and 
considerations, including (1) targeting Federal oversight to critical 
areas, such as to reduce improper payments or to manage other program 
risks; (2) having accurate and complete data on key measures, such as 
beneficiary access, service use, and related costs, to inform any 
potential change; and (3) balancing States' ongoing efforts to waive 
statutory requirements with an appropriate level of oversight, as 
historically we have identified multiple instances where improved 
oversight of such efforts was warranted.\8\
---------------------------------------------------------------------------
    \8\ GAO, Medicaid: State Views on Program Administration 
Challenges, GAO-20-407 (Washington, DC: April 30, 2020).

    Question. At the beginning of the public health emergency (PHE), 
Congress provided the Health and Human Services (HHS) Secretary with 
authority to waive Medicare requirements for telehealth payment during 
the PHE. This allowed more than 140 telehealth services to be provided 
that previously were not allowed or were limited. Some limitations 
included a lack of payment parity, geographic limitations on where 
services are provided, and restrictions on audio-only telehealth 
services. Similar flexibilities were granted to States under Medicaid. 
Most of these flexibilities will be go away once the PHE ends. MedPAC 
reports ``there is not yet evidence on how the combination of 
telehealth and in-person care affects quality and costs in the Medicare 
---------------------------------------------------------------------------
program.''

    Your written testimony mentioned that the ``Medicare and Medicaid 
programs are on GAO's high-risk list'' when it comes to telehealth ``in 
part due to concerns about fraud, waste, and abuse.'' While the public 
health emergency is still in place, what program integrity measures 
should CMS put in place to stop these high-risk activities?

    Answer. As reported in our testimony, telehealth services can pose 
heightened program integrity risks to the Medicare and Medicaid 
programs stemming from increased program spending, the lack of complete 
data, and suspens1dns of some program safeguards. Our ongoing work on 
Medicare telehealth services, which we expect to issue in late 2021, 
will examine the telehealth-related vulnerabilities CMS has identified 
and control activities the agency has put in place to address them.

    We also reported in our testimony that CMS is conducting and 
updating program integrity risk assessments for all Medicaid waivers 
and flexibilities issued as a result of the pandemic. According to CMS 
officials, the risk assessments He an ongoing process and may be 
updated, for example, when certain risk mitigation strategies are 
implemented. In April 2021, CMS officials said that the agency was 
developing a webinar and toolkit for States to conduct risk 
assessments. We will continue to monitor these actions as part of our 
ongoing work examining telehealth in Medicaid during COVID-19, which we 
expect to issue in early 2022.

    Question. Your written testimony mentioned that the ``quality of 
telehealth services has not been fully analyzed.'' What quality metrics 
should GAO and Congress be using?

    Answer. We will report on CMS's progress on this topic in our 
ongoing work on Medicare and Medicaid telehealth services. CMS has 
tasked the National Quality Forum with updating its framework for 
assessing the quality of telehealth services, and in February 2021, CMS 
officials told us that they are still exploring these measures.

    Question. Is GAO looking at the Medicare Advantage telehealth 
experience pre-pandemic and throughout the pandemic to inform its 
recommendations? If so, what kind of data does GAO have and how is it 
using that data to inform recommendations?

    Answer. Our ongoing work on Medicare telehealth services focuses on 
the fee-for-service program through data analysis and interviews with 
selected payer and other stakeholders. To the extent these interviews 
provide insights into telehealth services in the Medicare Advantage 
program, we will discuss these in our ongoing work.

    Question. Expanding Medicare FFS telehealth after the PHE ends 
should consider implications of federalism including scope-of-practice, 
medical malpractice, and credentialing and licensing. What other 
federalism considerations should Congress take into account when 
determining telehealth expansion in Medicare FFS?

    Answer. We have no plans at this time to explore these issues in 
our ongoing work on Medicare telehealth services.

                                 ______
                                 
               Questions Submitted by Hon. John Barrasso
    Question. Before coming to the Senate, I had the privilege of 
practicing medicine in Wyoming. Rural health care faced challenges 
prior to the pandemic. In particular, we know since 2010 more than 135 
rural hospitals have closed.

    In the Senate, I am proud to help lead the bipartisan Rural Health 
Caucus. This group is committed to ensuring patients in rural America 
can get access to the care they need.

    Can you specifically discuss the changes in Federal health-care 
policy that you believe have helped rural providers the most during 
this pandemic?

    Can you please discuss any specific changes that Congress should 
consider to better support rural health-care providers?

    Answer. As we noted in our testimony, Medicare telehealth waivers 
enabled beneficiaries in both rural and urban areas to receive care 
from their home. A July 2020 Issue Brief from the Assistant Secretary 
for Planning and Evaluation indicated that utilization of telehealth in 
rural areas increased significantly between March and April 2020.\9\ 
However, as we also noted in our testimony, disparate effects from 
COVID-19 extend to beneficiaries' receipt of services. Beneficiaries in 
urban areas received more telehealth services or were more likely to 
use telehealth services than beneficiaries in rural areas both in 
Medicare and in one State's Medicaid program. Additionally, providers 
face challenges offering telehealth services due in part to limited 
patient access to broadband Internet. Specifically, in March 2021, we 
reported that as of February 18, 2021, the Federal Communication 
Commission's COVID-19 Telehealth Program had disbursed $143.2 million 
in awards to eligible providers, including funding targeted towards 
patient care in rural populations.\10\ While we have not assessed the 
changes that helped rural providers the most during the pandemic, we 
have reported on rural health care in our ongoing COVID-19 reporting, 
for example, on Provider Relief Fund allocations and disbursements to 
rural health-care facilities and Veterans Health Administration 
outreach to rural veterans.\11\ We will continue to monitor 
beneficiaries' receipt of services in urban and rural areas as part of 
our ongoing work examining telehealth in both programs during COVID-19, 
which we expect to issue in late 2021 and early 2022, respectively.
---------------------------------------------------------------------------
    \9\ Department of Health and Human Services, Assistant Secretary 
for Planning and Evaluation (ASPE), Medicare Beneficiary Use of 
Telehealth Visits: Early Data from the Start of COVID-19 Pandemic 
(Washington, DC: July 28, 2020). ASPE reported that the proportion of 
weekly rural primary care visits delivered via telehealth increased 
from virtually none prior to the pandemic to about 25 percent mid-April 
before gradually decreasing to about 10 percent by May.
    \10\ GAO, COVID-19: Sustained Federal Action Is Crucial as Pandemic 
Enters Its Second Year, GAO-21-387 (Washington, DC: March 31, 2021).
    \11\ For example, see GAO, COVID-19: Opportunities to Improve 
Federal Response and Recovery Efforts, GAO-20-625 (Washington, DC: June 
25, 2020); GAO, COVID-19: Urgent Actions Needed to Better Ensure an 
Effective Federal Response, GAO-21-191 (Washington, DC: November 30, 
2020); and GAO-21-387.

    Question. Prior to the pandemic, I introduced bipartisan 
legislation with Senator Tina Smith, which among other things, would 
---------------------------------------------------------------------------
allow Rural Health Clinics (RHCs) to provide more telehealth services.

    I was pleased that Congress through the CARES Act authorized both 
Rural Health Clinics and Federally Qualified Health Centers to furnish 
telehealth services to Medicare beneficiaries during the public health 
emergency.

    Can you discuss the importance of Rural Health Clinics and 
Federally Qualified Health Centers continuing to provide telehealth 
services after the public health emergency has ended?

    Answer. As we noted in our testimony, CMS waived or modified 
certain telehealth provisions to increase access to care and give 
providers more flexibilities in treating beneficiaries. We also noted 
in our testimony that telehealth has been a major part of efforts to 
provide services while limiting beneficiary exposure to COVID-19, and 
that extending or ending waivers and flexibilities may affect 
beneficiary health and safety in unknown ways. We will continue to 
monitor utilization of telehealth services, including telehealth 
services utilized by geographic location, as part of our ongoing work 
examining Medicare telehealth waivers.

    Question. My wife Bobbi and I are passionate about improving access 
to mental health services. This pandemic has clearly impacted the 
mental, as well as the physical health of our Nation.

    For people living in rural America, getting help from a mental 
health provider was challenging before the pandemic. This is why 
Senator Stabenow and I have long supported professional counselors and 
marriage and family therapists participating in Medicare. We believe 
that increasing the number of mental health providers able to care for 
our Nation's seniors is an important priority.

    Please discuss how telehealth has impacted the ability of patients 
to receive mental health services during the pandemic.

    Can you please identify ways Congress can improve access to mental 
health services, including expanding the number of providers that can 
participate in Medicare?

    Answer. Access to mental health services remains a growing concern 
as the pandemic continues. As we noted in our testimony, in Medicaid, 
preliminary data from CMS show outpatient mental health services for 
adults age 19 to 64 declined starting in March and continuing through 
July--despite CMS approving waivers and flexibilities to help ensure 
the availability of care. In March 2021, we reported on longstanding 
concerns about the availability of behavioral health treatment, 
particularly for low-income individuals.\12\ Evidence collected during 
the pandemic suggests the prevalence of behavioral health conditions 
has increased, while access to in-
person behavioral health services has decreased. In our March 2021 
report, we reiterated a 2019 recommendation that the Federal agencies 
involved in the oversight of mental health parity requirements evaluate 
the effectiveness of their oversight efforts. As of March 2021, the 
agencies had not yet implemented this recommendation.
---------------------------------------------------------------------------
    \12\ GAO, Behavioral Health: Patient Access, Provider Claims 
Payment, and the Effects of the COVID-19 Pandemic, GAO-21-437R 
(Washington, DC: March 31, 2021).

    Telehealth may help provide access to mental and behavioral health 
services for beneficiaries. In our March 2021 report, we reported that 
the increased use of and payment for telehealth has had a positive 
effect during the pandemic, leading to improved access to behavioral 
health services for some patients and resulting in fewer missed 
appointments, according to most stakeholders. Further, CMS data show 
that 60 percent of Medicare beneficiaries receiving mental health 
services received them through telehealth between March 17th and June 
13, 2020. We will continue to monitor utilization of telehealth 
services, including mental and behavioral health services, as part of 
---------------------------------------------------------------------------
our ongoing work examining Medicare telehealth waivers.

                                 ______
                                 
      Prepared Statement of Narayana Murali, M.D., Board Member, 
 America's Physician Groups; and Executive Director, Marshfield Clinic
    Good morning, Chairman Wyden, Ranking Member Crapo, and members of 
the committee. My name is Dr. Narayana Murali, and I serve as the 
executive vice president of care delivery and chief strategy officer of 
the Marshfield Clinic Health System. I also serve as the executive 
director of Marshfield Clinic, headquartered in Marshfield, WI. It is 
my honor to be here today to discuss this important topic.

    It is my privilege to testify on behalf of America's Physician 
Groups and myself. APG is a national professional association 
representing over 300 physician groups that employ or contract with 
approximately 195,000 physicians that provide care to nearly 45 million 
patients. It is the vision of APG's member organizations to transition 
from the fee-for-service (FFS) reimbursement system to a value-based 
system where physician groups are held accountable for the cost and 
quality of care they provide to their patients. APG's preferred model 
of capitated, delegated, and coordinated care, eliminates incentives 
for waste associated with Fee for Service reimbursement. I am here to 
make the case for permanently supporting the telehealth flexibilities 
created in during the PHE, with some refinements.

    Since the outset of the pandemic, APG members in all 50 States have 
risen to the challenge presented by COVID-19. Our members have been at 
the forefront of caring for patients, as well as the communities we 
serve from coast to coast. The challenges have been immense, and the 
risks associated with COVID-19 remain serious today. However, the 
lessons and experiences we have gained--as difficult as it has been at 
times--can serve as opportunities to embrace changes, so we can 
continually improve services we provide to our patients and 
communities. This is especially true when it comes to the waivers and 
flexibilities made available to address the Nation's current public 
health emergency (PHE). The widespread adoption and utilization of 
telehealth services in a variety of health-care settings have been 
lifelines to patients, ensuring access and continuity of care during 
some of the darkest days of the pandemic when alternatives were non-
existent. This is particularly true for those physician groups that 
have moved away from FFS (where earnings are tied to volume of services 
rendered) and are participating in models of care where the provider 
takes partial or full financial risk for quality, outcomes and total 
cost of care (degree of risk may be shared with a health plan or fully 
absorbed by the provider--globally capitated contracts).

    I joined the Marshfield Clinic in 2006 as a nephrologist, having 
practiced and furthered my education in India, Australia, and the 
United States. I did an internal medicine residency at Mayo School of 
Graduate Medical Education, a National Institutes of Health-sponsored 
Clinician Investigator Training Program and fellowship in kidney 
disease at the Mayo Clinic College of Medicine, Rochester, MN. I serve 
as the prime site principal investigator of the Wisconsin Consortium 
for the All of Us Research Program, a historic effort to gather data 
from one million or more people living in the United States to 
accelerate research, improve health, and deliver precision medicine. In 
addition, I serve as the secretary of American Physicians Group, the 
vice chair of the governing council of the Integrated Physician and 
Practice Section of the American Medical Association, and on several 
other not-for-profit boards. As a physician with decades of experience 
treating patients and navigating the health-care system, I would like 
to especially commend Congress and the various relevant Federal 
agencies for their efforts to address the struggles health-care 
providers and organizations have alike faced during the COVID-19 
pandemic. Yes, we have all come a long way and yet much work remains to 
be done.

    Marshfield Clinic Health System (MCHS), which Marshfield Clinic is 
a part of, is an integrated health system serving northern, central, 
and western Wisconsin. We are one of the Nation's largest fully 
integrated systems serving a predominantly rural population. Our 1,400 
physicians and providers accommodate 3.5 million patient encounters 
each year across our 10 hospitals and over 60 ambulatory clinical 
sites. Our primary service area encompasses over 80 percent of the 
rural population of the State of Wisconsin. In fact, over half of our 
60+ facilities are located in communities of less than 2,000 people. We 
are the largest provider of primary and specialty care in our region. 
As stewards of our communities and to what we call home along with our 
patients, we have been committed to community engagement activities 
that support the rural and underserved communities. We are a teaching 
health system, providing over 1,300 students with over 2,300 
educational experiences throughout our system. The Marshfield Clinic 
Research Institute is the largest not for profit, private medical 
research institute in Wisconsin with more than 30 Ph.D. and M.D. 
scientists and 150 physicians engaged in medical research.

    As a fully integrated health system, MCHS has a rich legacy of over 
104 years and a long history of providing accessible, affordable and 
high quality, compassionate health care. A third of the counties we 
serve have less than two workers per Medicare beneficiary, and our 
patients are older, sicker and poorer than average in the State of 
Wisconsin and the Nation. Forty-two percent of the children in our 
primary service area are eligible for reduced or free school lunches.

    Telehealth at MCHS did not have its genesis in the pandemic. It has 
been a foundational element in our clinical delivery of care for rural 
Wisconsin. In fact, we have used telehealth services since 1997, and it 
has become an important resource to care for patients in often remote 
and distant locations throughout our service area, which is 
approximately 45,000 square miles, just bigger than the State of Maine. 
In 2019, by our estimates use of telehealth saved our patients over 1.2 
million driving miles. For older and sicker patients who cannot 
transport themselves, this is very impactful. To this, add the 
inclement weather and the challenges of harsh and cold winters. 
Additionally, in rural areas few, if any, public transportation systems 
serve as safety net for our patients. A critical lever we have 
leveraged to manage the cost of care for our patients and communities 
is our full risk, globally capitated arrangements with our not for 
profit Security Health Plan, and other models of risk based 
arrangements with payers in the private and governmental markets. 
Capitated arrangements have allowed us to innovate, invest and 
implement effective systems of care for our patients while also passing 
on the benefits in terms of lower premiums and additional benefits such 
as hearing aids and spectacles. These programs have improved outcomes, 
reduced costs and waste, and ensured high-quality and accessible health 
care. Presently, Marshfield serves 68,224 patients in a globally 
capitated, full risk arrangement. We also serve another 51,131 patients 
on value-based contracts.

    Relying on the knowledge gleaned from our several decades' long 
history of utilizing telehealth services in our clinical care models, 
and our present experience of responding to COVID-19, I would like to 
share the following perspectives and substantiate why these are 
relevant for your consideration.

    1.  Telehealth adoption has increased exponentially. With the 
Federal waivers and commercial insurance coverage expansion during the 
PHE, almost 20 percent of ambulatory care can be safely provided 
through telehealth.
    2.  Expanded utilization of telehealth by baby boomers and senior 
citizens has resulted in improved patient access, increased 
convenience, and appropriate care albeit with less than robust, 
integrated platforms. Creating such platforms within the framework of 
existing health care and EHR systems can reduce overall cost of health 
care.
    3.  Blanket telehealth waivers issued in response to the pandemic 
have enabled the industry to continue its population health and health 
promotion initiatives and provide innovative programs such as Hospital 
Without Walls.

    As we look forward to the next phases of the pandemic response and 
the return to whatever our new paradigm will be, embracing telehealth 
and stopping its backslide is critical. I urge you and your colleagues 
to fully support and implement effective and responsible policy that 
ensures continued accessibility to high-quality telehealth services 
that benefits patients, and their overall health.
  patient behavior and preferences, an mchs snapshot, and an apg view
    Since COVID 19, patient preferences on how they choose to engage 
with physicians and Health systems has forever changed. In MCHS, we 
serve around 100,000 outpatients a month with some cyclical drop in 
Wisconsin winters. Those appointments have declined to about 90,000 
outpatients a month during the PHE. In entire year of 2019, we 
registered about 12,500 telehealth encounters, with about 200 
clinicians providing telehealth services in any given month.

    In 2020, across all demographies, telehealth visits skyrocketed 
from a pre-pandemic average of about 2 percent of visits a month, by 
21-fold in April 2020. Within 4 weeks of the pandemic, MCHS was 
averaging 3,000 telehealth visits per week, and by week 8, we were 
delivering over 6,500 telehealth and phone care visits per week. During 
the time our centers were closed, telehealth and phone care services 
were able to provide access to 22 percent of our normally expected 
patient volume. Overall, in 2020, MCHS provided 240,000 telehealth and 
telephone encounters. All 1,400 physicians have been trained to provide 
this service.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    In the last 4 months, telehealth visits have plateaued to an 
average of 15.5 percent. In certain specialties, such as Behavioral 
health, 30 to 32 percent of our patients use telehealth or ``phone 
only'' visits.

    In discussions with my APG colleagues and several health system 
leaders across the nations, we all agree there has been a decline in 
telehealth numbers. Observational evidence suggests this 15-16 percent 
fraction of ``telehealth and phone visits'' over all appointments per 
month are a reflection of a new steady state for consumer behavior 
across the Nation. Baby boomers have increasingly adopted telehealth 
visits, as have many of our octogenarian parents.
       patient experience, loyalty, and direct-to-consumer models
    Patients seem to be willing to switch to telehealth as tolerance to 
waiting for appointments decreases. With increased access to convenient 
care, patient satisfaction in the care they receive from their 
physicians has also increased. In a survey of our patient population, 
Marshfield Clinic found that 68 percent of respondents reported being 
``highly satisfied'' or ``satisfied'' with their virtual visit. The 
most common reason given by patients for frustration with their 
telehealth visit was poor quality of Internet connection.

    Removal of geographic site origination and other burdensome 
regulatory burden would improve access to care. Our child psychologist 
in Lake Hallie, WI had to move to Colorado because of family 
commitments. With the low availability of skilled providers to cover 
these patients we worked with the State of Wisconsin for approval of 
telehealth services and invested in a telehealth room in Lake Hallie. 
Patients were offered the option to continue or switch to new provider. 
In two years, only one patient opted for a different provider. He sees 
about 1,200 encounters annually.
               digital divide (lack of broadband access)
    Phone-only telehealth services have been critical to delivering 
health care to the underserved, rural, and racial minorities. Even a 
year into the pandemic, meeting the regulatory expectations of audio-
video visits for risk adjustment in rural Wisconsin has been 
challenging. In April 2021, 57.6 percent of the 12,299 telehealth/phone 
patient appointments used ``phone only'' care. Our patients, who are 
old, have chronic illness sit in the parking lots of our schools and 
clinics to access broadband Wi-Fi that they lack at home for telehealth 
services. It is sad how little we, as one of the most developed nations 
in the world, are able to support our old, poor, needy and sick.

    According to the Federal Communications Commission, 19 million 
Americans lack access to fixed broadband service at threshold speeds--
and 14.5 million of those residents are reside in rural settings.\1\ 
According to one study, during the pandemic, Federally Qualified Health 
Center audio-only (``phone'') visits accounted for 65.4 percent for all 
primary care visits and 71.6 percent of behavior health visits.\2\ 
Centers for Medicare and Medicaid Services (CMS) estimates up to 30 
percent of visits during the pandemic have been audio-only.\3\ Rural 
residents should not be disadvantaged in accessing telehealth just 
because of where they live.
---------------------------------------------------------------------------
    \1\ https://www.fcc.gov/reports-research/reports/broadband-
progress-reports/eighth-broadband-progress-report.
    \2\ Uscher-Pines L, et al. ``Telehealth Use Among Safety-Net 
Organizations in California During the COVID-19 Pandemic.'' JAMA. 
2021;325(11):1106-1107.
    \3\ Verma, S. ``Early Impact of CMS Expansion of Medicare 
Telehealth During COVID-19.'' Health Affairs Blog 2020. https://
www.healthaffairs.org/do/10.1377/hblog20200715.454789/full/.
---------------------------------------------------------------------------
             travel for health care and its economic impact
    The economic impact on patient families of saved miles and time 
cannot be lost upon us. Our three pediatric neurologists are the only 
physicians with the subspecialty skills to see complicated neurological 
patients across a 45,000 square mile service area. In order for a child 
with well controlled epilepsy, the parent or parents are compelled to 
take time off from work, often for a whole day, all for a 30-minute 
physician visit that can be done over telehealth or telephone. This is 
a wasteful exercise of time, money, and resources. This child is an 
example of the 20 percent of medical care that is well suited for 
virtual care.

    Other such visits that are well suited for telehealth include 
follow-up visits, tele-dermatology, provider-to-provider consulting in 
subspecialty care, second opinions for highly specialized counseling, 
and radiology opinions. The benefits of reducing unnecessary travel, 
lost days of production for the family, and improved access to care 
along with downstream reduction in urgent and emergency care 
utilization are all important drivers of reducing cost of care and 
improving patient experience.

       geographic limitation and improving access to appropriate 
                      healthcare in rural america
    Overcoming geographic isolation through telehealth in rural America 
has critical relevance. There is limited access to public 
transportation, and long drive times to avail medical care. This is 
further compounded in winter when the roads are treacherous with black 
ice or travel is blinded by blowing winds and snow.

    A story that tugs at my heart is that of a 67-year-old diabetic 
woman who traveled 200 miles to see me, four times a year to titrate 
medications and optimize her health. In 2007, MCHS provided me the 
ability to provide virtual care, do a heart and lung and physical exam 
over video, review her vital signs with the assistance of a nurse, 
review her lab tests and arrange for diuretic infusions when her heart 
failure worsened. For 13 years, every year she has sent me a Christmas 
card and even now, when I no longer see her.
          incent investments for increased physician adoption
    In the wake of the pandemic, physicians have rapidly adapted to the 
new paradigm of care. The additional waivers and regulatory changes 
surrounding telehealth services have been vital in creating pathways 
for organizations facing financial peril to be creative and expand 
access to care.

    The present state involves working simultaneously with an 
electronic health record (EHR), a video platform, and a chat function 
with their medical teams to coordinate scheduling, lab tests and 
diagnostics, educating patients how to switch on their cameras, 
educating themselves in performing a good virtual physical exam and 
good ``web-side'' manners.

    Substantial investments in infrastructure are needed to ensure 
physicians can provide high quality, cost-effective, increased access 
to care through telehealth services. As patients become increasingly 
adroit with technology and physicians with telehealth workflows, access 
to critically needed services such as behavioral health, primary, and 
specialty care would also increase.
                        acute care without walls
    Since 2016, MCHS has provided, hospital-level care in patients' 
homes through use of telehealth, in-home nursing visits, and virtual 
visits by hospitalists. We treat over 100 acute care conditions such as 
asthma, congestive heart failure, pneumonia and chronic obstructive 
pulmonary disease (COPD) safely at home with proper monitoring and 
treatment protocols.\4\
---------------------------------------------------------------------------
    \4\ Centers for Medicare and Medicaid Services. (2020, November 
25). CMS Announces Comprehensive Strategy to Enhance Hospital Capacity 
Amid COVID-19 Surge [press release]. Retrieved from: https://
www.cms.gov/newsroom/press-releases/cms-announces-comprehensive-
strategy-enhance-hospital-capacity-amid-covid-19-surge.

    Our research highlighted in the August 15, 2019, New England 
Journal of Medicine Catalyst \5\ and those of others have demonstrated 
high rates of patient satisfaction and improved outcomes, and 
meaningful reductions in costs. As an author of this study, I will be 
the first to admit that the best place for a patient to recover is 
where they are most comfortable--and that is not in a hospital room in 
many instances.
---------------------------------------------------------------------------
    \5\ NEJM Catalyst, ``No Place Like Home: Bringing Inpatient Care to 
the Patient,'' Narayana Murali and Travis Messina. https://
catalyst.nejm.org/no-place-home-recovery-care.

        Our patients had 44 percent fewer 30-day readmissions, and a 
50-percent reduction in emergency department visits than Security 
Health Plan members within the same group of DRGs who were treated in 
the hospital.
        HRC patients had 37 percent shorter length of stay, compared 
with historical data from SHP members within our diagnosis-related 
groups. (Length of stay for HRC patients was measured as number of days 
in the ``acute'' phase.)
        Patient satisfaction was greater than 90 percent, based on the 
number of top-box responses for all questions administered via the HRC 
program patient satisfaction survey.
        The health plan saved approximately 15-30 percent per episode, 
when compared to our historical baseline costs.

    In late 2020, MCHS with bipartisan support from the congressional 
delegation that represents our service territory was granted a Section 
1135 waiver from CMS to more broadly implement the Acute Hospital Care 
at Home program. MCHS, was one of the first nine, health-care 
institutions in the country granted this waiver by CMS. MCHS was 
approved four hospital sites by CMS for Acute Care at Home, during the 
COVID pandemic. This waiver allowed us to expand our Hospital at Home, 
and has increased our capacity for the care of patients during the 
COVID-19 pandemic, providing greater flexibility and reducing the 
burden on providers caring for the most acutely sick patients.
                            recommendations
    In response to the committee's request, below are our 
recommendations.
I. Allow Acute Care Without Walls flexibilities to extend beyond the 
        PHE waiver
    Even in rural areas, this model has successfully improved access 
and outcomes. While the CMS allowed a blanket waiver to permit the 
expanded use of this program for the duration of the PHE, we continue 
to gain data and experience to improve the program. We hope and 
strongly urge that Congress recognize the success of these programs, 
and ensure these programs can continue to grow and increase access 
beyond the PHE.
II. Eliminate origination site and geographic limitations
    a.  These limitations are outdated based on our experience with the 
present waivers and can no longer be justified as guard rails to 
protect against fraud, waste, and abuse.
    b.  By creating certainty that telehealth will continue to be 
reimbursed by Federal health-care programs, Congress will give 
providers the certainty they need, to invest in the technology 
infrastructure, software and practice redesigns necessary to make 
telehealth part of their standard business operations. A lack of 
certainty could create new disparities among providers, and result in 
uneven access for patients.
III. Support and ensure access to reliable broadband
    It is imperative to invest in broadband technology to close the 
digital divide and ensure living in rural communities is not a barrier 
to accessing telehealth.
IV. Allow phone-only telehealth services for Medicare Advantage risk 
        adjustment until we overcome the challenges of Internet access
    The disparities in broadband access are exacerbated in rural, 
underserved and minorities. In fact, over half of our telehealth visits 
with our patients have been phone-only because of limited access to 
broadband, smart phones, or tablets. Medicare Advantage has allowed 
both audio and audio/video telehealth services. Audio-only (phone) has 
not been allowed for risk adjustment, which impairs appropriate funding 
for health-care delivery to the most vulnerable--an impact that will 
ultimately affect future Medicare member benefits and premium, given 
restrictions to formally document real risks is not true reflection of 
no risk. Our APG members agree that barriers that discourage patient 
participation through phone, when access to broadband is unavailable, 
prevent patients from receiving necessary care, and ultimately expose 
organizations that are in the capitated, value-based models to greater 
financial peril.
V. Ensure payment parity
    In order to guarantee that clinicians and systems have the 
appropriate incentives to invest in telehealth services and 
capabilities, Congress must ensure payment parity between in-person and 
virtual visits. Allowing for expanded telehealth without the guarantee 
of payment parity will create another barrier to adoption, limit 
overall uptake by providers, and stagnate access to this important 
treatment mechanism for patients. Congressional action on this front 
will also send an important message to commercial payers to guarantee 
parity across insurance markets.
VI. Reduce administrative burden on providers
    First off, every effort possible should be made to harmonize 
statutes and regulations at the Federal, State, and local levels to 
promote the continued adoption and utilization of telehealth. For 
example, Congress should explore the establishment of a form of blanket 
patient consent to facilitate the provider connecting with them via the 
2-way video method that the patient is most comfortable with. Congress 
must also work in concert with the Department of Health and Human 
Services and the Centers for Medicare and Medicaid Services to reduce 
burdensome regulations that inhibit the expansion of telehealth to 
smaller physician practices that reduce the ability of clinicians to 
focus on their most important task: serving their patients.
VII. Protect patient data while fostering innovation and access
    As patient satisfaction rises with the increased usage of 
telehealth services, creating a care environment that best serves 
patients and their needs is paramount. HIPAA waivers have been helpful 
in providing care and allowing patients (senior patients especially) to 
use compliant platforms they are familiar with. However, I am aware 
that some of these non-HIPAA compliant applications and platforms may 
compromise security and thus, it will be important to weigh the 
benefits of expanding access via the use of consumer-based technology 
versus potential privacy and security risks. All payers should be 
encouraged to align payment policies and coding requirements in order 
to ensure a seamless system of care that works in a coordinated manner 
across all providers and organizations.
VIII. Support integrating telehealth in EHR platforms
    Congress should consider supporting regulations and incentives for 
integrating telehealth in Electronic Health Record Platforms.

    I would again like to thank Chairman Wyden, Ranking Member Crapo, 
and the rest of the committee for granting me this opportunity to share 
these observations and recommendations with you during this hearing. We 
look forward to continuing to work with you on this very important 
issue and advancing America's health-care system.

                                 ______
                                 
      Questions Submitted for the Record to Narayana Murali, M.D.
              Questions Submitted by Hon. Thomas R. Carper
    Question. During the pandemic, telehealth has been an essential 
tool to get children the care that they need while minimizing risk. 
Although telehealth under Medicare has been a focus, close to 40 
million children are enrolled in Medicaid.

    What are the main policy changes we need to ensure this broader use 
of telehealth can be continued beyond the pandemic for children?

    Answer. Thank you for your question. You are right that while the 
focus of much our discussion centers around issues related to Medicare, 
we must focus on ensuring patients' access to telehealth services no 
matter what type of insurance coverage they use. When it comes to 
Medicaid, there are particular rules pertaining to what services can be 
provided, and by what type of provider. As telehealth becomes more 
ubiquitous in the delivery of care, Medicaid coverage of telehealth 
services should grow as well. A patient's access to telehealth should 
not be based on what type of insurance coverage they have. This 
includes the expansion of the CPT codes where telehealth is an option 
for Medicaid enrollees, both in managed care and traditional fee-for-
service reimbursement arrangements.

    There are also a number of State-level issues that will have to be 
addressed on a case-by-case basis. A good example of this was the 
passage of Wisconsin 2019 Act 56, which mandated parity in coverage for 
telehealth services for Medicaid enrollees.

    Additionally, patients must not be precluded from accessing 
telehealth due to lack of access to technology. This includes providing 
supports to ensure that individuals can use technology that allows for 
video visits, and that they have access to reliable Internet service. 
The truth of the matter is that while we take access to broadband 
coverage and smart phones for granted, many Americans, and especially 
those who rely on Medicaid, do not actually have access to these 
conveniences of every day life. Nineteen million Americans lack access 
to fixed broadband service at threshold speeds--and 14.5 million of 
those residents are reside in rural settings. And, many of our Medicaid 
patients cannot afford smart phones, or the service to use them. As a 
result, CMS should consider creating technology vouchers and reduced-
cost broadband as part of coverage, especially for chronic conditions.

    Question. During COVID-19, many States adopted temporary changes to 
their telehealth policies, such as expanding the scope of services and 
providers able to furnish telehealth, relaxing of licensure 
requirements and modifying reimbursement policies. Many States 
legislatures have also begun the work to adopt more permanent 
telehealth policy changes.

    How can the Federal Government best support State Medicaid programs 
in their efforts to expand telehealth?

    Answer. First and foremost, the Federal Government should continue 
to support the flexibilities to Medicaid programs that have been 
granted throughout the pandemic. While vaccinations are readily 
available and we are all trying to find ways to return to normal, we 
must realize that we are going to be dealing with the fallout of this 
pandemic for a very long time. As a result, States and Medicaid 
providers need time to recover from the pandemic and adequately prepare 
for the move away from the current flexibilities.

    CMS needs to develop and implement effective lines of 
communications with State Medicaid programs about future changes in the 
program. Furthermore, State Medicaid programs must undertake 
initiatives now to ensure that when the pandemic flexibilities expire 
that Medicaid enrollees are not all of a sudden unable to access 
telehealth services. This is an issue of equity and access.

    Further, providers need clarity about the scope and parameters of 
what is allowed under Medicaid when it comes to telehealth services so 
they can adequately plan and implement changes to their service models. 
Unnecessary and arbitrary obstacles to telehealth will serve as a 
disincentive to providers and patients, and result in missed 
opportunities to provide high-quality accessible health care, no matter 
the patient's coverage.

    Question. Are there Medicaid supports, incentives, and learnings 
that Federal policymakers could provide?

    Answer. Honestly, the ability to develop Medicaid programs that 
meet the unique needs of the patients we care for is the most important 
tool Federal lawmakers could provide. It is just a fact that the needs 
of patients in north central Wisconsin will be different than those of 
residents in Texas, Florida, or even Iowa for that matter. However, 
everything possible should be done to prevent arbitrary obstacles from 
getting in the way, like access to broadband and flexibility in how 
patients access care.

    Question. COVID-19 has introduced additional stress and trauma for 
children and families. Telehealth, and particularly audio-only 
telehealth has been a crucial tool to connect children and adolescents 
to needed mental health-care services.

    How can telehealth be best utilized to meet kids' mental health-
care needs, and can you speak to the use of audio-only telehealth 
specifically?

    Answer. Telehealth has the great potential to increase access and 
utilization of mental health services for children enrolled in 
Medicaid. This is something we must embrace. The pandemic has been 
catastrophic in terms of mental health for large segments of society, 
but especially children. Children in Medicaid have long been challenged 
to access mental/behavioral health services. For children in rural 
settings like Marshfield Clinic' service area, access is even more 
challenging because a lack of providers. However, throughout the 
pandemic we have been able to access care through video visits, and 
many instances through audio-only visits when they cannot take 
advantage of video visits. This has been an important tool to ensure 
access to vital mental health services, especially when children face 
serious mental health challenges resulting from the disruptions of the 
pandemic. Congress should ensure that CMS maintains the telehealth 
flexibilities that allow Medicaid enrollees, especially children the 
ability to access mental health services even after the end of the 
public health emergency.

    An important component to the delivery of this care is the use of 
audio-only visits. These visits routinely are the only way children can 
access mental health services in some rural areas that lack access to 
reliable broadband, or the patients and their families may not have 
access to video-enabled phones/computers. Additionally, audio-only 
visits help maintain regular and consistent engagement between patient 
and provider. And, phone-only visits are also great tools for check-ups 
in between regular appointments, especially in acute situations.

    Question. As State Medicaid programs look at expanding their use of 
telehealth, it is particularly important that vulnerable populations 
like children are not negatively impacted. Policies must be looked at 
through a health equity lens, considering access to reliable and 
affordable broadband services, access to devices that support HIPAA-
compliant telehealth platforms and coverage policies.

    How can Medicaid programs work to ensure telehealth policies are 
equitable for children and mitigate potential inequities that may 
arise?

    Answer. You concern about the expansion of telehealth services 
exacerbating health disparities is certainly valid. First and foremost, 
we must remember that telehealth is best integrated into a full 
spectrum of services available to all patients, based on their needs 
and unique circumstances in consultation with their medical provider. 
An individual should not be precluded from a particular care because of 
their type of insurance coverage.

    Medicaid programs must make efforts to ensure that access to 
reliable broadband is not an obstacle to accessing telehealth services. 
This is not just the issue of having broadband available. It also means 
being able to afford broadband. Broadband services, no matter whether a 
patient lives in a rural, urban or even suburban setting can be 
expensive. Affordability must be taken into account. Medicaid could 
consider providing broadband subsidies for enrollees, especially 
children because of the added value of supporting their educational 
pursuits, just like transportation subsidies.

    And, continuing to allow for phone-only will be an important bridge 
to ensure care is accessible, no matter the circumstances of the 
patient. In the end, it will always be necessary for a provider to make 
the final decision on the best way to treat their patient, but they 
should not be precluded because of arbitrary obstacles like access to 
smart technology like phones or tablets, or broadband access.

                                 ______
                                 
             Questions Submitted by Hon. Benjamin L. Cardin
    Question. We have seen licensure limits substantially restrict 
access to cross-State medical care during this unprecedented COVID-19 
emergency period. To maximize the utility of telehealth options and 
ensure provider accountability, some experts have suggested that States 
should do more to ensure mutual licensing reciprocity in the post-
pandemic environment.

    I am a cosponsor of Senator Murphy's Temporary Reciprocity to 
Ensure Access to Treatment Act (TREAT Act, S. 168/H.R. 708)--a narrowly 
tailored bill to enable providers licensed in good standing in one 
State to treat patients in any State for the duration of the COVID-19 
Public Health Emergency.

    How have health systems and patients benefited from State licensing 
reciprocity during the COVID19 public health emergency?

    Answer. You are certainly correct that State licensing reciprocity 
was an important tool to ensure access during the height of the 
pandemic. The greatest benefit was in patients being able to access 
high-quality care without unnecessary delays or obstacles.

    This reciprocity was especially important for rural providers such 
as Marshfield Clinic Health System. Our model is to bring as much care 
as close to home as possible for our patients. However, as a rural 
provider, recruiting and retaining talent can be difficult. According 
to a recent study, less than 5 percent of current medical students want 
to practice care in a town smaller than 50,000 people.

    During the pandemic, we were able to use licensing reciprocity to 
engage physicians in high-demand/need areas more quickly via 
telehealth, and to bring in necessary staff to bridge gaps in coverage. 
A perfect example of this is during a significant surge of COVID-19 
patients in the Midwest, we were able to secure staffing support from 
the Federal Emergency Management Administration and the U.S. Department 
of Defense. The staff that was assigned to our facilities were able to 
expedite their licensure through reciprocity flexibility. This meant 
they were not delayed in getting into clinical settings where they 
could provide much need support and relief to our permanent staff.

    Workforce is a major issue at all levels for rural medical 
providers, and reciprocity was an important tool we could use to take 
care of our patients. And to be frank with you all, after the harrowing 
last year and a half, I suspect that the health-care sector is going to 
be dealing with long-term staffing challenges. This will necessitate us 
to be creative and nimble in developing solutions that are not always 
easy, or quick. Continued reciprocity flexibility will help us recruit 
and on-board staff at multiple levels that could lead to delays in 
patient care.

    Question. I recently reintroduced the Home Health Emergency Access 
to Telehealth (HEAT) Act with Senators Collins and Shaheen. This bill 
would allow Medicare home health providers to be reimbursed for the 
telehealth services during a public health emergency. I also have heard 
from other home-based care providers, like hospice and palliative care 
as well as home-based primary care about the importance of telehealth 
during the emergency and into the future as services in the home and 
community continue to grow.

    Could you talk about your experiences using telehealth to 
supplement care for the populations you take care of?

    Answer. Telehealth at MCHS did not have its genesis in the 
pandemic. It has been a foundational element in our clinical delivery 
of care for rural Wisconsin. In fact, we have used telehealth services 
since 1997, and it has become an important resource to care for 
patients in often remote and distant locations throughout our service 
area, which is approximately 45,000 square miles, just bigger than the 
State of Maine. In 2019, by our estimates use of telehealth saved our 
patients over 1.2 million driving miles. For older and sicker patients 
who cannot transport themselves, this is very impactful. To this, add 
the inclement weather and the challenges of harsh and cold winters. 
Additionally, in rural areas few, if any, public transportation systems 
serve as safety net for our patients.

    During the peak of COVID, we converted about 35 percent of our out-
patient visits to telehealth visits, about 6,000 visits per week. And 
we leveraged the flexibilities granted by CMS to provide as much care 
as possible remotely, including inpatient level care of patients at 
home, mental and behavioral health services, rehabilitation and 
physical therapy services and even chronic care management to just to 
name some of the categories of care we transition to virtual platforms. 
Anecdotally, patients have had positive experiences and come to realize 
that the best place to heal or recuperate is their own home, not in a 
hospital bed. It has also been a chance for us as a system to 
reevaluate some of the services we provide and think more creatively. 
And, as a physician myself, I will admit that the pandemic forced many 
providers to reevaluate their preconceptions about what they could do 
via telehealth and what they have to do as part of an in-person 
clinical visit. It will take time to fully adjust our clinical approach 
and our operations as a health-care system. But telehealth is here to 
stay and has the chance to make a huge positive difference in the lives 
of our patients.

    Palliative care and hospice care are some of our most sacred duties 
as physicians to our patients and their loved ones. Even before the 
COVID-19 pandemic, MCHS was committed to using new models of care to 
provide comfort and support to patients throughout their care journey. 
Our model of home-based care, Home Recovery, has been deployed to 
assist patients in these circumstances. This is especially important in 
rural areas where palliative care and hospice facilities are less 
common. Additionally, because of longer distances between home and 
facility, virtual care cuts down on the stress to the patient, as well 
as burdens to their families/caregivers. And virtual care in these 
settings routinely allows for more fulsome discussion with families and 
the patients about their wishes, and gives greater peace to all 
involved.

    Continuing to allow for these types of services through telehealth 
and other virtual platforms will go a long way to ensuring all patients 
can go through this type of care with dignity. For the last 3 years 
MCHS has been at the forefront of delivering a large spectrum of 
services that are traditionally only offered as inpatient services to 
our patients in the comfort of their home. This experience has 
demonstrated that patients routinely prefer to be at home, and that 
outcomes at home are usually much better than in a hospital setting. 
That is because patients are most comfortable where they live. We 
should continue to expand on the opportunity to bring care to the homes 
of patients leveraging technology and telehealth, and when that is not 
possible to deliver it close to home at the best facility for the 
patient and their families. That will make a difference in the 
experience for all involved, the patient, their family and the 
provider.It is an exciting potential, and one that we should all work 
together to realize in the coming months and years.

    The number one barrier during this time was lack of technology in 
people homes and lack of sufficient broadband. About 65 percent of our 
telehealth visits during COVID were audio-only, underscoring both the 
importance of phone care continuing to maintain access to patients as 
well as the need to continue advancing broadband expansion. Congress 
must also do everything to ensure that a person's health-care coverage 
does not dictate the type of care they receive. There must be parity 
when it comes to access to telehealth services.

    Question. What lessons from the pandemic would you like to see 
brought forward into the future of care for home health, hospice, 
palliative, and other home-based care providers?

    Answer. Telehealth has the ability to improve outcomes, increase 
access and satisfaction for patients in all settings, and reduce 
health-care disparities. Some of the most important lessons gleaned 
confirmed long-held ideas about the potential of telehealth to improve 
the care we provide our patients.

    Telehealth can increase access, improve outcomes and patient 
satisfaction. Keep in mind, the cost of health care is not limited to 
the bill from a doctors' office. Patients often take time off of work, 
often unpaid, to drive up to 3 hours to receive care. Telehealth can 
increase access by allowing patient to present closer to home and this 
reduces their cost of accessing care.

    Telehealth has an important role to play in a comprehensive 
approach to care delivery, especially as we promote the move from 
volume to value. More frequent low-acuity contact with your provider is 
better than less frequent high-acuity contact. And, telehealth can be 
integrated to comprehensive care that includes auxiliary services like 
case management, physical or occupational therapy and even palliative 
care.

    Telehealth should continue to be an option for all patients, 
regardless of their location or the type of insurance they have. The 
site of service and geographic limitations that have been the hallmark 
of telehealth reimbursement policy in Medicare are outdated. They do 
not serve the best interests of the patients or the programs. While it 
is important to come up with a comprehensive system to monitor and 
track utilization of telehealth services, arbitrary limits will cause 
us to regress from the progress we have made. The ones that will 
ultimately pay the price for that lack of foresight will not be 
decision-makers, but instead patients and their loved ones.

                                 ______
                                 
               Questions Submitted by Hon. Chuck Grassley
    Question. Throughout the public health emergency, the Centers for 
Medicare and Medicaid Services (CMS) issued over 200 waivers under 
Medicare and approved more than 600 waivers and other flexibilities 
under Medicaid. While some of the regulations waived are specifically 
for responding to a pandemic, ensuring patient safety, controlling 
costs, and maintaining program integrity its clear innovation and 
common sense ideas in our health-care system have been stifled too 
often by Federal regulations. For example, CMS permanently added 
certain new services (including mental health and care planning 
services) that it had temporarily added to the approved list of 
Medicare telehealth services during the pandemic. Some regulations play 
an important role in protecting safety and maintaining program 
integrity but others may stifle good ideas.

    Is health care too regulated that it's stifling good ideas?

    Answer. Health-care regulation is not keeping up with technology 
and science. As a result, patients and providers are stuck in a system 
that is behind the times and not adequately harnessing all the 
innovation that is occurring throughout health care. And we are missing 
out on taking advantage of the potential fields like artificial 
intelligence and data analytics have to deliver new and improved care 
to our patients and communities.

    Good ideas are being brought to life each and every day. The real 
challenge is implementing them in a way that can have a meaningful 
impact on patients and their health-care providers, and the health 
system in general in any timely and useful way. A perfect example of 
this has been the long-time desire to promote a health-care system 
where value is rewarded over pure volume. This catch-phrase has 
seemingly been around for decades. But, it is hard to say we are much 
further along our journey from volume to value than when we started.

    For decades, American Physicians Group has been promoting capitated 
care. This model has been demonstrated to be in the best interests of 
providers, payers and patients. Experience during the pandemic has born 
this out. As decreased volumes imperiled providers reliant on fee-for-
service revenues, while many providers in capitated arrangements were 
able to manage the ups and downs more effectively.

    Regulatory frameworks should not be focused on what is allowed or 
not allowed. Instead, it should be focused on giving practitioners 
guidelines to achieve a shared goal like promoting value-based care, 
and then allow stakeholders (including providers, payers, technologists 
and leaders) the ability to create systems that they think will work 
best for their patients and communities.

    It is hard to imagine creating a universal health-care model that 
works as effectively in Marshfield, WI as it would in Laredo, TX, New 
York City, or even Manhattan, KS. We should be focusing on creating a 
regulatory system that lets providers tailor a system to the needs of 
their patients and communities, and promotes utilizing the best 
available technology and data to promote a culture of health and well-
being.

    Question. Should executive agencies sunset regulations in the 
future to enable more innovation in health care?

    Answer. The current health-care regulatory framework is a hindrance 
to the development and implementation of innovative models of care. We 
should reorient our approach to the regulatory system. Instead of 
overly prescriptive, or restrictive, regulations that do nothing to 
advance a culture of health, we should create a framework that allows 
providers, innovators and patients the power to create systems that are 
functional and effective in delivering care for all patients.

    When health-care leaders are conceptualizing new models of care and 
implementing new technology for their patients, they look for 
certainty. They need to know that what they are envisioning will be 
permitted well into the future. Potentially sunsetting, or requiring 
regulations to be renewed, could actually have the unintended 
consequence of creating uncertainty and cool the embrace of new 
technology and methods. Of the 18,000 or so regulations defined in the 
Code of Federal Regulations, sunsetting all regulations (SUNSET rule 
published in the Federal Register on November 4, 2020, 85 Fed. Reg. 
70096) without adequate review by the impacted stakeholders would 
likely have far-reaching economic impact and even greater impact on the 
ability to provide care due to regulatory uncertainty it will create 
for insurance providers and patients. During the pandemic, it would 
divert vital resources from HHS, away from providing needed support at 
the worst of times. Therefore while there are regulations that need 
change, the how, what, and when matters so as not to throw out the baby 
with the bath water. Instead of automatically sunsetting regulations, 
agency leadership should reframe how they construct proposed 
regulations and regulatory guidance to foster innovation.

    Unnecessary or overly burdensome regulations certainly need to be 
addressed. The experience we have had during the pandemic when 
regulatory flexibility was exercised appropriately is a great 
illustration. The quality of care a patient received did change from 
all indications, and these flexibilities allowed providers to think of 
new approaches to new and old problems. Creating an environment that 
fosters growth and innovation is imperative to improve the health and 
well-being of our patients and communities.

                                 ______
                                 
               Questions Submitted by Hon. John Barrasso
    Question. Before coming to the Senate, I had the privilege of 
practicing medicine in Wyoming. Rural health care faced challenges 
prior to the pandemic. In particular, we know since 2010 more than 135 
rural hospitals have closed.

    In the Senate, I am proud to help lead the bipartisan Rural Health 
Caucus. This group is committed to ensuring patients in rural America 
can get access to the care they need.

    Can you specifically discuss the changes in Federal health-care 
policy that you believe have helped rural providers the most during 
this pandemic?

    Answer. Thank you, Senator, for your focus on the important topic 
of how to support rural health-care providers. Even before the onset of 
the pandemic, rural health-care providers were struggling financially. 
This is the result of the unique challenges associated with delivering 
medical care to rural communities.

    By far, the expansion of telehealth services has made a huge 
difference for rural health-care providers. The suspension of 
geographic restrictions and site of service rules were a lifeline to 
patients during the darkest periods of the pandemic. When we had to 
curtail in-person care, telehealth became an important lifeline for our 
providers, and more importantly for our patients. For example, we went 
from doing about 200 telehealth visits per month before the beginning 
of the pandemic, to about 6000 visits per week in the spring of last 
year.

    And one of the most important lessons for providers and patients 
from the pandemic is the breadth and depth of services that can be 
provided via telehealth services. It is not just routine clinical 
visits, but behavior health and substance abuse support, physical 
therapy, pre-operative and post-operative appointments, and so much 
more. The expansion of the types of services allowed to be done through 
telehealth was vital to its broad acceptance at the outset of the 
pandemic, and even now.

    Furthermore, allowing audio-only telehealth visits was vital for a 
number of our patients, especially those in rural areas that do not 
have access to reliable broadband, or may not be comfortable with 
technology because of their age.

    Question. Can you please discuss any specific changes that Congress 
should consider to better support rural health-care providers?

    Answer. First and foremost, Congress must understand that the model 
to deliver care in rural areas is just plain different than those in 
more urban settings. As a result, as changes are made to the way 
reimbursement occurs, or rules about operations of facilities, the 
unique impacts on rural operations must be considered. And, it has to 
be acknowledged that the finances of rural health-care providers are 
routinely much more precarious than more populated areas. And, we have 
to understand that the population we serve is different as well. Rural 
residents on average are older, sicker, and poorer than their more 
urban counterparts. In some of the counties we serve, there are less 
than two workers per every Medicare beneficiary, so our payer mix is 
very different than a health system in suburban Washington, DC. Lastly, 
it should be remembered that access to care is an equity issue for 
rural residents as well. A person should not be limited in their 
medical options just because of where they choose to live.

    Achieving a high-functioning rural health-care ecosystem requires 
supporting and strengthening the programs that work well for rural 
residents. One such program is Rural Health Clinics. This program can 
help ensure access to care when otherwise it would not be economically 
feasible. However, recent changes to reimbursement at RHCs could 
restrict their growth moving forward, which is dangerous for rural 
communities. A new provision passed in December would cap reimbursement 
rates at newly created RHCs. This significant change came as a surprise 
to many in the rural health community, and has imperiled plans across 
the country to create RHCs in areas of significant medical need, 
including some of the areas we serve at MCHS.

    In the context of RHCs and telehealth, the long-standing limitation 
of providing telehealth services external to the RHC is overly 
burdensome and creates an unfair obstacle to accessing care. Before the 
waivers for COVID-19, a provider in an RHC could not connect to a 
facility outside of the RHC to render service. Clinicians would be 
required to use space specifically carved out of the RHC to have 
telehealth visits with outside clinicians. Further, restrictions on 
telehealth services at Federally Qualified Health Centers are 
unnecessary and again create an unjustifiable barrier to accessing care 
for those patients who rely on FQHCs for their care.

    Beyond these concrete examples, the issue of workforce is one of 
the most pressing for our system, and providers across the country. In 
the last 16 months, our front-line staff have truly embodied the 
moniker they were given as Healthcare Heroes. However, we are not 
facing challenges from burnout. And, this has to do with every level of 
employee, from frontline staff in the ICUs, to technologists and 
administrative staff who have been doing more than their fair share at 
work, while at the same time having to change their lives at home. This 
is a burgeoning problem that has no quick solution. Recruitment and 
retention in rural areas is always more difficult because of the unique 
circumstances of living in smaller communities, and the overall lack of 
a ready labor pool.

    Question. Prior to the pandemic, I introduced bipartisan 
legislation with Senator Tina Smith, which among other things, would 
allow Rural Health Clinics (RHCs) to provide more telehealth services.

    I was pleased that Congress through the CARES Act authorized both 
Rural Health Clinics and Federally Qualified Health Centers to furnish 
telehealth services to Medicare beneficiaries during the public health 
emergency.

    Can you discuss the importance of Rural Health Clinics and 
Federally Qualified Health Centers continuing to provide telehealth 
services after the public health emergency has ended?

    Answer. You are absolutely right to highlight the importance of 
RHCs and FQHCs in rural health care. For many rural communities that do 
not have a full hospital, RHCs and FQHCs are patients' only consistent 
connection to care. Every effort should be made to ensure that the 
restrictions to telehealth services at RHCs and FQHCs that were in 
place before the pandemic are not reinstated when the public health 
emergency ends. Otherwise, there will be an unfair difference in access 
based on where individuals access their care. This is wrong and 
unnecessary. Patients should be able to get the best care possible, no 
matter where they get their care, in consultation with their clinician.

    Question. My wife Bobbi and I are passionate about improving access 
to mental health services. This pandemic has clearly impacted the 
mental, as well as the physical health of our Nation.

    For people living in rural America, getting help from a mental 
health provider was challenging before the pandemic. This is why 
Senator Stabenow and I have long supported professional counselors and 
marriage and family therapists participating in Medicare. We believe 
that increasing the number of mental health providers able to care for 
our Nation's seniors is an important priority.

    Please discuss how telehealth has impacted the ability of patients 
to receive mental health services during the pandemic.

    Answer. The COVID-19 pandemic has demonstrated the importance of 
access to mental health services for all Americans, and the challenges 
that occur when we cannot meet those needs.

    A vast majority of behavioral health services are uniquely suited 
for telehealth. In fact, at MCHS, the behavioral health service line 
was the only group to experience an increase in volume in 2020. We saw 
an increase of approximately 20 percent in utilization and 
appointments. Further, we saw a decrease in no-show appointments, and 
greater adherence to a course of treatment. This is accentuated in 
rural areas where access to mental health services is more limited due 
to a dearth of providers, and because of the usually extra-long 
distances patients are sometimes required to travel to seek care.

    Telehealth has served as an important bridge to ensure patients 
have access to care, and as a way to address a chronic shortage of 
access to mental health services in rural areas. A case in point is 
research we have done about mental health and farmers. MCHS in 
partnership with the National Farm Medicine Center published an article 
in the Journal of Agromedicine in September 2020 after recognizing that 
we were seeing an increase in farmers receiving behavioral health 
services, a notoriously difficult population to engage in BH services, 
largely due to stigma. Farmers reported that not having to present in a 
facility where others were waiting in a waiting room was a significant 
reason they didn't previously request care.

    And I agree with you that we have to expand the types of providers 
eligible to provide mental health services in Medicare. Doing so will 
not only address access issues, but also ensure that patients can get 
the right type of care.

    Question. Can you please identify ways Congress can improve access 
to mental health services, including expanding the number of providers 
that can participate in Medicare?

    Answer. First and foremost, Congress must recognize that telehealth 
will continue to play a vital role to ensuring access to mental health 
services. It pales in comparison to the suffering many people have 
dealt with through this pandemic, but the emergence of telehealth as an 
important part of the continuum of care, especially in behavioral 
health, must be embraced and supported with the appropriate policy 
changes moving forward.

    Geographic restrictions and site of service regulations for 
behavioral health services in Medicare must be rescinded. The pandemic 
has shown that care can be effective care through telehealth and it 
should be available to all patients, no matter where they live and 
where they get their care.

    Furthermore, Congress can move forward with incentives for States 
to implement responsible and effective licensing rules that allow for 
delivery of telehealth services across State lines in selected fields, 
like mental health. This will mean that patients would have access to 
these important services no matter where they live. And, it would also 
fill in coverage gaps, especially in rural areas, where it is hard to 
recruit and retain trained mental health professionals. Lastly, it is 
important to ensure that there are a variety of providers eligible to 
provide services in the Medicare program, including licensed clinical 
social workers, family counselors and other non-physician providers.

    Question. I was interested in your testimony where you discussed 
the need to reduce the administrative burdens on health-care providers.

    I agree telehealth is transforming the way we are providing care. 
However, in Wyoming, most of our providers are part of smaller 
hospitals and practices. We need to make sure government regulation is 
not making it more difficult for these providers to serve their 
patients.

    Can you discuss specific ways Congress can reduce the 
administrative burden in providing care through telehealth?

    Answer. We must create an environment that supports delivery of 
high-quality care and does not unnecessarily burden patients or 
providers. As the use of telehealth continues to expand, CMS must 
simplify the process for coding and billing of telehealth services. 
Complexity will serve as a deterrent for providers and their offices to 
wholly embrace telehealth. Also, CMS should approach telehealth through 
the lens of maximizing the categories of providers eligible to provide 
care through telehealth services. This includes advanced practice 
clinicians, as well as medical students with appropriate supervision. 
The future of health care will include telehealth, and we are doing a 
disservice to patients and future clinicians if we fail to provide 
appropriate training in how to provide care in this medium.

    Further, CMS should ensure that there is parity for Medicaid 
enrollees when it comes to telehealth services. Providers and their 
staff should not have to sift through different regulations to 
understand what services a patient is eligible for based on their 
insurance coverage. We cannot allow a tiered system to emerge. And, we 
must figure out a framework that allows for appropriate care across 
borders, especially in high priority fields like behavioral health.

    Question. Wyoming has many passionate advocates supporting both 
hospice and palliative care. These folks are committed to ensuring 
patients have the highest quality of life and are able stay out of the 
hospital and with their families. This is why I help lead the 
bipartisan Comprehensive Care Caucus. Our mission is to improve both 
palliative and hospice care for patients.

    Answer. Palliative care and hospice care are some of our most 
sacred duties we have as physicians to our patients, and their loved 
ones. Even before the COVID-19 pandemic, MCHS was committed to using 
new models of care to provide comfort and support to patients 
throughout their care journey. Our model of home-based care, Home 
Recovery, has been deployed to assist patients in these circumstances. 
This is especially important in rural areas where palliative care and 
hospice facilities are less common. Additionally, because of longer 
distances between home and facility, virtual care cuts down on the 
stress to the patient, as well as burdens to their families/caregivers. 
And virtual care in these settings routinely allows for more fulsome 
discussion with families and the patients about their wishes, and gives 
greater peace to all involved.

    Continuing to allow for these types of services through telehealth 
and other virtual platforms will go a long way to ensuring all patients 
can go through this type of care with dignity. For the last 3 years 
MCHS has been at the forefront of delivering a large spectrum of 
services that are traditionally only offered as inpatient services to 
our patients in the comfort of their home. This experience has 
demonstrated that patients routinely prefer to be at home, and that 
outcomes at home are usually much better than in a hospital setting. 
That is because patients are most comfortable where they live.

    We should continue to expand on the opportunity to bring care to 
the homes of patients leveraging technology and telehealth, and when 
that is not possible to deliver it close to home at the best facility 
for the patient and their families. That will make a difference in the 
experience for all involved, the patient, their family and the 
provider. It is an exciting potential, and one that we should all work 
together to realize in the coming months and years. To achieve this 
grand goal, we must allow programs like the Hospital Without Walls and 
other flexibilities to remain intact and to establish new policies that 
promote home- based care. It will also be necessary to educate 
providers, payers, and patients about the best practices in delivering 
care this way, and how it benefits all parties involved.

                                 ______
                                 
                 Prepared Statement of Hon. Ron Wyden, 
                       a U.S. Senator From Oregon
    When COVID-19 hit, it was no longer safe to meet face to face, take 
a bus to the doctor's office, or even walk into the hospital for care. 
Congress, Federal agencies, and health-care providers had to act fast 
with bold changes to prevent a dramatic disruption of health care in 
America.

    This morning's hearing is an opportunity to talk about the changes 
that ought to stick around post-pandemic, and there's no better example 
than telehealth. Right at the top, I want to thank Senator Crapo for 
proposing a hearing on this vital topic, where there's a big 
opportunity for the two sides to work together.

    The telehealth challenge has always been about balancing the speed 
and efficiency of new technologies with the need for health-care 
quality and accountability. During the pandemic, some patients have 
felt like they had to jump through too many hoops to get access to 
telehealth. My view is, as a general proposition, patients ought to 
have telehealth available as an option after seeing a provider for the 
first time.

    In some cases, the right approach might be to give the green light 
for telehealth from the beginning. I hope today the committee is able 
to discuss how to go about striking that balance after a year of 
telehealth experience during the pandemic.

    Last year, in the CARES Act, Congress allowed health-care providers 
in Medicare to offer telehealth services to all seniors, regardless of 
whether they lived in the biggest city or the smallest rural town. That 
brought badly needed health-care safely into the homes of tens of 
millions of seniors nationwide.

    The CARES Act also allowed Federally Qualified Health Centers, 
including community health centers and Rural Health Clinics, to receive 
Medicare payment for telehealth services, allowing more health-care 
providers to help meet the overwhelming demand for remote health 
services.

    Fortunately, the Finance Committee had already paved the way for a 
lot of these changes, which means they were a lot easier to adopt. 
Telehealth has been a Finance Committee priority for years, 
particularly when it's part of the effort to update the Medicare 
guarantee.

    For many years, the Congress fell behind in terms of recognizing 
the transformation of this flagship health-care program. When the 
Medicare program was designed, it was built to cover acute conditions--
broken ankles under Medicare Part A, bouts of the flu under Part B. 
Modern-day Medicare is about cancer, diabetes, heart disease, and more 
of the chronic health conditions that are a lot more complicated and 
more expensive to treat. Telehealth is going to be a bigger part of 
that transformation going forward.

    The CHRONIC Care Act, passed by this committee in 2017, marked the 
very first time seniors could get telehealth at home for kidney 
disease. The law also made it easier to use telehealth to diagnose and 
treat strokes. It allowed more flexibility for Medicare Advantage plans 
and Accountable Care Organizations. When the pandemic hit, CMS already 
had a head start for telehealth.

    Federal agencies also took advantage of existing law to allow 
providers to care for their patients in fresh ways. For example, 
certain hospital doctors and nurses were able to travel out into their 
communities and provide services at home that would typically be 
reserved for inpatient care.

    Others were able to set up temporary spaces like tents near 
hospitals themselves. That wasn't allowed in ordinary times pre-
pandemic. These steps have increased capacity, kept patients safe, and 
helped maintain care.

    Today the committee will hear from physicians and hospitals who 
have been on the front lines, as well as health policy experts. They 
have seen how these fresh approaches transformed care. In my view, 
there is bipartisan interest in building on the changes that worked 
well for both seniors and providers.

    That bipartisan work has already begun. At the end of last year, 
Congress passed legislation that allowed all seniors in Medicare to 
receive mental health services via telehealth, including at home. My 
view is, mental health services ought to be available via telehealth 
for all Americans. That provision was part of a bill I authored that 
would also permanently allow telehealth for routine health-care visits 
in Medicare, known as evaluation and management services. I'm going to 
keep working to make that a reality.

    So there's a lot for the committee to discuss today. I'd like to 
welcome the witnesses, and again I want to thank Ranking Member Crapo 
for his partnership on this bipartisan issue.

                                 ______
                                 

             Medicare Payment Advisory Commission (MedPAC)

                      425 I Street, NW, Suite 701

                          Washington, DC 20001

                              202-220-3700

                        https://www.medpac.gov/

Michael E. Chernew, Ph.D., Chair  Paul B. Ginsburg, Ph.D., Vice Chair 
              James E. Mathews, Ph.D., Executive Director

             Statement of Michael E. Chernew, Ph.D., Chair

The Medicare Payment Advisory Commission (MedPAC) is a small 
congressional support agency established by the Balanced Budget Act of 
1997 (Pub. L. 105-33) to provide independent, nonpartisan policy and 
technical advice to the Congress on issues affecting the Medicare 
program. The Commission's goal is to achieve a Medicare program that 
ensures beneficiary access to high-quality care, pays health-care 
providers and plans fairly by rewarding efficiency and quality, and 
spends tax dollars responsibly. The Commission would like to thank 
Chair Wyden and Ranking Member Crapo for the opportunity to submit a 
statement for the record today.

The Congress and the administration granted temporary modifications to 
Medicare policies to enable providers, health plans, and others to 
effectively respond to the coronavirus pandemic. While many of these 
actions have been helpful in addressing the short-term issues presented 
by the pandemic, continuing those changes indefinitely would have 
drawbacks. Therefore, policymakers should be cautious about extending 
them beyond the duration of the public health emergency (PHE) or other 
scheduled expiration date.

Introduction

The Commission acknowledges the catastrophic consequences the 
coronavirus pandemic has had on all Americans and the health-care 
delivery system. Medicare beneficiaries are at particular risk of 
developing COVID-19, and those over 65 years old are more likely to 
suffer complications and die compared to those who are younger and have 
fewer comorbidities. Non White beneficiaries have faced 
disproportionately high rates of mortality due to COVID-19, reflecting, 
in part, longstanding inequities in the health-care system. The 
Commission also recognizes the heroic work performed by the nation's 
health-care workers, who have been on the front lines of this health 
crisis for more than a year, and thanks them for their tireless 
dedication and service.

The coronavirus pandemic has put our nation's health-care system under 
enormous strain. Starting in March of last year, cases of patients 
infected with the coronavirus began to rise sharply at institutional 
settings, like hospitals and nursing homes. Hospital emergency rooms 
and intensive care units were regularly filled with patients affected 
by the pandemic, and beneficiaries in nursing homes have accounted for 
a disproportionate share of fatalities from COVID-19.

Meanwhile, the volume of ambulatory care services furnished to Medicare 
beneficiaries dropped sharply last spring as patients delayed or 
avoided care, and access to some services was curtailed to avoid 
spreading the disease. The number of ambulatory care services furnished 
to Medicare beneficiaries in the spring of 2020 was about half of the 
volume of the same services furnished during the same period the year 
before. The sudden decline in service volume during this period placed 
many providers under financial stress and may have put patient health 
and well-being at risk.

 Actions Taken to Modify Medicare Policies in Response to the Public 
                    Health Emergency

As the coronavirus emerged in the U.S. and our health-care system 
confronted extraordinary challenges, the Secretary of Health and Human 
Services first declared the public health emergency in January 2020.\1\ 
Starting in March 2020, CMS and the Congress made numerous changes to 
Medicare policies and granted regulatory flexibilities aimed at helping 
health-care providers respond to the pandemic. We applaud CMS and 
policymakers for acting rapidly to provide a comprehensive array of 
policy modifications and flexibilities during an unprecedented time.
---------------------------------------------------------------------------
    \1\ Under section 319 of the Public Health Services Act, the 
Secretary of Health and Human Services may determine that a disease or 
disorder presents a public health emergency (PHE) or that a PHE, 
including significant outbreaks of infectious disease or bioterrorist 
attacks, otherwise exists. On January 31, 2020, the Secretary first 
determined the existence of a coronavirus PHE since January 27, 2020, 
based on confirmed cases of COVID-19 in the U.S. Since then, the 
coronavirus PHE has been renewed five times, most recently on April 15, 
2021, and is scheduled to expire on July 20, 2021 (Office of the 
Assistant Secretary for Preparedness and Response 2021).

According to a report from the Commonwealth Fund, the administration 
and Congress modified more than 200 Medicare program policies and 
requirements between January and July 2020 (Podulka and Blum 2020). In 
addition, CMS has been issuing subregulatory flexibilities to providers 
and plans since the PHE began. Some of these measures have been phased 
out, but many of these temporary policy changes are scheduled to remain 
---------------------------------------------------------------------------
in effect for the duration of the PHE.

In general, the steps taken by CMS and the Congress are time limited 
and intended to support providers in diagnosing and treating COVID-19 
patients by reducing or eliminating certain regulatory requirements and 
enabling providers to treat Medicare beneficiaries under social 
distancing protocols. The regulatory and legislative changes fall into 
nine broad categories (Podulka and Blum 2020):

      Alternative care sites.
      Benefits and care management.
      Conditions of participation.
      Expanded testing.
      Payment systems and quality programs.
      Provider capacity and workforce.
      Reporting and audit requirements.
      Safety requirements.
      Telehealth.

A plurality of the regulatory changes eased some provider eligibility 
requirements. Regulatory waivers allowed providers to furnish services 
outside the state where they are enrolled and permitted beneficiaries 
to receive care in settings other than acute care hospitals (e.g., 
homes and skilled nursing facilities) to allow for surge capacity in 
those hospitals. Some of the changes suspended audits and quality 
reporting requirements or granted more flexibility over which measures 
to report. CMS has also expanded access to telehealth services in a 
variety of ways, including temporarily eliminating geographic 
restrictions on where such services can be provided and expanding the 
types of services that can be furnished remotely.

Although the pandemic-related policy changes and flexibilities have 
touched almost every part of the Medicare program, I want to focus on 
two areas where the changes are especially important: telehealth and 
post-acute care.

Telehealth: The changes made to Medicare's telehealth coverage and 
payment policies enabled more types of services to be furnished 
remotely to more Medicare beneficiaries. These changes contributed to a 
substantial increase in the number of Medicare-covered services 
furnished via remote technologies, which helped to offset the decrease 
in in-person clinician visits.

Post-acute care: CMS modified numerous post-acute care (PAC) policies 
and requirements to preserve hospital capacity for beneficiaries with 
COVID-19. These actions enabled inpatient rehabilitation facilities and 
long-term care hospitals to treat certain hospital-level patients that 
do not meet certain requirements for these PAC settings and, in some 
cases, be paid the higher PAC-level payments. These waivers also 
extended skilled nursing facility coverage to beneficiaries who 
normally would not qualify.

The temporary waivers and other policy changes gave providers the 
flexibility to maintain access to care under social distancing 
guidelines and helped providers to respond to surges in COVID-19 cases 
by providing capacity beyond the acute care setting. These have been 
important tools for providers during the pandemic, but policymakers 
would be remiss in thinking that the extending these measures has only 
the potential for good. The underlying policies and regulations that 
have been waived or altered are designed to protect beneficiaries, 
support program integrity, and minimize potential overuse and misuse 
based on the incentives of the payment systems. As decisions are made 
about which pandemic-related measures should be continued, policymakers 
need to account for the fact that not all actors in the health-care 
system are well-intentioned, and remain vigilant in protecting the 
Medicare program, beneficiaries, and taxpayers.

Telehealth

Medicare coverage of telehealth services before the PHE was limited by 
statute under the physician fee schedule (PFS). Before the PHE, 
Medicare covered telehealth services if they were provided to 
beneficiaries who received the service at a clinician's office or 
certain health-care facilities (known as ``originating sites'') located 
in a rural area, with some exceptions.\2\ Medicare has historically 
been cautious about covering telehealth services because of 
uncertainties about the impact of telehealth on total spending, 
quality, and program integrity.
---------------------------------------------------------------------------
    \2\ Medicare pays for some telehealth services outside of rural 
areas and in any location, including a patient's home, including 
telehealth services for substance use disorders, for end-stage renal 
disease patients receiving home dialysis, and for mental health 
conditions (if the physician or practitioner has furnished an in-person 
service to the individual within the 6 months prior to the first time 
they furnish the telehealth service, and during subsequent periods that 
the Secretary would determine). Medicare also covers telehealth 
services to treat patients with a stroke in hospitals in urban and 
rural areas.

Prior to the PHE, the Commission evaluated the use of telehealth in the 
Medicare program and whether telehealth services covered under 
commercial plans should be incorporated into the Medicare fee-for-
service (FFS) program (Medicare Payment Advisory Commission 2018). Our 
analysis of a sample of commercial insurers found a lack of uniformity 
in how these insurers covered telehealth services. Consequently, we did 
not make recommendations about covering specific telehealth services in 
Medicare. Instead, the Commission recommended that policymakers should 
use a set of principles (access, quality, and cost) to evaluate 
---------------------------------------------------------------------------
individual telehealth services before covering them in Medicare.

To increase access to care and help limit community spread of COVID-19 
during the PHE, Medicare temporarily expanded coverage of telehealth 
under the PFS to all Medicare beneficiaries, including telehealth 
visits provided to patients at home (Table 1).


 Table 1. Selected Temporary Telehealth Expansions to the Physician Fee
               Schedule During the Public Health Emergency
------------------------------------------------------------------------
                                Pre-PHE               During the PHE
------------------------------------------------------------------------
Who can receive        Clinicians can provide    Clinicians may provide
 telehealth services?   telehealth services to    telehealth services to
                        Medicare beneficiaries    Medicare beneficiaries
                        in certain originating    outside of rural areas
                        sites in rural areas      and in the patient's
                        (e.g., a clinician's      home.
                        office or hospital but
                        not the beneficiary's
                        home).
------------------------------------------------------------------------
Which types of         Limited set of services   CMS pays for over 140
 telehealth services    (does not include audio-  additional services
 does Medicare pay      only E&M visits).         (e.g., emergency
 for?                                             department visits,
                                                  radiation treatment
                                                  management). CMS
                                                  allows audio-only
                                                  interaction for some
                                                  of the telehealth
                                                  services and covers
                                                  audio-only E&M codes.
------------------------------------------------------------------------
How much does          PFS rate for facility-    PFS rate is the same as
 Medicare pay for       based services (less      if the service were
 telehealth services?   than the nonfacility      furnished in person
                        rate).                    (facility or
                                                  nonfacility rate,
                                                  depending on the
                                                  clinician's location).
                                                  Same for audio-only
                                                  visits.
------------------------------------------------------------------------
What are the costs to  Standard cost sharing.    Clinicians are
 beneficiaries?                                   permitted to reduce or
                                                  waive cost sharing.
------------------------------------------------------------------------
Note: PHE (public health emergency), E&M (evaluation and management),
  PFS (physician fee schedule). Under the PFS, clinicians who provide
  services in facilities such as hospitals receive a lower payment rate
  (the facility rate) than clinicians who provide services in offices
  (the nonfacility rate).


During the PHE, demand for telehealth services soared as providers and 
beneficiaries sought to reduce the risk and spread of infection by 
avoiding in-person visits. According to an analysis of FFS Medicare 
claims data from the first 6 months of 2020 and the first 6 months of 
2019, there were 8.4 million telehealth services paid under the PFS in 
April 2020, compared with 102,000 in February 2020 (Medicare Payment 
Advisory Commission 2021). The number of telehealth services declined 
to 5.6 million in June 2020, as the number of in-person services began 
to rebound. During the first 6 months of 2020, 10.3 million 
beneficiaries in FFS Medicare (32 percent of the total) received at 
least one telehealth service, compared with 134,000 beneficiaries 
during the first 6 months of 2019. The share of all primary care 
services conducted by telehealth rose dramatically from less than 1 
percent in January 2020 to 47 percent in April.\3\ The share declined 
to 31 percent in May and 18 percent in June as in-person primary care 
services rebounded. The Commission will analyze more recent claims data 
over the next year.
---------------------------------------------------------------------------
    \3\ Primary care services include the following PFS services: 
office/outpatient evaluation and management (E&M) visits, home E&M 
visits, E&M visits to patients in certain non-inpatient hospital 
settings (nursing facility, domiciliary, rest home, and custodial 
care), audio-only E&M visits, chronic care management, transitional 
care management, Welcome to Medicare visits, annual wellness visits, e-
visits, and advance care planning services.
---------------------------------------------------------------------------

 Rationale for Telehealth Expansion and Potential Safeguards

During the past year, the Commission discussed whether the temporary 
telehealth expansions should continue in Medicare after the PHE. Many 
providers and beneficiaries have described the benefits of increased 
access and convenience from telehealth during the PHE. Advocates of 
telehealth services support making the temporary expansion of 
telehealth in Medicare permanent after the PHE. They assert that these 
services can expand access to care, increase convenience to patients, 
improve quality, and reduce costs relative to in-person care. However, 
there is a risk that under FFS Medicare, telehealth services could 
supplement--rather than substitute for--in-person services, thereby 
increasing spending for Medicare and patients (Ashwood et al. 2017, 
Mehrotra et al. 2020). Telehealth could lead to higher volume if 
telehealth providers induce demand for their services, if the greater 
convenience of telehealth leads beneficiaries to use telehealth 
services more frequently than in-person services, or if additional in-
person follow-up visits are required. Although there are some clinical 
trials comparing telehealth and in-person care, there is not yet 
evidence on how the combination of telehealth and in-person care 
affects quality of care and outcomes.

Expanding telehealth services also raises program integrity concerns. 
Telehealth companies have been involved in several large fraud cases, 
resulting in billions of dollars in losses for Medicare. For example, 
the Department of Justice (DOJ) recently charged defendants--including 
telemedicine companies--with submitting false and fraudulent claims 
worth more than $4.5 billion to federal health programs and private 
insurers (Department of Justice 2020). Telehealth technology makes it 
easier to carry out fraud on a large scale because clinicians employed 
by fraudulent telehealth companies can interact with many beneficiaries 
from different parts of the country in a short amount of time. In 
addition, if beneficiaries become more comfortable receiving care by 
telehealth, they might become more vulnerable to being exploited by 
companies that pretend to be legitimate telehealth providers.

In considering a permanent expansion of telehealth, it is important to 
balance the potential of telehealth to improve beneficiaries' access to 
care with the risk of higher spending due to overuse, while ensuring 
that beneficiaries receive high-quality care. In our March 2021 report 
to the Congress, we present a policy option for expanding FFS 
Medicare's coverage of telehealth services after the PHE (Medicare 
Payment Advisory Commission 2021). In developing this policy option, we 
maintain our previous recommendation that policymakers should use the 
principles of access, cost, and quality to evaluate individual 
telehealth services before covering them under Medicare.

Under this policy option, policymakers should continue some telehealth 
expansions for a limited duration following the end of the PHE (e.g., 
one to two years) to gather more evidence about the impact of the 
telehealth expansions on total spending, access, patient experience, 
and outcomes of care. Policymakers should use this evidence to inform 
any permanent changes. First, Medicare should temporarily pay for 
specified telehealth services provided to all beneficiaries regardless 
of their location. Second, Medicare should temporarily cover selected 
telehealth services in addition to services covered before the PHE if 
there is potential for clinical benefit. Third, to improve access to 
those without the capability to engage in a video visit from their 
home, Medicare should temporarily cover certain telehealth services 
when they are provided through an audio only interaction if there is 
potential for clinical benefit.

Other telehealth policies that were adopted during the PHE should end 
when the PHE ends. First, Medicare should return to paying the fee 
schedule's facility rate for telehealth services instead of paying 
either the facility or nonfacility rate, as it does during the PHE. CMS 
should also collect data from practices and other entities on the costs 
they incur to provide telehealth services and make any future changes 
to telehealth payment rates based on those costs. We expect the rates 
for telehealth services to be lower than rates for in-person services 
because services delivered via telehealth likely do not require the 
same practice costs as services provided in a physical office. Although 
telehealth may require upfront investments in technology and training, 
in the long run the marginal cost of a telehealth service should be 
lower than that of an in-person service (Mehrotra et al. 2020).

In addition, Medicare should require the same share of beneficiary cost 
sharing for telehealth as it does for in-person service after the PHE. 
Because telehealth services are more convenient for beneficiaries to 
access, they have a higher risk of overuse than in-person services, 
particularly in the context of a fee-for-service payment system in 
which providers have a financial incentive to bill for more services. 
Requiring beneficiaries to pay a portion of the cost of telehealth 
services would help reduce the possibility of overuse.

After the PHE, CMS should implement other safeguards to protect the 
Medicare program and its beneficiaries from unnecessary spending and 
potential fraud related to telehealth, including:

      Applying additional scrutiny to outlier clinicians who bill many 
more telehealth services per beneficiary than other clinicians;

      Requiring clinicians to provide an in-person, face-to-face visit 
before they order high-cost durable medical equipment or high-cost 
clinical laboratory tests; and

      Prohibiting ``incident to'' billing for telehealth services 
provided by any clinician who can bill Medicare directly.

In future work, we will continue to monitor beneficiaries' and 
providers' experiences with telehealth in Medicare and the use of 
telehealth during the PHE. We plan to continue exploring trends in 
telehealth use and spending using more recent Medicare claims data. 
This summer, we will ask clinicians and Medicare beneficiaries about 
their use of telehealth during focus groups, and we will ask 
beneficiaries and privately insured individuals about their use of 
telehealth during our annual telephone survey. In addition, we continue 
to meet with telehealth companies and other stakeholders and will 
regularly inform the Congress of our work.

Post-Acute Care

Institutional post-acute care (PAC) settings-skilled nursing facilities 
(SNFs), inpatient rehabilitation facilities (IRFs), and long-term care 
hospitals (LTCHs)-provide care to patients who need skilled 
institutional care to recuperate and regain function, typically 
following an acute care hospital stay. The Medicare program maintains 
separate conditions/requirements of participation and coverage rules 
and uses setting-specific prospective payment systems (PPSs) to pay for 
stays in each setting. Distinct facility and patient requirements help 
ensure that care provided in each setting is consistent with Medicare 
coverage rules and help control unnecessary spending for care in high-
cost settings when patients' conditions do not warrant this level of 
care.

During the PHE, CMS used its emergency and other waiver authority to 
modify numerous policies and requirements intended to preserve hospital 
capacity for beneficiaries with COVID-19 (Centers for Medicare and 
Medicaid Services 2021b). Waivers allowed IRFs and LTCHs to be paid the 
higher-level payments for some cases that do not qualify as IRF or LTCH 
stays, and they extended SNF coverage to beneficiaries who normally 
would not qualify for SNF stays. The SNF, IRF, and LTCH facility and 
patient requirements and PHE-related waivers are summarized below.

Skilled nursing facility requirement. Beneficiaries who need daily, 
short-term skilled nursing or rehabilitation care on an inpatient basis 
following a hospital stay of at least three days are eligible to 
receive covered services in SNFs. By limiting coverage to post-hospital 
``skilled'' services, the program extends coverage for services similar 
to those provided to hospital inpatients, but at a lower level of care, 
and effectively excludes long-term care, which is not a covered 
Medicare benefit.

Skilled nursing facility waiver. During the PHE, CMS is waiving the 
requirement for a three-day prior hospitalization for coverage of a SNF 
stay for beneficiaries who experience dislocations or were otherwise 
affected by COVID-19. In addition, for certain beneficiaries who 
recently exhausted their SNF benefits, CMS authorizes renewed SNF 
coverage without first having to start a new benefit period. These 
waivers allowed facilities to ``skill in place'' beneficiaries who 
required skilled care without having to transfer them to a hospital for 
a three-day hospital stay and helped retain hospital capacity for 
COVID-19 patients. CMS estimated that about 16 percent of SNF 
admissions in fiscal year 2020 used a waiver, and the majority of those 
were attributed to the waived prior hospital stay requirement (Centers 
for Medicare and Medicaid Services 2021b).

Inpatient rehabilitation facility requirements. After an illness, 
injury, or surgery, some beneficiaries need intensive inpatient 
rehabilitation services, such as physical, occupational, or speech 
therapy. For a facility to receive payment as an IRF, 60 percent of its 
admissions must be for one of 13 conditions that typically require 
intensive rehabilitation therapy (referred to as the ``60-percent 
rule''). To qualify for admission to an IRF, a beneficiary must be able 
to tolerate and benefit from intensive therapy, typically defined as 
three hours of therapy a day at least five days a week (referred to as 
the ``3-hour rule''). These Medicare requirements help ensure that only 
the most appropriate patients are eligible to receive care at this 
relatively costly setting, given that many beneficiaries are able to 
receive care at lower-cost settings.

Inpatient rehabilitation facility waiver. CMS is allowing IRFs to 
exclude from the calculation of their compliance with the 60-percent 
rule those patients who were admitted in response to the PHE. CMS is 
also waiving the three-hour therapy rule, as required by Section 
3711(a) of the Coronavirus Aid, Relief, and Economic Security (CARES) 
Act. These waivers effectively allow IRFs to admit patients who would 
not normally qualify for IRF care and provide additional hospital beds 
for surge capacity in communities that need it. These cases may be paid 
the IRF PPS rates in freestanding IRFs in areas experiencing a surge 
during the PHE.\4\
---------------------------------------------------------------------------
    \4\ A state (or region, as applicable) that is experiencing a surge 
means a state (or region, as applicable) that satisfies all of the 
following, as determined by applicable state and local officials: (1) 
all vulnerable individuals continue to shelter in place, (2) 
individuals continue social distancing, (3) individuals avoid 
socializing in groups of more than 10, (4) non-essential travel is 
minimized, (5) visits to senior living facilities and hospitals are 
prohibited, and (6) schools and organized youth activities remain 
closed (Centers for Medicare and Medicaid Services 2021a).

Long-term care hospital requirements. Some patients with profound 
debilitation of multiple systems, frequently with ongoing respiratory 
failure, receive care in an LTCH. To be paid at the higher standard 
Medicare LTCH payment rate, a case must immediately follow an acute 
care hospital stay, not be a psychiatric or rehabilitation case, and 
the preceding hospital stay must include three or more days in an 
intensive care unit or the LTCH case must include mechanical 
ventilation services for at least 96 hours. If these requirements are 
not met, cases are paid at a lower ``site-neutral'' rate. In addition, 
to qualify for Medicare payment as an LTCH, a facility must have an 
average length of stay greater than 25 days for Medicare cases paid the 
LTCH PPS standard payment rate. Finally, if less than 50 percent of 
Medicare discharges qualify for the standard LTCH PPS rate, the 
facility is to be paid under the acute care hospital PPS until that 
share reaches 50 percent or higher. As with Medicare's IRF 
requirements, LTCH criteria were implemented to ensure that Medicare 
does not pay the high LTCH rates for lower-acuity cases that can be 
---------------------------------------------------------------------------
cared for in other, lower-resource intensive settings.

Long-term care hospital waiver. Consistent with section 3711(b) of the 
CARES Act, all cases admitted are being paid the LTCH payment rate, 
even those that normally would not qualify for the higher LTCH rate, 
for the duration of the PHE. In addition, all cases will be counted as 
discharges paid the LTCH PPS rate for purposes of calculating an LTCH's 
share of Medicare discharges that qualify for the standard LTCH PPS 
rate. In addition, CMS waived the 25-day average length-of-stay 
requirement to participate in the LTCH PPS when an LTCH admits or 
discharges patients to meet the demands of the PHE. These waivers 
enable LTCHs to treat a broad mix of patients, including overflow 
short-term acute care hospital patients, and be paid LTCH payment 
rates.

 Waived PAC Criteria Should Be Reinstated When the Public Health 
                    Emergency Ends

The waivers of facility and patient requirements for SNFs, IRFs, and 
LTCHs are examples of policy changes that provide flexibility to expand 
capacity and reduce patient transfers for the duration of the PHE. The 
waivers allowed providers to be paid for Medicare patients that would 
not ordinarily qualify for payment in those settings or to be paid 
higher rates for those patients during the PHE, but there are 
compelling reasons to reinstate these waived requirements after the PHE 
is over. Making these changes permanent would roll back gains in 
defining appropriate use of costly settings and expose the Medicare 
program to increased spending. For example, until 2016, the lack of 
meaningful criteria for LTCH use resulted in admissions of less-complex 
patients who could be cared for appropriately in lower-cost settings. 
The Commission and CMS had long been concerned that caring for lower-
acuity patients in LTCHs increased spending without demonstrable 
improvements in quality or outcomes (Medicare Payment Advisory 
Commission 2020). When ``site-neutral'' payments for less-complex 
patients were implemented starting in 2016 and LTCHs received lower 
acute hospital rates for these cases, providers responded by reducing 
the number of site-neutral cases treated in LTCHs (Medicare Payment 
Advisory Commission 2021).

Studies of the impact of eliminating the SNF prior-hospitalization 
requirement (along with other changes) under the Medicare Catastrophic 
Coverage Act suggest that spending would increase substantially without 
the three-day rule to act as a guardrail for program spending (Aaronson 
et al. 1994, Laliberte et al. 1997, Office of Inspector General 1991). 
To balance the objectives of updating the policy to reflect current 
hospital practices yet protect the Hospital Insurance Trust Fund, in 
2015 the Commission recommended that the three-day policy be revised to 
allow up to two days spent in outpatient observation status to count 
toward the three-day prior hospitalization requirement (Medicare 
Payment Advisory Commission 2015). When the three day hospital stay 
waiver is lifted, the Congress should revise it to allow two of the 
days in observation status to count towards meeting the required three-
day stay.

While Medicare permitted the SNF three-day stay requirement to be 
waived for entities participating in bundled payment demonstrations, 
some entities did not take advantage of this flexibility (Dummit et al. 
2018, Lewin Group 2019, The Lewin Group 2020). Similarly, not all Next 
Generation ACOs elected to waive the three-day stay requirement (NORC 
at the University of Chicago 2020). However, since these bundled 
payment entities and ACOs are at full risk, this experience may not be 
relevant to entities operating under traditional FFS Medicare. This is 
because they already have a financial incentive to control the total 
cost of care to Medicare, unlike providers not at financial risk under 
traditional Medicare.

In 2016, the Commission recommended design features of a unified 
payment system for post-acute care that would pay for PAC services 
based on patient characteristics and needs, rather than setting 
(Medicare Payment Advisory Commission 2016). Later, it outlined a 
patient centered approach to align regulatory requirements so that 
providers would face similar regulatory requirements for treating 
similar patients (Medicare Payment Advisory Commission 2019). Until a 
uniform payment system is implemented and regulatory requirements are 
aligned, institutional PAC settings' patient and facility criteria 
provide important program safeguards against paying for unnecessary 
care and help ensure that care provided in costly, intensive settings 
is targeted to patients who can benefit from that level of care.

 Policymakers Should Be Cautious About Making Current Flexibilities and 
                    Policy Modifications Permanent

It is important to keep in mind the reasons that policies and rules in 
place prior to the pandemic exist. Many of the Medicare policy changes 
made in response to PHE affect important beneficiary protections, as 
well as measures designed to deter fraud, overuse, or inappropriate 
spending. The intended effects of the regulatory flexibilities and 
other changes to Medicare's policies are to maintain beneficiary access 
to needed services and help the health-care system to respond to the 
pandemic, but these flexibilities can also have negative effects. For 
example, waiving conditions of participation can expand access and 
minimize provider burden, but looser regulations may also negatively 
affect quality of care and quality of life for patients and put 
Medicare at higher risk for waste and fraud by creating opportunities 
for those who wish to exploit the program to do so.

If it is determined that any temporary policy changes are leading to 
poor health outcomes, patient harm, or increases in fraud and abuse, 
policymakers should take immediate action to curtail those 
flexibilities prior to the end of the PHE. Likewise, some of the 
temporary policy changes that were viewed as necessary during the worst 
days of the PHE--such as increased payment rates for certain services--
may no longer be needed as the effects of the pandemic wind down.

In other cases, decisions about whether to extend or make permanent 
policy modifications after they are scheduled to expire should be made 
based on evaluation of data collected not only during the pandemic, but 
also during more typical circumstances. That being said, we do not yet 
have reliable information about how policy modifications and 
flexibilities granted during the PHE have affected health status, 
access, spending, program integrity, and other important 
considerations. Furthermore, findings on the effects of policy changes 
based on data collected during a pandemic may not be generalizable to 
the post-pandemic environment. For instance, the impact of the 
modifications that increased use of telehealth on quality and cost of 
care are largely unknown and will take time to fully analyze, and 
findings from 2020 could be shaped by factors that may not be 
applicable after the pandemic.

Conclusion

MedPAC recognizes the tremendous challenges the coronavirus pandemic 
has imposed on beneficiaries, providers, and the rest of the health-
care system. We applaud the quick and decisive actions taken by the 
Congress and CMS aimed at maintaining access to care and enabling an 
effective response to the public health emergency. In general, the 
Commission has been supportive of the temporary waivers, flexibilities, 
and other changes to Medicare policies implemented during the PHE. We 
are supportive of continuing some of the telehealth expansions for a 
limited time, beyond the PHE, provided that adequate oversight and 
protections are in place to protect the Medicare program and 
beneficiaries. We would not advise extending the PAC waivers beyond the 
PHE.

The Commission is also supportive of efforts by this Committee and 
others to review the changes and make determinations about which, if 
any, flexibilities and policy changes should be continued, and which 
should be reinstated once the PHE ends. We realize many stakeholders 
see the benefits of less regulatory oversight and expanded coverage of 
services like telehealth, along with other pandemic-related policy 
changes, and wish to see them made permanent. But the Commission is 
concerned about the implications of indefinitely continuing Medicare 
policy modifications and flexibilities that were granted in direct 
response to the unique circumstances of the coronavirus pandemic. There 
are trade-offs to extending PHE-related modifications, and the benefits 
of continuing these changes must be weighed against the potential 
drawbacks, including substantial spending and program integrity 
implications.

Although we are concerned about the potential for some of the waivers 
and coverage expansions to lead to overuse of services and reductions 
in quality of care, these modifications may not have the same drawbacks 
when implemented in alternative payment arrangements to traditional FFS 
where an entity is at financial risk for the cost and quality of care. 
In fact, many existing Medicare alternative payment models (APMs) 
contain waivers and flexibilities similar to those granted during the 
PHE. As noted earlier, many APMs permit beneficiaries to receive care 
in a SNF without a preceding three-day inpatient hospital stay, and 
there are fewer restrictions on telehealth compared to traditional FFS. 
The Commission is hopeful that the continued development of such models 
can help facilitate more flexibility for providers and expanded 
coverage of technologies such as telehealth, while minimizing the 
negative behaviors.

In closing, MedPAC urges the administration and the Congress to 
carefully consider how making waivers permanent will affect the quality 
of care beneficiaries receive, the willingness of providers to continue 
to participate in the Medicare program, and the already challenging 
issues of fiscal solvency and Medicare program integrity. The 
Commission plans to continue to follow the status of the temporary 
policy changes and waivers granted during the PHE and will be closely 
monitoring their impact on the program. Ultimately, all decisions about 
whether to continue these measures beyond the PHE should balance the 
benefits of expanding access to care and reducing administrative burden 
with the need to minimize the potentially negative effects that the 
rules and policies were originally designed to prevent.

References

Aaronson, W.E., J.S. Zinn, and M.D. Rosko. 1994. The success and repeal 
of the Medicare Catastrophic Coverage Act: A paradoxical lesson for 
health-care reform. Journal of Health Politics, Policy and Law 19, no. 
4 (Winter): 753-771.

Ashwood, J.S., A. Mehrotra, D. Cowling, et al. 2017. Direct-to-consumer 
telehealth may increase access to care but does not decrease spending. 
Health Affairs 36, no. 3 (March 1st): 485-491.

Centers for Medicare and Medicaid Services, Department of Health and 
Human Services. 2021a. Medicare and Medicaid programs, Basic Health 
Program, and Exchanges; additional policy and regulatory revisions in 
response to the COVID-19 public health emergency and delay of certain 
reporting requirements for the Skilled Nursing Facility Quality 
Reporting Program. Interim final rule with comment period. Federal 
Register 85, no. 90 (May 8): 27550-27629.

Centers for Medicare and Medicaid Services, Department of Health and 
Human Services. 2021b. Medicare program; prospective payment system and 
consolidated billing for skilled nursing facilities; updates to the 
Quality Reporting Program and Value-Based Purchasing Program for 
federal fiscal year 2022. Proposed rule. Federal Register 86, no. 71 
(April 15): 19954-20022.

Department of Justice. 2020. National health-care fraud and opioid 
takedown results in charges against 345 defendants responsible for more 
than $6 billion in alleged fraud losses. News release. September 30th, 
https://www.justice.gov/opa/pr/national-health-care-fraud-and-opioid-
takedown-results-charges-against-345-defendants.

Dummit, L., G. Marrufo, J. Marshall, et al. 2018. CMS Bundled Payments 
for Care improvement Initiative Models 2-4: Year 5 evaluation and 
monitoring annual report. Falls Church, VA: The Lewin Group.

Laliberte, L., V. Mor, K. Berg, et al. 1997. Impact of the Medicare 
Catastrophic Coverage Act on nursing homes. Milbank Quarterly 75, no. 
2: 203-233.

Lewin Group. 2019. CMS Comprehensive Care for Joint Replacement Model: 
Performance year 2 evaluation report--Appendices. Falls Church, VA: The 
Lewin Group, https://downloads.cms.gov/files/cmmi/cjr-secondannrpt-
app.pdf.

Medicare Payment Advisory Commission. 2015. Report to the Congress: 
Medicare and the health care delivery system. Washington, DC: MedPAC.

Medicare Payment Advisory Commission. 2016. Report to the Congress: 
Medicare and the health care delivery system. Washington, DC: MedPAC.

Medicare Payment Advisory Commission. 2018. Report to the Congress: 
Medicare payment policy. Washington, DC: MedPAC.

Medicare Payment Advisory Commission. 2019. Report to the Congress: 
Medicare and the health care delivery system. Washington, DC: MedPAC.

Medicare Payment Advisory Commission. 2020. Report to the Congress: 
Medicare payment policy. Washington, DC: MedPAC.

Medicare Payment Advisory Commission. 2021. Report to the Congress: 
Medicare payment policy. Washington, DC: MedPAC.

Mehrotra, A., B. Wang, and G. Snyder. 2020. Telemedicine: What should 
the post pandemic regulatory and payment landscape look like? Issue 
brief. New York, NY: The Commonwealth Fund.

NORC at the University of Chicago. 2020. Second evaluation report 
technical appendices: Next Generation Accountable Care Organization 
Model evaluation. Report prepared by staff from NORC at the University 
of Chicago for the Center for Medicare and Medicaid Innovation, 
Bethesda, MD: NORC.

Office of Inspector General, Department of Health and Human Services. 
1991. Influences on Medicare's skilled nursing facility benefit, 
Washington, DC: OIG.

Office of the Assistant Secretary for Preparedness and Response, 
Department of Health and Human Services. 2021. Renewal of determination 
that a public health emergency exists, https://www.phe.gov/emergency/
news/healthactions/phe/Pages/COVID-l5April2021.aspx.

Podulka, J., and J. Blum. 2020. Regulatory changes to Medicare in 
response to COVID-19. Issue brief, Washington, DC: Commonwealth Fund, 
https://www.
commonwealthfund.org/publications/issue-briefs/2020/aug/regulatory-
changes-medicare-response-covid-19.

The Lewin Group. 2020. CMS Comprehensive Care for Joint Replacement 
Model: Performance year 3 evaluation report. Falls Church, VA: The 
Lewin Group, Abt Associates, GDIT, and Telligen, https://
innovation.cms.gov/data-and-reports/2020/cjr-thirdannrpt.

                                 ______
                                 

                             Communications

                              ----------                              


                            Adventist Health
May 26, 2021

Senator Ron Wyden
Chairman
U.S. Senate
Committee on Finance
Washington, DC 20510

Senator Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
Washington, DC 20510

RE: Mayo Clinic Statement for the Record for the Committee hearing 
entitled: ``COVID-19 Health Care Flexibilities: Perspectives, 
Experiences, and Lessons Learned,'' May 19, 2021

Dear Chairman Wyden and Ranking Member Crapo:

On behalf of Adventist Health and the patients we serve, thank you for 
holding the May 19, 2021 hearing on ``COVID-19 Health Care 
Flexibilities: Perspectives, Experiences, and Lessons Learned.'' We 
commend the committee for addressing this important issue and analyzing 
critical lessons learned from the hospital and patient perspectives. We 
look forward to supporting the evolution and advancement of health-care 
flexibilities today and post-pandemic.

Adventist Health is a faith-based, nonprofit integrated health system 
serving more than 80 communities in California, Hawaii, and Oregon. 
Adventist Health provides compassionate care in 23 rural and urban 
safety net hospitals. We operate the largest network of rural health 
clinics in California, with more than 20 percent of California's Rural 
Health Clinics as a part of the system. Our rural Health Clinics (RHCs) 
provide care to about 315,000 individuals who mostly live in medically 
underserved communities.

Adventist Health is transforming the health-care experience, shifting 
from providing care to focusing on the overall health of the 
communities it serves. This includes embracing technology that makes 
care more convenient and accessible. The beginning of 2020 introduced a 
disruption that has created more opportunities for virtual visits, 
which are an essential component of health-care innovation that have 
proven to be a lifeline during the COVID-19 pandemic. This innovative 
approach also offers insights on the virtual hospital of the future. In 
May of 2020, Adventist Health created a new care model that is 
reshaping the way acute care is delivered to the system's communities. 
Hospital@Home, in collaboration with Medically Home Group, Inc. and 
Huron, is a virtual hospital that harnesses virtual and telemedicine 
technologies proven successful in hospitals for the last decade, to 
provide care in a patient's home.

Telehealth services, like those provided by Hospital@Home, are more 
convenient and accessible than traditional office visits and can 
greatly benefit populations who find it difficult to manage their 
health-care needs in person. Our virtual visits provide crucial access 
to care for high-risk patients who need to stay home to protect 
themselves, both during public health crises and in normal times. Our 
telehealth services also provide vital access for patients in rural 
communities, where in-person clinic visits may require extraneous time 
and effort to schedule and attend. Virtual visits are also an essential 
way for patients to receive mental and behavioral health-care services 
that are increasingly necessary for whole-person care, but often 
difficult to access. Telehealth services are an important way for 
traditionally disadvantaged patient populations to easily connect to 
primary as well as specialty care providers that may not be accessible 
in person. It has been a critical lifeline for the patients and 
communities we proudly serve.

The past year has demonstrated the undeniable value of virtual care. 
However, much work remains to be done to ensure the continued growth of 
telehealth and preserving beneficiary choice in how care is furnished. 
Expedient action from Congress is essential to permanently establish 
the flexibilities granted to CMS during the COVID-19 pandemic and to 
subsequently authorize CMS to build out an accompanying regulatory 
framework.

Virtual Care at Adventist Health

During the pandemic, Adventist Health's clinical and digital teams 
provided essential remote care through 300,000 telephone and video 
visits. Through our virtual care we have seen a decrease in missed 
visits, our patient satisfaction rates have increased and we are able 
to create access points to our most vulnerable populations where we 
otherwise would not have.

Hospital@Home

In one of the most significant developments in remote care, in May of 
2020, Adventist Health launched its Hospital@Home program to furnish 
acute-level services to patients in their home. Adventist Health's 
Hospital@Home serves patients in 7 locations throughout California and 
Oregon. The program has served hundreds of patients, delivering complex 
comprehensive acute care to qualifying patients in their homes. These 
services, provided in person and virtually, include infusions, nursing 
care, medications, laboratory and imaging services, and rehabilitation 
services from a network of registered nurses, community paramedics, and 
an ecosystem of support team members--all under the clinical direction 
of credentialed board certified hospitalists in Adventist Health 
command centers.

The availability of an acute care option at home was a critical tool in 
the pandemic response and Adventist Health's hospitals are approved 
participants under the CMS Acute Care at Home (CMS ACH) program 
announced in November 2020.

Our model counters isolation created by the COVID-19 pandemic and 
allows family members to be at a patient's bedside in their home, while 
helping hospitals balance the increased demand for hospital beds. The 
Adventist Health Hospital@Home care model is applied in emergency 
medicine, acute level COVID-19 care, and for patients with infections 
and chronic disease exacerbation (e.g., CHF, COPD). This broad spectrum 
of applications unlocks patients' homes as a meaningful addition to 
flexible medical care capacity and supports greater health system 
resiliency, while meeting the needs and wants of patients who prefer to 
be cared for at home or in a home-like setting. The CMS ACH waiver 
expires at the end of the PHE, and it is essential that Congress act to 
extend the current waivers to enable Medicare beneficiaries to continue 
to access safe and effective acute-level care in the comfort of their 
home.

Since launching Hospital@Home in May 2020, Adventist Health has been 
collecting and analyzing data on Hospital@Home's impact on patient 
care, experience, acuity, readmission rates, and mortality. To date, 
Adventist Health has cared for over 500 patients and has had over 3,000 
patient days, with promising data. For Adventist Health patients 
receiving care in the Hospital@Home program, the 30-day hospital 
readmission rate is 43.4% lower than the comparable population in the 
same timeframe within Adventist Health's traditional (brick and mortar) 
hospital practice.

To assess 2020 patient satisfaction, data collected using inpatient 
HCAHPS surveys have been generated for Hospital@Home patients, 
resulting in top decile scores for overall rating - 89.4% (n=53) - and 
would recommend - 87% (n=46).

Recommendations for Health Care Flexibilities

Adventist Health supports keeping these important flexibilities in 
place so that we can ensure that our forward momentum is built upon and 
that the significant investments in telehealth infrastructure and 
accessible patient care are maintained.

      Geographic and originating site restrictions. Before the 
pandemic, Medicare required that a patient either live in a rural or 
certain health professional shortage area or only use telehealth at an 
approved originating site, such as a hospital or physician's office. 
Together, these restrictions functionally prevented beneficiaries from 
accessing telehealth at home. Only about 2 percent of beneficiaries 
reside in zip codes that meet the traditional geographic and 
originating site criteria.
      FQHC and RHC expansion. Without making permanent the COVID-19 
regulatory flexibility, Rural Health Clinics (RHCs) and Federally 
Qualified Health Centers (FQHCs) will not be allowed to serve as 
distant site telehealth providers. This prevents low-income and 
geographically isolated individuals from utilizing accessible points of 
care for telehealth visits, creating barriers to affordable treatment 
for the populations who often need it most.

      Qualifying providers. When the PHE ends, CMS would currently 
have to revert to policies that restrict the types of providers that 
can deliver reimbursable virtual care to Medicare beneficiaries. 
Commonly accessed providers like physical therapists, occupational 
therapists and speech language pathologists would no longer be able to 
bill for telehealth services.

      Audio-Only Services. Audio-only services are critically 
important for many populations. Technology challenges, such as access 
to Internet/broadband and low digital literacy, is a telehealth barrier 
for 64% of patients. These patients require audio-only services to meet 
their unique needs.

      Hospital Without Walls. Acute Hospital Care at Home waivers 
mitigate the residual impacts of COVID-19 on public health and 
encourage broader adoption of providing patient centered health-care 
services in the home.

Thank you again for holding this important hearing. We look forward to 
continuing to work with Congress and HHS to ensure that access and 
quality care are available to our patients and our communities during 
and beyond the PHE, as well as to further provide groundwork for 
greater innovations in health-care delivery for the future.

Sincerely,

Scott Reiner, CEO

                                 ______
                                 
                         Advocate Aurora Health
June 2, 2021

Hon. Ron Wyden                      Hon. Mike Crapo
Chairman                            Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
219 Dirksen Senate Office Building  219 Dirksen Senate Office Building
Washington, DC 20510                Washington, DC 20510

Re: Written Testimony Submitted to the Senate Committee on Finance for 
the May 19, 2021 Hearing Record, ``COVID-19 Health Care Flexibilities: 
Perspectives, Experiences, and Lessons Learned''

Dear Chairman Wyden and Ranking Member Crapo:

On behalf of Advocate Aurora Health (Advocate Aurora), thank you for 
holding a hearing on May 19, 2021 titled, ``COVID-19 Health Care 
Flexibilities: Perspectives, Experiences, and Lessons Learned.'' We are 
grateful for your leadership on--and attention to--this important 
topic. We appreciate the opportunity to submit this statement for the 
hearing record and thank you in advance for your consideration of our 
recommendations for how to sustain the gains made in telehealth 
deployment during the Public Health Emergency (PHE), fully harness the 
potential telehealth holds for tackling many of the challenging health-
care issues facing our nation, including how to increase access to 
quality care, lower costs, eliminate health-care disparities, and 
address socioeconomic determinants of health (SDOH), such as lack of 
safe, reliable transportation.

Our clinicians feel strongly that telehealth, remote patient 
monitoring, and other health technology together are a powerful set of 
tools that can help expand access to care for rural and underserved 
communities, such as South Chicago and inner-city Milwaukee. For many 
patients, having the option to engage with a clinician via telehealth 
offers them a convenient clinical option as it eliminates the need for 
transportation, parking, and childcare and reduces absences from school 
or work. Further, for some patients with mobility challenges, 
disabilities, or other special needs, such as autism, telehealth and 
remote care can provide a more effective, less burdensome, and less 
stressful clinical care experience.

As enumerated further below, Advocate Aurora has appreciated the 
waivers and flexibilities afforded to clinicians during the PHE, and in 
particular, the waivers associated with telehealth have supported our 
ability to maintain continuity of care for a significant number of our 
patients and to expand access to care to traditionally underserved 
individuals and communities. As we begin to emerge from the PHE, it 
will be imperative that we retain the advances in telehealth. We thank 
you in advance for your consideration of our recommendations and 
requests with respect to making the PHE telehealth and related changes 
permanent.

Overview of Advocate Aurora

Advocate Aurora is a leading employer in the Midwest with more than 
75,000 team members, including more than 22,000 nurses and the region's 
largest employed medical staff and home health organization. The system 
serves nearly 3 million patients annually; across both Illinois and 
Wisconsin, in particular, we serve an estimated 695,000 Medicare 
beneficiaries and more than 485,000 individuals with Medicaid coverage.

With more than 500 sites of care, Advocate Aurora is engaged in 
hundreds of clinical trials and research studies, and is nationally 
recognized for its expertise in cardiology, neurosciences, oncology, 
and pediatrics. The organization contributed $2.2 billion in charitable 
care and services to its communities in 2019. Advocate Aurora brings 
its strengths, assets, and commitment to delivering value and outcomes 
to individuals, families, and communities throughout Illinois and 
Wisconsin.

Advocate Aurora also serves as a transformative leader and strong 
partner with the federal government in the journey from volume to 
value. The Centers for Medicare & Medicaid Services in 2020 announced 
that Advocate Aurora Health's three affiliated Accountable Care 
Organizations (ACOs) combined saved taxpayers $87.5 million through the 
Medicare Shared Savings Program, the most of any integrated system in 
the country.

Advocate Aurora and Telehealth

Advocate Aurora has long been engaged in the provision of care through 
telehealth, as it is an important tool in reaching rural and 
underserved communities, including individuals with special needs, such 
as people who are deaf and hard-of-hearing. For example, we are proud 
that more than 15 years ago we were the only Chicago area provider to 
offer tele-psychiatry visits using videoconferencing and clinicians who 
speak American Sign Language (ASL) to deaf and hard-of-hearing patients 
who were living in southern Illinois. These patients had unmet mental 
health needs but there were no providers in the community who spoke ASL 
and an audio-only visit is ineffective and inappropriate. By offering 
video-tele-psychiatry with ASL speakers, patients could access the 
specialty care they needed without the burden of having to travel. 
Since that time, we have significantly expanded our telehealth and 
digital medicine offerings in Illinois and Wisconsin.

We connect to our patients through videoconferencing, remote 
monitoring, electronic consults, and wireless communications and we 
deploy these technologies to provide primary, urgent care, and 
specialty services. The strategic utilization of telehealth--both prior 
to and during the PHE--allows us to offer patients an important, safe, 
and convenient care option.

Advocate Aurora Telemedicine ED Triage

For example, prior to the PHE, we successfully implemented remote video 
monitoring technology to help reduce overcrowding at Aurora Sinai 
Medical Center's Emergency Department (ED) in Milwaukee, Wisconsin, one 
of our busiest EDs. This telemedicine program allows patients to be 
seen initially by an Advocate Aurora clinician via video when they 
arrive, with a nurse at the patient's side. By having additional 
clinicians available via telemedicine--with triage assistance and on-
site clinician support--patients are seen by a clinician faster and, in 
turn, they experience a reduced time to diagnoses and quicker 
initiation of treatment.

      The program has helped to reduce door-to-provider times from 60 
minutes to about 10 minutes, on average.
      The average length of stay has declined by 40 minutes.
      The leave-without-being-seen rate has plummeted from 8% to 2%.
      Overcrowding in the ED has decreased significantly.

Advocate Aurora's Experience with Telehealth During the PHE

We are eager to sustain the recent advances made in the utilization and 
adoption of telehealth; while the advantages and power of telehealth 
have been known for decades, the importance of virtual care has become 
profoundly clear in the past year during the PHE. Starting in March 
2020, providers and patients alike sought ways to interact that reduced 
their risk of exposure to COVID-19. Many physicians and Advance 
Practice Clinicians (APCs) could not be in the office or at the 
hospital due to COVID-19 restrictions but could still see patients 
through virtual care. Telehealth helped reduce unnecessary patient and 
provider exposure to COVID-19 and allowed us to preserve scarce PPE 
during shortages.

Moreover, many patients, including home care patients, were fearful of 
seeing their care providers in person but were eager to engage in a 
visit through audio or video means. Further, as noted earlier, many 
patients have mobility issues, disabilities, transportation challenges, 
or home, work, or school obligations that make traveling to an office, 
clinic, or hospital campus extremely burdensome even in non-pandemic 
times. With vast disruption with public transportation systems and 
patients experiencing greater stress overall, telehealth allowed us to 
provide convenient, continuity of care for our patients across the care 
spectrum--primary, specialty, post-acute, chronic disease management, 
etc.

Advocate Aurora's behavioral health-care physicians and APCs in 
particular have noticed a significant reduction in canceled or missed 
appointments and high patient satisfaction levels among patients using 
tele-behavioral health services. Our behavioral health patients 
consistently gave high daily ratings to virtual treatment with an 
average rating of 8.7 out of 10. When questioned about future 
preferences, 72% of patients either preferred virtual to in-person 
treatment or were neutral. Across the Advocate Aurora system, 90% of 
patients were satisfied after virtual visits and likely to use virtual 
visits again. Further, 91-93% found it either easy or very easy to 
interact with their provider via video.

In 2019 and before the pandemic, an estimated 300 Advocate Aurora 
physicians and APCs performed 13,026 virtual health visits. By the end 
of 2020, Advocate Aurora's virtual care program:\1\
---------------------------------------------------------------------------
    \1\ Advocate Aurora's virtual care services are comprised of Quick 
Care, E-Visits, telephonic, and virtual clinic visits.

      Provided a total of 876,000 virtual visits to 507,375 unique 
patients;
      Reached a diverse patient population: 17% Black/African 
American, 10% Hispanic or Latino; and 3% Asian;
      Experienced most demand (45%) within primary care with Family 
Practice providers accounting for 27% of visits and Internal Medicine 
providers comprising 18% of visits, while Behavioral Health services 
were 14% of visits, followed by Cardiology at 6%;
      Delivered care to patients in 15 states; and
      Had a payer mix of 32% Medicare, 12% Medicaid, 51% commercial 
insurance, and 5% self-paying patients or another payer source.

 Advocate Aurora Supports Making Permanent the PHE-Related Telehealth 
                    Policy Changes

Advocate Aurora very much appreciates the changes that both the Centers 
for Medicare and Medicaid Services (CMS) and Congress have made since 
the start of the PHE to ensure that patients can receive care via 
telehealth, should they so choose. We enumerate below a number of the 
flexibilities and waivers currently available that we respectfully 
request be made permanent. We understand that some of the waivers and 
flexibilities can be made permanent under existing CMS authority, while 
others require Congressional action. We urge you and your colleagues to 
work with CMS to ensure all of these policies are made permanent so 
patients can continue to benefit from what telehealth offers them. 
Specifically, we ask that you continue to allow:

      All patients, irrespective of their geography (e.g., rural) and 
physical location (e.g., home), to receive telehealth services in the 
location of their choosing.
      Medicare to pay for telehealth services at the same rate as in-
office visits for all diagnoses.
      Practitioners to provide telehealth services to both new and 
established Medicare patients.

We appreciate that audio-only telehealth was an important focus during 
the hearing. Audio-only telehealth flexibilities have allowed our 
clinicians a convenient and effective way to maintain and expand access 
to care during the pandemic. Currently these audio-only visits 
represent approximately 35% of our total virtual health consults, 
providing care to 285,601 unique patients. Audio-only visits 
experienced most demand from our Family Practice providers (18%) and 
Internal Medicine providers (18%) followed by our Behavioral Health, 
Oncology and Cardiology specialists. 45% of our patients receiving 
audio-only virtual visits are covered by Medicare, 12% by Medicaid 
while 36% are covered by commercial insurance with the remainder 
receiving coverage from self-pay or some other source. We strongly 
support policymakers continuing to allow:

      Practitioners to provide audio-only telephone evaluation and 
management visits for new and established patients; this is especially 
important for patients who may not have Internet access or a smart 
phone.
      Practitioners licensed in one state to be reimbursed for 
services provided to Medicare beneficiaries in another state and 
reduction of burdens preventing reciprocity in state licensures.
      Practitioners such as licensed clinical social workers, clinical 
psychologists, physical therapists, occupational therapists, and 
speech-language pathologists to provide--and be reimbursed for--
telehealth, virtual check-ins, e-visits, and telephone calls to 
patients.
      Practitioners to provide a greater range of services to 
beneficiaries via telehealth, including ED visits.
      Medical screening exams (MSEs), a requirement under Emergency 
Medical Treatment and Labor Act (EMTALA), to be performed via 
telehealth.

Further, we very much appreciate that CMS and the Office of Inspector 
General at the Department of Health and Human Services (HHS) have 
offered relief from enforcement of Stark Self-Referral and Anti-
Kickback laws during the PHE. As you know, while well intended when 
they were designed, the nature of health-care delivery has changed 
significantly in the decades since these laws were passed and their 
implementing regulations promulgated. We urge that many of these 
flexibilities be made permanent so that patients can have access to the 
technologies they need to benefit from advances in virtual care. We are 
concerned that underserved and vulnerable patient populations may not 
have access to the needed technologies primarily used for telemedicine, 
including broadband Internet access and smartphones, yet providers 
cannot provide financial help so patients can secure these needed 
tools.

Without a permanent change, hospitals face significant legal risk if 
they want to provide a subsidy to their physicians to purchase 
telehealth technologies, like specialized tablets to perform remote 
patient monitoring, or if they want to give patients, free of cost or 
at reduced prices, devices such as wearable ``stethoscopes,'' blue-
tooth enabled-digital blood pressure cuffs, or a virtual care kit for a 
home examination. Patients who cannot afford the out-of-pocket costs 
for these devices, apps, etc. will be unable to benefit from 
innovative, patient-centered virtual care. This further exacerbates 
inequities and health disparities, and prevents physicians and APCs 
from being able to address many SDOH. We appreciate the recent changes 
CMS and HHS have made to the Stark and Anti-Kickback regulations but we 
urge federal policymakers to further modernize these outdated laws and 
regulations so that underserved and vulnerable patients can have access 
to the care and tools they need and deserve.

Summary

Again, we thank you for the opportunity to submit this statement for 
the hearing record and we stand ready to work with you to ensure that 
the advances made in leveraging telehealth are maintained so we can 
continue to improve and transform health care in America, particularly 
for our most vulnerable patient populations. To that end, we urge you 
and your colleagues to make permanent the PHE-related telehealth 
waivers and flexibilities.

On behalf of Advocate Aurora's physicians, nurses, other health 
professionals and associates, and the patients, families, and 
communities we serve, thank you for your leadership and commitment to 
ensuring that we as a nation sustain the gains made in expanding access 
to care via telehealth and other virtual care offerings. We look 
forward to working with you throughout the 117th Congress to improve 
the health and well-being of the communities we serve.

Sincerely,

Meghan Woltman
Chief Government Affairs Officer

                                 ______
                                 
                      Alliance for Connected Care

                      1100 H Street, NW, Suite 740

                          Washington, DC 20005

                      https://connectwithcare.org/

The Alliance for Connected Care appreciates the opportunity to submit 
testimony for this hearing examining COVID-19 health-care 
flexibilities. The Alliance for Connected Care (the Alliance) is an 
advocacy organization dedicated to facilitating the delivery of high-
quality care using connected care technology. Our members are leading 
health care and technology companies from across the health-care 
spectrum, representing insurers, health systems, and technology 
innovators. Our Advisory Board includes more than 30 patient and 
provider groups, including many types of clinician specialty and 
patient advocacy groups who wish to better utilize the opportunities 
created by telehealth.

The Alliance will focus comments on (1) Research and evidence we have 
gathered thus far; (2) recommendations for future telehealth expansion 
that Congress should consider--including steps to ensure equitable 
access; and (3) Recommendations for telehealth ``guardrail'' provisions 
that Congress should consider to prevent fraud, waste and abuse in the 
health-care system.

While we prefer the implementation of permanent policies described in 
our recommendations below, the Alliance supports a two-year clean 
extension of telehealth flexibilities exercised during the COVID-19 
pandemic, including 1834(m) Medicare telehealth waivers, a safe harbor 
for employer-subsidized telehealth for people with Health Savings 
Account eligible High-Deductible Health Plans, and the flexibility for 
Critical Access Hospitals to continue to bill telehealth as they have 
during the pandemic. We want policymakers to feel comfortable that 
access to telehealth services in Medicare will not negatively impact 
health-care quality, or the federal budget. Therefore, we recommend 
Congress wait to make permanent policy until more peer-reviewed 
research has been published, government studies--such as the study 
underway by AHRQ--have been completed, the Office of the Inspector 
General has examined the level of fraud in telehealth during the Public 
Health Emergency, and when we have observed what the use of telehealth 
during ``normal times.''

Telehealth Research and Evidence

We have a unique opportunity afforded by the PHE to understand the 
effects of telehealth on clinical practice--and to make direct apples-
to-apples comparisons across service modality. The sudden shift to 
virtual services generated fee-for-service (FFS) data and empirical 
provider and patient experience that didn't exist prior to the 
pandemic. This data is just now being understood, and peer-reviewed 
studies and reports are forthcoming. We believe it is essential to take 
this new evidence into account when writing permanent laws especially 
given that pre-pandemic telehealth studies were either narrowly-focused 
or relied on inferences on the impact of Medicare using commercial or 
Veterans Affairs data.

The COVID-19 pandemic has resulted in drastic increases in telemedicine 
utilization, introducing millions of Americans to a new way to access 
health-care. Data from the Centers for Disease Control and Prevention 
(CDC) finds that during the period of June 26--November 6, 2020, 30.2 
percent of weekly health center visits occurred via telehealth. In 
addition, preliminary data \1\ from the Centers for Medicare and 
Medicaid Services (CMS) show that between mid-March and mid-October 
2020, over 24.5 million out of 63 million beneficiaries and enrollees 
have received a Medicare telemedicine service during the PHE. Finally, 
an HHS Office of the Assistant Secretary for Planning and Evaluation 
(ASPE) Medicare fee-for-service (FFS) telehealth report \2\ found that 
from mid-March through early July more than 10.1 million traditional 
Medicare beneficiaries used telehealth, including nearly 50 percent of 
primary care visits conducted via telehealth in April vs. less than 1 
percent before the COVID-19 pandemic. In addition to providing a 
lifeline to continuity of care, it is important to note that the net 
number of Medicare FFS primary care in-person and telehealth visits 
combined remained below pre-pandemic levels. As in-person care began to 
resume in May, telehealth visits dropped to 30 percent but there was 
still no net visit increase. We infer this and other data showing that 
as in-person visits increased, telehealth visits decreased, that there 
was a substitution effect. A claims-based analysis \3\ suggests that 
approximately $250 billion in health care spend could be shifted to 
virtual care in the long term--roughly 20 percent of all Medicare, 
Medicaid and commercial outpatient, office and home health spend. The 
effects of the COVID- 19 pandemic on patients seeking or avoiding care 
still need further analysis, but these data suggest that telehealth 
substituted for in-person care without increasing utilization.
---------------------------------------------------------------------------
    \1\ https://www.cms.gov/newsroom/press-releases/trump-
administration-finalizes-permanent-expansion-medicare-telehealth-
services-and-improved-payment.
    \2\ https://aspe.hhs.gov/sites/default/files/private/pdf/263866/hp-
issue-brief-medicare-telehealth.pdf.
    \3\ https://www.mckinsey.com/industries/healthcare-systems-and-
services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-
19-reality?_lrsc=a92397a2-f826-4e32-863b-4f1f467784d
1&cid=other-soc-lke.

In addition to telehealth largely substituting for in-person care, 
policymakers should consider telehealth's ability to increase 
efficiencies and improve access where barriers to care exist. COVID-19 
has dramatically heightened awareness of existing health disparities 
and made the call to address these longstanding issues more urgent. 
Transportation is just one example of a barrier to care that telehealth 
can alleviate. Transportation barriers are regularly cited \4\ as 
barriers to access, particularly for low-incomes or under/uninsured 
populations--leading to missed appointments, delayed care, and poor 
health outcomes. In a 2018 proposed rule,\5\ CMS estimated that 
telemedicine is saving Medicare patients $60 million in travel time, 
with a projected estimate of $100 million by 2024 and $170 million by 
2029. CMS also noted that these estimates tend to underestimate the 
impacts of telemedicine. Higher projections estimate $540 million in 
savings by 2029.
---------------------------------------------------------------------------
    \4\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265215/
#:%7E:text=Transportation%20
barriers%20are%20often%20cited,and%20thus%20poorer%20health%20outcomes.
    \5\ https://www.govinfo.gov/content/pkg/FR-2018-11-01/pdf/2018-
23599.pdf.

The experience during COVID-19 has pushed forward a revolution in 
consumer attitudes toward virtual care. Polling data from the 
University of Michigan \6\ showed that one in four older adults had 
used telemedicine during the first three months of the pandemic, 
compared to just 4% in 2019. The same poll showed that 64% of those 
surveyed in June 2020 were comfortable with using videoconferencing 
technology for any purpose, up from 53% in May 2019.
---------------------------------------------------------------------------
    \6\ https://labblog.uofmhealth.org/rounds/telehealth-visits-
skyrocket-for-older-adults-but-concerns-and-barriers-remain.
---------------------------------------------------------------------------

Top Telehealth Priorities

      Remove geographic and originating site restrictions on 
telehealth in Medicare. The COVID-19 pandemic has clearly demonstrated 
the need for telehealth in rural areas, in urban areas, at work, at 
school, at home and many other locations. These provisions are obsolete 
and outdated and should be removed from statute entirely. The location 
of the patient should not matter for telehealth--only the quality of 
the care being delivered.
          Please note that the removal of the originating 
site construct, a relic from an era in which telehealth was an office-
to-office interaction, is better policy that the addition of the home 
as a site for telehealth services or a waiver of these restrictions.\7\
---------------------------------------------------------------------------
    \7\ The Alliance strongly supports the Telehealth Modernization Act 
(H.R. 1332), introduced by Senators Tim Scott and Brian Schatz, which 
would eliminate the originating site construct completely.

      Remove distant site provider list restrictions to allow all 
Medicare providers who deliver telehealth-appropriate services to 
provide those services to beneficiaries through telehealth when 
clinically appropriate and covered by Medicare--including physical 
therapists, occupational therapists, speech-language pathologists, 
social workers, and others. Additionally, work to ensure that in-person 
payment models, such as those in which a facility/provider organization 
bills on behalf of a care-team can be fully compatible with virtual 
---------------------------------------------------------------------------
care environment.

      Ensure Federally Qualified Health Centers, Critical Access 
Hospitals, and Rural Health Clinics can furnish telehealth in Medicare 
and be reimbursed fairly for those services, despite unique payment 
characteristics and challenges for each. Please note that Critical 
Access Hospitals (CAHs) are sometimes omitted from this list, but are a 
crucial component of a health-care system able to reach all Medicare 
beneficiaries and must be able to directly bill for telehealth services 
as a distant site provider.

      Make permanent the Health and Human Services (HHS) emergency 
waiver authority for virtual care so that it can be quickly leveraged 
during future emergencies. Telehealth has maintained critical 
connections between patients and health-care practitioners during the 
pandemic, and should be enabled for a future wildfire, flood, 
hurricane, or other emergency.

      Make permanent the HDHP/HSA Telehealth Safe Harbor created in 
Section 3701 of the CARES Act. This provision allows Americans with 
health savings account (HSA) eligible high deductible health plans 
(HDHP) to receive cost-free or discounted telehealth and remote care 
services prior to the patient reaching their deductible. According to 
the Bureau of Labor Statistics (BLS), only 15 percent of workers 
employed in the private sector participated in an HDHP in 2010. By 
2018, that number had risen to 45 percent. With significant numbers of 
American workers now relying on coverage through account-based plans, 
policymakers can meaningfully expand access to care by permanently 
allowing first-dollar coverage of virtual care under HDHPs.

      Allow employers to offer telehealth benefits for seasonal and 
part-time workers. Congress should designate standalone telehealth as 
an excepted benefit so that this service can be offered to part-time 
employees, seasonal workers, interns, new employees in a waiting 
period, etc. Currently, standalone telehealth benefits are considered a 
``health plan'' under Affordable Care Act (ACA) rules. That means they 
must be paired with a full medical benefit that meets all of the 
different ACA requirements. In June 2020, the Department of Labor 
created flexibility \8\ for large employers to offer telehealth to non-
eligible employees but this access will end with the PHE.
---------------------------------------------------------------------------
    \8\ https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-
activities/resource-center/faqs/aca-part-43.pdf.

      Enable the Centers for Medicare and Medicaid Services (CMS) to 
investigate and retain some ``Hospital Without Walls'' authorities 
after the end of the public health emergency and encourage that these 
authorities be used to maintain site of care flexibility whenever the 
services provided are clinically appropriate for virtual delivery. We 
believe that expanded capability for hospitals to remotely monitor and 
care for patients could lead to shorter or avoided hospital stays and 
lower costs--a potential benefit for both seniors and the Medicare 
---------------------------------------------------------------------------
program.

      Fund a comprehensive study of telehealth during the COVID-19 
pandemic using claims data and qualitative interviews with providers 
and patients who used telehealth during the pandemic. The study should 
to answer specific questions critical to future telehealth decision-
making by Congress and regulators at CMS. Suggested priorities include:

        1.  Is telehealth being adequately leveraged to address health 
disparities, and what policies could Congress or HHS enact to ensure 
telehealth is a tool to increase access to those most in need of health 
care?
        2.  To what extent are Medicare telehealth services during the 
PHE replacing in-person care?
              How often to telehealth services require a follow-up in 
person visit and how often are they fulfilling patient needs?
              Is the availability of telehealth increasing 
utilization, and if so, are they primary care or preventative services 
with the potential to prevent a more costly encounter downstream?
        3.  Are there specific, high-cost areas of the Medicare program 
that might lower long-term costs through telehealth utilization?
              Are care coordination codes that have been shown to 
improve care such as 99495 and 99496 being used more frequently during 
virtual care?
              Has the shift to using telehealth to manage lower acuity 
conditions in skilled nursing facilities prevented unnecessary 
transfers to hospitals?
        4.  To what extent have CMS permissions for virtual/remote 
supervision of health-care professionals been utilized during the 
COVID-19 pandemic? Have these permissions resulted in patient harm? How 
have health-care providers expanded their capability and capacity using 
this tool during the PHE.
        5.  In addition to HHS investigations of fraud and abuse, what 
has been the health-care provider, patient, and health plan experience 
with fraud perpetrated through virtual tools during the PHE?

      Facilitate the removal of remaining telehealth restrictions on 
alternative payment models
          Accountable Care Organization's (ACO) telehealth 
flexibility is limited a narrow set of ACOs with downside risk and 
prospective assignment--even though other tools apply to all ACOs. 
Since all participants in the Medicare Shared Savings Program are being 
held accountable for quality, cost, and patient experience, all of them 
should have flexibility to use telehealth tools to deliver care. We 
recommend eliminating Sec. 1899. [42 U.S.C. 1395jjj] (I)(2) 
requirements limiting participation to a select set of ACOs. (We 
believe CMS may already have the statutory authority to make these 
changes under 42 U.S.C. 1315a(d)(1) and 42 U.S.C. 1395jjj(f) if 
directing the use of authority instead would keep the score down)

      Allow the Centers for Medicare and Medicaid Services to cover 
audio-only telehealth services where necessary to bridge gaps in access 
to care. This would include, at a minimum, flexibility for areas with 
limited broadband service, for populations without telehealth-capable 
devices, or in necessary situations such as a future public health 
emergency. We anticipate that CMS would also maintain a list of 
services that were appropriate for this emergency audio-only care, as 
it has done during the PHE, and that the clinician would document the 
reason.

      Expand virtual chronic disease interventions with the potential 
to prevent downstream costs to the Medicare program. The most obvious 
example are virtual diabetes prevention programs (DPP), which can 
produce transformative weight loss reducing the prevalence of obesity 
and comorbidities including prediabetes and type 2 diabetes. These 
programs can produce better outcomes for patients and would likely 
reduce downstream costs to the Medicare program, not only by expanding 
access to a broader set of beneficiaries but by keeping patients 
engaged and creating more sustainable lifestyle changes. During the 
COVID-19 PHE, CMS has allowed DPP providers to practice virtually, but 
it has not created a long-term pathway for virtual DPP programs. As 
much of the commercial market has already moved to virtual care and 
app-driven interventions, the DPP program must be able to adapt to meet 
patients where they are and expand access to services for individuals 
not near a physical DPP provider.

      Expand the mandate of the Office for the Advancement of 
Telehealth at HRSA and require it to develop tools and resources on 
telehealth services that can be distributed to small health-care 
practices, patients, and consumer organizations. Additionally, explore 
partnerships with leading consumer and patient organizations to educate 
seniors about telehealth services, including the use of technology and 
how to verify the identity of a health-care provider.

      Encourage CMS to continue facilitating greater use of remote 
patient monitoring (RPM) technology through policy, including ongoing 
flexibility for allowing acceptance of patient-reported data for scales 
up to meet connected device requirements.

Recommendations for Fraud, Waste, and Abuse

The Alliance understands that with change sometimes comes risk, and 
that Congress holds ultimate authority for protecting the Medicare 
program. We understand and respect this responsibility. We also believe 
that, using the data we are collecting about the provision of 
telehealth services during the PHE, the Medicare program and the Office 
of the Inspector General at HHS will be able to target and 
differentiate nearly all fraudulent behavior. Congress must trust this 
capability and authority, rather than creating barriers to access 
between Medicare beneficiaries and critical health services.

The Alliance and its members strongly believe that an in-person 
requirement, as Congress created in the Consolidated Appropriations 
Act, 2021 (Pub. L. 116-260) is never the right guardrail for a 
telehealth service. Requiring an in-person visit constrains telehealth 
from helping individuals that are homebound, have transportation 
challenges, live in underserved areas, etc. It does not constrain those 
using telehealth for convenience. This creates a perversion of the 
Medicare payment system by reducing access for those who need it most, 
while allowing access for others. We cannot create a guardrail that is 
an access barrier between patients and their clinicians--it will lead 
to harm the most vulnerable and access-constrained Medicare 
beneficiaries.

We also believe it is important to note that nearly all of the fraud 
Congress may seek to prevent is fraud that mirrors activities currently 
occurring during in-person care. These concerns include fraudulent 
Medicare enrollment, false claims, fake patients, and durable medical 
equipment (DME) prescribing. All of these issues are problems for the 
Medicare program--and should be addressed as Medicare fraud problems. 
They are not new problems for telehealth services. Therefore, an in-
person requirement would hinder legitimate telehealth providers while 
doing very little to stop fraudulent actors. Instead of creating 
barriers to services for Medicare beneficiaries, Congress must empower 
CMS to address fraudulent actors.

We are pleased to note that on February 26, 2021, OIG Principal Deputy 
Inspector General Grimm issued a statement \9\ to this effect--
differentiating between fraud perpetrated through virtual tools and 
telehealth fraud.
---------------------------------------------------------------------------
    \9\ https://oig.hhs.gov/coronavirus/letter-grimm-
02262021.asp?utm_source=oig-home&utm_
medium=oig-hero&utm_campaign=oig-grimm-letter-02262021.

        We are aware of concerns raised regarding enforcement actions 
        related to ``telefraud'' schemes, and it is important to 
        distinguish those schemes from telehealth fraud. In the last 
        few years, OIG has conducted several large investigations of 
        fraud schemes that inappropriately leveraged the reach of 
        telemarketing schemes in combination with unscrupulous doctors 
        conducting sham remote visits to increase the size and scale of 
        the perpetrator's criminal operations. In many cases, the 
        criminals did not bill for the sham telehealth visit. Instead, 
        the perpetrators billed fraudulently for other items or 
        services, like durable medical equipment or genetic tests. We 
        will continue to vigilantly pursue these ``telefraud'' schemes 
        and monitor the evolution of scams that may relate to 
        telehealth.

Recommendations

With the understanding the Congress may still want to pursue additional 
guardrails against fraud, waste, and abuse as part of telehealth 
legislation, we offer the following alternatives. Please note that many 
of these are simple regulatory changes, and could be issued as 
recommendations to CMS.

      Enhance the ability of HHS to fight fraud in Medicare through 
new resources and capacity
          Provide additional funding for OIG to strengthen 
existing fraud, waste, and abuse mechanisms that have already been 
proven successful in fighting fraud perpetrated through virtual tools. 
The House Ways and Means minority staff has proposed workable text to 
this effect that we support.
          We also support the development of OIG telehealth 
compliance guidance to health-care organizations to help prevent and 
mitigate unintentional mistakes related to Medicare telehealth billing.
          Strengthen the Public-Private Partnership for 
Health Care Waste, Fraud and Abuse Detection created by the 
Consolidated Appropriations Act of 2021 (Section 1128C(a) of the Social 
Security Act (42 U.S.C. 1320a-7c(a))). This public-private partnership 
must be empowered with experts with experience in virtual care delivery 
and payment.
              After--(6)(E)(i)(II) add ``(III) The executive board 
shall include no less than 3 individuals with significant expertise 
delivering and managing the delivery of virtual care, including 
practitioners, medical directors and individuals with oversight of 
telehealth programs, and virtual care experts with experience in 
corporate fraud prevention.

      Work with CMS to develop restrictions on the solicitation of 
Medicare Fee-For-Service telehealth services. It is our understanding 
that one of the primary ways in which fraudulent actors exploit virtual 
services is by calling Medicare beneficiaries to solicit their 
interested in high-value DME products. We believe a restriction on 
marketing, as currently exists for DME, would significantly hinder 
situations in which DME fraud actors exploit telehealth services to 
drive DME sales. As long as there was a significant allowance for 
legitimate marketing practices, we do not believe this restriction 
would hinder legitimate telehealth providers.

      Work with CMS to strengthen the Medicare provider enrollment 
process. The provider enrollment process is the best tool to prevent 
fraudulent actors from billing the Medicare program. Rather 
strengthened to identify and screen higher risk entrants.

      Encourage CMS to advantage of the enhanced data capabilities 
present in most telehealth platforms. Technology platforms that provide 
telehealth are often capable of automatically recording times, dates, 
patient information, prescribing, and other details which can be used 
to enhance compliance. These technologies should allow for the greater 
use of audits and other forms of retroactive monitoring approaches on 
providers. As long as data capture requirements are very clear, and 
that compliance with any requirements do not impose a significant 
regulatory burden they could be a compliance tool. (Please note that 
very small- providers should likely be exempted from these burdens.)

      Work with CMS to develop targeted restrictions on high-value, 
high-risk DME prescribing through telehealth. While we continue to 
believe that there are some appropriate circumstances for this 
prescribing, a step like this could significantly lower risk to the 
Medicare program.

Thank you for your consideration of these recommendations. Some 
combination of these recommendations could protect the Medicare program 
while aligning with the recommendations of the Task Force on Telehealth 
Policy,\10\ which stated ``we should not hold telehealth to higher 
standards than other care sites, and we should trust clinicians 
providing telehealth services to triage patients needing a higher level 
or care or in-patient care, as we do in other care settings. As is done 
in other care settings, patients' preference for obtaining care in-
person or via telehealth should be respected.''
---------------------------------------------------------------------------
    \10\ https://www.ncqa.org/programs/data-and-information-technology/
telehealth/taskforce-on-telehealth-policy/taskforce-on-telehealth-
policy-findings-and-recommendations-overarching-issues/.

Thank you for your consideration--we look forward to working with you 
on this important effort. Please contact Chris Adamec at 
---------------------------------------------------------------------------
[email protected] with any questions.

Sincerely,

Krista Drobac
Executive Director

                                 ______
                                 
                    America's Health Insurance Plans

                      601 Pennsylvania Avenue, NW

                       South Building, Suite 500

                          Washington, DC 20004

Everyone deserves access to affordable, high-quality care and coverage. 
This is a core principle for health insurance providers and our 
industry. America's Health Insurance Plans (AHIP) greatly appreciates 
the Committee holding this hearing on COVID-19 health-care 
flexibilities.\1\
---------------------------------------------------------------------------
    \1\ America's Health Insurance Plans (AHIP) is the national 
association whose members provide coverage for health care and related 
services to millions of Americans every day. Through these offerings, 
we improve and protect the health and financial security of consumers, 
families, businesses, communities, and the nation. We are committed to 
market-based solutions and public-private partnerships that improve 
affordability, value, access, and well-being for consumers.

Through temporary flexibilities enacted during the national emergency 
period, health insurance providers have expanded access to virtual care 
via telehealth so that Americans can get the care they need when and 
where they need it. Health insurance providers have also innovated the 
way care can be delivered, especially for individuals who are homebound 
to ensure the safety and well-being of their members during the COVID-
---------------------------------------------------------------------------
19 pandemic.

AHIP looks forward to working with the Committee to ensure that many of 
the flexibilities enacted during the pandemic will endure beyond COVID-
19 in order to continue to provide Americans with affordable, 
convenient, high quality care.

Telehealth Growth During COVID-19

The COVID-19 crisis led to an exponential increase in telehealth use as 
a safe and convenient way for people to access needed care. Telehealth 
claims increased over 8,000 percent in April 2020 compared to April 
2019.\2\ Several health insurance providers have seen 50 times the 
number of telehealth claims as in years past, with telehealth claims in 
some cases comprising roughly 25 percent of all claims in 2020.\3\ 
Among those experiencing significant growth are Blue Cross of Idaho, 
which processed more than 90,500 telehealth claims between March and 
June of 2020, with telehealth representing more than one-quarter of all 
claims.\4\
---------------------------------------------------------------------------
    \2\ https://www.fairhealth.org/states-by-the-numbers/telehealth.
    \3\ https://www.ahip.org/telehealth-growth-during-covid-19/.
    \4\ https://www.ahip.org/telehealth-growth-during-covid-19/.

Patients and providers understand and experience the value of 
telehealth. They accept--and often prefer--digital technologies as an 
essential part of health-care delivery. Telehealth delivers convenient 
---------------------------------------------------------------------------
access to affordable, high-quality care.

Patients have taken advantage of telehealth from wherever they are, 
making it a vital tool to bridge health-care gaps nationwide. For 
patients in rural communities or underserved areas with a shortage of 
practicing clinicians, telehealth programs and remote patient 
monitoring can make care more accessible, efficient, and sustainable 
than it otherwise would be. Patients can connect with a doctor within 
seconds rather than driving long distances for an office visit. 
Patients who can access care remotely can also avoid challenges 
associated with taking time off work or finding childcare. Those 
accessing behavioral health services can do so from the privacy of 
their own homes and free from stigma. Telehealth is a tool that can 
connect patients with care in the most convenient, comfortable 
settings--without the challenges of finding in-person care.

Additionally, telehealth costs less. Even before the pandemic, 93 
percent of consumers who used telehealth said that it has lowered their 
health-care costs.\5\ Furthermore, studies have shown that a virtual 
visit can save up to $100 compared to a visit in other care settings 
(e.g., urgent care, primary care, emergency room) when accounting for 
cost of services, cost of travel to a physical care setting, and lost 
earnings associated with travel and wait times.\6\
---------------------------------------------------------------------------
    \5\ https://www.prnewswire.com/news-releases/39-of-tech-savvy-
consumers-have-not-heard-of-telemedicine-healthmine-survey-
300241737.html.
    \6\ https://news.regence.com/releases/regence-data-measures-real-
world-savings-for-telehealth-users.

By connecting patients with convenient care, providers are also 
reporting lower no-show rates with telehealth.\7\ Telehealth can lead 
to better management of chronic diseases, reduced travel times, reduced 
emergency department visits, and fewer or shorter hospital stays.\8\ 
Patients are healthier and have better peace of mind by getting the 
right care at the right time and in the right setting.
---------------------------------------------------------------------------
    \7\ https://www.healthcareitnews.com/news/telehealth-linked-ehr-
drastically-reduces-no-show
-rate-garfield-health-
center#::text=Data%20for%20October%202020%20shows,the%20office%20
for%20an%20appointment.
    \8\ https://www.ahip.org/wp-content/uploads/FactSheet_Telehealth-
030719.pdf.

Faster expansion of telehealth has been made possible through 
flexibilities implemented during the COVID-19 crisis. For instance, the 
Coronavirus Preparedness and Response Supplemental Appropriations Act 
(CARES Act) temporarily authorized the Secretary of Health and Human 
Services (HHS) to waive originating site requirements for telehealth 
services under Medicare, as well as allowing reimbursement of more 
video-enabled telehealth and audio-only telehealth services for the 
duration of the COVID-19 public health emergency (PHE). HHS also 
expanded the number and types of providers who are eligible and 
licensed to deliver care via telehealth and allowed providers to waive 
telehealth visit cost-sharing for Federal health-care programs.\9\ 
Medicare Advantage (MA) plans were also allowed to waive or reduce 
enrollee cost-sharing for telehealth benefits and expand coverage of 
telehealth services beyond those approved in the plan's benefit 
package.\10\ These measures allowed for greater flexibility in 
telehealth use for both patients and providers, leading to exponential 
growth in use.
---------------------------------------------------------------------------
    \9\ 45 CFR Sec. Sec. 160, 164 (2020). See www.govinfo.gov/content/
pkg/FR-2020-04-21/pdf/2020-08416.pdf (accessed February 23, 2021).
    \10\ https://www.cms.gov/files/document/updated-guidance-ma-and-
part-d-plan-sponsors-42120.pdf.

The Centers for Medicare and Medicaid Services (CMS) issued guidance 
allowing health insurance providers in the individual and group market 
to amend plan benefits during the 2020 plan year to expand coverage for 
telehealth services.\11\ Many health insurance providers have since 
reduced or eliminated cost-sharing for telehealth during the PHE, and 
broadened coverage of telehealth benefits by expanding coverage options 
and increasing telehealth provider networks. CMS issued guidance on 
remote supervision of nurse practitioners and physician assistants, 
expanding the capacity to treat patients without requiring every 
element of care to be in-
person. These policies helped many patients remain safe from possible 
and unnecessary exposure to COVID-19 in waiting rooms or other in-
person care settings while still ensuring that patients received high-
quality care.
---------------------------------------------------------------------------
    \11\ www.cms.gov/files/document/faqs-telehealth-covid-19.pdf.

Many states provided similar flexibilities in state Medicaid and CHIP 
programs and facilitated the delivery of telehealth by modifying 
provider licensure restrictions that have long served as a barrier to 
the effective delivery of telehealth.\12\ However, most of the actions 
on both the state and federal levels are limited in scope and temporary 
for the public health emergency. Long-term telehealth policy changes 
are necessary to drive innovation, promote investment, and address 
patient needs during periods of stability and crisis.
---------------------------------------------------------------------------
    \12\ Spring2021_SummaryChartFINAL.pdf (digitaloceanspaces.com).
---------------------------------------------------------------------------

Homebound Care During COVID-19

As the COVID-19 crisis disrupted lives and livelihoods, it also 
worsened health disparities and access to care for vulnerable 
populations, including homebound populations and seniors. Additionally, 
many home health and home and community-based services (HCBS) providers 
lacked sufficient supplies of personal protective equipment (PPE), 
creating significant risk for providers and patients, and exacerbating 
the challenges in reaching patients who were afraid to receive care out 
of concern over potential exposure to COVID-19.

Nationally, between 2 million and 4.4 million older adults are 
homebound with the vast majority receiving services from Medicare, 
Medicaid, or both.\13\ More than 600,000 people receive Medicaid funded 
home health services, 1.2 million people receive Medicaid funded 
personal care services, and total enrollment in Medicaid HCBS waivers 
exceed 2.5 million people. According to a 2019 MedPAC report, about 3.4 
million Medicare beneficiaries received home health care in 2017.\14\
---------------------------------------------------------------------------
    \13\ https://www.washingtonpost.com/health/vaccinating-homebound-
seniors/2021/03/26/a06c71f8-7620-11eb-9537-496158cc5fd9_story.html.
    \14\ http://www.medpac.gov/docs/default-source/reports/
mar19_medpac_ch9_sec.pdf?sfvrsn=0#
::text=In%202017%2C%20about%203.4%20million%20Medicare%20beneficiaries%
20received%20
home%20care,billion%20on%20home%20health%20services.

Medicare requires that individuals be homebound to receive home health 
care. Given limits on the use of Medicare's home health benefit, there 
are significant numbers of Medicare beneficiaries who are in fact 
homebound but not receiving home health services. In 2011, the 
prevalence of homebound Medicare beneficiaries was estimated to be 5.6 
percent, or about 2 million people.\15\ Applying the same percentage to 
today's Medicare population, an estimated 3.5 million Medicare 
beneficiaries are homebound. During the public health emergency (PHE), 
CMS expanded the Medicare definition of homebound to allow patients to 
be considered such if it is medically contraindicated for the patient 
to leave the home. This includes patients with a confirmed or suspected 
COVID-19 diagnosis or patients with conditions making them more 
susceptible to contract COVID-19.
---------------------------------------------------------------------------
    \15\ https://www.researchgate.net/publication/
277251465_Epidemiology_of_the_Homebound_
Population_in_the_United_States.

The Biden Administration proposed to increase funding for HCBS by $400 
billion in the American Jobs Plans and recently outlined $1.4 billion 
in funding from the American Rescue Plan for Older Americans Act 
programs, including programs to support vaccine outreach and 
coordination, address social isolation, provide family caregiver 
support, and offer nutrition support.\16\ As part of the American 
Rescue Plan Act, states can also receive a temporary 10 percentage 
point increase to the federal medical assistance percentage (FMAP) for 
certain Medicaid HCBS from April 1, 2021, through March 31, 2022.
---------------------------------------------------------------------------
    \16\ https://www.whitehouse.gov/briefing-room/statements-releases/
2021/05/03/fact-sheet-biden-harris-administration-delivers-funds-to-
support-the-health-of-older-americans/.

Health insurance providers know that many Americans are homebound or 
rely on caregivers and family members to manage their health even under 
normal conditions. Plans are playing a leadership role in meeting the 
medical and social needs of their members and helping to provide 
emotional support to members, their families, and caregivers, and 
making sure individuals and caregivers have access to peer coaches and 
support specialists with information on social services.

 Health Insurance Providers Are Committed to Delivering Affordable and 
                    Convenient Care Through Telehealth and Homebound 
                    Care

During the COVID-19 crisis, health insurance providers have expanded 
and innovated in the way care is delivered. Many of AHIP's member 
companies significantly expanded telehealth accessibility and benefits, 
effectively encouraging people to continue to receive care they need 
despite the public health crisis.

Those who are older, live in rural areas, are a racial or ethnic 
minority, have a lower socioeconomic status, or represent other 
vulnerable populations may have less access to broadband and other 
technologies and resources necessary to fully leverage the promise of 
telehealth.\17\ These same populations often face disparities in access 
to in-person services.
---------------------------------------------------------------------------
    \17\ https://www.pewresearch.org/fact-tank/2019/05/07/digital-
divide-persists-even-as-lower-income-americans-make-gains-in-tech-
adoption/; https://www.pewresearch.org/fact-tank/2019/08/20/
smartphones-help-blacks-hispanics-bridge-some-but-not-all-digital-gaps-
with-whites/. 

America's health insurance providers embrace digital solutions that 
help increase access to care and want to ensure that the people they 
serve, regardless of where they live or their economic situation, can 
---------------------------------------------------------------------------
access safe and convenient care. For instance:

      Centene has worked with Samsung Electronics America to supply 
providers with 13,000 Samsung Galaxy A10e smartphones to disseminate to 
patients who would not otherwise be able to receive their health care 
virtually.
      CareOregon is working with providers to supply flip phones and 
basic smartphones along with data plans for their members.
      Blue Shield Promise (the Medicaid Managed Care Organization of 
Blue Shield of California) and LA Care partnered to establish resource 
centers for local communities to provide members with wellness programs 
and to connect them with local resources to address socioeconomic 
needs. As their services and programs moved online due to COVID-19, 
Blue Shield Promise and LA Care offered technology and Wi-Fi to help 
their members access virtual programs, services, and telehealth.

Health insurance providers are encouraging their vulnerable members, 
particularly older people and others who may have delayed care, to get 
their preventive screenings, routine care, and chronic condition 
management despite the COVID-19 pandemic.

      Bright Health makes non-emergency transportation available for 
all members, and ride limits are being waived for non-emergency visits 
to and from their doctor.
      Priority Health has partnered with technology company Papa to 
connect college students with Medicare members with specific chronic 
conditions who need assistance with transportation, house chores, 
technology lessons, companionship, and other senior services.
      Humana mailed more than 1 million in-home preventive screening 
kits to members in 2020, helping increase access to routine screenings 
that many members have put off during the COVID-19 crisis.

Health insurance providers have also taken proactive actions to provide 
COVID vaccines for vulnerable seniors, individuals who are homebound, 
and other vulnerable populations.

Given the vast majority of Medicare beneficiaries are enrolled in 
Medicare Advantage or Medicare Part D (50.8 million)\18\ and 40 \19\ 
states leverage Medicaid Managed Care as their delivery system 
(including 25 \20\ who use health plans to deliver managed long-term 
services and supports), health insurance providers are uniquely 
situated to help get the homebound population vaccinated quickly, 
effectively, and equitably.
---------------------------------------------------------------------------
    \18\ https://www.cms.gov/research-statistics-data-and-
systemsstatistics-trends-and-reportsmcra
dvpartdenroldatamonthly/contract-summary-2021-05.
    \19\ https://www.kff.org/medicaid/issue-brief/10-things-to-know-
about-medicaid-managed-care
/
#::text=As%20of%20July%202019%2C%2040,Medicaid%20beneficiaries%20(Figur
e%201).
    \20\ https://www.macpac.gov/subtopic/managed-long-term-services-
and-supports/.

On March 3, 2021, the White House, America's Health Insurance Plans 
(AHIP) and the Blue Cross Blue Shield Association announced the Vaccine 
Community Connectors (VCC) pilot initiative. As vaccine supplies expand 
and appointments become more available, health insurance providers have 
---------------------------------------------------------------------------
committed to use their combined expertise, data, and insights to:

      Identify seniors who are vulnerable to COVID-19 and who live in 
areas where vaccination rates are most inequitable;
      Work with partners in the community to educate seniors on the 
safety, efficacy, and value of COVID-19 vaccines;
      Contact those seniors who are eligible to get a vaccine through 
multiple channels to facilitate vaccine appointment scheduling;
      Coordinate services to help overcome barriers that may stand 
between them and getting vaccinated; and
      Track and report progress to ensure those who need vaccinations 
most are receiving them.

The VCC has since expanded to include the Medicaid population, many of 
whom are members of the at-risk and underserved communities this 
program aims to reach.\21\
---------------------------------------------------------------------------
    \21\ https://www.communityplans.net/acap-joins-ahip-bcbsa-in-
advancing-vaccine-accessibility-and-equity-initiative/.

As part of these broader vaccination efforts, health insurance 
providers are helping vulnerable, homebound individuals to receive the 
COVID-19 vaccine. Examples of health plans partnering to address the 
---------------------------------------------------------------------------
needs of homebound individuals are growing across the country include:

      Commonwealth Care Alliance (CCA) has partnered with the 
Commonwealth of Massachusetts to lead the state's effort to vaccinate 
homebound individuals. In this partnership, CCA serves as the vaccine 
coordinator for the Massachusetts homebound population. CCA manages a 
technological, logistical, and provider infrastructure to receive 
referrals of state-screened homebound residents for outreach and 
appointment scheduling, vaccine distribution, delivery of vaccines to 
people's homes, and reporting on their performance. CCA has expanded 
the program to all homebound individuals in Massachusetts, regardless 
of health plan.\22\
---------------------------------------------------------------------------
    \22\ https://www.commonwealthcarealliance.org/news/2021/march/
commonwealth-care-alliance-to-lead-massachusetts-h.
---------------------------------------------------------------------------
      SCAN Health Plan provides in-home COVID-19 vaccinations to 
homebound plan members and their families in Los Angeles County. The 
vaccination program is made possible through a unique partnership 
between SCAN and MedArrive, a logistics platform that enables health-
care payers and providers to seamlessly extend care services into the 
home, unlocking access to highly qualified, trusted EMTs and 
Paramedics. The vaccines are being administered by trained EMTs at no 
cost to the members. Caregivers and other eligible household members 
are also receiving the vaccine at no cost.\23\
---------------------------------------------------------------------------
    \23\ https://www.businesswire.com/news/home/20210426005231/en/.
---------------------------------------------------------------------------
      HealthPartners has collaborated with 10 health systems across 
Minnesota to coordinate efforts to distribute and administer vaccines, 
leveraging HealthPartners' home health subsidiary to offer vaccines in 
people's homes.
      Blue Cross Blue Shield of Tennessee is bringing vaccines to 
their homebound members by working with local health departments, 
provider partners, and local emergency services to identify, educate, 
and deliver vaccines to those with mobility issues.

 Policy Recommendations to Strengthen Health Care Flexibilities, 
                    Telehealth and Homebound Care

AHIP is ready to work with Congress and the Administration to 
strengthen telehealth and homebound care and establish policies that 
ensure the programs' long-term sustainability. Policymakers can further 
advance this work by embracing comprehensive, multi-stakeholder 
approaches:

(1) Make permanent the flexibilities in benefit design implemented 
during the PHE. The Coronavirus Preparedness and Response Supplemental 
Appropriations Act allowed the HHS Secretary to waive certain Medicare 
telehealth payment requirements and the CARES Act enacted flexibility 
for commercial health insurance providers to cover telemedicine. 
Congress should pass legislation to make these provisions permanent and 
redefine how Medicare and commercial (e.g., employer-sponsored 
coverage) and individual market enrollees can access telehealth. To 
solidify several regulations implemented by CMS and HHS during the 
COVID-19 crisis, Congress should revise section 1834(m) of the Social 
Security Act to allow for flexibility in benefit design for originating 
sites, eligible geographies, eligible services, and eligible providers. 
In reviewing this law, we encourage Congress is to leave room for 
flexibility and innovation--the speed at which telehealth and virtual 
care evolved during the COVID-19 crisis alone shows how quickly the 
care delivery landscape can change. We recommend against lawmakers 
attempting to strictly define the future of virtual care and instead 
allowing health insurance providers and other innovators the 
opportunities to connect patients with the most convenient, affordable, 
and high-quality care available.

Additionally, while telehealth may be no more subject to fraud and 
abuse than other modalities, it will be essential to monitor the impact 
of telehealth on health outcomes, including quality and costs.

(2) Pass S. 150, the Ensuring Parity in MA for Audio-Only Telehealth 
Act of 2021. This bipartisan bill would reduce health disparities that 
result from unequal access to health technology, broadband service, and 
video telehealth platforms. It would also ensure that the more than 
26.5 million seniors and people with disabilities who receive their 
Medicare benefits through Medicare Advantage (MA) and PACE continue to 
receive the high-quality care on which they rely.

Rural patients may have trouble accessing technology or broadband 
services necessary to support video-enabled telehealth. Additionally, 
seniors or frail populations may have physical limitations that prevent 
them from using video-enabled telehealth platforms. An audio-only 
telehealth visit may be the only option for these patients to safely 
and conveniently access needed care. MA plans have taken decisive steps 
to support these patients by expanding telehealth services, including 
providing coverage for telephonic (also known as ``audio-only'') 
telehealth at the onset of the COVID-19 pandemic despite CMS's decision 
to exclude diagnoses identified during the delivery of this care in 
determining the severity of those patients' health conditions.

In addition, allowing diagnoses from audio-only telehealth services to 
count for MA and PACE risk adjustment will help ensure patient health 
costs are adequately accounted for and reimbursed. Without the accurate 
documentation of diagnoses for MA and PACE risk adjustment, the 
programs will effectively experience cuts, leaving MA and PACE 
organizations and providers with fewer resources necessary to care for 
patients. This could lead to unequal access, fewer choices, higher 
premiums, or reduced benefits for beneficiaries in the long run. Given 
that MA and PACE plan rates are benchmarked at the county level, this 
impact could be particularly acute in areas where accessing video-
enabled telehealth posed more significant challenges for many 
enrollees, enhancing disparities between communities on either side of 
the digital divide.

That is why AHIP strongly supports S. 150, the Ensuring Parity in MA 
for Audio-Only Telehealth Act of 2021, introduced by Senators Catherine 
Cortez Masto and Tim Scott. This bipartisan legislation would reduce 
health disparities due to unequal access to health technology while 
supporting the more than 26.5 million Americans enrolled in MA and PACE 
and the providers who have cared for them throughout the COVID-19 
crisis.

AHIP recently joined with 17 other health-care organizations in support 
of the bill.\24\ We appreciate the Committee's focus on the importance 
of telehealth and the recognition that for many Medicare beneficiaries, 
a phone call is their best or only option for immediately accessing 
health care. We look forward to working with the lead sponsors of S. 
150 and the Senate Finance Committee to support the MA and PACE 
programs, their provider partners, and the 43 percent of Medicare 
beneficiaries choosing these programs for their care.
---------------------------------------------------------------------------
    \24\ https://www.ahip.org/wp-content/uploads/04.28.21-Stakeholder-
LoS-HR-2166-and-S-150.
pdf.

(3) Improve Workforce Opportunity and Support for Caregivers and Home 
Health Care Providers. Lack of training, lack of opportunity, and low 
wages lead to low job satisfaction, high rates of caregiver burnout, 
and high rates of turnover. Many in the workforce cite lack of 
professional development and growth as a reason for exiting the direct 
care workforce. Studies have shown a decrease in departures among 
workers who are offered training and a career ladder.\25\ Policymakers 
and health insurance providers must champion efforts to create training 
opportunities and develop pathways to promotion.
---------------------------------------------------------------------------
    \25\ https://www.leadingage.org/sites/default/files/
Direct%20Care%20Workers%20Report%20%
20FINAL%20%282%29.pdf.

(4) Sustain Funding for HCBS. We support enacting measures that 
incentivize adoption and expansion of HCBS as an alternative to 
institutional care in state Medicaid programs. Policies such as 
sustained enhanced federal financial participation and flexibilities 
for states in developing HCBS infrastructure are key elements in making 
---------------------------------------------------------------------------
home-based care available to everyone who needs it.

(5) Extend Telehealth Safe Harbor for High Deductible Health Plans. The 
CARES Act created a temporary safe harbor for High Deductible Health 
Plans (HDHPs) that may be paired with tax-advantaged Health Savings 
Accounts (HSAs) to allow health insurance providers offering those 
plans to pay for telehealth services without applying a deductible. 
This safe harbor has allowed plans to offer benefits that better serve 
the needs of the more than 32 million Americans enrolled in these 
plans, particularly during the pandemic. This flexibility is both cost-
effective and, as with access to virtual care in other plan types, 
highly responsive to patient needs. The safe harbor applies only to 
commercial health plans that begin prior to December 31, 2021, and many 
health insurance providers and their employer clients would like to see 
this safe harbor extended. There continues to be strong bipartisan 
support for extending the safe harbor and promoting greater utilization 
of telehealth among commercial plans while helping working families 
access care when it is convenient to them without imposing undue costs. 
We urge Congress to take bipartisan action to extend this highly 
popular change to HDHPs.

Conclusion

Everyone deserves access to affordable, high-quality care, whether 
delivered directly to a person in their home or virtually. Together 
with the Administration, Congress, and our provider partners, health 
insurance providers are working to ensure that patients continue to 
have access to health care when they need it so that no community is 
left behind. AHIP thanks the Committee for focusing on this important 
issue, and we look forward to working together on more initiatives to 
improve health care in every community.

                                 ______
                                 
              American Association of Nurse Practitioners
On behalf of the more than 118,000 individual members of the American 
Association of Nurse Practitioners (AANP), and the over 325,000 nurse 
practitioners (NPs) across the nation, we appreciate the opportunity to 
provide the following statement for the record to the United States 
Senate Committee on Finance (the Committee). We commend Chairman Wyden, 
Ranking Member Crapo and the members of the Committee for holding this 
hearing on the experiences and lessons learned regarding COVID-19 
flexibilities. NPs have been on the front lines providing care to 
patients since the onset of this pandemic, and many of these 
flexibilities, specifically those related to telehealth and workforce 
expansion, have been integral in their ability to provide high-quality 
and timely care to patients. Making these waivers permanent will 
increase patient access to health care, particularly in rural and 
underserved communities, and help alleviate the health-care disparities 
that were exacerbated by this pandemic.

As you are aware, NPs are advanced practice registered nurses who are 
prepared at the masters or doctoral level to provide primary, acute, 
chronic and specialty care to patients of all ages and walks of life. 
Daily practice includes: assessment; ordering, performing, supervising 
and interpreting diagnostic and laboratory tests; making diagnoses; 
initiating and managing treatment including prescribing medication and 
non-pharmacologic treatments; coordinating care; counseling; and 
educating patients and their families and communities. NPs practice in 
nearly every health-care setting including clinics, hospitals, Veterans 
Health Administration and Indian Health Services facilities, emergency 
rooms, urgent care sites, private physician or NP practices (both 
managed and owned by NPs), skilled nursing facilities (SNFs), nursing 
facilities (NFs), schools, colleges and universities, retail clinics, 
public health departments, nurse managed clinics, homeless clinics, and 
home health. NPs hold prescriptive authority in all 50 states and the 
District of Columbia and complete more than one billion patient visits 
annually.

NPs have a particularly large impact on primary care as approximately 
70% of all NP graduates deliver primary care.\1\ NPs comprise 
approximately one quarter of the primary care workforce, with that 
percentage growing annually.\2\ They provide a substantial portion of 
health care in rural areas and areas of lower socioeconomic and health 
status. As such, they understand the barriers to care that face 
vulnerable populations on a daily basis.\3\, \4\, 
\5\ NPs are the second largest provider group in the National Health 
Services Corps \6\ and the number of NPs practicing in community health 
centers has grown significantly over the past decade.\7\
---------------------------------------------------------------------------
    \1\ https://www.aanp.org/about/all-about-nps/np-fact-sheet.
    \2\ ``Rural and Nonrural Primary Care Physician Practices 
Increasingly Rely on Nurse Practitioners,'' Hilary Barnes, Michael R. 
Richards, Matthew D. McHugh, and Grant Martsolf, Health Affairs 2018 
37:6, 908-914.
    \3\ Davis, M.A., Anthopolos, R., Tootoo, J., Titler, M., Bynum, 
J.P.W., and Shipman, S.A. (2018). ``Supply of Healthcare Providers in 
Relation to County Socioeconomic and Health Status.'' Journal of 
General Internal Medicine, 4-6. https://doi.org/10.1007/s11606-017-
4287-4.
    \4\ Xue, Y., Smith, J.A., and Spetz, J. (2019). ``Primary Care 
Nurse Practitioners and Physicians in Low-Income and Rural Areas, 2010-
2016.'' Journal of the American Medical Association, 321(1), 102-105.
    \5\ Andrilla, C.H.A., Patterson, D.G., Moore, T.E., Coulthard, C., 
and Larson, E.H. (2018). ``Projected Contributions of Nurse 
Practitioners and Physicians Assistants to Buprenorphine Treatment 
Services for Opioid Use Disorder in Rural Areas.'' Medical Care 
Research and Review, Epub ahead. https://doi.org/10.1177/
1077558718793070.
    \6\ https://www.hrsa.gov/sites/default/files/hrsa/about/budget/
budget-justification-fy2021.
pdf.
    \7\ https://www.nachc.org/wp-content/uploads/2020/01/Chartbook-
2020-Final.pdf.

As noted in the testimony before the Committee provided by Jessica 
Farb, Director of Health Care for the Government Accountability Office, 
the Medicare waivers issued by the Centers for Medicare and Medicaid 
Services (CMS) for the COVID-19 public health emergency (PHE) can 
broadly be broken into three categories: expansion of hospital 
services, workforce expansion and telehealth services. Our comments 
will focus on workforce expansion and telehealth services. First, we 
would like to highlight the impact that some of these flexibilities 
have had for our members, their patients and communities. For instance, 
AANP members have reported that the waiver authorizing NPs to perform 
the initial assessment and all other mandatory assessments in skilled 
nursing facilities has provided flexibility to meet the needs of 
skilled nursing facility (SNF) patients while also meeting the other 
demands that COVID-19 has placed on their communities. Additionally, 
increased coverage of telehealth and remote technologies, particularly 
coverage and increased reimbursement for audio-only services, has been 
an essential lifeline for meeting the needs of their patients. Many of 
our members have patients who lack access to audio-video technology, 
and they would have had to make the difficult choice between delaying 
care or risking exposure to COVID-19 if this authorization had not been 
made.

Workforce Expansion

During the PHE, CMS waived multiple barriers to practice within the 
Medicare program that have previously prevented nurse practitioners 
from practicing to the full extent of their education, clinical 
training and State scope of practice. Below are waivers that should be 
made permanent before the end of the PHE. These recommendations are 
consistent with the National Academies of Science, Engineering and 
Medicine report The Future of Nursing 2020-2030: Charting a Path to 
Achieve Health Equity which recommends that ``[b]y 2022, all changes in 
policies and state and federal laws adopted in response to COVID-19 
should be made permanent, including those that expanded scope of 
practice, telehealth eligibility, insurance coverage, and payment 
parity for services nurses provide.''\8\ The World Health 
Organization's State of the World's Nursing 2020 report also recommends 
modernizing regulations to authorize APRNs to practice to the full 
extent of their education and clinical training, and noted the positive 
impact this would have on addressing health-care disparities and 
improving health-care access within vulnerable communities.\9\
---------------------------------------------------------------------------
    \8\ https://www.nap.edu/resource/25982/
FON%20One%20Pagers%20Lifting%20Barriers.pdf.
    \9\ https://apps.who.int/iris/bitstream/handle/10665/331673/
9789240003293-eng.pdf.

Removing barriers to care for NPs and their patients has also garnered 
widespread bipartisan support. In addition to bipartisan support in 
Congress, reports issued by the American Enterprise Institute,\10\ the 
Brookings Institution,\11\ the Federal Trade Commission \12\ and the 
U.S. Department of Health and Human Services under the past two 
administrations \13\, \14\, \15\ have all 
highlighted the positive impact of removing barriers on NPs and their 
patients.
---------------------------------------------------------------------------
    \10\ https://www.aei.org/wp-content/uploads/2018/09/Nurse-
practitioners.pdf.
    \11\ https://www.brookings.edu/wp-content/uploads/2018/06/
AM_Web_20190122.pdf.
    \12\ https://www.aanp.org/advocacy/advocacy-resource/ftc-advocacy.
    \13\ https://www.hhs.gov/sites/default/files/Reforming-Americas-
Healthcare-System-Through-Choice-and-Competition.pdf.
    \14\ https://aspe.hhs.gov/pdf-report/impact-state-scope-practice-
laws-and-other-factors-practice-and-supply-primary-care-nurse-
practitioners.
    \15\ https://www.cms.gov/About-CMS/Agency-Information/OMH/
Downloads/Rural-Strategy-2018.pdf.

State experience has also shown that removing state restrictions on NP 
practice improve access to care for patients in rural areas, reduce 
unnecessary complications, lower costs and improve quality of life. 
Currently, twenty-three states and DC are considered Full Practice 
Authority (FPA) states because their licensure laws allow full and 
direct access to NPs. No state has ever moved away from FPA once it has 
---------------------------------------------------------------------------
been enacted.

States that restrict the legal authorization of NPs to practice their 
profession limit patient choice and decrease access to care, with 
particularly acute effects in rural areas.\16\ Recent studies have 
found that restrictive practice environments are associated with a 
lower percentage of NPs obtaining medication-assisted treatment (MAT) 
waivers.\17\ States that adopt FPA have found overall positive rural 
health-care workforce trends. Arizona adopted FPA in 2001 and found 
that ``the number of Arizona licensed NPs in the state increased 52% 
from 2002 to 2007'', with the largest increase occurring in rural 
areas.\18\ Other states that have reported similar workforce trends 
include Nevada,\19\ Nebraska \20\ and North Dakota.\21\ South Dakota 
also reported reduced administrative costs after adopting FPA.\22\ 
These results highlight the importance of removing barriers to practice 
on NPs to increase access to care for patients.
---------------------------------------------------------------------------
    \16\ https://www.ftc.gov/system/files/documents/reports/policy-
perspectives-competition-regulation-advanced-practice-nurses/
140307aprnpolicypaper.pdf.
    \17\ https://jamanetwork.com/journals/jama/fullarticle/
2730102?widget=personalizedcontent
&previousarticle=2737024.
    \18\ http://azahec.uahs.arizona.edu/sites/default/files/u9/
azworkforcetrendanalysis02-06.pdf.
    \19\ https://www.healthaffairs.org/do/10.1377/hblog20181211.872778/
full/.
    \20\ Holmes, L.R., Assistant, F.C., and Waltman, N. (2019). 
Increased access to nurse practitioner care in rural Nebraska after 
removal of required integrated practice agreement, 31(5).
    \21\ https://cnpd.und.edu/research/_files/docs/cnpd-
ndnpwfreport.pdf.
    \22\ http://sdlegislature.gov/docs/legsession/2017/FiscalNotes/
fn61A.pdf.
---------------------------------------------------------------------------
             Authorizing NPs to perform all mandatory visits in SNFs.
As noted above, authorizing NPs to perform all mandatory visits in SNFs 
has enabled practices and SNFs to maximize their workforce. This waiver 
improves continuity of care and infection control by reducing 
unnecessary contacts among patients and multiple providers. This is 
also consistent with the permanent policy for Medicaid nursing 
facilities,\23\ creating further alignment between these two programs 
and improving care for dual-eligibles. Patients and health-care 
providers in SNFs have been hardest hit by COVID-19. Making this waiver 
permanent will provide them with the necessary flexibility to provide 
the care that patients require for the duration of the PHE and beyond.
---------------------------------------------------------------------------
    \23\ 42 CFR 483.30(f).
---------------------------------------------------------------------------
             Authorizing NPs in rural health clinics (RHCs) and 
                    federally qualified health centers (FQHCs) to 
                    practice to the top of their license.
Waiving the requirement for physician supervision of NPs in RHCs and 
FQHCs has provided much needed workforce flexibility in rural and 
underserved communities where provider shortages are being exacerbated 
by COVID-19. Our members reported that this waiver has helped the 
entire health-care workforce because they are able to increase the 
focus on patient care instead of unnecessary paperwork and more 
expeditiously provide necessary treatments to their patients.
             Authorizing NPs in critical access hospitals (CAHs) to 
                    practice to the top of their license.
We support making the waiver of the CAH physician physical presence 
requirement permanent. This will enable NPs in CAHs to practice to the 
full extent of their education and clinical training. NPs who stated 
that this waiver was implemented in their facilities have reported 
positive impacts including: reduced regulatory burden for the clinical 
workforce, allowing more time to be spent on direct patient care, 
improved continuity of care, and more timely initiation of necessary 
treatments. Making this waiver permanent would improve the ability of 
CAHs to appropriately utilize their entire health-care workforce to 
meet the needs of their patients following the PHE.
             Authorizing Medicare hospital patients to be under the 
                    care of an NP.
Waiving the requirement that every admitted hospital patient be placed 
under the care of a physician enables NPs in hospitals to practice to 
the top of their license and authorizes hospitals to optimize their 
workforce strategies. Similar to the CAH waiver, NPs who stated that 
this waiver was implemented in their facilities reported that this 
waiver has streamlined the health care delivery process and improved 
continuity of care. Facilities also increased the utilization of NPs in 
leadership positions and participation in administrative planning for 
emergency policies. While some of the changes that were reported were 
allowed prior to the PHE, the removal of this barrier was noted to have 
positive ancillary impacts on many additional hospital policies and 
bylaws.

Telehealth Services

As mentioned previously, increased flexibility to provide telehealth to 
patients has been an essential component of providing care during 
COVID-19 and will continue to be integral to clinicians after the PHE. 
Specific telehealth provisions that we support making permanent are 
removing the geographic limitations, removing originating site 
restrictions so that patients can receive telehealth in their homes and 
increased coverage and reimbursement for audio-only telehealth 
services. We also support the expansion of telehealth to previously 
uncovered services and visits when the clinician determines that it is 
clinically appropriate. These flexibilities have enabled NPs and other 
clinicians to reach patients who otherwise may have been unable to 
receive medically necessary health care, particularly in rural and 
underserved communities.

Conclusion

AANP appreciates the Committee's examination of these flexibilities 
granted under the PHE. These flexibilities are essential to building 
back a robust health-care system after the pandemic and ensuring that 
all providers are practicing to the full extent of their education and 
clinical training. We look forward to working together to improve our 
health-care system in the wake of the COVID-19 pandemic.

                                 ______
                                 
                     American Hospital Association

                          800 10th Street, NW

                       Two CityCenter, Suite 400

                       Washington, DC 20001-4956

                             (202) 638-1100

On behalf of our nearly 5,000 member hospitals, health systems and 
other health-care organizations, our clinician partners--including more 
than 270,000 affiliated physicians, 2 million nurses and other 
caregivers--and the 43,000 health-care leaders who belong to our 
professional membership groups, the American Hospital Association (AHA) 
appreciates the opportunity to submit this statement for the record. 
Since the first COVID-19 cases were diagnosed and the pandemic changed 
the ways in which patients were able to access traditional health-care 
settings, providers were required to navigate significant challenges to 
ensure their services were still able to reach millions of patients. In 
response, Congress and the Administration granted various flexibilities 
intended to improve access and facilitate the delivery of safe, quality 
care.

As health-care providers reflect on lessons learned and plan a post-
pandemic course for the future, it is evident that several of the 
flexibilities have enhanced the patient experience and led to better 
outcomes. The AHA believes that, if extended, these flexibilities can 
continue to drive significant improvements in patient care long after 
the public health emergency (PHE) ends. Given the beneficial impact of 
those specific flexibilities, the AHA urges Congress and the 
Administration to make them permanent. In addition, a second group of 
flexibilities will remain critically important for some time following 
the PHE and will require a carefully crafted phase-out plan to ensure 
enough time is provided for a necessary transition. Without action from 
Congress and the Administration prior to the termination of the PHE, we 
are concerned that much of the progress made because of the 
implementation of many of these flexibilities may be unnecessarily 
halted or even lost. America's hospitals, health systems and post-acute 
care providers have taken significant steps to improve the way care can 
be delivered due to the pandemic, and failing to seize the opportunity 
presented by the progress made would be a step back for the nation's 
health-care infrastructure. Following are the AHA's recommendations for 
each category of flexibilities.

Flexibilities That Should Be Made Permanent

Telehealth Provisions. The increased use of telehealth since the start 
of the PHE is producing high-quality outcomes for patients, enhancing 
patient experience, and protecting access for individuals susceptible 
to infection. With the appropriate statutory and regulatory framework, 
this beneficial shift in care delivery could continue to improve 
patient experiences and outcomes and deliver health system efficiencies 
beyond the pandemic. The AHA urges Congress and the Administration to 
consider making these flexibilities permanent.

Telehealth policies should work together to maintain access for 
patients by connecting them to vital health-care services and their 
personal providers through videoconferencing, remote monitoring, 
electronic consults and wireless communications. We support the 
following: elimination of the 1834(m) geographic and originating site 
restriction; coverage and reimbursement for audio-only services; an 
expanded list of providers and facilities eligible to deliver and bill 
for telehealth services, including rural health clinics and federally 
qualified health centers; a national approach to licensure so that 
providers can safely provide virtual care across state lines; and, 
adequate reimbursement for the substantial costs of establishing and 
maintaining a telehealth infrastructure, among others.

Payment Flexibility. In addition to the payment flexibilities needed to 
continue effectively offering telehealth services beyond the PHE, 
further payment flexibility is necessary to ensure access to care for 
patients. Specifically, Congress and the Administration should consider 
permanently increasing flexibility for site-neutral payment exceptions 
for providers seeking to relocate hospital outpatient departments and 
other off-campus provider-based departments. These steps would permit 
hospitals and health systems to better and more effectively serve their 
communities.

Hospital-at-Home Programs. The pandemic forced providers to rethink 
ways to deliver care safely to all patients, while simultaneously 
responding to surges in COVID-19 cases. To help providers make 
necessary adaptations, the Centers for Medicare & Medicaid Services 
(CMS) created new opportunities for providers to implement hospital-at-
home programs.

These flexibilities permit approved providers to offer safe hospital 
care to eligible patients in their homes, and the results have proved 
pivotal in caring for COVID-19 and non-COVID-19 patients during the 
pandemic. While the initial aim of this flexibility was to increase 
health-care capacity while keeping patients safe at home during the 
PHE, promising outcomes are demonstrating the need for hospital-at-home 
to be made permanent.

Hospitals and health systems are increasingly interested in standing up 
hospital-at-home programs, yet many hesitate to do so without 
assurances that their programs, which are very popular among patients 
and their families, could continue to exist beyond the PHE. Extending 
the hospital-at-home flexibilities permanently can engage providers who 
may be hesitant to implement these programs now and will help transform 
the way more providers deliver care, while enhancing the patient 
experience. Given the benefits provided by this program, AHA 
anticipates considerable additional provider interest and growth of 
hospital-at-home programs should the flexibilities be made permanent.

Workforce Assistance. The COVID-19 pandemic has exacerbated the strain 
on an already overworked and understaffed health-care workforce. To 
help mitigate that strain, we support allowing health-care 
professionals to practice at the top of their licenses and permanently 
permitting out-of-state providers to perform certain services when they 
are licensed in another state. We also support extensions of the five-
year cap-building period for new Graduate Medical Education (GME) 
programs to account for COVID-19-related challenges and support long-
term sustainability of physician training. Permanently extending these 
workforce flexibilities would help alleviate workforce shortages as the 
PHE ends.

Review of Certain Conditions of Participation. The PHE has shed light 
on several shortcomings and outdated practices across the national 
health-care infrastructure; however, it also creates the unique 
opportunity to reevaluate and improve upon processes based on the 
lessons we have learned thus far. Conditions of participation (CoPs) 
are a logical starting point for review and reevaluation, as they serve 
as the foundation for ensuring high quality care and safety for 
patients and set the baseline for hospital participation in the 
Medicare and Medicaid programs. Compliance with the CoPs and the 
potential for termination from the Medicare and Medicaid programs for 
non-compliance serve as valuable tools ensuring hospitals are meeting 
critical safety and quality requirements. However, the past year's 
experiences demonstrated the need to modernize certain CoPs. For 
example, reexamining and updating infection control and life safety 
code requirements would allow hospitals and health systems to continue 
to employ innovative approaches, such as allowing for separate facility 
entrances for potentially infectious patients and minimizing personal 
protective equipment (PPE) use and infection risk by placing IV tubes 
outside patient rooms. The AHA has urged CMS to collaborate with 
providers to determine how specific CoPs can be revamped to improve 
quality and safety.

Rural Capacity. CMS should continue to support increased bed capacity 
in rural areas when an emergency requires such action. Rural hospitals 
should be held harmless for increasing bed capacity during any future 
emergency, and those providers should be permitted to maintain pre-
emergency bed counts for applicable payment programs, designations and 
other operational flexibilities.

Flexibilities Requiring a Transition Period

Emergency Use Authorization (EUA) Transition. The COVID-19 pandemic 
placed significant strain on an already fragile medical supply chain 
and highlighted several substantial flaws in the acquisition process. 
Many of those impacts still exist today to varying degrees. In response 
to supply chain disruptions, the Food and Drug Administration (FDA) 
issued an unprecedented number of EUAs to help mitigate constant 
disruption and continuous impact. The EUAs covered a broad range of 
devices, from respirators and COVID-19 tests to ventilators and 
decontamination systems. These EUAs saved lives by opening up new 
supply lines to ensure providers have the items they need to safely and 
effectively care for patients throughout the pandemic. However, the 
EUAs are not a silver bullet, and additional disruptions will occur 
post-pandemic. Congress should reassess how the supply chain operates 
and consider modifications to mitigate further disruptions. To ensure 
supply chain stability, the FDA should offer full approval to those 
devices deemed necessary, and provide sufficient transition periods to 
move away from devices that do not receive full approval.

Personal Protective Equipment. The COVID-19 pandemic illuminated 
several supply chain shortcomings, not least of which was adequate 
access to PPE necessary to keep both front-line health-care workers and 
patients safe. In response to the massive PPE shortages, the FDA issued 
EUAs for a number of items, such as respirators and facemasks. To 
address the short- and long-term challenges associated with PPE, the 
FDA should take steps to ensure a reasonable wind-down of PPE EUA 
flexibilities to allow the supply chain to recalibrate and providers to 
use supply on-hand. In addition, the FDA should examine the long-term 
fragility of the PPE supply chain and consider offering certain non-
traditional medical PPE manufacturers the opportunity to receive full 
medical supply authorization from the FDA. Finally, as this wind-down 
occurs, the FDA and other federal agencies, including the Occupational 
Safety and Health Administration (OSHA), the National Institute for 
Occupational Safety and Health (NIOSH) and the Centers for Disease 
Control and Prevention (CDC) should work together to ensure a 
coordinated approach to the transition.

Health Information and Data Sharing. Robust health information and data 
exchange capabilities among providers and with patients and government 
agencies are foundational to improving care delivery, supporting better 
health outcomes and facilitating emergency response. Data exchange 
capabilities support decision-making at the point of care and the data 
generated can provide insights into health disparities and inequities 
at the patient and population health levels. Yet, to realize these 
benefits, robust, secure infrastructure must be in place for all 
entities, utilizing a common set of data definitions and standards. 
Requirements around data collection and sharing also must be well 
defined and well understood by health-care providers and have a clear 
value proposition. Building this information technology infrastructure 
requires significant resources, both capital and workforce, and 
extensive efforts to redesign procedures and workflows and train 
clinicians and staff across the organization. Until all of these core 
building blocks are in place across the health information exchange 
continuum, implementation of new requirements on health-care providers, 
such as the Office of National Coordination for Health Information 
Technology's information blocking rules and CMS' admit, discharge and 
transfer notification CoP, should be delayed.

Quality Measurement Reporting. During the pandemic, CMS provided 
hospitals relief from quality reporting requirements, including making 
quality reporting optional in Q1 and Q2 of 2020, and allowing hospitals 
to apply for reporting waivers using the pandemic as justification. We 
note, however, that hospital performance on the measurement programs, 
like readmissions, hospital-acquired conditions and value-based 
purchasing, will be affected over multiple fiscal years to come, and it 
is vital that performance be assessed reliably and fairly. For that 
reason, CMS should use its statutory flexibilities to not apply payment 
adjustments in program years where it determines that, as a result of 
measure reporting exceptions, it has insufficient data to calculate 
national performance in a reliable manner.

Federal Medical Assistance Percentages (FMAP) Increase. The temporary 
FMAP increase in the COVID-19 relief laws has provided critical 
financial support for states to ensure their Medicaid programs can 
provide coverage for millions of their citizens during the COVID-19 
pandemic. The temporary FMAP increase of 6.2 percentage points is set 
to expire at the end of the quarter in which the PHE ends. To benefit 
from the temporary FMAP increase, states must meet certain maintenance 
of effort requirements, including continuous enrollment for those 
enrolled in the program as of March 18, 2020. State governments, 
advocates and stakeholders recommend that additional federal funding 
will be needed for up to a year after the PHE ends. Extending FMAP will 
provide a smooth process to reevaluate Medicaid COVID-19-related 
coverage extensions.

Congress addressed a similar situation during the Great Recession of 
2008-2009. Then, the FMAP was increased by 6.2 percentage points for 27 
months (through the end of 2010) and then extended and tapered down 
from 6.2 % to 3.2% and finally to 1.2% for another six months ending in 
June 2011. Congress should consider a comparable approach for states at 
the end of the PHE. Congress also should consider an enhanced FMAP for 
states with high unemployment rates. During the Great Recession, states 
with increases in unemployment rates of 3.5% received an enhanced FMAP 
above the 6.2%.

Medicaid Coverage, Enrollment and Outreach. The PHE enabled states to 
leverage Medicaid's emergency authorities to make temporary changes to 
their programs that increased access to coverage and care. Most 
policies adopted by states helped individuals qualify for and enroll in 
Medicaid coverage. The two major pathways for states to change Medicaid 
eligibility, coverage and enrollment during the PHE were: Medicaid 
disaster relief state plan amendments that allow states to modify their 
state Medicaid plans quickly to change eligibility, benefits, cost 
sharing and payments; and disaster relief verification plan addenda 
that allowed state agencies to verify eligibility and use electronic 
data sources without prior approval from CMS.

The coverage needs facing states--and the policy changes needed to 
respond adequately--will continue to exist beyond the PHE. To provide 
continued flexibility, CMS should relax hospital-based presumptive 
eligibility standards, maximize flexibility for income verification and 
the use of self-attestation, and continue allowing qualified entities 
like hospitals to make presumptive eligibility determinations for all 
Medicaid eligibility groups.

Post-acute Care. Post-acute care (PAC) providers continue to play a key 
role in the national COVID-19 response. In communities that faced or 
are facing surges of the virus, they have treated many of the sickest 
COVID-19 patients following hospital discharge, as well as provided 
important relief to hospitals and other settings overwhelmed by 
patients with and recovering from the virus. Concurrently, the 
prospective payment systems (PPS) of three of the four PAC settings--
the long-term care hospital, inpatient rehabilitation hospital, and 
skilled nursing facility PPSs--have been in the midst of major payment 
transformations during the PHE. The collective magnitude of the PHE and 
these PPS redesigns is extensive, and time is needed for policyholders 
and stakeholders to disentangle and understand the longer-term 
ramifications of each. Thus far, their combined impact includes, as 
examples, material reductions in case volume and overall payments, the 
rise of average levels of patient acuity, facility closures, personnel 
shifts and revised clinical pathways. For example, AHA analysis shows 
that, in comparison to prior patterns, case volume for these settings 
dropped by 6% to 30% while the average case-mix index rose from between 
2.5% and 6.9% over the prior year.i In recognition of this 
complex dynamic, the recent FY 2022 PAC proposed rule calls upon 
stakeholders to provide guidance on how to account for both of these 
overlapping and powerful drivers of change. At this time, it remains 
unclear which of these and other operational impacts will persist after 
the PHE, but given their scope and duration, it seems possible that the 
PAC field will not return to its pre-PHE profile. Given this level of 
change and uncertainty, key PAC flexibilities should remain in effect 
during a transition period that follows the official end of the PHE. In 
particular, such extended flexibilities should include PHE-levels of 
payment and coverage for highest acuity COVID-19 patients who remain in 
the PAC setting following the PHE, including those ``long-haul COVID-19 
patients'' for whom the virus has concluded but related symptoms 
remain.
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    i These data compare a 12-month period during the PHE, 
January 27, 2020 through January 26, 2021, to a pre-PHE 12-month 
period, January 26, 2019 through January 26, 2020. Data source: 
Medicare fee-for-service claims, Centers for Medicare and Medicaid 
Services, Chronic Conditions Data Warehouse, https://www2.ccwdata.org/
web/guest/home.

The AHA is gratified that the Committee is examining the many 
flexibilities granted during the COVID-19 pandemic. We stand ready to 
work with the Committee as you consider learnings from these 
flexibilities and how to ensure that the nation's health-care system 
can continue to evolve for the benefit of patients and the health of 
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their communities.

                                 ______
                                 
                      American Medical Association

                 25 Massachusetts Avenue, NW, Suite 600

                          Washington, DC 20001

                    Division of Legislative Counsel

                             (202) 789-7426

The American Medical Association (AMA) appreciates the opportunity to 
provide a statement for the record to the Senate Finance Committee as 
part of the hearing on ``COVID-19 Health Care Flexibilities: 
Perspectives, Experiences, and Lessons Learned.'' We welcome the 
opportunity to support congressional efforts to ensure patients and 
physicians continue to have access to valuable services that 
flexibilities during the COVID-19 Public Health Emergency (PHE) 
enabled. In particular, the AMA strongly supports congressional efforts 
to ensure that Medicare beneficiaries have access to telehealth 
services and to make permanent valuable flexibilities provided for the 
treatment of substance abuse services, hospital at home services, and 
the Medicare Diabetes Prevention Model.

Telehealth Flexibilities Should Remain in Place

Telehealth is a critical part of the future of effective, efficient, 
and equitable delivery of health care in the United States. Efforts 
must continue to build capacity and support access to care centered on 
where the patient is located (to the greatest extent it is clinically 
efficacious), and to ensure physicians and other health-care 
professionals have the tools to optimize care delivery. The AMA has 
been a leader in advocating for expanded access to telehealth services 
for Americans because it has the capacity to improve access to care for 
many underserved populations and improve outcomes for at-risk patients, 
particularly those with chronic diseases and/or functional impairments.

In response to the COVID-19 PHE, Congress passed the CARES Act, which, 
among other things, provided the Centers for Medicare and Medicaid 
Services (CMS) the authority to waive the geographic and originating 
site requirements for the duration of the COVID-19 PHE, which CMS 
subsequently did.\1\ Following these policy actions, telehealth usage 
among Medicare beneficiaries has expanded greatly as patients could, 
for the first time, access telehealth services from wherever they are 
located, including their home, regardless of where they reside in the 
country. The AMA remains deeply grateful for these flexibilities, which 
have allowed Medicare patients across the country to receive care from 
their homes. With many physician offices closed, elective procedures 
postponed, personal protective equipment difficult to obtain, and an 
ongoing infectious disease pandemic that has forced patients to stay 
home for their safety, the ability to provide services directly to 
patients regardless of where they are located via telehealth has 
allowed many vital health-care services to continue. In addition to 
facilitating continuity of care for patients being treated for acute 
and chronic conditions, telehealth has also facilitated initial 
assessment of patients experiencing potential COVID-19 symptoms and 
those who have been in close contact with people diagnosed with COVID-
19 to determine if referrals for testing or treatment are indicated 
while minimizing risks to patients, practice staff, and others. With 
this expansion of services has come a recognition from patients, 
physicians, and other providers that telehealth services offer 
effective and convenient health care in many circumstances. Congress 
must act now to ensure that Medicare patients can continue to access 
telehealth services from wherever they are located after the pandemic 
ends by modernizing the Social Security Act to keep pace with our 
digital future.
---------------------------------------------------------------------------
    \1\ Coronavirus, Relief, and Economic Security (CARES) Act, Pub L. 
No. 116-136, 134 Stat. 281 (2020), https://www.congress.gov/116/plaws/
publ136/PLAW-116publ136.pdf.

However, without further legislative action from Congress, Medicare 
beneficiaries who have come to rely on telehealth services during the 
PHE will abruptly lose access to these services completely. Under 
section 1834(m) of the Social Security Act (SSA), Medicare is 
prohibited from covering and paying for telehealth services delivered 
via two-way audio-visual technology unless care is provided at an 
eligible site in a rural area.\2\ This means that, in order to access 
telehealth services, patients must live in an eligible rural location, 
and must also travel to an eligible ``originating site''--a qualified 
health-care facility--to receive telehealth services, except in the few 
cases where Congress has authorized provision of telehealth services in 
the home of an individual.\3\ As a result, the 1834(m) restrictions bar 
the majority of Medicare beneficiaries from using widely available two-
way audio-visual technologies to access covered telehealth services 
unless they live in a rural area, and with a few exceptions, even those 
in rural areas must travel to an eligible health-care site.
---------------------------------------------------------------------------
    \2\ Special Payment Rules for Particular Items and Services, 42 
U.S.C. Sec. 1395m(m), https://www.ssa.gov/OP_Home/ssact/title18/
1834.htm.
    \3\ For example, substance abuse disorder treatment delivered via 
telehealth is explicitly exempted from the geographic and origination 
restrictions.

Congress must act now to remove the origination and geographic 
restrictions on telehealth coverage for Medicare patients. Continued 
access to telehealth services beyond the PHE is critical for patient 
populations that have come to rely on its availability. That is why the 
AMA supports S. 368/H.R. 1332, the ``Telehealth Modernization Act of 
2021,'' which would eliminate the 1834(m) statutory restrictions on 
originating site and geographic location, thereby ensuring Medicare 
coverage of telehealth services regardless of where the patient is 
located. It is critically important that Medicare beneficiaries 
continue to be able to access telehealth services from their physicians 
without arbitrary restrictions throughout the COVID-19 public health 
emergency and beyond.
The PHE Has Demonstrated the Value of Telehealth
The success of telehealth technology adoption during the COVID-19 
public health emergency has made it abundantly clear that geographic 
and origination restrictions on accessing telehealth services are 
outdated and arbitrary given today's technology that allows for access 
to digital tools from anywhere. Physicians and patients have seen the 
value of telehealth services and should not be forced to stop using 
these tools when the public health emergency ends. Some have argued 
that statutory changes cannot be made without additional data on how 
telehealth services are used, however, this has the problem backwards. 
More data is not necessary to determine that the underlying policy 
needs to be permanent, but instead can help CMS determine which 
services need to continue to be covered or can be safely removed from 
the Medicare telehealth list. In the meantime, the certainty that 
appropriate telehealth services will be covered would provide 
physicians confidence in investing in new technology and give patients 
peace of mind that they can continue to access services in a way that 
works best for them.

The rapid and widespread adoption of telehealth by physicians in 2020 
was one of the most significant improvements in health-care delivery in 
decades. The new telehealth coverage and payment policies enabled 
physicians to deliver valuable services they previously could not 
afford to provide but that their patients needed. With legislative 
provisions such as the establishment of the CMS Innovation Center and 
Medicare's Quality Payment Program, Congress has sought for many years 
to support physician adoption of innovations in the delivery of care. 
The successful adoption of telehealth throughout the country has 
demonstrated that, if the financial barriers are removed, physicians 
will adopt important innovations in the delivery of care that are 
necessary to improve their patients' health.

Telehealth technologies allow physicians to increase continuity of 
care, extend access beyond normal clinic hours, and help overcome 
clinician shortages, especially in rural and other underserved 
populations. This ultimately helps health systems and physician 
practices focus more on chronic disease management, enhance patient 
wellness, improve efficiency, provide higher quality of care, and 
increase patient satisfaction. Telehealth has helped increase provider/
patient communication, increase provider/patient trust, and access to 
real-time information related to a patient's social determinants of 
health (i.e., a patient's physical living environment, economic 
stability, or food insecurity), which can lead to better health 
outcomes and reduced care costs. The ability to gain greater access to 
chronic disease management services and better assess the impact of a 
patient's social determinants of health will undoubtedly contribute to 
improved treatment and health outcomes for historically marginalized 
and minoritized populations as well.

Telehealth services can help patients avoid delaying care that can lead 
to expensive emergency department visits and hospitalizations. They 
also cut down on trips to the office that may be difficult or risky for 
patients with functional or mobility impairments, frail elderly who 
need a caregiver to accompany them, those who need to stay home to care 
for other family members, and patients who are immunocompromised or 
vulnerable to infection. Providing access to telehealth services 
creates greater safety and efficiencies for both patients and 
physicians, delivering value to the Medicare program.

Physician practices are ready to invest in the technology required to 
provide these services; however, it will be very difficult to provide 
the sustained financial commitment needed to incorporate delivery of 
telehealth services into their workflows if the coverage is only 
temporary. The removal of coverage and financial barriers has allowed 
the explosive growth in telehealth and certainty about future coverage 
is necessary for it to continue. It has allowed CMS to make more 
informed decisions about which services to cover, and, in fact, CMS has 
expanded coverage of telehealth services greatly during the PHE.\4\ 
While more data behind current telehealth usage trends may be valuable 
to gather evidence about which particular Current Procedural 
Terminology' (CPT') codes need to stay on the 
Medicare telehealth list, that is a much different concern than whether 
nationwide coverage and ability to deliver care to patients wherever 
they are located should be available; these determinations are already 
appropriately made by CMS.
---------------------------------------------------------------------------
    \4\ Medicare Physician Fee Schedule 2021, 85 Fed. Reg. 84472 
(December 28, 2020), https://www.govinfo.gov/content/pkg/FR-2020-12-28/
pdf/2020-26815.pdf.

While CMS has expanded coverage of telehealth services during the PHE, 
only Congress can assure all Medicare beneficiaries can receive equal 
access to those services moving forward. Delaying action, such as 
extending the current 1834(m) waiver authority, will only make it more 
expensive to change the policy permanently in the future.
CMS Already Makes Coverage Determinations on Telehealth Services
CMS currently has all the tools necessary at its disposal to make 
determinations about which telehealth services it should cover and at 
what payment level. For the duration of the COVID-19 PHE, CMS has added 
many services to the list of those that Medicare pays for when they are 
provided via telehealth. The newly covered services include emergency 
department visits, observation care, hospital and nursing facility 
admission and discharge services, critical care, and home care, as well 
as services like ventilator management that have been especially 
necessary for COVID-19 patients. The newly added services have greatly 
assisted physicians during the PHE when both patients and health 
professionals needed to maintain physical distance from others as much 
as possible. Through telehealth communications, for example, an 
emergency physician, potentially assisted by members of the patient's 
household, can diagnose, and treat emergency conditions without sick 
patients having to endure difficult travel and expose themselves and 
others to SARS-CoV-2 and other dangers. In all, CMS added interim 
Medicare coverage for more than 150 services for the duration of the 
COVID-19 PHE at payment parity with in- person services. Equivalent 
payment for telehealth services during the PHE was crucial to ensure 
physicians could cover the cost associated with offering virtual care. 
In future rulemaking, CMS has indicated it may extend the interim 
coverage for a longer period of time to help gather more evidence of 
how the services are used when provided via telehealth outside the 
context of a pandemic.

The only thing holding CMS back from expanding access to appropriate 
telehealth services to its beneficiaries are the outdated restrictions 
currently in the statute. Since telehealth is simply a modality for 
delivering health care, AMA continues to urge Congress and CMS to 
provide payment parity for two-way audio-visual services upon 
conclusion of the COVID-19 pandemic.
Telehealth Helps Provide Access to Health Care to Underserved 
        Communities
Access to telehealth services can help reduce inequalities in care for 
underserved communities by providing access to services for patients 
regardless of where they are located. Patients in rural areas or 
underserved urban communities often have to travel long distances to 
access care, especially specialty services including emergency and 
critical care. Telehealth can also help eliminate commutes to physician 
offices for those with mobility or transportation difficulties.

In conjunction with expanded access to telehealth services, the AMA 
supports Congressional efforts to expand high-speed broadband Internet 
access to underserved communities and increase digital literacy 
education efforts. Patients cannot take advantage of telehealth 
services if they do not have the requisite Internet connection to 
access them or the appropriate skills to use digital technologies. 
Providing digital literacy skills is particularly important for non-
English speaking patients and is another crucial aspect of ensuring 
health equity. Solving this problem requires enhanced funding for 
broadband Internet infrastructure in rural areas and support for 
underserved urban communities and households to gain access to 
affordable Internet access, as well as support for patient education on 
how to use digital tools.
Concerns About Fraud and Abuse and Overutilization Are Misplaced
Some have raised concerns that expanded coverage of telehealth services 
could lead to greater fraud and abuse or duplication of medical 
services. The AMA believes these concerns are misplaced given CMS' 
existing tools for combating fraud and abuse, the increased ability 
telehealth services provide for documentation and tracking, and the 
lack of data to suggest that fraud and abuse or duplication are of 
particular concern for telehealth services. Therefore, Congress should 
not create artificial barriers to telehealth by defining an established 
doctor-patient relationship inconsistently with the standard of care or 
otherwise creating unique and burdensome fraud and abuse requirements 
that would stifle access to telehealth services. The AMA supports 
removing restrictions on access to Medicare tele-mental health services 
that were included in H.R. 133, the Consolidated Appropriations Act, 
2021. Specifically, the new requirement that Medicare beneficiaries 
must be seen in person at least once by the physician or non-physician 
practitioner during the six-month period prior to the first telehealth 
services should be repealed. Such restrictions were not imposed on 
tele-mental health services covered by Medicare prior to the passage of 
the COVID-19 telehealth waiver, or on tele-mental health services 
covered by Medicare under the waiver during the PHE. Moreover, they are 
not supported by the data we have seen regarding the benefits of 
increased access and improved patient adherence to treatment in tele-
mental health services and they directly conflict with the standard of 
care.

CMS and the Office of Inspector General (OIG) at HHS already have all 
of the Medicare coverage and payment and fraud and abuse authorities to 
monitor telehealth service compliance just as they do any other 
Medicare covered service. Additional restrictions do not currently 
apply under the Medicare Advantage, the Center for Medicare and 
Medicaid Innovation, section 1116 waiver authorities, the existing 
Medicare telehealth coverage authority, or other technologies such as 
phone, text, or remote patient monitoring.

In recent remarks regarding the potential for telehealth fraud, 
Principal Deputy Inspector Grimm of OIG never mentioned any concerns 
with OIG's authority or ability to address concerns of fraud and 
abuse.\5\ Instead, he described OIG's concerns with ``telefraud'' 
schemes which he distinguished from telehealth fraud, in which bad 
actors use ``telehealth'' as a basis for fraudulent charges for medical 
equipment or prescriptions which are unrelated to the telehealth 
service at issue. In those cases, fraudulent actors typically do not 
bill for the televisit but instead used the sham televisit to induce a 
patient to agree to receive unneeded items and gather their info. In 
other words, whether or not the telehealth service itself is covered 
has no impact on these kinds of fraudulent schemes.
---------------------------------------------------------------------------
    \5\ Principal Deputy Inspector Grimm on Telehealth (February 26, 
2021), https://oig.hhs.gov/coronavirus/letter-grimm-02262021.asp.

Moreover, telehealth services may prove even easier to monitor for 
fraud and abuse because of the digital footprint created by these 
services, state practice of medicine laws requiring documentation of 
these services, and the ability to track their usage with Modifier 95. 
Telehealth services are even more likely to have electronic 
documentation in medical record systems than in-person services. 
Practice of medicine laws in all 50 states permit physicians to 
establish relationships with patients virtually so long as it is 
appropriate for the service to be received via telehealth. In addition, 
two-way audio-visual services can be effectively deciphered and tracked 
by CMS via the Modifier 95. The Modifier 95 describes ``synchronous 
telemedicine services rendered via a real time Interactive audio and 
video telecommunications system'' and is applicable for all codes 
listed in Appendix P of the CPT manual. The Modifier 95, along with 
listing the Place of Service (POS) equal to what it would have been for 
the in-person service, is also applicable for telemedicine services 
rendered during the COVID-19 PHE. The requirement to code with the 
Modifier 95 enables CMS to properly decipher and track telemedicine 
services, thus improving the chances of identifying and rooting out 
---------------------------------------------------------------------------
fraud, waste, and abuse.

Data analyzed by CMS since the start of the PHE shows that fears of 
overutilization are overblown. Data from Medicare claims from Q1 and Q2 
show that less than 4% of telehealth spending was for new patient 
audiovisual office visits. Moreover, nothing in the data or anecdotal 
evidence suggests that telehealth services have been duplicative of in 
person services rather than used as an alternative or in addition to in 
person care. The AMA will continue to monitor and analyze the data as 
it becomes available, but this suggests that there is no reason to 
think better access to telehealth will lead to an explosion in 
unnecessary services.

As a result, Congress should refrain from imposing new and 
discriminatory restrictions on the use of audio-visual communications 
technologies, such as restrictions on how a physician-patient 
relationship can be established. AMA policy, established in 2014, 
states that a valid physician-patient relationship may be established 
virtually face-to-face via real-time audio and video technology, if 
appropriate for the service being furnished.\6\ It also allows for the 
relationship to be established in a variety of other ways such as 
meeting standards of care set by a major specialty society. All 50 
states and the territories allow a physician-patient relationship to be 
established virtually or through other means. The exact parameters vary 
by state; however, many state laws are based on an AMA model law. 
Congress should not impose a one-size-fits-all requirement on services 
furnished via telehealth technology that are in direct conflict with 
standards of care and that do not exist for other technologies.
---------------------------------------------------------------------------
    \6\ American Medical Association, H-480.496: Coverage of and 
Payment for Telemedicine, https://policysearch.ama-assn.org/
policyfinder/detail/telemedicine?uri=%2FAMADoc%2FHOD.
xml-0-4347.xml (last modified, 2019).

Gains made in access to telehealth will be greatly hampered if unique 
and arbitrary barriers are erected around the use of telehealth 
services. Such barriers will have a dramatic and negative impact on 
patients seeking care, particularly during the current COVID-19 
pandemic, and in any future pandemic where patients need access to care 
without the concerns surrounding a visit to a crowded health-care 
facility.

Audio-only Services Should Remain Covered

The AMA also strongly supports coverage for audio-only services and has 
called on CMS to continue this coverage after the PHE ends. There are 
numerous patients and entire communities that have no access to the 
Internet connectivity necessary to utilize audio-visual telehealth 
services in their homes. There are also medical practices that do not 
have sufficient connectivity to provide audio-visual telehealth 
services. Patients who cannot utilize audio-visual telehealth services 
include those in communities lacking broadband access, those where the 
technological capabilities are present, but the patient cannot afford 
it, and others who have access to the technology and the connectivity 
but do not know how to use it. Inability to use audio-visual telehealth 
services is also a matter of health equity. Too often it is the same 
communities that face other barriers to good health outcomes who also 
face these technology barriers, such as Native Americans living on 
reservations and those in the rural South's Black Belt. But patients 
who cannot participate in audio-visual telehealth services are no less 
sick than those who can, and it is important to their health care to 
retain access to these services.

Pursuant to authority granted under the CARES Act, CMS waived the 
requirements of section 1834(m)(1) of the Social Security Act and 42 
CFR Sec. 410.78(a)(3) for use of interactive telecommunications systems 
to furnish telehealth services, to the extent they require use of video 
technology for certain services. This has allowed the use of audio-only 
equipment to furnish services described by the codes for audio-only 
telephone evaluation and management services, and behavioral health 
counseling and educational services. Expanded use of audio-visual 
telehealth services during the pandemic has made it clear that 
requiring the use of video limits the number of patients who can 
benefit from telecommunications-supported services, particularly lower-
income patients, and those in rural and other areas with limited 
Internet access. It would be inappropriate to prevent these patients 
from accessing such services. In addition, we have heard from many 
physicians about the need to have access to audio-only services because 
a number of their patients, even those who own the technology needed 
for two-way real-time audio-visual communication, do not know how to 
employ it or for other reasons are not comfortable communicating with 
their physician in this manner.

Audio-only services are an important part of a fully integrated care 
plan and physicians should be able to permanently deliver E/M 
(evaluation and management) services by telephone to patients who need 
a telecommunications-based service in the home but who do not have 
access to a video connection or cannot successfully use one. Without 
access to an audio-only option, limitations in Internet and/or 
technology access as well as lack of experience with its use will 
increase inequities in access to medical care and widen disparities in 
health outcomes.

 Flexibilities for the Treatment of Substance Abuse Disorder Should Be 
                    Continued

Early on in the COVID-19 Public Health Emergency, the Drug Enforcement 
Administration (DEA) and Substance Abuse and Mental Health Services 
Administration (SAMHSA) put several important flexibilities in place to 
help DEA-registered physicians manage care for their patients with 
opioid use disorder (OUD). During this PHE, physicians who have a 
waiver allowing them to prescribe buprenorphine for the treatment of 
OUD can initiate and continue this treatment based on telehealth visits 
and audio-only visits with patients. Opioid Treatment Programs can also 
initiate new patients and treat existing patients being managed with 
buprenorphine based on telehealth and phone visits. Patients cannot be 
initiated with methadone treatment based on telehealth visits, but 
existing patients on methadone can be managed via telehealth or phone. 
Opioid Treatment Programs can also provide patients who are stable with 
take-home medication.

Based on a survey led by the American Academy of Addiction Psychiatry 
and conducted last summer of more than 1,000 physicians and other 
health professionals who treat OUD, these new flexibilities were 
extremely important in allowing them to continue to manage their 
patients' care. A major finding of the survey is that more than 80% of 
X-waivered survey respondents want the telehealth options to continue 
after the COVID-19 PHE. The AMA has written to the DEA urging that 
these flexibilities remain in place at least until the end of the 
opioid PHE and believes Congress should support these continued 
flexibilities.

 Hospital at Home Services Flexibilities Should Remain

A number of other countries pay for delivering services equivalent to 
hospital inpatient care to patients in their own homes. These 
``hospital at home'' services have been successful in allowing patients 
with specific types of conditions that qualify for inpatient care to 
receive services in the home and avoid the risks associated with an 
inpatient admission. The services are more intensive than can be 
supported through traditional home health-care payments. Although some 
hospitals in the U.S. were delivering hospital at home care and some 
Medicare Advantage plans were paying for it before the PHE, the service 
was difficult to sustain or expand without payment support from 
Medicare because a minimum number of patients need to participate in 
order for the service to be cost-effective. During the pandemic, one of 
the key flexibilities that CMS now has allowed is for hospitals to 
deliver services to patients in their homes. It would be desirable to 
continue this flexibility after the national emergency ends for the 
subset of patients who meet the criteria used in hospital at home 
programs in the U.S. and other countries.

 Medicare Diabetes Prevention Expanded Model Flexibilities Should be 
                    Made Permanent

Through the rulemaking process for the 2021 Medicare physician payment 
schedule, CMS adopted important flexibilities that are effective for 
the duration of the COVID-19 PHE and in future 1135 waiver emergencies 
that could cause a disruption to in-person MDPP services. These MDPP 
policies will only apply in emergency situations, however, and not on 
an ongoing basis. MDPP services are being significantly underutilized. 
If the MDPP flexibilities that have been adopted for COVID-19 and 
future emergencies were instead continued as regular, ongoing MDPP 
policies, it would significantly strengthen the effectiveness of 
diabetes prevention services for Medicare patients with prediabetes. 
The AMA strongly urges Congress to pass H.R. 2807, the PREVENT Diabetes 
Act.

To furnish virtual services during an emergency period, MDPP suppliers 
must already have preliminary or full CDC Diabetes Prevention Program 
recognition for in-person services. CMS continues to bar virtual-only 
suppliers that have achieved CDC recognition from furnishing MDPP 
services, even during the PHE. Under its current regulations, CMS will 
require MDPP providers to resume in-person services at the conclusion 
of the COVID-19 PHE. Against AMA urging, CMS has declined to allow 
virtual providers to participate in MDPP to the fullest extent either 
during or after the PHE. CMS regulations also prohibit patients from 
participating in their MDPP sessions virtually when offered by 
suppliers who provide both in-person and virtual services except during 
an emergency period. Many patients with prediabetes are unable to 
effectively participate in in-person MDPP sessions, often because they 
live far from any supplier location or because the sessions are not 
offered at times that are convenient for them. The MDPP should be 
modified to allow patients to obtain their session virtually at any 
time.

CMS regulations also impose a once-per-lifetime limit on patients 
obtaining MDPP services. During an emergency period, patients who 
continue their MDPP participation through virtual services will still 
be subject to the once-per-lifetime limit, but patients whose MDPP 
participation is interrupted by an emergency period will be able to 
restart MDPP services with the first core session after the emergency 
period ends. Other Medicare behavior modification programs such as 
tobacco cessation and obesity counseling do not have lifetime limits 
and there is no justification for a once-per-lifetime limit on MDPP 
services. This limit should be lifted for all patients, not just those 
who discontinue MDPP during a declared emergency.

 Conclusion

The AMA thanks the Committee for this hearing and for the careful 
consideration of the flexibilities that have been put in place for the 
COVID-19 PHE. We look forward to working with the Committee and 
Congress to seek solutions that will ensure patients can continue to 
benefit from these flexibilities after the end of the PHE.

                                 ______
                                 
         American Medical Rehabilitation Providers Association

                    529 14th Street, NW, Suite 1280

                          Washington, DC 20045

                          Phone: 202-591-2469

                           Fax: 202-591-2445

The American Medical Rehabilitation Providers Association (AMRPA) 
commends the Senate Committee on Finance for its efforts to closely 
assess the nation's response to the COVID-19 public health emergency 
(PHE) and determine whether and what type of permanent policy changes 
should be considered in the PHE aftermath. In particular, AMRPA was 
pleased to hear Chairman Wyden remark that there ``is bipartisan 
interest in building on the changes that worked well for both seniors 
and providers'' during the PHE, as we believe that getting patient and 
provider feedback is critical in the assessment of COVID-19 waivers. As 
providers who were able to furnish critical care to acute COVID- 19 
survivors due to the numerous statutory and regulatory flexibilities 
granted to our field, we appreciate the opportunity to offer 
recommendations from the inpatient rehabilitation hospital perspective.

AMRPA is the national trade association representing more than 650 
freestanding inpatient rehabilitation hospitals and rehabilitation 
units of general hospitals (referred to collectively by regulators as 
inpatient rehabilitation facilities, or IRFs). As you may be aware, 
IRFs have and continue to play a vital role in their communities' PHE 
response effort, due in large part to their hospital-level care, 
clinical competence, personnel, quality, equipment, and emergency 
response/preparedness capabilities that distinguish IRFs from other 
post-acute care (PAC) settings. Patients' access to IRFs during the 
pandemic has been particularly critical in light of the unprecedented 
surge demands faced by acute-care hospitals and the infection control 
and safety issues that restricted patients' access to other PAC 
options. Through the utilization of waivers granted during the PHE, 
AMRPA members have continually reported the long-term, positive impact 
that medical rehabilitation has had for both COVID-19 survivors and 
other complex patients who required medical rehabilitation care during 
the PHE. As the Medicare program now faces a confluence of an aging 
population, the new clinical and care delivery challenges presented by 
``long- hauler'' COVID-19 survivors, and Trust Fund insolvency 
projections, protecting patient access to inpatient rehabilitation has 
never been more important. It is therefore vital that Congress takes 
steps to ensure IRFs have the appropriate regulatory environment and 
resources for the duration of the PHE and beyond.

As background, AMRPA engaged extensively with both Congressional 
offices and the Centers for Medicare and Medicaid Services (CMS) since 
the beginning of the pandemic regarding the flexibilities that would be 
needed to address the surges of both COVID-19 and non-COVID-19 patients 
requiring hospital-level care during the PHE. Given that IRFs are 
arguably the most closely-regulated post-acute care entity within the 
Medicare program, wide-ranging flexibilities were needed with respect 
to admission criteria, documentation, and reporting requirements, among 
others. CMS leaders conveyed to AMRPA that the comprehensive 
flexibilities granted to IRFs during this time were intended to 
facilitate timely and effective patient access to IRFs and ensure that 
IRF providers were able to dedicate time and resources to patient care 
rather than regulatory burdens. As the Finance Committee contemplates a 
legislative response that builds off the ``lessons learned'' from the 
COVID-19 pandemic and protects patient access to care in an evolving 
health-care environment, we appreciate your consideration of our 
legislative recommendations informed by the PHE. While our 
recommendations may evolve in future stages of the PHE and its 
aftermath, our primary asks currently include:

      Consider commonsense reforms to key IRF coverage requirements to 
better reflect the value of rehabilitation services for patients;
      Prohibit the use of prior authorization by Medicare Advantage 
plans in all future PHEs and throughout their duration, and implement 
significant reforms to current prior authorization practices that 
harmfully impeded care over the past year (AMRPA has supported the 
recently-introduced H.R. 3173, the Improving Seniors Access to Timely 
Care Act, as a key first step in this regard);
      Permanently implement some of the critical telehealth-related 
waivers and flexibilities granted during the PHE (e.g., the recognition 
of physical therapists, occupational therapists, respiratory therapists 
and speech-language pathologists as telehealth providers);
      Ensure providers can practice across state lines, or at minimum, 
authorize interstate licensing immediately upon any future PHE 
declaration; and
      Reset the implementation of the IMPACT Act timeline to account 
for the ongoing burdens on each PAC sector and the need to account for 
the COVID-19 PHE in any future payment reform effort.

We believe many of these asks complement the 117th Congress' broader 
focus on burden reduction and regulatory modernization efforts, and 
AMRPA stands ready to work with your offices as specific legislation is 
considered.

Our more detailed recommendations follow:

Using PHE Flexibilities to Modernize IRF Coverage Rules

At the beginning of the pandemic, two key IRF coverage waivers were 
granted to maximize patient access to IRFs--the 60% rule and the 3-hour 
rule. Even before the PHE, AMRPA urged policymakers to reexamine these 
rules and modernize them in light of the significant policy and 
operational changes that have occurred since their implementation. With 
both rules currently suspended due to the PHE, AMRPA believes it is an 
optimal time to reassess and refine these rules.

As background, the current ``60% rule'' broadly requires that 60% of 
the IRF's patients must have a qualifying condition in order to be paid 
as an IRF under the Medicare program. There are currently 13 such 
conditions, including, stroke, spinal cord or brain injury, and hip 
fracture, among others. There have been no major categories added for 
decades--despite medical and technological advancements that have led 
broader patient populations to gain significant clinical benefits from 
IRF care. The waiver of the 60% rule during the PHE has improved access 
for patients that had conditions other than those categorized as a 
compliant condition--such as oncology and cardiac-related conditions, 
and COVID-19--and led to improved outcomes and functional recoveries 
for such patients. AMRPA therefore urges Congress to direct CMS to 
revisit and potentially broaden the 60% rule's ``compliant'' conditions 
before putting the rule back into effect. This would be an important 
step to both protect patient access and ensure that Medicare 
regulations reflect the current state of medicine.

Similarly, AMRPA asks Congress to modernize the 3-hour rule, which 
requires an IRF patient to participate in, and benefit from, at least 
three hours of rehabilitation therapy per day, five days per week (or 
15 hours per week if documented appropriately). Due to a 2010 
regulatory change, only physical therapy, occupational therapy, speech 
therapy, and/or orthotics and prosthetics are countable therapies 
toward the 3-hour threshold. AMRPA recognizes that the volume of 
therapy received by IRF patients is among the characteristics that 
distinguish IRF care from other PAC settings. At the same time, AMRPA 
has advocated for the inclusion of other therapy modalities that 
rehabilitation physicians often determine are necessary for patients' 
full functional recovery, such as psychological services, 
neuropsychological services, and respiratory therapy. AMRPA members 
already provide these therapies when needed (despite their exclusion 
from the 3-hour rule calculation) given the clear benefit that they 
provide for a range of complex patients in IRFs. Their utilization and 
the benefit provided to patients clearly demonstrates that these 
therapies should be recognized as part of the ``intensive 
rehabilitation therapy program'' for which the 3-hour rule is 
attributed.

The rationale for counting these modalities toward the 3-hour threshold 
is all the more compelling in light of the impact of the PHE waiver. 
The aforementioned therapies were particularly beneficial as patients 
with acute respiratory disease were treated by IRFs during the 
pandemic, and AMRPA members expressed appreciation for the flexibility 
provided through the waiver in this regard. As such, AMRPA believes 
that they should permanently be allowed to count toward the threshold 
in the PHE aftermath. We have already worked with Congressional offices 
to discuss a bill that would deliver these much-needed modernizations, 
and we look forward to working with the Finance Committee to facilitate 
its introduction and advancement in the 117th Congress.

On a related issue, AMRPA requests that the full 3-hour rule waiver be 
included within the scope of flexibilities that can be granted by CMS 
(via Section 1135 waivers) in future PHEs. This would negate the need 
for Congressional action and ensure that this rule be waived promptly 
by regulators in emergency circumstances.

Significant Reforms to Prior Authorization Practices

In the first quarter of 2020, many Medicare Advantage (MA) plans 
voluntarily waived their prior authorization/pre-authorization policies 
to ensure that patients were able to access IRF beds in the safest and 
most timely way possible. These voluntary waivers enabled patients that 
were ready for clinical intervention to receive such care 
expeditiously, rather than incur the 3-5 business day delays that these 
policies frequently impart. Unfortunately, after the first few months 
of the pandemic, most MA plans reinstated prior authorization 
requirements. This severely impeded movement of patients from acute-
care hospitals into PAC settings, exacerbating an already critical 
hospital bed shortage. Data that AMRPA has examined from the time 
period before, during and after the suspension of prior authorization 
made clear that the removal this requirement provided access to complex 
patients that otherwise may have been delayed or denied receiving care. 
The positive impact of these waivers makes it clear that prior 
authorization policies must be fully and immediately suspended in all 
future public health emergencies for the emergency's full duration, and 
we urge you to include this protection statutorily in future pandemic- 
focused legislation.

In addition, AMRPA believes there are a number of reforms that must be 
made to prior authorization policies outside of the context of a PHE. 
Under current practices, an MA representative who has never seen or 
examined the patient, and often lacks training or expertise in 
rehabilitation medicine, second- guesses the judgement of the treating 
physicians that have deemed an admission to an IRF to be medically 
necessary and appropriate. In turn, these prior authorization policies 
often cause lengthy delays or inappropriate denials for patients 
needing IRF care, which adversely affects outcomes and functional 
recovery. With prior authorization practices now generally back in 
effect across the nation, AMRPA members report that these policies are 
once again compromising timely patient access to timely IRF care.

AMRPA therefore asks Congress to advance H.R. 3173--the Improving 
Seniors' Access to Care Act--as an initial and commonsense step towards 
prior authorization reform. Importantly, the legislation would direct 
HHS to establish that prior authorization decisions to be made in 
``real time'' to address the aforementioned delays and inappropriate 
referrals tied to current practices. AMRPA believes that 6 hours is an 
appropriate ``real time'' measure for an inpatient rehabilitation 
admission authorization decision, and we look forward to working with 
both Congress and ultimately HHS in this regard. Furthermore, AMRPA 
asks the Committee to consider other legislative actions to improve 
prior authorization practices, such as:

      Strengthen beneficiary protections for all MA enrollees by 
ensuring prior authorization requests are reviewed by physicians with 
appropriate training and experience in inpatient rehabilitation.
      Limit or eliminate the use of proprietary guidelines/decision 
tools to ensure enrollees' statutory right to Medicare fee-for-service 
benefits are fulfilled and that admission decisions take into account 
patient-specific characteristics and conditions.

Telehealth Expansion

Some of the most important waivers granted during the COVID-19 PHE 
relate to telehealth expansion, particularly for medical rehabilitation 
patients. In particular, AMRPA strongly supported policymakers' 
decision to (1) expand the list of telehealth services that can be 
provided in the Medicare program via telehealth to include therapy 
services, (2) recognize therapists--including physical therapists, 
occupational therapists, and speech-language pathologists--as eligible 
telehealth providers, (3) relax distant site guidelines, and (4) permit 
a broader range of telemedicine in the context of inpatient care--such 
as remote consultations and virtual team meetings. Many of our hospital 
members report that these waivers allow patients to continue the 
outpatient therapy component of their intensive rehabilitation program 
without undertaking the risk of entering the hospital or outpatient 
care setting. We therefore urge Congress to enact legislation to make 
these flexibilities permanent in the PHE aftermath.

Even before the COVID-19 pandemic, AMRPA is on record expressing 
support of efforts--such as the CONNECT for Health Act (which was again 
recently reintroduced in the 117th Congress)--to modernize telehealth 
rules in the Medicare program to better reflect the state of medicine 
and technology. Consistent with this position, AMRPA believes that 
these outpatient therapy-focused waivers will prove beneficial outside 
of a PHE, such as when patients face other obstacles (e.g., weather, 
protests, or mobility restrictions) that prevent them from traveling to 
an IRF or outpatient therapy site. At the same time, clearer billing 
rules--particularly for hospital outpatient departments--may be 
required to ensure sufficient uptake. Further, Congress should consider 
flexibility within the definition of telehealth, such as allowing 
audio-only services for those patients unable to use or without access 
to video technology or Internet connectivity. AMRPA therefore believes 
that permanent implementation of these telehealth waivers and requisite 
guidance to the industry is a commonsense way to improve patient access 
to care without compromising quality or safety.

Implementing Interstate Licensing Flexibilities

During the PHE, numerous AMRPA members were able to provide critical 
capacity to acute-care hospitals across state lines and provide both 
surge and COVID-19 patients with the acute beds they required. The 
interstate licensing flexibilities offered by CMS were utilized broadly 
by IRF providers and helped ensure that patients received the timely 
care they required for survival and recovery, without jeopardizing the 
quality of the care they received. AMRPA therefore requests that these 
flexibilities be made permanent to alleviate patient access issues and 
address arbitrary restrictions on care options when patients live near 
state lines. At minimum, AMRPA urges Congress to ensure that interstate 
licensing flexibilities are automatically triggered whenever a PHE is 
declared to ensure that partner hospitals in different states can 
immediately assist each other in furnishing the capacity and provider 
access required for their patients. Additionally, and consistent with 
our telehealth-related recommendations, AMRPA also recommends that 
providers be allowed to practice across state lines via telehealth in 
the same way they would be permitted to do so in-person.

 Delaying the Implementation Timeline and Considering Other Potential 
                    Changes to the IMPACT Act

As Congress assesses policy changes informed by COVID-19 waivers and 
flexibilities, AMRPA urges Members to also be mindful of the lessons 
learned by and about post-acute care providers in the context of other 
legislative efforts. Specifically, AMRPA believes the PHE requires 
policymakers to reconsider the timing and underlying goals of the 
unified post-acute care (UPAC) prototype required under the IMPACT Act. 
With respect to timing, AMRPA has long been concerned about the data 
being used to develop a UPAC prototype given the significant changes in 
each of the post-acute care setting payment systems since the 
implementation of the IMPACT Act. The current PHE now raises new and 
serious concerns about the use of claims and cost data for any year 
that the PHE is/was in effect and the years immediately following. 
Therefore, as policymakers consider how the COVID-19 PHE should impact 
future work related to post-acute care reform, the development of a 
UPAC prototype should at the very least be delayed for several years 
until useable data is available.

This delay would also allow policymakers to consider the seismic impact 
of the COVID-19 PHE on the post-acute care continuum and the permanent 
changes in care delivery that will stem from the exact policy changes 
being considered through the Committee in this line of work (for 
example, the impact of future telehealth expansions). Therefore, AMRPA 
urges the Committee to support The Resetting the IMPACT Act (H.R. 
2455), which would make these commonsense reforms and reset the 
timeframe in a way that could improve the accuracy of a prototype (and 
ensure more meaningful stakeholder engagement). We also look forward to 
working with the Committee to ensure that any future payment and 
coverage changes are informed by the lessons the Committee seeks to 
glean from the PHE.

In closing, AMRPA applauds the leadership of the Committee and greatly 
appreciates the opportunity to provide comments on how COVID-19 waivers 
should inform future policy changes. Should you wish to discuss our 
comments further, please contact Kate Beller ([email protected]; 973-
224-4501) or Kristen O'Brien ([email protected]).

Sincerely,

Anthony Cuzzola
Chairman, AMRPA Board of Directors
Vice President/Administrator
JFK Johnson Rehabilitation Institute
Hackensack Meridian Health

                                 ______
                                 
               American Occupational Therapy Association

                  6116 Executive Boulevard, Suite 200

                     North Bethesda, MD 20852-4929

                              [email protected]

                              301-652-6611

                         https://www.aota.org/

Pandemic Experience Demonstrates Need to Continue OT Telehealth Options 
      for Medicare Beneficiaries After the Public Health Emergency

The American Occupational Therapy Association (AOTA) is the national 
professional association representing the interests of more than 
230,000 occupational therapists, occupational therapy assistants, and 
students of occupational therapy. The science-driven, evidence-based 
practice of occupational therapy enables people of all ages to live 
life to its fullest by promoting participation in daily occupations or 
activities. In so doing, growth, development, and overall functional 
abilities are enhanced, and the effects associated with illness, 
injuries, and disability are minimized.

        Telehealth and Occupational Therapy Before the Pandemic

As noted in AOTA's Telehealth in Occupational Therapy backgrounder 
(attached), some occupational therapy professionals were providing 
occupational therapy (OT) services via telehealth before the COVID-19 
pandemic struck, with significant innovation occurring at the Veterans 
Administration. The number of OT telehealth encounters increased 
dramatically, however, as Congress and CMS reacted quickly to enable 
Medicare beneficiaries to receive OT and other therapy services via 
telehealth during the declared Public Health Emergency (PHE) to 
minimize infection risk.

Congressional action was essential to waive statutory restrictions on 
CMS that prevented occupational therapy practitioners and other therapy 
providers' ability to provide services to Medicare beneficiaries via 
telehealth. CMS responded to Congressional waivers included in the 
CARES Act by issuing an emergency rule that added a series of therapy 
CPT' codes to the telehealth services list, and then 
subsequently issued another rule that included occupational therapy 
practitioners as eligible Medicare telehealth providers. This 
effectively enabled OTs to provide services via telehealth to Part B 
Medicare beneficiaries during the COVID-19 emergency; however, these 
waivers are not permanent.

The delivery of OT services via telehealth expanded exponentially after 
the CMS waivers were issued, and in response to actions by state 
Medicaid plans and private insurance to also allow patients to receive 
OT services via telehealth to reduce infection risk. This enabled 
occupational therapy professionals to continue to provide essential OT 
services, while gaining the necessary experience to fully appreciate 
potential benefits to patients that are unrelated to minimizing in-
person contact during a pandemic.

Congressional action is now essential to enable OT services to continue 
to be provided to Medicare beneficiaries via telehealth when 
appropriate, as CMS has indicated that it does not have the authority 
to do so under existing statute. The Expanded Telehealth Access Act 
(H.R. 2168) was introduced in the House by Reps. Mikie Sherrill (D-NJ) 
and David McKinley (R-WV) to enable OT professionals as well as 
physical therapists (PTs), speech-language pathologists (SLPs), and 
audiologists to provide services via telehealth under Section 1834(m) 
of the Social Security Act. Unless Congress acts, Medicare 
beneficiaries will face a telehealth ``cliff'' when the PHE ends, 
whereby beneficiaries who are now accustomed to receiving some OT 
services via telehealth, suddenly lose access to such services.

           Experience During PHE Demonstrates Effectiveness 
                     of OT Services via Telehealth

The rapid expansion of telehealth as a delivery mechanism for OT 
services during the PHE has enabled occupational therapists and 
occupational therapy assistants to demonstrate the clear value of these 
services provided alone or in conjunction with in-person services. 
Telehealth has been especially beneficial for people in rural and other 
underserved areas and to those for whom travel to receive services was 
already a barrier to access, including people with disabilities.

OT practitioners report that telehealth has enhanced the effectiveness 
of OT services for Medicare beneficiaries in many ways. It has enabled 
more patients to start care on the day ordered and to minimize 
cancellations, postponements, and schedule changes that are commonly 
connected to transportation, mobility, caregiver availability, weather, 
and other issues related to treatment in a clinical setting. This in 
turn has enabled some patients to complete treatment sooner and with 
fewer visits, which can reduce the cost of care.

Telehealth has also made it much easier to connect with beneficiary 
caregivers who are often unable to take the time required to travel 
with the patient to in-person visits. This is especially important for 
some patients in the Medicare population who rely more heavily on a 
caregiver for assistance during appointments and for follow-up in the 
home. In addition, telehealth visits have enabled OT professionals to 
better identify home safety issues, which are often minimized or not 
referenced at all by patients during an office visit. This can be 
crucial in preventing falls, addressing functional decline, and 
avoiding costly emergency room visits and hospital admissions which, in 
turn, can reduce the cost of care.

     Research Demonstrates Efficacy of OT Delivered via Telehealth

A study (infographic attached) by Focus on Health Outcomes (FOTO), one 
of the major health data registries used by therapists, reported on 
five data-driven benefits of therapy when provided via teleheatlh 
utilizing differing proportions of in-person and telehealth visits per 
patient. The study indicated that therapy provided via telehealth can 
promote patient confidence, drive better attendance numbers, and 
sustain the continuity of care for existing patients. It also indicated 
that therapy services provided via telehealth and non-telehealth were 
equally effective in relation to improving the functional status of 
patients, with differing mixes of teleheatlh and in-person visits 
utilized as needed/desired by the patient. In addition, the study 
demonstrated a reduced number of visits per episode of care when 
telehealth was involved, and equal patient satisfaction.\1\
---------------------------------------------------------------------------
    \1\ Data-Driven Benefits of Telehealth for Rehab Therapists (2020). 
Net Health, https://www.nethealth.com/5-data-driven-benefits-of-
telehealth-for-rehab-therapists/.

The AOTA Telehealth Position Paper \2\ summarizes how occupational 
therapy practitioners use telehealth technologies as a method for 
service delivery for evaluation, intervention, consultation, 
monitoring, and supervision of students and other personnel. Further, 
it references the results of research on the use of telehealth in 
rehabilitation or habilitation, which includes occupational therapy.
---------------------------------------------------------------------------
    \2\ American Occupational Therapy Association (2013). Telehealth. 
American Journal of Occupational Therapy, 67(6 Suppl.), S69-S90, http:/
/dx.doi.org/10.5014/ajot.2013.67S69.

There is a growing base of evidence demonstrating the efficacy of 
technologically mediated occupational therapy.\3\ Ongoing research at 
University of Southern California Mrs. T. H. Chan Division of 
Occupational Science and Occupational Therapy Faculty Practice has 
shown that increased use of telehealth for pain-management patients 
decreased cancellations, increased access, and improved treatment 
effectiveness. Patient satisfaction with telehealth is also high. A 
more detailed list of their findings follows:
---------------------------------------------------------------------------
    \3\ Cason J (2009). A Pilot Telerehabilitation Program: Delivering 
Early Intervention Services to Rural Families. International Journal of 
Telerehabilitation, 2009;1(1):29-37. Hoffmann T, Russell T, Thompson L, 
Vincent A, Nelson M. (2008). Using the Internet to assess activities of 
daily living and hand function in people with Parkinson's disease. 
NeuroRehabilitation, 23, 253-261. Ng EM, Polatajko HJ, Marziali E, Hunt 
A, Dawson DR (2013). Telerehabilitation for addressing executive 
dysfunction after traumatic brain injury. Brain Inj. 2013;27(5):548-64.

      Ability to access more people with chronic pain by eliminating 
the geographic barrier of having to drive to an in-person session. A 
recent evaluation of a telehealth group intervention for pain 
management, specifically for patients living in rural or remote areas, 
revealed that participants benefited from telehealth specialty pain 
management services.\4\
---------------------------------------------------------------------------
    \4\ Scriven, H., Doherty, D.P., and Ward, E.C. (2019). Evaluation 
of a multisite telehealth group model for persistent pain management 
for rural/remote participants. Rural and Remote Health, 19(1).
---------------------------------------------------------------------------
      Decreased cancellation rates due to pain flare ups or symptom 
exacerbations because patients do not have to commute to in-person 
sessions, but can participate from the comfort of their own home where 
they can access many of their pain management tools (i.e., medication, 
heat/ice, self-massage units, lying down as needed, more control over 
ambient temperature).
      Improved treatment effectiveness due to improved ability to 
assess and evaluate a person's home environment and contextual factors, 
rather than through verbal discussion or photos. This allows for more 
effective problem solving and identification of environmental barriers. 
This is especially clear in OT interventions for pain regarding body 
mechanics, ergonomics, physical activity routines, sleep positioning, 
falls prevention and recovery, and placement of durable medical 
equipment for optimal safety.
      Improved continuity of care because patients who would travel 
long distances to come to the clinic may only be seen for treatment 1x/
month, but with telehealth services, they can be seen weekly for 
improved accountability and to support long-term, sustainable behavior 
change.
      Improved patient satisfaction--patients are reporting improved 
participation and effectiveness of treatment because commuting to the 
clinic and driving can often be a trigger of pain or stress. By 
eliminating this factor, patients avoid starting treatment sessions in 
pain or fatigue and are able to participate more effectively during 
session.
      Reduced social isolation and occupational deprivation--due to 
compounding factors of managing a chronic condition and the long-term 
effects of pandemic-
related restrictions, patients are reporting feelings of isolation and 
reduced functional participation in daily routines and meaningful 
activities. Experiencing occupational deprivation can have detrimental 
effects on health and wellness, self-efficacy, and identity.\5\ With OT 
telehealth, patients can collaborate with their OT to identify 
strategies and opportunities to engage in occupations and social 
activities to combat isolation, occupational deprivation, and 
associated adverse health consequences.
---------------------------------------------------------------------------
    \5\ Whiteford, Gail. (2000). Occupational deprivation: global 
challenge in the new millennium. British Journal of Occupational 
Therapy, 63(5).

Additional research has shown strong strength of evidence that 
motivational interviewing, fatigue management, and medication adherence 
---------------------------------------------------------------------------
performed via telehealth lead to positive outcomes.

Based on this research, both Medicare beneficiaries and the Medicare 
Program would see great benefits in quality care, reduced costs, and 
reduced hospitalizations if occupational therapy is utilized fully. 
AOTA asserts that the same ethical and professional standards that 
apply to the traditional delivery of occupational therapy services also 
apply to the delivery of services received via telehealth. Occupational 
therapy interventions delivered via telehealth can assist patients to 
regain, develop, and build functional independence in everyday life 
activities to significantly enhance a Medicare beneficiary's quality of 
life. Telehealth may also address provider shortages and access 
problems, making necessary occupational therapy services available to 
underserved beneficiaries in remote, inaccessible, or rural settings 
and to beneficiaries with limited mobility outside their home. Further, 
occupational therapy is the chief profession with expertise in 
activities of daily living and community environments, which may be 
better observed and evaluated through telehealth services when the 
beneficiary is in their home environment.

             Occupational Therapists Describe Benefits of 
                      OT via Telehealth During PHE

AOTA commends the Government Accounting Office for conducting a study 
on the use of telehealth during the PHE, and we look forward to seeing 
the results of their work. In addition, examples of the use of 
telehealth to provide OT services during the PHE follow, as described 
by OT professionals:

      Telehealth has been crucial for service to our CMS patients in 
our Post-ICU multidisciplinary clinic during the pandemic and would 
continue to be a vital resource for these patients. Many of these 
patients will not be able to access the services for a variety of 
reasons if we cannot continue with telehealth.
      Telemedicine has been a very helpful but unexpected resource for 
service delivery. One of the primary barriers to clients participating 
in the 55+ Program in the past has been transportation. Many clients 
are fearful of driving, unable to drive due to other health conditions, 
or do not have access to a vehicle and alternative transportation is 
too expensive. Telemedicine has allowed these clients access to 
treatment now.
      Initially many of my older adult clients struggled and were 
fearful of technology and did not think they would be able to 
participate in online treatment. With coaching and assistance, many 
clients have overcome these barriers and now are using technology more 
to connect with family, friends, and other community resources. It has 
helped to decrease isolation for many both for treatment and in the 
community.
      I am an occupational therapist in an outpatient neurological 
clinic. The majority of my patient caseload includes adults and older 
adults with comorbidities and/or [who] are immuno-compromised. During 
the global pandemic, taking months off of therapy could have resulted 
in significant decrease in function for some of the patients I serve. 
Our clinic was on the edge of our seats while waiting to hear the CMS 
changes to allow occupational therapy providers to provide telehealth 
services. Once the change had been made, it opened up a new world of 
opportunity for us to serve these patients who so needed skilled 
therapy, but were unable to physically come into the clinic. As 
occupational therapists, we adapt. I am able to provide individualized, 
client-centered care through a new medium that was aligned with the 
patient's plan of care to reach their functional goals. Without the 
ability to provide the skilled services via telehealth, our clients 
would not have received the care they needed. Patients have been 
surprised with the effectiveness of telehealth therapy services. If CMS 
allows these changes to be permanent, we would be able to better serve 
those patients in effective ways through the use of this technology.
      Clients who have difficulty with transportation to the clinic or 
consistent transportation have been able to receive services and those 
that have anxiety with new providers or leaving home have benefitted in 
that this is a great bridge to start with to start to expose to social 
skills and situations and still provide them with the therapy that they 
need to succeed.
      One particular patient was a woman with Parkinson's. She and her 
husband were sleeping on an air mattress in their den because she had a 
hip fracture and was not steady enough to climb the stairs to her 
bedroom. After her OT eval, she refused further in-person visits. I 
trialed telehealth visits with great success. I was able to have the 
husband aim the camera so that I was able to provide placement of 
recommended grab bars in the bathrooms, both upper and lower levels, as 
well as get a tour of the second level, something I had not been able 
to assess at the eval. I was able to help with technique and 
positioning for upper extremity exercises, and eventually, I was able 
to teach the husband how to assist the patient up/down the stairs, 
safely, as well as teach bed mobility so that the patient was able to 
sleep in her own bed upstairs versus an air mattress on the floor on 
the main level. She and her husband looked forward to my weekly visits 
and always updated me on the progress she had made. They were so 
grateful for the therapy I was able to provide remotely.

          Global Telehealth Issues of Specific Concern to AOTA

While Congressional action is urgently needed now to allow occupational 
therapy professionals to provide services via telehealth after the PHE, 
AOTA also notes that for telehealth to move forward in any way, several 
other issues must also be addressed. In order to maximize the benefit 
of telehealth services, the originating site for a telehealth visit 
must be the patient's home, especially for OT services as described 
above. In addition, there is no justification for a payment 
differential for telehealth services, as practice expenses are unlikely 
to go down since practitioners need to maintain an office to perform 
both telehealth and in-person visits. Additionally, practice expense 
may increase as practitioners invest in HIPAA-compliant software and 
other technology to assist in telehealth visits. AOTA appreciates the 
relaxation of HIPAA requirements during the PHE for telehealth 
software; however, these restrictions should be reinstated after the 
PHE ends to protect the security of Personal Health Information. 
Finally, Congress must allow some limited services to be provided via 
audio only, especially in the area of mental health and substance 
abuse, with self-care as an example of a code used by OT professionals.

                Summary--Congressional Action Essential 
                   to Avoid Therapy Telehealth Cliff

In summary, OT interventions delivered via telehealth have enabled 
patients to develop, regain, and build functional independence in 
everyday life. Telehealth has also demonstrated advantages over in-
person visits in some situations, especially for people in rural and 
underserved areas, and for the large number of seniors in all 
communities who face transportation and mobility issues, especially 
those with disabilities. Telehealth is also an ideal platform for 
conducting home safety evaluations as it provides a window into the 
person's home and often great access to their caregiver.

As noted, Congressional action is essential to enable Medicare 
beneficiaries to continue to receive OT services via telehealth when 
appropriate. Passage of the Expanded Telehealth Access Act (H.R. 2168) 
would enable OT professionals as well as PTs, SLPs, and audiologists to 
provide services via telehealth under Section 1834(m) of the Social 
Security Act. Unless Congress acts, Medicare beneficiaries will face a 
telehealth ``cliff'' when the PHE ends, whereby beneficiaries who are 
now accustomed to receiving some OT services via telehealth suddenly 
lose access to such services. We urge Congress to prevent this outcome.

                                 ______
                                 
                    American Pharmacists Association

                      2215 Constitution Avenue, NW

                          Washington, DC 20037

Chairman Wyden, Ranking Member Crapo, and Members of the Committee, the 
American Pharmacists Association (APhA) is pleased to submit the 
following Statement for the Record for the U.S. Senate Finance 
Committee Hearing, ``COVID-19 Health Care Flexibilities: Perspectives, 
Experiences, and Lessons Learned.''

APhA is the largest association of pharmacists in the United States 
advancing the entire pharmacy profession. APhA represents pharmacists 
in all practice settings, including community pharmacies, hospitals, 
long-term care facilities, specialty pharmacies, community health 
centers, physician offices, ambulatory clinics, managed care 
organizations, hospice settings, and government facilities. Our members 
strive to improve medication use, advance patient care, and enhance 
public health.

APhA thanks the Committee for holding this important hearing examining 
COVID-19 health-care flexibilities. During the COVID-19 public health 
emergency (PHE), pharmacists have demonstrated the ability to 
significantly expand access to care and equity in care,\1\ and they 
will continue to do so if certain regulatory barriers are permanently 
removed. The pandemic has demonstrated how essential and accessible 
pharmacists are in the United States. Pharmacists and pharmacies' 
lights stayed on from the start of the pandemic and are essential 
components of public health infrastructure.
---------------------------------------------------------------------------
    \1\ National Pharmacy Organizations Unite to Take a Stand Against 
Racial Injustice. June 5, 2020, available at: https://www.accp.com/
docs/news/Pharmacy_Statement_On_Racial_Injus
tice.pdf.

As you know, the fight against COVID-19 has demanded the federal 
government take action to allow pharmacists and other health-care 
professionals to do more of what they are trained to do. By being more 
flexible about certain requirements and expanding scope of practice 
through new authorities, the federal government made it easier for 
pharmacists to provide care to patients during the COVID-19 PHE. The 
problem is many of these flexibilities and authorities are not 
considered permanent and further action is needed to expand access to 
pharmacist-provided services. If action is not taken, patients will not 
be able to receive needed care at pharmacies across the country once 
---------------------------------------------------------------------------
the PHE ends.

Accordingly, APhA urges Congress to expeditiously use its authority to 
pass legislation to make permanent:

      Pharmacists' ability to order, authorize, test, treat, and 
administer immunizations and therapeutics against infectious diseases;
      Removal of operational barriers that address workforce and 
workflow issues which previously prevented pharmacists from engaging in 
patient care;
      Including pharmacists under existing and future telehealth 
flexibilities; and
      Maintaining compounding flexibilities to address current and 
future drug shortages.

 Securing Ability of Pharmacists to Order, Authorize, Test, Treat, 
                    Immunize, and Provide Other Services

Many of these new authorities and flexibilities, including pharmacists' 
ability to order and administer COVID-19 and childhood vaccines and 
COVID-19, influenza, and RSV tests, as well as pharmacy interns and 
technicians to administer COVID-19 tests and vaccinations to persons 
aged 3 years or older as well as childhood vaccines to individuals ages 
3 to 18 years old should continue as they have significantly increased 
patient access and care.

 Removal of Operational Barriers for Pharmacists

The COVID-19 pandemic has stressed and strained our health-care system 
and revealed generations of health inequities in communities of color, 
medically underserved, and rural areas. In order to protect public 
health, detect and respond to future epidemics, and improve the 
equitable delivery of health care, every pharmacist needs to be able to 
support health-care teams.

In January 2021, the Department of Health and Human Services (HHS), 
under the Public Readiness and Emergency Preparedness Act (PREP Act), 
authorized any health-care provider, including pharmacists, who are 
licensed or certified in a state to prescribe, dispense, and/or 
administer COVID-19 vaccines across state lines, during the public 
health emergency.\2\ Congress needs to make this authority permanent to 
maintain the ability of pharmacists to fill gaps in primary care and 
surge to meet public health crises.
---------------------------------------------------------------------------
    \2\ https://www.phe.gov/Preparedness/legal/prepact/Pages/COVID-
Amendment5.aspx.

Additionally, the Centers for Medicare and Medicaid Services (CMS) has 
encouraged insurance plans to practice flexibility regarding prior 
authorization protocols, refills, deliveries, and pharmacy audits. 
These practices have reduced the administrative burden on clinicians 
and allowed for more efficient patient care, testing and vaccine 
delivery. Given the benefits to patients and the system, we recommend 
that Congress pass legislation to require all Medicare Advantage (MA) 
and Part D plans to continue offering these flexibilities to prevent 
decreased medication adherence in vulnerable populations, especially 
older adults and people of color. CMS has also issued policies relaxing 
Medicare Part D audit requirements for signature logs. Accordingly, we 
recommend Congress make the following policies permanent for MA, Part D 
---------------------------------------------------------------------------
plans and contracted pharmacy benefit managers (PBMs):

      Relaxing to the greatest extent possible prior authorization 
requirements, where appropriate;
      Suspending plan-coordinated pharmacy audits during any PHE; and
      Waiving medication delivery documentation and signature log 
requirements to limit unnecessary contact with sick and potentially 
infectious patients.

 Including Pharmacists under Existing and Future Telehealth 
                    Flexibilities

The rapid shift to telehealth services during the COVID-19 PHE has 
illustrated the value of telehealth long-term, particularly for 
patients with mobility issues and those in rural and/or medically 
underserved areas. Prior to the PHE, pharmacists were already actively 
involved in virtual care delivery for Medicare beneficiaries through 
provision of Part B services such as Chronic Care Management (CCM), 
Transitional Care Management (TCM), Continuous Glucose Monitoring 
(CGM), Remote Patient Monitoring (RPM), and Behavioral Health 
Integration (BHI), as well as Medication Therapy Management Services in 
the Part D program. The onset of the COVID-19 pandemic has brought 
about additional opportunities to leverage pharmacists in telehealth 
services, including medication management services, chronic disease 
management, education on healthy lifestyle interventions, patient 
counseling on point of care diagnostic tests, and more.

APhA recommends Congress take the following steps to enhance patient 
access to telehealth services:

      Make permanent the authority allowing direct supervision to be 
provided using real-time interactive audio and video technology under 
incident to physician services arrangements;
      Make permanent the authority allowing Medicare-enrolled 
pharmacies offering accredited diabetes self-management training (DSMT) 
programs to offer DSMT services via telehealth;
      Designate pharmacists as practitioners (providers) for the 
Medicare Telehealth Benefit, and add patient care services provided by 
pharmacists using telehealth to the Medicare Telehealth List;
      Ensure Medicare payment for pharmacist-provided telehealth and 
in-person services is commensurate with the time and complexity of the 
services provided;
      Allow for telephonic or video prescription counseling of 
patients to facilitate contactless care; and
      Make permanent Medicare coverage and payment of audio-only 
telephone calls for opioid treatment program therapy, counseling, and 
periodic assessments.

 Maintaining Compounding Flexibilities to Address Current and Future 
                    Drug Shortages

Drug shortages are another factor that can negatively affect patients 
in terms of medication cost and the availability of their treatments. 
APhA urges the Committee to consider mechanisms to both better control 
the price of medications in shortage and improve tracking and 
prediction systems used to identify drugs in shortage. For example, FDA 
issued temporary guidance granting flexibility for pharmacists to 
compound certain necessary medications under 503A and 503B for 
hospitalized patients without patient-specific prescriptions to address 
COVID-19. Many of our members have told us FDA's compounding 
flexibility is the only reason hospitals were able to keep up with 
patient demand. Accordingly, the recent flexibility to compound 
medications under both sections 503A and 503B are likely to be 
necessary for the foreseeable future, and we strongly urge the 
Committee to pass legislation to codify this flexibility to address 
drug shortages. We believe maintaining stability within the supply 
chain during the global COVID-19 pandemic is crucial. We strongly urge 
the Committee to focus on solutions that harness existing relationships 
with international trading partners to promote supply chain resiliency 
and diversity while avoiding measures that could undermine our ability 
to work with the international community.

 S. 1362/H.R. 2759, the Pharmacy and Medically Underserved Areas 
                    Enhancement Act

The COVID-19 pandemic has further illustrated how difficult it is for 
some patients living in medically underserved communities to access 
care and achieve optimal medication therapy outcomes. A strong body of 
evidence has shown that including pharmacists on interprofessional 
patient care teams with physicians, nurses, and other health-care 
providers produces better health outcomes and cost savings. Pharmacists 
are one of the most accessible health-care providers in the nation, 
with nearly 90% of Americans living within five miles of one of the 
nation's 88,000 pharmacies.\3\
---------------------------------------------------------------------------
    \3\ NCPDP Pharmacy File, ArcGIS Census Tract File. NACDS Economics 
Department.

Despite the fact that many states and Medicaid programs are turning to 
pharmacists to increase access to health care, Medicare Part B does not 
cover many of the impactful and valuable patient care services 
pharmacists can provide. As proven during the COVID-19 pandemic, 
pharmacists are an underutilized and accessible health-care resource 
who can positively affect beneficiaries' care and the entire Medicare 
---------------------------------------------------------------------------
program.

Accordingly, APhA strongly urges the Committee to include S. 1362, the 
Pharmacy and Medically Underserved Areas Enhancement Act, recently 
introduced by Committee members Charles Grassley (R-IA), Robert Casey 
(D-PA), and Sherrod Brown (D-OH), in the Committee's legislative 
package to allow pharmacists to deliver vital patient care services in 
medically underserved areas to help break down the barriers to 
achieving health-care equity in this country, improve patient care, 
health outcomes, the impact of medications,\4\ and consequently, lower 
health-care costs and extend the viability of the Medicare program.
---------------------------------------------------------------------------
    \4\ See, Avalere Health. Exploring Pharmacists' Role in a Changing 
Healthcare Environment. May 2014, available at: http://avalere.com/
expertise/life-sciences/insights/exploring-pharmacists-role-in-a-
changing-healthcare-environment. Also, see, Avalere Health. Developing 
Trends in Delivery and Reimbursement of Pharmacist Services. October 
2015, available at: http://avalere.com/expertise/managed-care/insights/
new-analysis-identifies-factors-that-can-facilitate-broader-
reimbursement-o.

By recognizing pharmacists as providers under Medicare Part B, S. 1362 
would enable Medicare patients in medically underserved communities to 
better access health care through state-licensed pharmacists practicing 
according to their own state's scope of practice. In medically 
underserved communities, pharmacists are often the closest health-care 
professional and the most accessible outside normal business hours. S. 
1362 recognizes that pharmacists can play an integral role in 
addressing these longstanding disparities to help meet health equity 
goals \5\ and ensure that our most vulnerable patients have access to 
the care they need where they live. Helping patients receive the care 
they need, when they need it, is a common sense and bipartisan solution 
that will improve outcomes and reduce overall costs.
---------------------------------------------------------------------------
    \5\ The White House. Executive Order on Advancing Racial Equity and 
Support for Underserved Communities Through the Federal Government. 
January 20, 2021, available at: https://www.whitehouse.gov/briefing-
room/presidential-actions/2021/01/20/executive-order-advancing-racial-
equity-and-support-for-underserved-communities-through-the-federal-
government/.
---------------------------------------------------------------------------

Conclusion

APhA would like to thank the Committee for holding this important 
hearing and for continuing to work with us by making key COVID-19 
health-care flexibilities permanent and including S. 1362 in your 
legislative package to increase access to pharmacist-provided patient 
care services for medically underserved communities to promote health-
care equity. Please contact Alicia Kerry J. Mica, Senior Lobbyist, at 
[email protected] or by phone at (202) 429-7507 as a resource as you 
consider this legislation. Thank you again for the opportunity to 
provide comments on this important issue.

                                 ______
                                 
                 American Physical Therapy Association

                      3030 Potomac Ave., Suite 100

                       Alexandria, VA 22305-3085

                              703-684-2782

                         https://www.apta.org/

May 18, 2021

Senator Ron Wyden                   Senator Mike Crapo
Chairman                            Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance

Dear Chairman Wyden and Ranking Member Crapo,

On behalf of our more than 100,000 member physical therapists, physical 
therapist assistants, and students of physical therapy, the American 
Physical Therapy Association appreciates the opportunity to provide a 
statement for the record on the committee's hearing ``COVID-19 Health 
Care Flexibilities: Perspectives, Experiences, and Lessons Learned.'' 
APTA is dedicated to building a community that advances the physical 
therapy profession to improve the health of society. As experts in 
rehabilitation, prehabilitation, and habilitation, physical therapists 
play a unique role in society in prevention, wellness, fitness, health 
promotion, and management of disease and disability for individuals 
across the age span--helping individuals improve overall health and 
prevent the need for avoidable health-care services. Physical 
therapists' roles include education, direct intervention, research, 
advocacy, and collaborative consultation. These roles are essential to 
the profession's vision of transforming society by optimizing movement 
to improve the human experience.

Value of Physical Therapy Through Telehealth

The ongoing coronavirus pandemic has highlighted the need for patients, 
health systems, payers, and providers to rapidly adopt or expand models 
and modes of care delivery that minimize disruptions in care and the 
risks associated with those disruptions. The expansion of telehealth 
payment and practice policies under the section 1135 waivers during 
this Public Health Emergency, including permitting physical therapy 
services to be furnished via telehealth by physical therapists and 
physical therapy assistants across settings has demonstrated that many 
needs can be safely and effectively met via the use of technology and 
that patients can have improved access to skilled care by leveraging 
these resources.

Physical therapy is well-suited for telehealth--primarily as an 
enhancement of in-person services, although a telehealth visit also may 
replace an in-person visit when needed or indicated. Physical 
therapists and physical therapist assistants can use telehealth as a 
supplement to in-person services to evaluate and treat a variety of 
conditions prevalent in the Medicare population, including but not 
limited to Alzheimer's disease, arthritis, cognitive/neurological/
vestibular disorders, multiple sclerosis, musculoskeletal conditions, 
Parkinson disease, pelvic floor dysfunction, frailty, and sarcopenia.

Physical therapists make determinations, in consultation with patients 
and caregivers, regarding the appropriate mix of in-person and 
telehealth services to meet the goals in the plan of care. The 
evaluation and treatment of a patient via the use of telehealth allows 
the physical therapist to interact with the patient within the real-
life context of their home environment, which is not easily replicable 
in the clinic. Patient and caregiver self-efficacy are inherent goals 
of care, and telehealth not only allows a physical therapist to 
maintain the continuity of care anticipated in the plan of care but 
also allows for immediate and effective engagement when a specific 
challenge arises. A patient's and/or caregiver's ability to interact in 
their own environment with a physical therapist when they are facing a 
challenge, rather than waiting for the next appointment, can be 
invaluable in supporting the adoption of effective strategies to 
improve function, enhance safety, and promote engagement.

Skilled physical therapy interventions delivered through an electronic 
or digital medium have the potential to prevent falls, functional 
decline, costly emergency room visits, and hospital admissions and 
readmissions. Further, physical therapists already are experienced in 
modifying exercises for the patient to perform them safely at home, as 
a home exercise program is a common element of a treatment plan for 
patients who are treated in person. Education and home exercise 
programs--including those focused on falls prevention--function 
particularly well with telehealth because the physical therapist can 
evaluate and treat the patient within the real-life context of their 
home environment. This is not easily replicated in the office setting.

Physical therapy progresses patients toward total independence of their 
program in their own homes. Telehealth facilitates this objective,\1\ 
as the physical therapist can progress the patient in their native 
environment rather than in a ``simulated'' one in the clinic. Moreover, 
a patient's and/or caregiver's ability to interact in their own 
environment with a physical therapist can be invaluable in supporting 
the adoption of effective strategies to improve function, enhance 
safety, and promote engagement. Telehealth expands the clinical impact 
of physical therapy by providing patients on-demand access to their 
physical therapist to promote increased adherence, access to booster 
sessions to ensure sustainability of therapeutic gains and functional 
performance, and access to supplemental care in-between in-person 
visits to reduce the length of the episode of care and to lower costs.
---------------------------------------------------------------------------
    \1\ https://clinicaltrials.gov/ct2/show/NCT02914210.

Moreover, physical therapy is not synonymous with exercise. Although 
much of skilled physical therapy is high-touch, a significant component 
is transition of skills--promoting self-efficacy, environmental 
assessment and modification, training and education, and, most 
important, ongoing assessment, analysis, and clinical decision-making. 
A critical component of physical therapy is the prescription of 
carryover techniques, tasks, and activities--not just exercise--by a 
patient in their own environment. Physical therapy services performed 
---------------------------------------------------------------------------
via telehealth enhance this component of care.

Examples of physical therapy providers using telecommunications 
technology to provide real-time, interactive audio and video care 
include the following:

      Physical therapy practitioners use telehealth technologies to 
conduct evaluations or reevaluations \2\ or provide quicker screening, 
assessment, and referrals that improve care coordination.
---------------------------------------------------------------------------
    \2\ https://pubmed.ncbi.nlm.nih.gov/26658151/.
---------------------------------------------------------------------------
      Physical therapy practitioners provide interventions use 
telehealth by interacting with the patient in real time to provide 
instruction in exercise and activity performance, observing return 
demonstration and instruction in modifications or progressions of a 
program, providing caregiver support, and promoting self-efficacy.
      Physical therapy practitioners provide verbal and visual 
instructions and cues to modify how patients perform various 
activities. They also may suggest that the patient or caregiver modify 
the environment for safety reasons, or to potentially produce even more 
optimal outcomes.
      Physical therapy practitioners use telehealth technologies to 
provide prehabilitation and conduct home safety evaluations.
      Physical therapy practitioners use telehealth technologies to 
observe how patients interact with their environment and/or other 
caregivers, and to provide caregiver education.
      Physical therapy practitioners can assess the carryover of the 
activity modification strategies and activities to determine 
effectiveness immediately rather than waiting for the next in-person 
visit.
      Physical therapists use telehealth to reduce the number of ``in-
clinic'' visits and still maintain important follow-up care. This might 
reduce travel time and/or burden for a patient--which, for some 
conditions, might result in faster healing. This also prevents any 
delays in modifying a program when it needs to be upgraded or 
downgraded.
      Physical therapists can use technology to satisfy supervision 
requirements.
      A physical therapist can co-treat with another clinician who is 
treating via real-time audio and visual technology.
      A treating physical therapist can consult directly with another 
physical therapist or physical therapist assistant for collaboration 
and/or to obtain specialty recommendations to incorporate into an 
existing plan of care.
      Physical therapists use telehealth for quick check-ins with 
established patients.

Telehealth services furnished by physical therapists and physical 
therapist assistants offer cost savings, allow for coordination of 
care, and may improve adherence and patient satisfaction. Many studies 
\3\ have illustrated the clinical benefit of telerehabilitation for a 
variety of conditions, including pelvic floor dysfunction \4\ and 
multiple sclerosis.\5\
---------------------------------------------------------------------------
    \3\ https://pubmed.ncbi.nlm.nih.gov/26940798/.
    \4\ https://www.researchgate.net/publication/
330736628_Telerehabilitation_for_Treating_
Pelvic_Floor_Dysfunction_A_Case_Series_of_3_Patients%27_Experiences.
    \5\ https://pubmed.ncbi.nlm.nih.gov/31042118/.

A 2019 study \6\ examined the efficacy of home-based telerehabilitation 
versus in-
clinic therapy for adults after stroke, finding that poststroke 
activity-based training resulted in substantial gains in patients' arm 
motor function whether provided via telerehabilitation or in person. 
Other studies \7\ show that home-based telerehabilitation significantly 
improved veterans' functional independence, cognition, and patient 
satisfaction. See Appendix A for additional studies. Physical 
therapists also have been collecting a variety of data related to 
health outcomes and ease of use of technology. To promote data 
collection, APTA developed a patient satisfaction survey \8\ for 
providers to share with their patients, which is available in both 
English and Spanish.
---------------------------------------------------------------------------
    \6\ https://pubmed.ncbi.nlm.nih.gov/31233135/.
    \7\ https://pubmed.ncbi.nlm.nih.gov/26658151/.
    \8\ https://www.aptahpa.org/page/COVID19.

When considering the value of telehealth furnished by physical 
therapists and physical therapist assistants, Congress should consider 
the effects of telehealth on downstream spending. Hospital admissions 
and readmissions, emergency department visits, and urgent care visits, 
among other expenses, potentially will decrease if patients have access 
to both in-person and telehealth services.

Patient Access

Telehealth helps to overcome access barriers caused by distance, lack 
of availability of specialists and/or subspecialists, impaired 
mobility, and the burden associated with commuting/arranging 
transportation to a physical therapy appointment. Using virtual 
engagement tools can prevent unnecessary exposure during a pandemic, 
epidemic, or even the annual flu season--a feature especially important 
for frail and immunocompromised persons. Furthermore, access to 
telehealth services is critical for beneficiaries who live in areas 
with inclement weather, which is a deterrent to traveling outside of 
the home.

For patients who have difficulty leaving their homes without 
assistance, lack transportation, or need to travel long distances, the 
ability to supplement or replace in-person sessions with those 
furnished via telehealth greatly increases access to care and ensures 
uninterrupted courses of therapy. Telehealth is a tool to overcome 
access barriers caused by distance, unavailability of specialists and/
or subspecialists, inclement weather, and impaired mobility. For 
example, a Colorado physical therapist practice that offers treatments 
for neurological conditions provides a significant portion of the care 
via telehealth, for several reasons: (1) the area's sometimes severe 
inclement weather; (2) the patient's vestibular condition that renders 
them unable to drive, forcing them to rely on friends or family to 
drive them; and (3) a lack of physical therapy providers within a 
reasonable driving distance--particularly providers that address 
dizziness and balance issues.

Access to health-care services is critical to good health and 
functional performance, yet Medicare beneficiaries, particularly those 
who reside in rural areas, face a variety of access barriers. 
Individuals across the lifespan want the ability to appropriately 
access telehealth, and telehealth is key to helping individuals age in 
place. If we as a nation truly wish to help individuals age in their 
homes, telehealth is a key to making this a reality. As demand for care 
to help individuals with chronic conditions continues to grow, Congress 
should recommend telehealth payment and coverage policies that will 
improve beneficiary access and increase collaboration and efficiency of 
care across the care continuum.

Further, access to physical therapy in rural, medically underserved, 
and health professional shortage areas often depends on the 
availability of physical therapist assistants to provide care under the 
supervision of physical therapists. Unfortunately, the 15% Medicare 
Physician Fee Schedule payment reduction for services furnished in 
whole or in part by physical therapist assistants beginning in 2022 
will have a detrimental impact on the ability of physical therapy 
providers, particularly in rural areas, to continue to deliver care. 
The payment reduction will unfairly penalize providers in rural, 
medically underserved, and health professional shortage areas. Access 
to medical care already is dwindling in rural localities. Physical 
therapists and physical therapist assistants play a crucial role in 
bridging these gaps in access to care.

Quality

APTA developed a patient satisfaction survey \9\ about the use of 
telehealth for providers to share with their patients in English and 
Spanish based on AHRQ's guidance. Copied below are the results from a 
physical therapist vestibular practice in Colorado that asked some of 
the questions from this survey:
---------------------------------------------------------------------------
    \9\ https://www.aptahpa.org/page/COVID19.

      The experience was an effective way to get my physical therapy: 
70% of respondents strongly agreed; 30% agreed.
      Feelings of comfortability being evaluated and treated via 
telehealth: 67% of respondents strongly agreed; 20% agreed; 10% were 
neutral.
      Feelings of physical safety receiving physical therapy treatment 
via telehealth: 83% of respondents strongly agreed; 17% of respondents 
agreed.
      Overall satisfied with the experience: 93% strongly agreed; 7% 
agreed.
      In response to the question: If a telehealth visit was not 
available to you from this PT clinic, how would you plan to receive PT 
in future? 10% of respondents said they would seek telehealth from 
another clinic, 10% said they would not seek care, 60% said they would 
seek in-person care with the clinic, and 17% provided other answers, 
including:
          ``I don't know what I would do.''
          ``I might not seek care. This is the safest way 
for me to receive care.''

In addition, the following are stories shared by Medicare beneficiaries 
during the COVID-19 pandemic:

Medicare Beneficiary #1:
      The beneficiary was experiencing severe back pain, had 
significant physical limitations, and used pain medications daily. She 
was ``high risk'' for COVID-19, so she engaged in physical therapy via 
telehealth. After an initial evaluation in the clinic and several 
telehealth sessions at her home, she is now walking pain-free, can 
engage in more physical activity, and has reduced her pain medications. 
These telehealth visits have allowed her to care for her husband, who 
is in hospice.
Medicare Beneficiary #2:
      I am writing to express my gratitude for the telehealth services 
that were provided during the COVID-19 pandemic. I was happy to start 
in the clinic and then transition to a home-based program so that I 
could carry the work into my daily routine, while staying safe at home. 
After every meeting, I felt better and felt that I had gotten a good 
workout. I would recommend telehealth services to a friend or family 
member. Even out of quarantine, I feel as though the telehealth 
services may be beneficial to those who cannot go to an appointment in 
person. I advocate that Medicare continues to allow telehealth services 
to be furnished by physical therapists in the future.
Medicare Beneficiary #3:
      I was being treated for thoracic outlet syndrome and referred to 
physical therapy. I found my experience most successful. Due to COVID-
19, I was able to do telehealth therapy from home. Once the clinic was 
able to reopen, I was able to resume office visits and have continued 
to make good progress. I have had a very positive experience.
Medicare Beneficiary #4:
      I am writing to express my appreciation for the telehealth 
services that were provided during this COVID-19 pandemic. About 7 or 8 
weeks ago I had to have physical therapy for a pinched nerve. I 
contacted you since my husband was already participating in your 
telehealth program. I have been working with the DPT and have had 
wonderful results. I have used my 1- and 2-pound weights as well as my 
wall to do push-ups. I also use my banister to do rowing exercises. I 
would recommend telehealth services to a friend or family member or 
anyone who should ask and I'm hoping that these telehealth services 
continue in the future. This is a great way to remain safe at home, 
which is critical during this pandemic

Recommendations

Current statutes limit Medicare beneficiaries from receiving telehealth 
services, including a geography limitation, site limitation, and 
provider limitation. Congress must pass legislation that permanently 
affords providers and patients the ability to furnish and receive 
telehealth, just as they have done during the COVID-19 PHE.

Congress should:

    (1)  Enact the Expanded Telehealth Access Act of 2021 (H.R. 2168). 
This legislation would permanently allow rehabilitation providers to 
use telehealth under Medicare after the PHE is declared over. 
Specifically, the bill adds physical therapists, physical therapist 
assistants, occupational therapists, occupational therapy assistants, 
audiologists, and speech language pathologists and facilities that 
furnish outpatient therapy, as authorized providers of telehealth under 
Medicare.
    (2)  Enact changes to Section 1834(m)(4)(C)(i) of the Social 
Security Act so that telehealth services, including therapy services, 
will no longer be restricted by geographic location of the beneficiary 
or the originating site. All Medicare beneficiaries should be eligible 
to receive telehealth services from their home, whether that home is in 
the community or part of an institutional setting.

Federal policies also should advance a definition of parity that 
includes equal coverage, reimbursement, and cost-sharing (copayments, 
coinsurance, and deductibles) for audio-only telehealth, audio and 
visual telehealth, and in-person visits, particularly given the fact 
that telehealth is merely a modality to enable physical therapists and 
physical therapist assistants, for example, to provide care within 
their scope of practice. In addition, such policies should promote 
outreach to patients with limited technology and connectivity and offer 
flexibility in platforms that can be used for audio and visual (live 
video) interactions, audio-only options, online patient portals, etc.

Conclusion

We appreciate the opportunity to provide the committee with our 
perspective on the role of telehealth in physical therapy and the need 
to continue to provide Medicare beneficiaries this option beyond the 
PHE. Should you have any questions, please do not hesitate to contact 
David Scala, APTA congressional affairs senior specialist, at 
[email protected]. Thank you for your consideration.

Sincerely,

Sharon L. Dunn, PT, Ph.D.
Board-Certified Clinical Specialist in Orthopaedic Physical Therapy
President

                                 ______
                                 
                   American Telemedicine Association

                    901 North Glebe Road, Suite 850

                          Arlington, VA 22203

                            T: 703-373-9600

                              May 19, 2021

The Honorable Ron Wyden             The Honorable Mike Crapo
Chair                               Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
Washington, DC 20515                Washington, DC 20515

RE: ATA Testimony for Senate Finance Committee Hearing on ``COVID-19 
Health Care Flexibilities: Perspective, Experience, and Lessons 
Learned''

On behalf of the American Telemedicine Association (ATA), thank you for 
thoughtfully considering the future of telehealth during the upcoming 
Finance Committee hearing entitled, ``COVID-19 Health Care 
Flexibilities: Perspective, Experiences, and Lessons Learned'' on 
Wednesday, May 19. Federal flexibilities over the past year have 
allowed patients to continue to access much-needed care even as the 
health-care system was shuddered by the pandemic. This hearing is an 
essential step toward determining and enacting commonsense policies 
that will ensure Medicare seniors are not pushed off the telehealth 
cliff at the end of the current COVID-19 Public Health Emergency (PHE). 
Please accept this letter as testimony by the ATA and continue to 
consider the ATA as a resource as we work together on this important 
bipartisan issue.

As the only organization exclusively devoted to expanding access to 
care through telehealth, the ATA appreciates the opportunity to share 
our federal policy priorities for 2021. During the COVID-19 PHE, 
telehealth has finally become a reality for millions of Americans out 
of necessity. This has been possible because of swift, decisive actions 
by Congress and the Department of Health and Human Services (HHS). 
However, unless Congress acts again before the end of the PHE, 
telehealth access will vanish for millions of Medicare beneficiaries 
overnight. As you consider how to address this looming telehealth 
cliff, we request that you review ATA's Permanent Policy 
Recommendations \1\ as well as ATA's Federal Legislative Priorities.\2\
---------------------------------------------------------------------------
    \1\ https://www.americantelemed.org/policies/ata-recommendations-
for-permanent-telehealth-policy/.
    \2\ https://www.americantelemed.org/policies/atas-federal-
telehealth-legislative-tracker/.

We encourage you to ensure policies reflect beneficiaries' and 
providers' growing interest in having telehealth as a choice when 
accessing care. Data continues to show that Medicare beneficiaries like 
telehealth and want to keep it. The nonpartisan Medicare Payment 
Advisory Commission's \3\ annual beneficiary survey this year found 
that 90% of Medicare respondents were satisfied with telehealth. The 
ATA has worked with partners to identify similar trends,\4\ including 
nearly two thirds of patients expecting telehealth to continue post-
pandemic. To ensure these patients have the choice to access telehealth 
in the future, the ATA has prioritized the following policies for 
consideration in the 117th Congress and would greatly appreciate the 
Committee's taking these priorities into consideration when drafting 
potential telehealth legislation.
---------------------------------------------------------------------------
    \3\ http://medpac.gov/docs/default-source/reports/
mar21_medpac_report_to_the_congress_sec.
pdf.
    \4\ https://www.americantelemed.org/in-the-news/covid-19-
healthcare-coalition-surveys-patients-on-telehealth-impact-during-
covid-19/.

      Remove provisions in law that mandate, for telehealth delivery 
of care or reimbursement, a prior in-person relationship between 
practitioner and patient.
      Allow state licensing boards and practitioners to determine the 
appropriate standards of care for patients. This includes removing the 
in-person requirement for telemental health services in the recently 
signed Consolidated Appropriations Act.
      Permanently remove the geographic and originating site barriers 
in statute.
      The originating site should be wherever the patient is located, 
including but not limited to a patient's home.
      Enhance HHS authority to determine appropriate telehealth 
services and providers.
      Ensure Federally Qualified Health Centers (FQHCs) and Rural 
Health Clinics (RHCs) can furnish telehealth and receive equitable 
reimbursement.
      Make permanent HHS's temporary waiver authority for future 
emergencies.
      Support existing fraud, waste, and abuse resources within HHS, 
including the Health Care Fraud and Abuse Control Program.

The ATA is proud that telehealth is a strong bipartisan issue in 
Congress. The above listed priorities have been reflected in several 
bipartisan bills already under consideration this Congress, including 
the Telehealth Modernization Act (S. 368, H.R. 1332), the Protecting 
Access to Post-COVID-19 Telehealth Act (H.R. 366), and the soon-to-be-
reintroduced CONNECT for Health Act. The ATA would greatly appreciate 
your support of each of these important pieces of legislation.

At minimum, the ATA urges Congress to remove existing statutory 
barriers that limit access to care and not simply replace existing 
statutory access restrictions with new ones. For far too long, 1834(m) 
of the Social Security Act has categorically excluded too many patients 
from even having the option to access care via telehealth because of 
the law's antiquated and arbitrary barriers whose only purpose is to 
limit access to health care. Providers and patients are best suited to 
determine clinical appropriateness of medical services, not federal 
law. The 1834(m) restrictions are nearing 20 years old, and by allowing 
them to persist, Congress will only punish Medicare beneficiaries by 
banning their access to technology already available to non-Medicare 
patients. As such, the ATA urges the Committee to take great care in 
considering the consequences of having restrictions specifically 
codified in statute as opposed to allowing these issues to be decided 
at the regulatory level. By explicitly and arbitrarily limiting care in 
statute through so-called ``guardrails,'' legislators will 
unnecessarily stifle innovation and tie the hands of regulators, 
providers, and patients. Should the Committee have concerns with cost, 
utilization, or telefraud, the ATA stands ready to work with you on our 
shared goal of ensuring program integrity. As such, please consider 
ATA's recently released Program Integrity Overview \5\ as a resource.
---------------------------------------------------------------------------
    \5\ https://www.americantelemed.org/wp-content/uploads/2021/03/ATA-
Program-Integrity-One-Pager-3-1-21.pdf.

While the ATA appreciates Congress's recent actions to expand access to 
care, specific restrictions on patients, providers, services, or the 
modality of care in statute only add to complexities in the health-care 
system. One of the ATA's main federal policy priorities is removing the 
in-person requirement for telemental health services which was included 
in the Consolidated Appropriations Act, 2021, Pub. L. 116-260 (e.g., 
Section 123 establishes coverage and reimbursement of a telemental 
health service only if the practitioner has conducted an in-person 
examination of the patient in the prior six months and subsequently 
continues to conduct in-person exams at such a frequency to be 
determined by HHS). The ATA strongly opposes statutory in-person 
requirements as they create arbitrary and clinically unsupported 
---------------------------------------------------------------------------
barriers to accessing affordable, quality health care.

Today, not a single state in the U.S. requires a prior in-person 
relationship. At the national level, the association of state 
regulators who oversee standards of medical care, the Federation of 
State Medical Boards, stated that ``. . . the relationship is clearly 
established when the physician agrees to undertake diagnosis and 
treatment of the patient, and the patient agrees to be treated, whether 
or not there has been an encounter in person between the physician (or 
other appropriately supervised health-care practitioner) and patient.''

We cannot ignore the importance of providing all Americans, regardless 
of whether they have a medical provider with whom they have an 
established relationship, the opportunity to access health care. 
Requiring a physician and patient to meet in person before receiving 
certain telehealth services would be a huge step backward, and we hope 
to work with you to find an alternative to in-person requirements.

Thank you again for holding this important hearing and for your 
thoughtful deliberation on how your committee can enable access to 
quality health-care services for Medicare beneficiaries. The ATA's 
policy development and ultimate recommendations are guided by a 
specific set of policy principles \6\ which all support the goal of 
promoting a health-care system where people have access to safe, 
effective, and appropriate care when and where they need it. Please 
know the ATA is honored to continue to be a resource for you, the 
Committee, and your dedicated staff. If you have any questions or would 
like to further discuss the ATA's perspective, please contact 
[email protected].
---------------------------------------------------------------------------
    \6\ https://www.americantelemed.org/policy/.

---------------------------------------------------------------------------
Kind regards,

Kyle Zebley
Public Policy Director

                                 ______
                                 
                   Association for Clinical Oncology

                       2318 Mill Road, Suite 800

                          Alexandria, VA 22314

                            T: 571-483-1300

                            F: 571-366-9530

                         https://beta.asco.org/

May 19, 2021

The Honorable Ron Wyden             The Honorable Mike Crapo
Chair                               Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
219 Dirksen Senate Office Building  219 Dirksen Senate Office Building
Washington, DC 20510                Washington, DC 20510

Dear Chairman Wyden and Ranking Member Crapo,

The Association for Clinical Oncology (ASCO) commends the Committee for 
holding the May 19, 2021, hearing, ``COVID-19 Health Care 
Flexibilities: Perspectives, Experiences, and Lessons Learned.'' We are 
pleased to provide the attached comments on regulatory flexibilities 
during the pandemic that have made a difference in cancer care.

ASCO is the world's leading professional society representing 
physicians who care for people with cancer. With nearly 45,000 members, 
our core mission is to ensure that patients with cancer have meaningful 
access to high quality, equitable cancer care.

In addition to the attached comments on regulatory policies, ASCO urges 
Congress to address the 4% PAYGO cuts before they are scheduled to take 
effect in Medicare and extend the Medicare sequestration moratorium. We 
appreciate Congress' extension of the Medicare sequestration moratorium 
through the end of 2021 but are seriously concerned about the impact a 
6% Medicare cut will have on cancer care if PAYGO and sequestration are 
not addressed before the end of this year.

Thank you for examining these important issues. If you have questions 
on our comments or any other issues related to the treatment of 
patients with cancer, please do not hesitate to contact Jennifer 
Brunelle at [email protected].

Sincerely,

Monica Bertagnolli, M.D., FACS, FASCO
Chair of the Board

                                 ______
                                 
December 23, 2020

Alex Azar
Secretary
Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201

Dear Secretary Azar,

The nature of the COVID-19 pandemic and resulting public health 
emergency required unprecedented response and flexibility across the 
health-care sector to avoid disruption in care delivery, continuity of 
research activities and to ensure the protection and safety of patients 
and health-care workers. Additionally, in the face of economic 
pressures created by the pandemic, practices, health-care facilities 
and institutions--functioning as employers and businesses--required 
similar response and flexibility from state and federal policymakers. 
The Association for Clinical Oncology (ASCO) appreciates the 
opportunity to provide feedback on The Agency's Request for Information 
on Regulatory Relief Efforts to support Economic Recovery.

ASCO is a national organization representing more than 45,000 oncology 
professionals who care for people living with cancer. Through research, 
education, and promotion of the highest-quality patient care, our 
members are committed to ensuring that evidence-based practice for the 
prevention, diagnosis, and treatment of cancer are available to all 
Americans. ASCO supports major quality initiatives that enhance 
performance measurement and improvement, clinical practice guidelines, 
big data analytics, and the value of cancer care.

Cancer patients and survivors are one of the most vulnerable patient 
populations, and face increased risk related to COVID-19. Prior to the 
public health emergency, certain longstanding policies, care delivery 
practices and research procedures posed barriers to the efficient 
delivery of care and effective clinical research. During the pandemic, 
temporary regulatory relief offered by the Agency on some of those same 
policies, coupled with the nimbleness of the health-care sector, proved 
beneficial to patients and enabled the nation's health-care system to 
continue to operate safely during the time of crisis. ASCO commends the 
Administration and the Department of Health and Human Services (HHS) 
for recognizing the need to modify existing policies that would have 
significantly affected care for cancer patients. Like many 
organizations, ASCO has taken the opportunity to evaluate whether the 
changes in care delivery and research prompted by the pandemic could 
inform new approaches to delivery of high quality, high value care and 
research moving forward.

ASCO recently published the Road to Recovery Report: Learning from the 
COVID-19 Experience to Improve Clinical Research and Cancer Care, which 
outlines recommendations based on lessons learned during the pandemic. 
Proposed actions and policies aim to make cancer care delivery and 
research opportunities more accessible and equitable for patients in 
every community. With these recommendations, ASCO intends to address 
long-standing cancer care disparities that have been highlighted by the 
pandemic. To achieve these goals, certain regulatory flexibilities 
driven by the pandemic may need to be permanent--or at least extended 
for a minimum of 24 months following expiration of the PHE. This would 
enable cancer patients to continue access to life-saving treatments for 
their disease, for providers to continue delivery of high-quality 
cancer care, and all in the cancer community to benefit from 
protections against personal and economic the impacts COVID-19.

Part I: Cancer care delivery--Policies and regulatory action must build 
on strategies that have helped to meet patients' most urgent needs in 
the worst of the pandemic. Specifically:

Increased access to and equity of care--by making expanded coverage for 
telemedicine permanent; preventing Medicaid cuts; ensuring accessible, 
affordable and comprehensive insurance plans, and preventing other 
threats to patients' health coverage; enhancing grants and other 
support for oncology practices in underserved communities; and 
sustaining federal safety net programs.

Protecting patient safety--for example, by creating new chemotherapy 
infection control standards that account for viral threats like the 
novel coronavirus; ensuring reliable access to personal protective 
equipment (PPE) and future COVID vaccines; and limiting home infusion 
of potentially risky chemotherapy to exceptional circumstances.

Supporting patient and provider well-being--by expanding access to 
behavioral health care and psychosocial support for patients; and 
enhancing training and support for care teams, which have been 
disrupted by staffing changes and burnout in the face of the pandemic.

Additional recommendations related to Cancer Care Delivery can be found 
in the Road to Recovery Report.\1\
---------------------------------------------------------------------------
    \1\ https://ascopubs.org/doi/full/10.1200/JCO.20.02953.

Below, ASCO outlines recommendations for regulatory policies 
---------------------------------------------------------------------------
implemented temporarily during the PHE to be permanently implemented.

A.  Telemedicine--Generally, ASCO supports the flexibility CMS has 
implemented to ensure telemedicine is available to more practitioners 
and patients during the COVID-19 PHE, and we urge CMS to extend those 
expanded telemedicine policies after the expiration of the PHE. In 
addition to Medicare beneficiaries, we support the permanent 
implementation of these policies for Medicare Advantage as well as 
Medicaid enrollees.
    4--Notification of Enforcement Discretion for Telehealth Remote 
Communications

ASCO supports the use of HIPAA compliant audio/visual technology after 
the expiration of the PHE.

Privacy and data security issues and concerns related to health care 
information technology (HIT) have been key barriers to adoption of 
telemedicine and impact the confidence of patients and practitioners 
using these tools. As the use of telemedicine continues to increase, it 
will necessarily generate large quantities of personal health 
information and data, highlighting the need for data protection. Clear 
direction on the application of HIPAA requirements and necessary 
liability protections for providers is needed.\2\
---------------------------------------------------------------------------
    \2\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/advocacy-and-policy/documents/2020-ASCO-Interim-Position-
Statement-Telemedicine-FINAL.pdf.

---------------------------------------------------------------------------
111--Communication Technology Based Services (CTBS); and

112--Direct Supervision by Interactive Telecommunications Technology

ASCO supports the permanent implementation of policies allowing the 
provision and reimbursement of CTBS for new and established patients. 
Additionally, ASCO supports permanent implementation of provisions 
allowing direct supervision through interactive telecommunications 
technology. However, ASCO does not support direct supervision through 
interactive telecommunications technology in the context of home 
infusion for anti-cancer therapies outside of the PHE.

Mitigating the need for an in-person visit is critical for cancer 
patients, who are at an increased risk during the PHE, but may also 
experience similar risks because of compromised immune systems during 
cancer treatment. Allowing both new and established patients use of 
CTBS to access necessary care during brief communication mitigates the 
need for an in-person visit that could represent an exposure risk. 
Granting physicians flexibility to provide clinically appropriate and 
high-quality care to these beneficiaries via telemedicine can help keep 
these vulnerable patients in their homes, reducing unnecessary exposure 
to all illnesses, not just COVID-19.

Regarding direct supervision for home infusion of anti-cancer 
therapies, ASCO believes that guardrails need to be in place as this 
temporary policy introduces the potential for risk.\3\ There is a 
paucity of evidence directly comparing the safety of chemotherapy 
infusions in the home with treatments delivered in outpatient settings. 
Most of the literature examines home infusion in general, which is of 
limited utility given the toxicity and hazardous materials specific to 
chemotherapy. However, multiple criteria in ASCO's existing safety 
standards may be difficult to satisfy in the home infusion context. For 
example, safety principles emphasize using more than one practitioner 
to verify and document patient name, drug name, dosage, infusion 
volume, route/rate of administration, etc., to minimize errors and 
prevent patient harm. Within a health-care setting additional trained 
staff are available for such verification. In the home infusion 
setting, these verifications need to be performed virtually and with 
multiple forms of identification, as sending multiple health workers to 
supervise home infusions may not be practical or feasible. Most 
importantly, certain adverse events that may quickly escalate and 
become life-threatening emergencies may not be able to be safely 
resolved in the patient's home.\4\
---------------------------------------------------------------------------
    \3\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/2020-COVID19-IFC1-Comment-Letter.pdf.
    \4\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/advocacy-and-policy/documents/2020_Home-Infusion-Position-
Statement.pdf.

In addition to safety concerns outlined above, there are workforce and 
reimbursement issues that present challenges with home infusion of 
anticancer therapy. An oncology nurse in a clinical setting can safely 
supervise infusion of multiple patients at once, compared to single-
patient oversight in the home setting. There may therefore be 
insufficient oncology nursing expertise to widely adopt home infusion 
and substituting generalist infusion nurses does not provide the same 
level of patient safety.\5\
---------------------------------------------------------------------------
    \5\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/advocacy-and-policy/documents/2020_Home-Infusion-Position-
Statement.pdf.

---------------------------------------------------------------------------
113--Telephone Evaluation and Management (E/M) Services Codes

ASCO supports the implementation of permanent policies to allow 
Telephone Evaluation and Management Services. ASCO encourages 
Policymakers and payers at the national and state levels to ensure 
robust, adequate reimbursement and coverage of telemedicine for care 
delivery via audio and/or audio and visual formats regardless of site 
of service.\6\
---------------------------------------------------------------------------
    \6\ https://ascopubs.org/doi/pdf/10.1200/jco.2008.21.1680.

State and federal policymakers should make permanent coverage and 
reimbursement for audio- visual and when appropriate, audio-only 
services and continue to expand coverage for all modes of delivery of 
telemedicine. The lack of broadband and/or access to technology for 
both patients and physicians will not be limited to the time during the 
PHE; therefore, we urge that all respective agencies extend these 
regulatory changes beyond the PHE. Patient populations who lack 
computer skills or broadband access could potentially benefit 
especially from audio-only services.\7\
---------------------------------------------------------------------------
    \7\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/advocacy-and-policy/documents/2020-ASCO-Interim-Position-
Statement-Telemedicine-FINAL.pdf.

ASCO is committed to supporting efforts that ensure oncologists have 
the resources they need to provide high-quality cancer care regardless 
of where that care is delivered; therefore, we believe CMS should cover 
and reimburse audio-only services. Analysis of data from ASCO practices 
shows that of all services provided through technology-based 
communications from mid-March through mid-June, audio-only visits make 
up 35%-50% of these technology-based visits; virtual check-ins made up 
less than 1%.\8\ Cancer patients are relying heavily on audio-only E/M 
services and need CMS to ensure they have access to the care they need.
---------------------------------------------------------------------------
    \8\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/practice-and-guidelines/documents/2020-PracticeNET-COVID19-
Insights.pdf.

ASCO's Policy Statement on Cancer Disparities and Health Equity commits 
ASCO to ``support and promote policies, systems, environments, and 
practices to address persistent barriers to equitable receipt of high-
quality cancer care across the care continuum.''\9\ CMS should work to 
promote health equity through encouraging the use of telemedicine in 
all care settings, including but not limited to rural and safety net 
providers. CMS should cover and reimburse audio-only services in order 
to prevent the unintentional exacerbation of health inequities.
---------------------------------------------------------------------------
    \9\ https://ascopubs.org/doi/pdf/10.1200/jco.2008.21.1680.

While we agree with the agency that telehealth platforms incorporating 
both audio/visual two-way communication--when available--is preferred, 
there are instances when this is not possible. This lack of access to 
technology, often impacting patients vulnerable to other disparities in 
care, will not be limited to the time during the PHE; therefore, we 
urge the agency to permanently cover and reimburse audio-only services 
beyond the PHE.\10\
---------------------------------------------------------------------------
    \10\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/ASCO-MPFS-QPP-2021-Comments.pdf.

115--Use of Telecommunications Technology Under the Medicare Home 
---------------------------------------------------------------------------
Health Benefit

ASCO supports CMS' proposal to permit patient services and/or 
monitoring performed through telecommunication technology on a 
permanent basis when such services are included as part of the home 
health plan of care.

ASCO supports CMS' proposal to make this temporary flexibility provided 
during the COVID-19 PHE a permanent part of the Medicare home health 
program. This proposal will ensure patient access to the latest 
technology and give home health agencies the confidence that that they 
can continue to use telecommunications technology as part of patient 
care beyond the PHE. Cancer patients, because they are often immuno-
compromised, are an especially vulnerable subset of the Medicare 
population. Granting HHAs the flexibility to provide clinically 
appropriate and high-quality care to these beneficiaries through 
technology can help keep these vulnerable patients in their homes, 
reducing unnecessary exposure to all illnesses, not just COVID-19.\11\
---------------------------------------------------------------------------
    \11\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/2020-2021-Home-Health-Comment-Letter.pdf.

122--Physician Supervision Flexibility for Outpatient Hospitals--
Outpatient Hospital Therapeutic Services Assigned to the Non-surgical 
---------------------------------------------------------------------------
Extended Duration Therapeutic Services (NSEDTS) Level of Supervision

We believe this flexibility to change the generally applicable minimum 
required level of supervision for hospital outpatient therapeutic 
services from direct supervision to general supervision for services 
furnished by all hospitals and critical access hospitals (CAHs) may 
have many positive effects on physician workload. Permanent 
implementation could allow physicians to devote more time to clinical 
work and allow more flexibility on the part of cancer clinics to 
provide more timely care.

ASCO remains committed to ensuring that cancer patients have access to 
high quality and safe care. While we support CMS's proposal, we urge 
CMS to carefully monitor its implementation to ensure that it does not 
unintentionally place some patients at elevated risk for medical 
errors.

125--Payment for Medicare Telehealth Services Under Section 1834(m) of 
the Act; and 149--Updating the Medicare Telehealth List on a Sub-
regulatory Basis

ASCO supports the permanent coverage and inclusion of additional 
services on the Medicare telehealth list, and we encourage CMS to 
continue soliciting stakeholder comments and feedback regarding 
potential future additions.

In our interim position statement,\12\ ASCO urges CMS to extend the 
expanded telemedicine policies after the expiration of the PHE. We 
support the permanent and temporary addition of services to the 
telehealth list, as this has the potential to increase access to 
services for cancer patients.
---------------------------------------------------------------------------
    \12\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/advocacy-and-policy/documents/2020-ASCO-Interim-Position-
Statement-Telemedicine-FINAL.pdf.

Additionally, ASCO urges CMS to evaluate the safety, quality of care, 
and outcomes resulting from telehealth visits and to consider such 
evidence and specialty input when considering additions in future 
rulemaking.\13\ Since CMS has the authority to add services to the list 
of covered Medicare telehealth services, we support updates to the 
Medicare Telehealth list on a sub-regulatory basis where there is 
demonstrated clinical benefit to the patient and other requirements are 
met.
---------------------------------------------------------------------------
    \13\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/ASCO-MPFS-QPP-2021-Comments.pdf.

B.  Testing/PPE--ASCO supports long-term and widespread distribution of 
any COVID-19 testing, treatment, or vaccine, to ensure accessibility to 
health-care providers and disadvantaged populations. ASCO urges the 
Agency to consider prioritizing resources in a transparent and ethical 
---------------------------------------------------------------------------
way.

    74--Policy for Coronavirus Disease 2019 Tests During the Public 
Health Emergency (Revised)

    ASCO believes there is a need for FDA premarket regulatory review 
for high risk tests in addition to CMS CLIA oversight. Physicians rely 
on high quality and accurate tests to appropriately diagnose and treat 
patients. There is also a need for flexibility in the review and 
approval of these tests particularly to inform cancer treatment 
planning. This flexibility is particularly important in oncology, as 
new information develops rapidly and is disseminated widely, leading to 
demand by both physicians and patients for new tests that impact 
medical decision-making.

C.  Access--As the leading organization for physicians and oncology 
professionals caring for people with cancer, ASCO is committed to 
promoting access to high quality, high value cancer care.

    29--Notifying FDA of a Permanent Discontinuance or Interruption in 
Manufacturing Under Section 506C of the FD&C Act Guidance for Industry;

    30--Exemption and Exclusion from Certain Requirements of the Drug 
Supply Chain Security Act During the COVID--19 Public Health Emergency; 
and

    61--Notifying CDRH of a Permanent Discontinuance or Interruption in 
Manufacturing of a Device Under Section 506J of the FD&C Act During the 
COVID-19 Public Health Emergency

    ASCO supports the continuation of policies to enhance transparency 
in the drug supply chain, assess and strengthen the Food and Drug 
Administration's (FDA) efforts to prevent shortages, and empower the 
FDA to have drug makers identify and address vulnerabilities in the 
supply chains to ensure access to critical medications.

    The spread of novel viruses such as COVID-19, and natural disasters 
such as hurricanes, have highlighted vulnerabilities in the drug supply 
chain that can lead to significant shortages of critical medications 
throughout the world. United States drug manufacturers currently rely 
on China for a majority of their active pharmaceutical ingredients, and 
this issue is being highlighted by the current COVID-19 epidemic. A 
disruption in the supply chain, whether caused by manufacturing or 
quality issues, will likely leave many patients without the critical 
medications they need.

    ASCO urges CMS to make permanent policies that would ensure 
information about shortages is publicly available. Providing the FDA 
with the necessary authority to ensure that drug makers increase 
transparency in their supply chains and identify and address potential 
manufacturing and quality issues, is critical to guaranteeing patient 
access to needed medications.

    221--Part D ``Refill-Too-Soon'' Edits and Maximum Day Supply;

    226--Prior Authorization;

    227--Home or Mail Delivery of Part D Drugs;

    285--Prior Authorization [Medicare Advantage]; and

    288--Prior Authorization for Part D Drugs.

    ASCO urges HHS to implement long-term policies to eliminate 
longstanding barriers to access associated with utilization management 
policies within the Medicare program, including Medicare Advantage and 
Medicare Part D, as well as Medicaid.

    ASCO has always advocated for adherence to high quality clinical 
pathways as a mechanism to drive appropriate use of medications, rather 
than arbitrary utilization management policies that largely focus on 
cost rather than clinical evidence. Temporary policies during the 
pandemic have relaxed certain utilization management strategies during 
the pandemic. ASCO appreciates the relaxation of policies like 
``refill-too-soon'' edits, giving patients the ability to obtain the 
maximum extended day supply available under their plan to allow an 
uninterrupted supply of critical medications. This is critical support 
at a time when disruptions to routine care may be expected.\14\ 
However, despite the attempt to relax utilization policies, ASCO 
members report they still experienced significant delays in care 
resulting from prior authorization requirements, particularly related 
to imaging. The pandemic has highlighted the need for permanent 
solutions to utilization barriers. ASCO continues to work with the AMA 
and others to achieve reforms related to utilization management. We 
call on the Agency to put renewed emphasis on addressing this 
longstanding and increasing burden on patients and their providers.
---------------------------------------------------------------------------
    \14\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/2020-COVID19-IFC1-Comment-Letter.pdf.

    Restrictive networks and requirements for patients to use 
designated specialty pharmacies for Part D drugs can impair patient 
care and access. Patients with cancer should be allowed to seek the 
services of their preferred pharmacy, including dispensing physicians. 
For cancer patients, this is important as some studies have suggested 
that practices with medically integrated services may improve patient 
---------------------------------------------------------------------------
adherence to treatment regimens.

D.  Quality Payment Program--ASCO encourages the Agency to continue 
flexibilities in quality reporting across all programs for two years, 
allowing these flexibilities to remain in effect through performance 
year 2022. This offers critical time for physician practices to adjust 
and begin to recover from the repercussions of the COVID-19 pandemic.

    106--Merit-based Incentive Payment System (MIPS) Updates

    ASCO supports the flexibilities provided to MIPS eligible 
clinicians to receive hardship exemptions for performance years 2020 
and 2021. We encourage the Agency to enable these flexibilities through 
performance year 2022 to allow practices to recover from the impact of 
the PHE.

    ASCO thanks CMS for recognizing that during this public health 
crisis it may be challenging or impossible for physicians, groups, and 
virtual groups to meet the data submission deadline due to 
circumstances beyond their control. We support flexibilities provided 
to MIPS eligible clinicians and group practices to choose to submit 
data or to apply for--and in some circumstances, receive 
automatically--a hardship exemption. Allowing these flexibilities to 
remain in effect through performance year 2022 will be important to 
recovery from the repercussions of COVID-19 and to preserving access to 
care in communities across the U.S.\15\
---------------------------------------------------------------------------
    \15\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/2020-COVID19-IFC1-Comment-Letter.pdf.

    ASCO supports submission of patient data to a COVID-19 clinical 
data registry for participation in Improvement Activity IA--ERP--3 and 
---------------------------------------------------------------------------
for extending this through the 2021 performance period.

    ASCO supports CMS' designation of data entry to clinical registries 
as a qualified Improvement Activity for clinicians who are caring for 
COVID-positive patients. ASCO established a COVID-19 registry to help 
the entire cancer community learn about the pattern of symptoms and 
severity of COVID-19 among patients with cancer. The ASCO Registry is 
designed to collect both baseline and follow-up data on how the disease 
impacts cancer care and cancer patient outcomes during the COVID-19 
pandemic--up to 12 months after a patient's COVID-19 diagnosis. Cancer 
patients with a COVID diagnosis are a special subgroup of individuals 
whose clinical condition need to be understood to ensure effective 
treatment protocols and positive health outcomes. ASCO thanks CMS for 
confirming that ASCO's Survey on COVID-19 in Oncology Registry is an 
acceptable registry for the attestation of this highly weighted 
practice improvement activity.

    ASCO supports the extension of this IA into 2021. It is likely that 
this improvement activity will remain relevant throughout the next year 
and possibly beyond, given the unknowns around how long the virus will 
persist in the community and possible long-term effects stemming from 
infection. Given the impact the coronavirus has on caring for cancer 
patients, it is imperative that oncologists submit meaningful 
improvement activity data that reflect real-world events and that are 
of value to patients and clinicians.\16\
---------------------------------------------------------------------------
    \16\ https://www.asco.org/sites/new-www.asco.org/files/content-
files/ASCO-COVID-19-IFC3.Comment-Letter.pdf.

With the following recommendations, we aim to make cancer research 
opportunities more accessible and equitable for patients in every 
---------------------------------------------------------------------------
community.

Part II: Clinical cancer research--Implementation of policies to ensure 
the clinical trials system is more resilient and flexible, and more 
accessible to patients must be a priority. Specifically:

Increase patient access and equity--by continuing remote and virtual 
approaches to consent, and other trial procedures; and by better 
integrating trials into routine cancer care.

Increase trial efficiency--by streamlining and standardizing regulatory 
and training requirements; and using central Institutional Review 
Boards and innovative trial designs, including adaptive trials, master 
protocols, and common control groups.

Increase flexibility so research will be more resilient in future 
crises--for example, by ``cross training'' research teams so that key 
functions can be led by various team members; and by sustaining 
flexibility, adopted during the pandemic, for site selection, 
initiation, and data collection.

ASCO also encourages the Agency to support enhanced data collection 
efforts to understand the impact of COVID-19 on patients with cancer, 
including its effect on social determinants of health.

Additional recommendations related to Cancer Care Delivery can be found 
in the Road to Recovery Report.

ASCO recommends the following policy be permanently implemented after 
the PHE.

    33--Institutional Review Board (IRB) Review of Individual Patient 
Expanded Access Requests for Investigational Drugs and Biological 
Products During the COVID-19 Public Health Emergency.

    ASCO continues to support the use of central IRBs as one way to 
promote efficiency, oversight, and review of clinical trial conduct, 
reduce costs and eliminate duplicative reviews by multiple 
institutions. During COVID-19, central IRBs were important in 
expediting research on testing and treatment. ASCO supports expanded 
access to address unmet needs for many patients and the approval to 
access investigational therapies should continue to be done so with 
establish standards of safety and efficacy.

Many of the flexibilities implemented during the PHE have indeed 
provided relief in managing the unprecedented crisis presented by the 
COVID-19 pandemic. We encourage the agency to make determinations 
regarding the future implication of policies and practices based 
emerging data, and lessons learned, and the experiences of patients, 
physicians, care teams and health systems, researchers, and research 
programs during the COVID-19 pandemic. We thank you for the opportunity 
to provide feedback. Should you have any questions, please contact Gina 
Baxter at [email protected] or Karen Hagerty at 
[email protected].

Sincerely,
Monica M. Bertagnolli, M.D., FACS, FASCO
Chair of the Board

                                 ______
                                 
                Association of American Medical Colleges

                      655 K Street, NW, Suite 100

                       Washington, DC 20001-2399

                             T 202-828-0400

                         https://www.aamc.org/

The AAMC (Association of American Medical Colleges) thanks the Senate 
Finance Committee for convening the May 19 hearing, ``COVID-19 Health 
Care Flexibilities: Perspectives, Experiences, and Lessons Learned,'' 
and for the opportunity to provide written comments for inclusion in 
the public record.

The AAMC is a not-for-profit association dedicated to transforming 
health through medical education, health care, medical research, and 
community collaborations. Its members are all 155 accredited U.S. and 
17 accredited Canadian medical schools; more than 400 teaching 
hospitals and health systems, including Department of Veterans Affairs 
medical centers; and more than 70 academic societies. Through these 
institutions and organizations, the AAMC leads and serves America's 
medical schools and teaching hospitals and their more than 179,000 
full-time faculty members, 92,000 medical students, 140,000 resident 
physicians, and 60,000 graduate students and postdoctoral researchers 
in the biomedical sciences.

The AAMC appreciates the work that this Committee, the Congress, and 
the Centers for Medicare and Medicaid Services (CMS) have done to 
provide important flexibilities to ensure that providers can continue 
to deliver quality health care for patients during the public health 
emergency (PHE). Many of these flexibilities have proven to expand 
access to care and should continue to be integrated into the health-
care system beyond the end of the PHE. Specifically, the AAMC urges 
Congress to:

      Remove patient location and rural site requirements to allow 
patients access to telehealth visits in any location.
      Reimburse providers the same amount for telehealth services as 
in-person visits.
      Allow Medicare payment for audio-only services.
      Allow patients to access telehealth services across state lines 
as appropriate.
      Allow for virtual supervision of residents by teaching 
physicians.
      Allow ``authorized practitioners'' to prescribe buprenorphine 
via telehealth.
      Improve access to broadband technology.
      Eliminate the skilled nursing facility (SNF) three-day prior 
hospitalization requirement.
      Expand the delivery of inpatient care in patients' homes.
      Consolidate all health-related waivers under the authority of 
the Health and Human Services (HHS) Secretary.

Telehealth Flexibilities

Teaching hospitals, faculty physicians, and other providers have 
responded to the PHE and the waivers and flexibilities provided by 
Congress by rapidly implementing telehealth in their settings and 
practices in order to provide continued access to medical care for 
their patients.Telehealth provides both patients and providers with a 
variety of benefits and expands access to care, especially to those in 
rural and other underserved areas.

      Increased Access for Patients Improves Care: Data from the 
Clinical Practice Solutions Center (CPSC),\1\ which contains claims 
data from 90 physician faculty practices, shows that in March and April 
2020, faculty practices on average were providing approximately 50% of 
their ambulatory visits via telehealth, a dramatic increase from the 
use of telehealth prior to the pandemic. This is consistent with 
reports from CMS regarding telehealth services provided to Medicare 
beneficiaries during that time frame.\2\ The use of telehealth expands 
care for the frail or elderly, for whom travel to a provider or 
facility is risky or difficult even when there is no pandemic. 
Telehealth also protects patients from exposure to infectious diseases, 
including COVID-19 and the seasonal flu. Physicians can effectively use 
telehealth to monitor the care of patients with chronic conditions, 
such as diabetes and heart conditions, reducing their risk of hospital 
admissions.
---------------------------------------------------------------------------
    \1\ The Clinical Practice Solutions Center (CPSC), owned by the 
Association of American Medical Colleges and Vizient, is the result of 
a partnership that works with member practice plans to collect data on 
provider practice patterns and performance. This analysis included data 
from 65 faculty practices.
    \2\ Health Affairs, Early Impact of CMS Expansion of Medicare 
Telehealth During COVID-19. July 15, 2020. https://
www.healthaffairs.org/do/10.1377/hblog20200715.454789/full/.

      Increased Access to Specialist Care: The use of telehealth 
enables specialists, such as pediatric specialists, cancer specialists, 
and critical care physicians, to bring their skills to rural areas and 
other areas that may not have subspecialty care in their communities. 
Immediate availability of a pediatric infectious disease specialist or 
a stroke critical care physician via telehealth can be life saving for 
those in remote, rural, or small size communities. In addition, 
telehealth can be used effectively to provide asynchronous consultation 
for front line providers. Patients can benefit from more timely access 
to the specialist's guidance and payers benefit from a less costly 
---------------------------------------------------------------------------
service by avoiding the new patient visit with a specialist.

      High Patient Satisfaction: Analyses of surveys of more than 
30,000 patients conducted by Press Ganey for services in March and 
April 2020 show that patients feel overwhelmingly positive about their 
virtual interactions with health-care providers.\3\ According to a 
recent Health Affairs article, 79% of patient respondents reported 
satisfaction with their telehealth visit and 78% felt that their health 
concern could be addressed via telehealth.\4\
---------------------------------------------------------------------------
    \3\ Press Ganey, The Rapid Transition to Telemedicine: Insights and 
Early Trends. May 19, 2020. https://www.pressganey.com/resources/white-
papers/the-rapid-transition-to-telemedicine-insights-and-early-
trends?s=White_Paper-PR.
    \4\ ``Congress: Act Now To Ensure Telehealth Access for Medicare 
Beneficiaries,'' Health Affairs Blog, May 10, 2021. https://
www.healthaffairs.org/do/10.1377/hblog20210505.751442/full/.

Due to statutory limitations, most of the current flexibilities are 
only in place until the end of the PHE. The AAMC believes telehealth is 
an important method to deliver health care in many circumstances and 
urges Congress to make legislative changes that would preserve these 
new practices and the gains we've made in telehealth to date, and to 
ensure that reimbursement remains at a level that supports the 
---------------------------------------------------------------------------
infrastructure needed to provide this level of telehealth services.

The AAMC recommends the following:

 Congress Should Remove Patient Location Restrictions and Rural Site 
                    Requirements

The AAMC strongly supports changes made by Congress that waived patient 
location restrictions that applied to telehealth service during the 
PHE. These changes have enabled CMS to pay for telehealth services 
furnished by physicians and other health-care providers to patients 
located in any geographic location and at any site, including the 
patient's home, during the PHE. We also thank Congress for including 
changes in the Consolidated Appropriations Act, 2021 that permanently 
allow patients to receive mental health services via telehealth 
regardless of the geographic location requirements ordinately 
applicable to Medicare telehealth services.

These changes have allowed patients to remain in their home, reducing 
their exposure to COVID-19 and reducing the risk of exposing another 
patient or their physician to COVID-19. Maintaining such a change even 
after the threat of the pandemic is contained would allow patients who 
find travel to an in-person appointment challenging to receive vital 
care, especially for patients with chronic conditions or disabilities 
who need regular monitoring. The AAMC encourages Congress to remove the 
rural site requirements and allow the home to be an originating site.

 Providers Should be Paid the Same Amount for Telehealth Services as 
                    Services Delivered In-Person

The AAMC strongly recommends that providers be paid the same for 
furnishing telehealth services as services delivered in person. The 
quality and cost of care delivered is not different if the patient is 
seen via telehealth. We recommend Congress provide a facility fee under 
the outpatient prospective payment system for telehealth services 
provided by physicians that would have been provided in the provider-
based entity.

Teaching hospitals and faculty practice plans have highlighted 
significant infrastructure costs to fully integrate their electronic 
health record systems with HIPAA-compliant telehealth programs. 
Physicians and hospitals employ medical assistants, nurses, and other 
staff to engage patients during telehealth visits and to coordinate 
care, regardless of whether the services are furnished in person or via 
telehealth. Before the virtual visit occurs, the physicians and other 
health-care professionals must be provided the technology they need and 
acquire a platform to use for the visits. Other staff will contact 
patients to complete registration, obtain consent for a telehealth 
visit, and ensure that the patient receives the email with a link to 
participate in the virtual visit. In addition, staff will educate the 
patients on the use of technology as needed to ensure they are able to 
participate in the visit.

On the day of the visit, clinical staff reach out to the patient to 
provide intake services (e.g., ask for chief complaint, symptoms, 
weight, temperature and help the patient identify a review of current 
medications and therapies) prior to the patient visit with the 
physician or health-care professional. The patient then participates in 
the visit with the physician, and at the conclusion of the visit, the 
physician must arrange any follow-up plan for the patient related to 
their care. Staff will follow-up as needed to schedule any additional 
visits for the treating physician or subspecialty referral, tests, or 
laboratory studies.

Without sufficient reimbursement, providers may no longer be able to 
continue to provide the current level of telehealth services to their 
patients.

Congress Should Allow Payment for Audio-Only Services

CMS established a separate Medicare payment for specific audio-only 
services to provide reimbursement at the same rates as in-person 
visits. However, the final 2021 physician fee schedule rule stated that 
this separate payment will no longer exist after the PHE ends, since 
CMS does not have the statutory authority to allow coverage and payment 
for telephone evaluation and management services.

Audio-only calls improve access to virtual care for patients who do not 
have access to the devices or broadband for audiovisual calls, are not 
comfortable with digital technology, or do not have someone available 
to assist them. During the PHE, coverage and payment for audio-only 
calls has been critical to ensure access to care for many patients. 
Physicians have been able to provide a wide array of services 
efficiently, effectively, and safely to patients using the telephone.

Data from the CPSC shows that approximately 30% of telehealth services 
were provided using audio-only telephone technology in April and May 
2020. The proportion of telephone/audio-only visits increased with the 
age of the patient. CMS data show that nearly one-third of Medicare 
beneficiaries received telehealth by audio-only telephone technology 
from March through June 2020,\5\ which is consistent with CPSC data.
---------------------------------------------------------------------------
    \5\ ASPE issue brief: Medicare Beneficiary Use of Telehealth 
Visits: Early Data from the Start of the COVID-19 Pandemic (7/18/2020); 
Health Affairs Blog; Early Impact of CMS Expansion of Medicare 
Telehealth During COVID-19. July 15, 2020. https://
www.healthaffairs.org/do/10.1377/hblog20200715.454789/abs.

Many factors contribute to the high use of audio-only services. 
Patients in rural areas or those with lower socioeconomic status are 
more likely to have limited broadband access and may not have access to 
the technology needed for two-way audio-visual communication. The Pew 
Research Center found that about a third of adults with household 
incomes below $30,000 per year do not own a smartphone and about 44% do 
not have home broadband services.\6\
---------------------------------------------------------------------------
    \6\ Pew Research Center, Digital divide persists even as lower-
income Americans makes gains in tech adoption. May 7, 2019. https://
www.pewresearch.org/fact-tank/2019/05/07/digital-divide-persists-even-
as-lower-income-americans-make-gains-in-tech-adoption/.

Some providers report that even when their patients have access to 
technology that would allow for audio-visual communication, they may be 
unable to use the technology without assistance, thus limiting them to 
telephone use. For these patients, the only option to receive services 
remotely is through a phone. Without coverage and payment for these 
audio-only services, there will be inequities in access to services for 
these specific populations. We urge Congress to permanently make 
changes to allow coverage and payment for audio-only services.

 Congress Should Allow Patients to Access Telehealth Services Delivered 
                    Across State Lines

As part of the COVID-19 response, Congress and CMS have allowed 
providers to be reimbursed by Medicare for telehealth services across 
state lines. This waiver creates an opportunity to improve patient 
access to services and to help improve continuity of care for patients 
who have relocated or who have traveled to receive their surgery or 
other services from a specialist in another state. While CMS has the 
authority to allow for payment under federal programs, states need to 
act to allow practice across state lines to occur.

The AAMC urges Congress to pass the Temporary Reciprocity to Ensure 
Access to Treatment Act (TREAT Act, S. 168, H.R. 708). This bipartisan, 
bicameral legislation would expand care for patients by creating a 
temporary uniform licensing standard for all practitioners and 
professionals that hold a valid license in good standing in any state 
to be permitted to practice in every state--including in-person and 
telehealth visits--during the COVID-19 public health emergency.

 Congress Should Allow for Virtual Supervision of Resident Physicians

During the PHE, CMS has allowed resident physicians to furnish 
telehealth services that are virtually supervised by the teaching 
physician. In the physician fee schedule final rule, CMS states that 
this policy regarding telehealth will be allowed on a permanent basis 
only in rural sites.

Resident education is a crucial step of professional development before 
autonomous clinical practice and requires varying levels of faculty 
supervision depending on where the resident is in training and 
developing competency. As part of this development, it is essential for 
residents to have the experience with telehealth visits while 
supervised as they will be providing them in the future to their 
patients when they practice autonomously.

The AAMC recommends that CMS allow residents to provide telehealth 
services permanently while a teaching physician is present via real-
time audio-visual communications technology after the PHE ends in all 
regions of the country. This change to CMS policy will improve patient 
access to care while also enhancing the resident's skills.

 Congress Should Allow ``Authorized Practitioners'' to Prescribe 
                    Buprenorphine via Telehealth

The AAMC supports the Substance Abuse and Mental Health Services 
Administration's and Drug Enforcement Agency's temporary change to 
allow ``authorized practitioners'' to prescribe buprenorphine to new 
and existing opioid use disorder patients for maintenance or 
detoxification treatment via telehealth examination without the need 
for a prior in-person visit. We urge Congress to make this change 
permanent to ensure this important expansion is not limited solely to 
the current PHE.

 Congress Should Takes Steps to Improve Access to Broadband Technology

In many parts of the country, providers and their patients have limited 
access to broadband connectivity, which has been a major barrier to use 
of telehealth. This is particularly true for rural areas and 
underserved communities. The Federal Communications Commission has 
reported that 30% of rural residents lack broadband services.\7\ Also, 
racial and ethnic minorities, older adults, and those with lower levels 
of socioeconomic status are less likely to have broadband access. In 
order to expand access to telehealth and other important online 
services, we recommend that Congress take steps to increase funding for 
broadband access and infrastructure development.
---------------------------------------------------------------------------
    \7\ Federal Communications Commission, 2018 Broadband Deployment 
Report, February 2, 2018. https://www.fcc.gov/reports-research/reports/
broadband-progress-reports/2018-broad
band-deployment-report.
---------------------------------------------------------------------------

 Other Targeted Health Care Flexibilities

Eliminate the SNF three-day prior hospitalization requirement.

CMS has waived the requirement for a three-day prior hospitalization 
for coverage of a SNF stay, which provides temporary emergency coverage 
of SNF services without a qualifying hospital stay for those people who 
experience dislocations or are otherwise affected by COVID-19. The AAMC 
supports this waiver and recommends that the SNF three-day prior 
hospitalization requirement be eliminated permanently to better 
coordinate and improve care for patients. Eliminating the three-day 
stay would rely on physicians' judgment to ensure that their patients 
receive the most appropriate care in the most appropriate settings 
without creating the possibility of an unforeseen financial burden on 
the patient.

 Expand the Delivery of Inpatient Care in Patients' Homes

CMS launched the Hospital Without Walls program in March 2020 to allow 
hospitals to provide services beyond their existing walls to help 
address the need to expand care capacity and to develop sites dedicated 
to COVID-19 treatment. The Acute Hospital Care At Home program is an 
expansion of this initiative that allows eligible hospitals to have 
regulatory flexibility to treat certain patients, who would otherwise 
be admitted to the hospital, in their homes and receive Medicare 
payment under the Inpatient Prospective Payment System.

The Acute Hospital Care At Home program launched with six health-care 
systems that have experience with providing acute hospital care at 
home. To date, 129 hospitals within 56 systems located in 30 states--
including many academic medical centers--have received waivers from CMS 
to participate in the program.\8\ The increase in hospital 
participation underscores the need for flexibility to meet the health-
care needs of certain patients without having to admit them into the 
inpatient setting.
---------------------------------------------------------------------------
    \8\ Updated as May 14, 2021. Updated list available at: https://
qualitynet.cms.gov/acute-hospital-care-at-home/resources.

The AAMC supports the flexibility and benefits this program provides 
for patients and urges Congress to maintain these flexibilities after 
the end of the PHE.

 Consolidate All Health-Related Waivers Under the Authority of the HHS 
                    Secretary

The AAMC is appreciative of the temporary health care-related 
regulatory flexibilities and emergency authorities granted by the 
federal government in response to the coronavirus. These flexibilities 
have been granted by the White House, HHS, and CMS, among others. To 
better coordinate these flexibilities, the AAMC recommends that all 
health-related waivers be consolidated under the authority of the HHS 
Secretary.

For example, Section 1135 waivers have offered essential relief and 
assistance for health-care providers during the pandemic by relaxing 
several requirements, including practice across state lines and 
timelines for federal reporting requirements. For the 1135 waivers to 
remain in effect, both a public health emergency and a national 
emergency must be declared by the HHS Secretary and President, 
respectively. The AAMC recommends that all health-related flexibilities 
be under the direction of the HHS Secretary, and not reliant upon the 
declaration of a national emergency.

Conclusion

The AAMC is very grateful for the work that this Committee, the 
Congress, and the Administration have done to provide important 
flexibilities to allow for the expansion of health-care delivery during 
the COVID-19 pandemic. We appreciate that the Senate Finance Committee 
is reviewing many of these flexibilities and thinking about how to 
incorporate them into the health-care system beyond the end of the 
public health emergency.

Please feel free to contact AAMC Chief Public Policy Officer Karen 
Fisher, JD ([email protected]) or AAMC Senior Director of Government 
Relations Leonard Marquez ([email protected]) with any questions or if 
we can provide more information. We look forward to continuing to work 
with you on these important issues.

                                 ______
                                 
                        Better Medicare Alliance

                     1411 K Street, NW, Suite 1400

                          Washington, DC 20005

                         202-735-0037 (office)

                           202-885-9968 (fax)

                       BetterMedicareAlliance.org

          Statement of Allyson Y. Schwartz, President and CEO

Better Medicare Alliance, on behalf of our Alliance and the 26 million 
beneficiaries enrolled in Medicare Advantage, is pleased to submit the 
following statement for the record related to the May 19, 2021 
Committee on Finance hearing titled COVID-19 Health Care Flexibilities: 
Perspectives, Experiences, and Lessons Learned.

Better Medicare Alliance is a community of 160 ally organizations and 
more than 500,000 grassroots beneficiary advocates who value Medicare 
Advantage and the affordable, high-quality, coordinated care it 
provides to over 26 million beneficiaries. Together, our diverse 
alliance of health plans, provider groups, aging service organizations, 
and beneficiaries share a commitment to ensuring Medicare Advantage is 
a high-quality, cost-effective option for current and future 
beneficiaries.

As a public-private partnership where seniors and individuals with 
disabilities receive Medicare benefits through a private integrated 
managed care plan, Medicare Advantage plans are paid a capitated 
monthly amount per beneficiary by the Centers for Medicare and Medicaid 
Services (CMS). The health plans then take full financial risk for care 
and services to enrollees. Capitated payments are determined six months 
prior to the start of the contract year and are used to provide 
coverage of health-care benefits to enrolled beneficiaries. Payments 
are adjusted by the health status of each beneficiary to ensure health 
plans receive adequate payment to cover the costs of all beneficiaries.

To ensure the capitated payments reflect the health status and 
demographic characteristics of individual beneficiaries, payment to 
Medicare Advantage plans are risk adjusted using demographic and 
diagnostic information. Risk assessment is required annually for each 
beneficiary to calculate a risk score that predicts costs for the 
upcoming year. For the risk adjustment process to function properly, it 
is necessary to collect data on beneficiaries each year through in-
person office visits, telehealth visits, or in-home health risk 
assessments. Accurate documentation of diagnoses by clinicians is a 
critical component of the risk adjustment process and ensures 
beneficiaries receive the appropriate care management and quality of 
services based on their conditions.

Transition to Telehealth During COVID-19 Pandemic

The COVID-19 pandemic, stay-at-home guidance, and advice to avoid 
clinical in-person settings unless necessary, particularly for at-risk 
populations like those over 65 years old and those with chronic 
conditions, led to a nationwide avoidance of in-person clinical care 
and delay of elective services. Among Medicare beneficiaries, 8 percent 
report forgoing care despite needing health-care services because of 
the pandemic.\1\ Reports like this highlight the importance of 
providing patients access to health-care services outside the physician 
office and resulted in a dramatic and rapid transition of clinical care 
being offered through telehealth visits starting in 2020. The use of 
telehealth visits has contributed meaningfully to allowing providers 
and health plans to reach out to beneficiaries and replace in-person 
visits--ensuring those with new medical concerns and those with ongoing 
chronic conditions have been able to interact with their providers to 
manage their health. Yet, while providers and health plans work 
together to provide needed care and reduce the impact of this pandemic 
for their patients, utilization of care and services was significantly 
lower in 2020 and has not yet fully returned to pre-pandemic levels.\2\
---------------------------------------------------------------------------
    \1\ https://www.cms.gov/files/document/medicare-current-
beneficiary-survey-covid-19-data-snapshot-infographic-fall-2020.pdf .
    \2\ https://www.healthsystemtracker.org/chart-collection/how-have-
healthcare-utilization-and-spending-changed-so-far-during-the-
coronavirus-pandemic/#item-covidcostsuse_marchupdate_3.

Between May 2019 and June 2020, the University of Michigan's National 
Poll on Healthy Aging found telehealth visit participation increased 
from 4 percent to 30 percent, respectively, among older adults.\3\ The 
same poll found the number of providers offering telehealth services 
increased from 14 percent to 62 percent during the same period of 
time.\4\ More recently, CMS found 64 percent of Medicare beneficiaries 
report their provider currently offers telehealth visits, and 45 
percent had a telehealth visit since July 2020.\5\
---------------------------------------------------------------------------
    \3\ https://www.healthyagingpoll.org/report/telehealth-use-among-
older-adults-and-during-covid-19.
    \4\ Id.
    \5\ https://www.cms.gov/files/document/medicare-current-
beneficiary-survey-covid-19-data-snapshot-infographic-fall-2020.pdf.

In Medicare Advantage, recent polling shows 40 percent of beneficiaries 
used telehealth services during the pandemic and gave the experience a 
91 percent satisfactory rating.\6\ The risk-bearing payment 
arrangements in Medicare Advantage further facilitated the 
implementation and expansion of telehealth visits during the pandemic. 
Compared to Traditional fee-for-service (FFS) Medicare, Medicare 
Advantage had a quicker transition to telehealth visits.\7\ Looking 
forward, 48 percent of people 65 years and older report a willingness 
to use telehealth despite not having used telehealth before, and 35 
percent expect to use telehealth with more frequency in the future.\8\
---------------------------------------------------------------------------
    \6\ https://bettermedicarealliance.org/wp-content/uploads/2021/01/
BMA_Seniors-on-Medicare-Memo_.pdf.
    \7\ https://bettermedicarealliance.org/wp-content/uploads/2020/07/
CIMA-July-2020-Telehealth-Report-FIN.pdf.
    \8\ https://static.americanwell.com/app/uploads/2020/09/Amwell-
2020-Physician-and-Consumer-Survey.pdf.
---------------------------------------------------------------------------

Impact on Risk Adjustment

Medicare Advantage is unique in requiring an accurate assessment of 
each beneficiary every year to determine their health conditions and 
ensure risk adjusted payments reflect a beneficiary's current diagnoses 
and conditions. It is critical to make use of the tools available to 
obtain this data.

Action has been taken by CMS to permit data obtained during audio-video 
telehealth visits to provide diagnoses for risk assessment, but the 
same is not allowed for data obtained during audio-only visits. Better 
Medicare Alliance urges Congress to address this inequity and permit 
the same use for audio-only telehealth visits. There are numerous 
reasons to support this allowance, most prominently because 
beneficiaries do not have equal ability or equivalent access to the 
technology needed for audio-video visits. Moreover, providers use 
audio-video and audio-only telehealth visits interchangeably to account 
for patient preference or capabilities. The distinction for risk 
assessment purposes inhibits the ability of providers to utilize these 
patient visits to obtain data required under Medicare Advantage.

Omitting the use of data obtained during audio-only telehealth visits 
unreasonably limits the use of available, timely, and clinically 
accurate data on these patients that could be used to provide the 
required information for millions of Medicare beneficiaries. Without 
this information, the data required by CMS to inform adequate payment 
based on health status will be incomplete and may impact payment 
stability for health plans and providers in subsequent years, as well 
as out-of-pocket costs and supplemental benefits for beneficiaries.

Better Medicare Alliance appreciates the opportunities provided to 
Medicare Advantage plans to offer telehealth visits and provide audio-
video devices to beneficiaries. Over the last year, health plans and 
providers have been able to routinely hold virtual visits with 
beneficiaries to ensure those most at risk due to chronic conditions 
have the attention and medications they need. In addition, health plans 
and providers have been able to assess general wellness and identify 
and address social risk factors as part of care management available in 
Medicare Advantage. Medicare Advantage has been a leader in the rapid 
transition to telehealth and in providing attention to non-clinical 
needs of beneficiaries to better help beneficiaries maintain their 
health and well-being during this unprecedented public health 
emergency. Telehealth has ensured continuity of care for millions of 
Medicare Advantage beneficiaries during COVID-19.

Barriers to Use of Telehealth Visits

The transition to virtual visits accelerated by the pandemic has 
revealed the reality that many older, lower-income, and rural seniors 
lack the tools or access necessary to complete audio-video telehealth 
visits.\9\
---------------------------------------------------------------------------
    \9\ https://bettermedicarealliance.org/wp-content/uploads/2020/07/
CIMA-July-2020-Telehealth-Report.pdf.

The rapid uptake in telehealth visits showed the flexibility and 
innovation of health plans, providers, and beneficiaries during this 
critical time. Nevertheless, the transition is not without barriers, 
and the distinction between audio-video and audio-only visits has 
highlighted the disparities present in telehealth. Though half of 
people over age 65 are willing to try telehealth, many beneficiaries 
have limitations that inhibit the use of audio-video telehealth 
visits.\10\ The reasons vary, but the potential barriers must be 
considered to ensure over 26 million Medicare Advantage beneficiaries 
continue to receive care without disruption.
---------------------------------------------------------------------------
    \10\ https://static.americanwell.com/app/uploads/2019/07/American-
Well-Telehealth-Index-2019-Consumer-Survey-eBook2.pdf.

Beneficiaries must be able to access the technology and devices 
necessary for telehealth visits. Access also includes having adequate 
Internet, financial means, and functional and cognitive ability. 
Together, such limitations of access inhibit a beneficiary's use of 
telehealth visits, specifically audio-video visits. While 92 percent of 
seniors own a cellphone, only 61 percent have a smartphone.\11\ The 
distinction between having a cellphone and smartphone is important 
because unlike cellphones, smartphones have the video capability 
necessary for an audio-video telehealth visit. Lower income 
beneficiaries are less likely to have a smartphone, further limiting 
access to audio-video telehealth visits.\12\ A recent study found 32 
percent of people 65 and older do not have a smartphone, tablet, or 
computer with Internet access at home.\13\
---------------------------------------------------------------------------
    \11\ https://www.pewresearch.org/Internet/fact-sheet/mobile/.
    \12\ https://bettermedicarealliance.org/wp-content/uploads/2020/07/
CIMA-July-2020-Telehealth-Report.pdf.
    \13\ https://www.kff.org/policy-watch/possibilities-and-limits-of-
telehealth-for-older-adults-during-the-covid-19-emergency/.

According to the FCC's 2018 Broadband Deployment Report, 24 million 
Americans do not have access to broadband Internet at the benchmark 
speed of 25 Mbps/3Mbps, which is considered the minimum speed standard 
and offers good Internet access. Additionally, the same report found 
rural areas lag behind urban areas in the deployment of mobile 
broadband and fixed broadband with 68.6 percent of people in rural 
areas having access to both compared to 97.9 percent in urban 
areas.\14\ Limited, or inadequate access to Internet prevents 
beneficiaries from using audio-video telehealth visits.
---------------------------------------------------------------------------
    \14\ https://www.fcc.gov/reports-research/reports/broadband-
progress-reports/2018-broadband-deployment-report.

Access problems are not limited to the Internet or devices, as some 
beneficiaries with functional or cognitive impairments are unable to 
utilize audio-video technology. These beneficiaries prefer audio-only 
over audio-video telehealth visits. Others may be limited by financial 
constraints that prevent them from purchasing the necessary devices and 
Internet services. Research found 34 percent of Medicare Advantage 
beneficiaries living under the Federal Poverty Level reported no 
Internet usage at all.\15\
---------------------------------------------------------------------------
    \15\ https://bettermedicarealliance.org/wp-content/uploads/2020/07/
CIMA-July-2020-Telehealth-Report-FIN.pdf.

In addition, not all beneficiaries are comfortable with the necessary 
technology used for audio-video visits. Nearly seven in ten adults 65 
and older say they have a computer, smart phone, or tablet with 
Internet access at home, but only 11 percent say they have recently 
used a device to talk to a health-care provider through an audio-video 
visit.\16\ During COVID-19, a survey of more than 1,000 Medicare 
Advantage beneficiaries in December 2020 found 40 percent used 
telehealth during the pandemic, an increase from 24 percent in May 
2020.\17\ However, nearly one-third of beneficiaries said they are 
uncomfortable using telehealth.\18\
---------------------------------------------------------------------------
    \16\ https://www.kff.org/policy-watch/possibilities-and-limits-of-
telehealth-for-older-adults-during-the-covid-19-emergency/.
    \17\ https://bettermedicarealliance.org/news/poll-seniors-give-
telehealth-high-marks-medicare-advantage-satisfaction-smashes-new-
record-2/.
    \18\ Id.

Lack of experience or comfort using audio-video technology appears to 
influence seniors' preference for audio-only because even those who are 
willing to use telehealth often choose audio-only rather than audio-
video visits. When given the option, 60 percent of Medicare Advantage 
beneficiaries prefer the telephone over other technology.\19\ Health 
providers are also reporting the usage of audio-only telehealth visits 
is vastly higher than audio-video telehealth visits. Security Health 
Plan reported 75 percent of their telehealth visits as audio-only, and 
Kaiser Permanente reported 85 percent of their telehealth visits as 
audio-only. CMS found nearly one-third of telehealth visits with 
Medicare beneficiaries between mid-March and mid-June 2020 were 
conducted by audio-only telephone.\20\ This is equivalent to over 3 
million visits and indicates a preference for audio-only telehealth 
visits.
---------------------------------------------------------------------------
    \19\ https://bettermedicarealliance.org/wp-content/uploads/2020/07/
CIMA-July-2020-Telehealth-Report-FIN.pdf.
    \20\ https://www.healthaffairs.org/do/10.1377/hblog20200715.454789/
full/.

More recent data show a majority, or 56 percent, of Medicare 
beneficiaries that had a telehealth visit since July 2020 used audio-
only telephone for their visit while only 28 percent used video and 16 
percent used both telephone and video.\21\ The share of Medicare 
beneficiaries that used audio-only for their telehealth visit was 
higher among certain demographics, including beneficiaries 75 years or 
older (65 percent), enrolled in both Medicare and Medicaid (67 
percent), or living in rural areas (65 percent).\22\ Additionally, the 
share of Hispanic (61 percent) and non-Hispanic Black (61 percent) 
beneficiaries using audio-only telehealth visits is higher than White 
beneficiaries (54 percent).\23\ The differences among demographics 
further highlight the disparities present in telehealth and illustrate 
the impact omitting data obtained during audio-only telehealth visits 
may have on Medicare Advantage beneficiaries.
---------------------------------------------------------------------------
    \21\ https://www.kff.org/medicare/issue-brief/medicare-and-
telehealth-coverage-and-use-during-the-covid-19-pandemic-and-options-
for-the-future/.
    \22\ Id.
    \23\ Id.

 Action Needed to Address Constraints on Use of Audio-Only Telehealth 
                    Visits

The public health emergency has led to the recognition of the need to 
eliminate barriers and burdens in accessing clinically appropriate 
care, especially for those in the Medicare Advantage population. The 
importance of telehealth visits during the pandemic in 2020 and 2021 is 
unquestionable and calls for Congress to take action to eliminate the 
unnecessary and potentially harmful constraints on the assessment and 
documentation of current health status to ensure the continuity of care 
for millions of people.

Bipartisan legislation introduced in the Senate, the Ensuring Parity in 
Medicare Advantage and PACE for Audio-Only Telehealth Act of 2021, 
acknowledges and addresses the disparities in the use of telehealth 
visits for data collection essential for risk assessments. Audio-only 
telehealth has proven to be an extremely valuable tool to ensure 
ongoing care is available during this unprecedented national public 
health emergency to beneficiaries who cannot access or use audio-video 
technology. Clinicians have been conducting audio-only visits in 
response to the needs and abilities of beneficiaries and these visits 
have been vital to the provision of necessary ongoing care for 
beneficiaries. Earlier research showed that telehealth visits produce 
similar outcomes as face-to-face appointments for chronic care 
management and the diagnoses and treatment were also equivalent. 
Research also shows that risk scores do not fluctuate much year over 
year.\24\ Excluding clinical data from audio-only visits that may not 
have been obtained otherwise means the data may be entirely absent for 
those beneficiaries utilizing audio-only visits, despite being 
available for reporting in each year of the pandemic.
---------------------------------------------------------------------------
    \24\ Flodgren G, Rachas A, Farmer AJ, Inzitari M, Sheppard S. 
Interactive telemedicine: effects of professional practice and health-
care outcomes. Cochrane Database of Systematic Reviews 2015, Issue 9. 
Art. No.: CD002098. DOI: 10.1002/14651858.CD002098.pub2 .
---------------------------------------------------------------------------

Call for Congress to Act

Data obtained during audio-only visits should be permitted to be used 
for risk adjustment purposes as it is essential for accurate risk 
adjustment for beneficiaries in the following year and may not have 
been collected in any other way due to the pandemic. These visits are 
recognized as clinical encounters in every other sense, making it only 
reasonable for diagnoses obtained through these patient-clinician 
encounters to be permitted to be used for risk adjustment.

By allowing audio-only visits during the ongoing pandemic to be used 
for risk assessment purposes, the health and well-being of over 26 
million Medicare Advantage beneficiaries will be protected now and in 
the future. We strongly urge Congress to take action that recognizes 
beneficiary circumstances with respect to and preference for audio-only 
telehealth technology and necessitates the flexibility to use audio-
only technology in the collection of clinical and diagnostic data for 
risk adjustment purposes.

Better Medicare Alliance thanks the Committee for the opportunity to 
submit these comments. We recognize the sponsors of the legislation, 
Ensuring Parity in Medicare Advantage and PACE for Audio-Only 
Telehealth Act of 2021, for their leadership. We hope to see the 
Committee consider this bill in the near future and support its passage 
in the Senate. We welcome the opportunity to continue to engage with 
the Committee on this important and timely issue.

                                 ______
                                 
                        Center for Fiscal Equity

                      14448 Parkvale Road, Suite 6

                          Rockville, MD 20853

                      [email protected]

                    Statement of Michael G. Bindner

Chairman Wyden and Ranking Member Crapo, thank you for the opportunity 
to submit these comments for the record to the Committee. These 
comments are similar to those provided on Telehealth to the Ways and 
Means Subcommittee on Health on April 28, 2021.

Flexible health-care delivery, especially Telehealth is part of 
increased automation in medicine. It began with electronic charting. 
The emergence of telehealth predates the pandemic. It started as a 
cutting edge way for experts to consult on cases. In recent years, it 
has included using radiologists in South Asia to read all manner of X-
Rays and scans, delivering a diagnosis to emergency rooms, urgent care 
and doctor's offices.

The question of taxation must be discussed at this point. Perhaps 
duties should be included for such off-shore medicine. They certainly 
must be in the event value added taxes are established in the United 
States. This would bring us into the OECD norm. Senator Hatch has 
retired, so it is now safe to talk of such things.

If we adopt Medicare for All, such taxes would be counter-productive. 
Without some kind of employer-paid subtraction value added tax, it is 
hard to see the creation of an affordable public option, let alone 
Medicare for All. Part of any transition would have to include an asset 
value added tax, which would include ending Pease and Affordable Care 
Act SMI taxes on non-wage income over $200,000. See the attachment for 
more information on these proposals.

The pandemic has made telemedicine the new normal. I will be glad to 
see it go, or at least play a smaller role. It is hard to get a good 
medical history and list of symptoms on a video conference or phone 
call. People likely died, either of complications from the pandemic 
(like suicide) or SARS-Cov-2. This requires explanation.

The disease occurs in five phases. In phase one, the patient 
experiences symptoms of a heavy cold which goes away after a week. This 
phase is largely ignored by the medical community because it is 
impossible to get to see a doctor in person. To be fair, most patients 
manage these symptoms with over-the-counter medication. Symptoms last 
for a week. Phase two is asymptotic.

People believe they are well, even if they assume they were suffering 
from COVID. In reality, most of the spread of the disease happens 
during phases one and two. During this period, people do not have 
fevers, coughing and all but one of the symptoms which are used to 
screen for COVID.

The intense symptoms start with phase three (SARS2) or phase four 
(assuming individuals have some degree of immunity from pulmonary 
disease, or possess inhalers--especially steroids--to manage them.

The patients who eventually die do not know that they have COVID. They 
believe that symptoms will go away in a week, just as they did in phase 
one. Access to primary care at this stage, as well as vital information 
on the disease would have saved lives at this point. Add fear of dying 
of COVID in the Intensive Care Unit and this fear became a self-
fulfilling prophesy.

The main feature of phase four is crushing fatigue, either from lung 
symptoms or the development of immunity. These symptoms are a two week 
version of the reaction to either the first shot (for people who have 
had the disease) or the booster (for people who have not been sick 
previously).

Phase five is the long-term healing, which includes coughing up mucus. 
Medications, such as Robitussin, are valuable for these symptoms. This 
phase takes a long time to clear.

Deaths are still declining, as the current available vectors are less 
likely to die. For a few weeks, they just wish they would. Younger 
patients are experiencing the third wave. Minnesota, Michigan and 
Ontario are likely still experiencing their first wave. This disease is 
spread by sneezing on people you know, usually at home or work. It has 
spread from Seattle and New York to the rest of the nation, meeting in 
the southwest and moving north. It is running out of places to go.

As more and more people get vaccinated or simply have the disease and 
recover, it likely will disappear, like magic. When it does, we can get 
back to normal medical practice. Quite a bit of care has been foregone 
during the pandemic. There is a lot of catching up to do.

Thank you for the opportunity to address the committee. We are, of 
course, available for direct testimony or to answer questions by 
members and staff.

 Attachment --Tax Reform, Center for Fiscal Equity, March 5, 2021

Individual payroll taxes. These are optional taxes for Old-Age and 
Survivors Insurance after age 60 for widows or 62 for retirees. We say 
optional because the collection of these taxes occurs if an income 
sensitive retirement income is deemed necessary for program acceptance. 
Higher incomes for most seniors would result if an employer 
contribution funded by the Subtraction VAT described below were 
credited on an equal dollar basis to all workers. If employee taxes are 
retained, the ceiling should be lowered to $85,000 to reduce benefits 
paid to wealthier individuals and a $16,000 floor should be established 
so that Earned Income Tax Credits are no longer needed. Subsidies for 
single workers should be abandoned in favor of radically higher minimum 
wages.

Wage Surtaxes. Individual income taxes on salaries, which exclude 
business taxes, above an individual standard deduction of $85,000 per 
year, will range from 6.5% to 26%. This tax will fund net interest on 
the debt (which will no longer be rolled over into new borrowing), 
redemption of the Social Security Trust Fund, strategic, sea and non-
continental U.S. military deployments, veterans' health benefits as the 
result of battlefield injuries, including mental health and addiction 
and eventual debt reduction. Transferring OASDI employer funding from 
existing payroll taxes would increase the rate but would allow it to 
decline over time. So would peace.

Asset Value-Added Tax (A-VAT). A replacement for capital gains taxes, 
dividend taxes, and the estate tax. It will apply to asset sales, 
dividend distributions, exercised options, rental income, inherited and 
gifted assets and the profits from short sales. Tax payments for option 
exercises and inherited assets will be reset, with prior tax payments 
for that asset eliminated so that the seller gets no benefit from them. 
In this perspective, it is the owner's increase in value that is taxed.

As with any sale of liquid or real assets, sales to a qualified broad-
based Employee Stock Ownership Plan will be tax free. These taxes will 
fund the same spending items as income or S-VAT surtaxes. This tax will 
end Tax Gap issues owed by high income individuals. A 26% rate is 
between the GOP 24% rate (including ACA-SM and Pease surtaxes) and the 
Democratic 28% rate. It's time to quit playing football with tax rates 
to attract side bets.

Subtraction Value-Added Tax (S-VAT). These are employer paid Net 
Business Receipts Taxes. S-VAT is a vehicle for tax benefits, including

      Health insurance or direct care, including veterans' health care 
for non-
battlefield injuries and long term care.

      Employer paid educational costs in lieu of taxes are provided as 
either 
employee-directed contributions to the public or private unionized 
school of their choice or direct tuition payments for employee children 
or for workers (including ESL and remedial skills). Wages will be paid 
to students to meet opportunity costs.

      Most importantly, a refundable child tax credit at median income 
levels (with inflation adjustments) distributed with pay.

Subsistence level benefits force the poor into servile labor. Wages and 
benefits must be high enough to provide justice and human dignity. This 
allows the ending of state administered subsidy programs and 
discourages abortions, and as such enactment must be scored as a must 
pass in voting rankings by pro-life organizations (and feminist 
organizations as well). To assure child subsidies are distributed, S-
VAT will not be border adjustable.

The S-VAT is also used for personal accounts in Social Security, 
provided that these accounts are insured through an insurance fund for 
all such accounts, that accounts go toward employee-ownership rather 
than for a subsidy for the investment industry. Both employers and 
employees must consent to a shift to these accounts, which will occur 
if corporate democracy in existing ESOPs is given a thorough test. So 
far it has not. S-VAT funded retirement accounts will be equal-dollar 
credited for every worker. They also have the advantage of drawing on 
both payroll and profit, making it less regressive.

A multi-tier S-VAT could replace income surtaxes in the same range. 
Some will use corporations to avoid these taxes, but that corporation 
would then pay all invoice and subtraction VAT payments (which would 
distribute tax benefits. Distributions from such corporations will be 
considered salary, not dividends.

Invoice Value-Added Tax (I-VAT). Border adjustable taxes will appear on 
purchase invoices. The rate varies according to what is being financed. 
If Medicare for All does not contain offsets for employers who fund 
their own medical personnel or for personal retirement accounts, both 
of which would otherwise be funded by an S-VAT, then they would be 
funded by the I-VAT to take advantage of border adjustability. I-VAT 
also forces everyone, from the working poor to the beneficiaries of 
inherited wealth, to pay taxes and share in the cost of government. 
Enactment of both the A-VAT and I-VAT ends the need for capital gains 
and inheritance taxes (apart from any initial payout). This tax would 
take care of the low-income Tax Gap.

I-VAT will fund domestic discretionary spending, equal dollar employer 
OASI contributions, and non-nuclear, non-deployed military spending, 
possibly on a regional basis. Regional I-VAT would both require a 
constitutional amendment to change the requirement that all excises be 
national and to discourage unnecessary spending, especially when 
allocated for electoral reasons rather than program needs. The latter 
could also be funded by the asset VAT (decreasing the rate by from 
19.5% to 13%).

As part of enactment, gross wages will be reduced to take into account 
the shift to S-VAT and I-VAT, however net income will be increased by 
the same percentage as the I-VAT. Adoption of S-VAT and I-VAT will 
replace pass-through and proprietary business and corporate income 
taxes.

Carbon Value-Added Tax (C-VAT). A Carbon tax with receipt visibility, 
which allows comparison shopping based on carbon content, even if it 
means a more expensive item with lower carbon is purchased. C-VAT would 
also replace fuel taxes. It will fund transportation costs, including 
mass transit, and research into alternative fuels (including fusion). 
This tax would not be border adjustable.

Summary

This plan can be summarized as a list of specific actions:

1.  Increase the standard deduction to workers making salaried income 
of $425,001 and over, shifting business filing to a separate tax on 
employers and eliminating all credits and deductions--starting at 6.5%, 
going up to 26%, in $85,000 brackets.

2.  Shift special rate taxes on capital income and gains from the 
income tax to an asset VAT. Expand the exclusion for sales to an ESOP 
to cooperatives and include sales of common and preferred stock. Mark 
option exercise and the first sale after inheritance, gift or donation 
to market.

3.  End personal filing for incomes under $425,000.

4.  Employers distribute the child tax credit with wages as an offset 
to their quarterly tax filing (ending annual filings).

5.  Employers collect and pay lower tier income taxes, starting at 
$85,000 at 6.5%, with an increase to 13% for all salary payments over 
$170,000 going up 6.5% for every $85,000--up to $340,000.

6.  Shift payment of HI, DI, SM (ACA) payroll taxes employee taxes to 
employers, remove caps on employer payroll taxes and credit them to 
workers on an equal dollar basis.

7.  Employer paid taxes could as easily be called a subtraction VAT, 
abolishing corporate income taxes. These should not be zero rated at 
the border.

8.  Expand current state/federal intergovernmental subtraction VAT to a 
full GST with limited exclusions (food would be taxed) and add a 
federal portion, which would also be collected by the states. Make 
these taxes zero rated at the border. Rate should be 19.5% and replace 
employer OASI contributions. Credit workers on an equal dollar basis.

9.  Change employee OASI of 6.5% from $18,000 to $85,000 income.

                                 ______
                                 
                        ERISA Industry Committee

                     701 8th Street, NW, Suite 610

                          Washington, DC 20001

                           Main 202-789-1400

                          http://www.eric.org/

Introduction and About ERIC

Chairman Wyden, Ranking Member Crapo, and members of the Committee, 
thank you for this opportunity to submit a statement for the record on 
behalf of The ERISA Industry Committee (ERIC) for the hearing entitled 
``COVID-19 Health Care Flexibilities: Perspectives, Experiences, and 
Lessons Learned.'' This is a critical hearing, because the Senate 
Finance Committee's jurisdiction far exceeds Medicare--policies 
determined by this Committee govern the benefits provided by employers, 
especially as they affect the rules regarding high deductible health 
plans (HDHPs) and the Affordable Care Act (ACA). Our statement details 
ways that the Committee and Congress can take decisive action to 
consolidate the telehealth gains made by private sector employers 
during COVID and consider expanding telehealth policies to the private 
sector so that employees and their families can access virtual care.

ERIC is a national nonprofit organization exclusively representing the 
largest employers in the United States in their capacity as sponsors of 
employee benefit plans for their nationwide workforces. ERIC's member 
companies voluntarily provide benefits that cover millions of active 
and retired workers and their families across the country. With member 
companies that are leaders in every sector of the economy and with 
stores, factories, offices, warehouses, and other operations in every 
state, ERIC is the voice of large employer plan sponsors on federal, 
state, and local public policies impacting their ability to sponsor 
benefit plans and to lawfully operate under ERISA's protection from a 
patchwork of different and conflicting state and local laws, in 
addition to federal law.

You are likely to engage with an ERIC member company when you drive a 
car or fill it with gas, use a cell phone or a computer, watch TV, dine 
out or at home, enjoy a beverage, fly on an airplane, visit a bank or 
hotel, benefit from our national defense, receive or send a package, go 
shopping, or use cosmetics.

ERIC member companies voluntarily offer comprehensive health benefits 
to millions of active and retired workers and their families across the 
country. Our members offer these great health benefits to attract and 
retain employees, be competitive for human capital, and improve health 
and provide peace of mind. On average, large employers pay around 85 
percent of health-care costs on behalf of our beneficiaries--that would 
be a gold or platinum plan if bought on anExchange. But we don't buy or 
sell health insurance; these plans are self-insured. In other words, 
ultimately it is the company that is on the hook for the vast majority 
of the costs of our patients' care. Prior to COVID-19, there were an 
estimated 181 million Americans who got health care through their job, 
with about 110 million of them in self-insured plans like ours.

Employers like ERIC member companies roll up their sleeves to improve 
how health care is delivered in communities across the country. They do 
this by developing value-driven and coordinated care programs, 
implementing employee wellness programs, providing transparency tools, 
and adopting a myriad of other innovations that improve quality and 
value to drive down costs. These efforts often use networks to guide 
our employees and their family members to providers that offer high 
value care. ERIC member companies' ERISA plans are not subject to many 
of the state and local requirements that apply to fully-insured 
products such as those sold on an ACA Exchange, because employers do 
not profit from health benefits--in fact, they're a huge expense.

The entire purpose of these benefits is to meet the needs of plan 
beneficiaries. Large employers have been essential in connecting 
employees and their families to programs and care such as through 
telehealth benefits. ERIC's member companies have been pioneers in 
offering robust access to telehealth. Telehealth enables our 
beneficiaries to obtain the care they need, when and where they need 
it, affordably and conveniently. It reduces the need to leave home or 
work and risk infection at a physician's office, provides a solution 
for individuals with limited mobility or access to transportation, and 
has the potential to address provider shortages, especially related to 
mental health, and improve choice and competition in health care. And 
telehealth is an important tool to help minority communities connect 
with doctors who share identity and culture, thus helping these 
individuals feel comfortable accessing the health-care system, no 
matter where they may be.

Nearly every ERIC member company offers comprehensive telehealth 
benefits and did so long before the COVID pandemic. As in most aspects 
of health insurance and value-driven plan design, self-insured 
employers have been the early adopters and drivers of telehealth 
expansion. With the onset of the pandemic, ERIC's member companies led 
the way in rolling out telehealth improvements--held back only by 
various federal and state government barriers. Congress should take 
decisive action to consolidate the telehealth gains made by private 
sector employees during COVID and consider expanding telehealth 
policies to the private sector so that employees and their families can 
access virtual care.

 Federal Actions Greatly Improve Telehealth for Medicare Beneficiaries 
                    but Leave the Private Sector Behind

Early on in the pandemic, the Administration and Congress quickly 
realized that unnecessary barriers to telehealth care would be a 
significant problem for Medicare beneficiaries. Many of those 
individuals were quarantined or in areas undergoing lockdowns. Many 
were in different states and regions that were experiencing peaks in 
hospital and provider capacity. And Medicare's own coverage of 
telehealth was nowhere near broad enough to replace much of the care 
that would otherwise be foregone due to medical facilities being closed 
to non-COVID patients.

The Administration and Congress acted quickly and decisively:

      Medicare promptly eliminated state licensure barriers, allowing 
a willing and qualified provider to see a willing Medicare patient via 
telehealth, without regard to their locations;

      Medicare promptly eliminated state telehealth barriers, such as 
requirements that patients travel to specific originating sites before 
they can access telehealth, limitations related to modality (e.g., 
video-only requirements, etc.), requirements that the provider and 
patient have a pre-existing relationship, and more; and

      Medicare expanded coverage to include more services for more 
patients, covered via telehealth.

These changes massively improved telehealth benefits for Medicare 
beneficiaries, instantly unleashing telehealth's vast potential to fill 
the voids created by the pandemic and its response--and paving the way 
for permanent improvement. In fact, in a December 4, 2020 letter, 49 
Congressional leaders called for making these changes permanent. While 
ERIC member companies are primarily outside of the Medicare system, we 
support making these Medicare improvements permanent. We have endorsed 
Senator Schatz's CONNECT for Health Act (S. 1512) to do just this. 
Medicare's embrace of telehealth is a boon to private sector patients, 
because it advances the creation of infrastructure, the adoption of 
telehealth by more providers, and provides proof that telehealth 
expansion can produce better access to care and savings.

Unfortunately, very few improvements have been made for patients in the 
private sector not covered by Medicare, despite employer efforts to 
expand and improve telehealth. Below we detail how private-sector 
patients are harmed by the current situation and what the Committee and 
Congress can do about it:

Care is still limited in many states only to a patient and provider 
both physically located in that state. Many states have failed to join 
interstate medical licensing compacts that provide reciprocity for 
mental health and other medical providers in other states, expanding 
the network of available providers for state beneficiaries to access. 
Congress waived these requirements for Medicare and should do the same 
for private sector beneficiaries or otherwise effectuate interstate 
practice. While some states have signed limited interstate reciprocity 
compacts, to recognize limited practice by limited types of providers, 
many have provided little or no licensure relief.

Restrictive licensure rules help some providers by essentially 
outlawing competition from out of state, but it hinders other providers 
from expanding their practice. The failure to recognize interstate 
medical licensure reciprocity for telehealth means that for many 
patients, the state government has banned them from logging on to their 
computer or smartphone and connecting with a readily available and 
qualified provider.

Many states still impose unnecessary barriers to the use of 
telemedicine. These barriers can range from requiring that a patient 
travel to a specific telehealth site before they can connect to a 
provider, limiting telehealth to specific technologies (for instance, 
requiring two-way video, which may be out of reach by those in rural or 
other areas without broadband access or the sophistication to work it, 
outlawing the use of ``portals'' and store-and-forward communications 
particularly helpful to identify skin conditions, pink eye, etc.), 
mandating that a patient can only do a telehealth visit with a doctor 
they already have a relationship with, and other barriers. While these 
barriers may be imposed under the guise of setting a standard of care 
or protecting patients, these requirements really serve to stymie 
telehealth, driving more care to (more expensive) in-person settings--
or preventing patients from obtaining care at all--and hampering wider 
telehealth adoption.

These restrictions also have significant equity impact creating 
barriers that disproportionately affect low-income populations, persons 
of color, or those with disabilities. At the same time, they serve to 
protect profits for high-income professions.

Rules imposed by the federal government prevent employers from offering 
telehealth to many beneficiaries. Employers generally cannot offer 
telehealth as an employee benefit, separate from health coverage, 
because, under Department of Labor regulations, telehealth benefits are 
deemed to be ``a plan'' for the purposes of ACA rules. This 
determination requires telehealth benefits to be paired with a full 
medical benefit that meets all of the different ACA requirements--1st-
dollar coverage of vaccines, essential health benefits and annual limit 
rules, and much more. Because telehealth is, by definition, limited and 
conducted remotely, it simply cannot meet all of the ACA requirements 
on its own.

To be clear, telehealth is not a ``modality'' of care. For employers, 
it is often an entirely different benefit, part of a suite of programs 
that are offered to employees and their families. In fact, employers 
often use a separate vendor to design and administer their telehealth 
benefits, rather than the insurance company or third-party 
administrator that services their full medical plan. But the result of 
treating this separate benefit as a ``group health plan'' is that 
telehealth cannot be offered as a standalone to anyone not enrolled in 
the full medical plan, which effectively bans employers from extending 
telehealth to all populations, including:

      Full-time employees who are not enrolled in the medical plan, or 
employees' family members, if the employee is on a self-only plan;

      Part-time employees ineligible for the medical benefit;

      Seasonal, agricultural, or other temporary workers;

      Interns, trainees, and the like; and,

      New employees on a waiting period for the full medical plan, 
among others.

ERIC notes that this is a serious anomaly--perhaps the first time in 
living memory that beneficiaries of government programs have more 
access, more flexibility, and in some ways, better benefits than 
private sector workers on employer-sponsored plans. Employers are 
generally the pioneers in health benefits, experimenting with and 
leading the way in driving value, innovation, quality, and flexibility 
for patients. Now, because of government barriers, private sector 
workers are being left behind.

Administrative action has provided limited relief. On June 23, 2020, 
the Department of Labor issued a Frequently Asked Question (FAQ Part 
43)\1\ that for the first time, allowed employers to expand standalone 
telehealth offerings, but with two key debilitating restrictions:
---------------------------------------------------------------------------
    \1\ https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-
activities/resource-center/faqs/aca-part-43.pdf.

(1)  Standalone telehealth may only be offered to individuals 
---------------------------------------------------------------------------
ineligible for the full medical/surgical benefit; and

(2)  Standalone telehealth may be offered to these individuals only 
until the end of the public health emergency.

While this FAQ was a step in the right direction, it unfortunately 
leaves a number of potential beneficiary cohorts behind (again, younger 
workers and those of less economic means are hardest hit), while the 
temporary nature served as a significant disincentive for large 
employers to implement a major benefit change. It is critical that 
Congress make permanent the allowance to offer standalone telehealth 
benefits, and expand the offering to unenrolled individuals, in 
addition to just those who are ineligible. If not, millions of people 
will lose this benefit that has enabled them to access providers, 
especially mental health providers, in a timely manner.

We will note one considerable improvement in telehealth that Congress 
has made for private sector workers: individuals enrolled in a HDHP 
with a health savings account (HSA) can now benefit from 1st-dollar 
coverage of telehealth, thanks to the enactment of the ``Telehealth 
Expansion Act'' (S. 3539), which was passed into law as part of the 
CARES Act (H.R. 748). Unfortunately, this telehealth improvement is 
time-limited and set to expire at the end of 2021.

Senators Daines (R-MT) and Cortez Masto (D-NV) have introduced a new 
version of the Telehealth Expansion Act, which would make the CARES Act 
policy permanent. ERIC strongly supports this legislation. We urge 
Congress to swiftly pass the Daines-Cortez Masto bill, and make 1st-
dollar coverage of telehealth permanent, so that workers in these plans 
can receive the care they need.

 Key Steps the Finance Committee Should Consider to Improve Telehealth

The solutions to many of these problems are within the Committee's 
jurisdiction, and employers look forward to continuing to provide 
technical assistance to Congress to implement solutions. We urge the 
Committee to advance provisions to address each of these barriers to 
care for private sector workers and put them on equal footing with 
Medicare beneficiaries.

First, Congress should pass the Temporary Reciprocity to Ensure Access 
to Treatment (TREAT) Act (S. 168) and enable providers to practice 
telehealth across state lines during the COVID-19 pandemic. Telehealth 
use has drastically increased over the past year, and some state 
licensing restrictions continue to disrupt patients' care. The TREAT 
Act would provide temporary state licensing reciprocity for all 
licensed and certified practitioners or professionals (those who treat 
physical and mental health conditions) in all states for all types of 
services (in-person and telehealth) during the COVID-19 Public Health 
Emergency. A provider who has achieved a medical license in their own 
state should be permitted to practice on the Internet, without states 
blocking them from seeing patients--and likewise, a patient who goes 
online to see a doctor should not be prevented by state rules from 
seeing a qualified provider who is licensed in another state. States 
should retain their rights to determine whether providers licensed in 
that state will be qualified to write prescriptions or otherwise 
develop a scope of practice. However, if a provider in another state 
has been deemed qualified, a state should not be permitted to prevent 
patients from seeing that provider or prevent the provider from 
operating to the fullest extent of their license in that interaction. 
For example, not allowing a qualified provider to prescribe medication 
during a medical visit or discuss treatment options during a mental 
health visit.

Congress should act immediately to ensure that patients who use 
telehealth for physical and mental health services will have the best 
chance of finding a provider ready and willing to see them on the other 
end during the public health emergency. Mental health-care providers 
prior to the pandemic were difficult to access, especially for those 
not living in urban areas. More than 60 percent of rural Americans live 
in mental health professional shortage areas, and the need for care has 
only been exacerbated during the COVID-19 pandemic.

Congress' immediate action will enable more competition and access in 
telehealth, creating incentives for providers to improve quality and 
affordable access for patients. At a time when anxiety and depressive 
disorders are at an ultimate high, access for patients is sorely needed 
in offering mental health-care services through telehealth.

In the longer term, we urge Congress to enact a permanent solution to 
interstate licensure. While this will require addressing some thorny 
questions, we have seen significant leadership in the past with respect 
to the issue. For instance, in a previous Congress, Congressmen Pallone 
and Nunes introduced the TELE-MED Act \2\ to permanently allow 
interstate practice for Medicare providers. Congress previously fixed 
this issue in the realm of sports medicine as well. While there are 
different possible paths forward (national reciprocity, a national 
license, one comprehensive interstate compact with financial incentives 
for states), employers urge Congress to work through this challenge and 
come to consensus on a solution.
---------------------------------------------------------------------------
    \2\ https://pallone.house.gov/press-release/pallone-and-nunes-
introduce-tele-med-act.

Second, Congress should establish a simple set of federal standards for 
telehealth, eliminating state barriers. We can think of no better 
example of interstate commerce than a willing doctor and willing 
patient connecting electronically via the Internet to do a telehealth 
visit. While it is entirely appropriate for a state to place standards 
to regulate the practice of medicine at brick-and-mortar medical 
facilities within the state's geographic boundaries, it makes little 
sense to have 50 different sets of rules for telehealth (practiced 
remotely on the Internet or via phone) depending on where a provider or 
---------------------------------------------------------------------------
patient may be located at any given moment.

Congress can also develop a set of rules that protect patients while 
maximizing flexibility and care, rather than some of the current 
protectionist rules that serve to block patients from care on the state 
level. The new set of rules should:

      Allow telehealth to establish a patient-provider relationship 
through an initial telehealth visit;

      Apply the same medical standard of care used for in-person to 
telehealth visits;

      Ensure that reimbursement is privately negotiated between 
providers and payers;

      Encourage cross state practice among providers;

      Promote continuity of care by encouraging telehealth providers 
to coordinate with a patient's primary care provider and 
interdisciplinary care team;

      Implement ``technology-neutral'' rules for telehealth, to 
``future-proof'' rules for advances in technology and best practices, 
and eliminate discrimination for patients who may not have access to 
broadband Internet or the sophistication to operate video, forward 
information, etc.;

      Eliminate all ``originating site'' requirements that arbitrarily 
limit patient access to telehealth;

      Preserve the same informed consent requirements for patients in 
telehealth that apply in person; and

      Ensure that telehealth providers may prescribe medication to 
patients with reasonable limits.

This simple, streamlined set of rules will provide clarity to providers 
and maximize access for patients.

Third, Congress should designate standalone telehealth as an ``excepted 
benefit'' so that it can be offered to more patients. This is the way 
Congress treats other ``add-on'' benefits like vision, dental, long-
term care, cancer-only plans, hospital indemnity insurance, and other 
benefits that are health-related but do not constitute a full medical 
plan. It would be a simple change by adding the word ``telehealth'' 
into the appropriate sections of the Internal Revenue Code (IRC), the 
Public Health Service Act (PHSA), and the Employee Retirement Income 
Security Act (ERISA).

Doing so would not affect an employer's responsibility to offer minimum 
essential coverage to employees, nor would it weaken an individual's 
responsibility to enroll in such. Employers or insurers could not swap 
out telehealth, which is limited in scope and closer to a supplement 
than a full medical plan, for a full medical benefit. It would simply 
open up employers' ability to offer telehealth benefits to millions of 
patients who currently are not allowed--by Congress--to access those 
benefits. There is precedent for Congress expanding the definition of 
excepted benefits (e.g., Congress previously acted to allow ``limited 
duration long term care'' benefits to be offered outside a medical 
plan).

In a recent survey, more than 25 percent of ERIC member companies 
stated that they would expand telehealth offerings immediately if 
Congress permitted it to be offered as a standalone benefit. This 
represents billions of dollars in private sector money that is 
currently being left on the table, and millions of Americans who could 
have access to telehealth coverage and care, if only the government 
would get out of the way. Many ERIC member companies are currently 
taking advantage of the DOL FAQ allowing limited telehealth expansion, 
but action by Congress could greatly increase these numbers, and thus, 
greatly increase patients' access to care.

While the Committee considers telehealth advancements for the private 
sector, more can be done for the millions of workers (approximately 
half the workforce) with HDHP plans. Congress should allow patients 
with a HDHP paired with a HSA to access worksite health centers via 
1st-dollar coverage as well. Worksite health and wellness centers are 
more critical today than ever before, as employers provide their 
employees with more widespread and easy access to preventive and 
primary care services, including vaccination and diagnostic testing 
services at the workplace. And during COVID, many of these health 
centers have gone virtual, providing care to workers throughout a given 
region, not just confined to a specific worksite. However, under 
current law, individual taxpayers may not contribute pre-tax dollars to 
an HSA if they also receive certain supplemental health benefits, which 
currently includes access to care at a worksite health center. The 
resulting policy is that individuals with an HDHP are required to pay 
the full price, no discounts, until they have paid through their full 
deductible. It's unfair and counterproductive, when employers want our 
beneficiaries to use the clinics. ERIC encourages Congress to address 
the inequity by permitting individuals to both benefit from discounted 
services offered at worksite employee centers and still be eligible to 
participate in and provide pre-tax contributions to HSAs.

 Counterproductive, Protectionist, Anti-Market Proposals: Worse Than 
                    Doing Nothing

Meanwhile, some stakeholders are asking Congress to implement 
telehealth changes that would go in the exact opposite direction, 
eliminating competitive markets, promoting low-value care, and reducing 
the potential for telehealth to be transformational for the medical 
system.

For instance, the Health Care at Home Act would mandate ERISA health 
plans to cover telehealth for any service that is covered in person, as 
well as mandate that telehealth services be reimbursed at the same 
amount as in-person services. Both of these changes fail to expand and 
improve telehealth and instead would uproot the blossoming market.

Large employers that offer health coverage through ERISA plans make 
decisions on services to cover based on clinical guidelines, evidence, 
and best practices. We learn from experience, advice from medical 
professional societies, bodies that evaluate quality and efficiency in 
health care, and other sources, and then use this information to 
develop benefits that drive the most value for our beneficiaries. The 
prospect of government imposition of a sweeping coverage mandate within 
ERISA plans would be an extreme break from precedent, not to mention a 
counterproductive endeavor that would inject more unproven and 
potentially low-value care into 
employer-sponsored coverage. This, in turn, would reduce the quality of 
coverage, while increasing costs for participants. It should be the 
responsibility of ERISA plan sponsors, not the government, to determine 
what care is appropriate to cover via telehealth settings.

Under current law, providers are free to negotiate telemedicine rates 
with payers--which has given rise to a thriving market in which 
competition drives cost efficiency, value, quality, and innovation. So, 
it should come as no surprise that certain provider groups are eager to 
destroy this market and instead set reimbursement by government fiat. 
It is wholly inappropriate and unprecedented for the federal government 
to mandate payment rates between two private parties.

Further, telehealth is cheaper than in-person care. Telehealth enables 
providers to treat more patients more efficiently, with less overhead 
cost, fewer staff, and lower expenses associated with operating brick-
and-mortar retail health settings. This has enabled telehealth 
providers to offer more competitive rates than in-person, which has 
been in no small part responsible for the telehealth renaissance. This 
has caused many employers to adopt and offer telehealth benefits long 
before the COVID emergency and driven the continuing exploration and 
innovation that serves to produce ongoing improvements for patients. 
Losing this successful competitive market would be a significant 
setback for patients and employers, and ultimately for up-and-coming 
providers who otherwise could cultivate opportunities in the telehealth 
space.

Conclusion

Thank you for this opportunity to share our views with the Committee. 
The ERISA Industry Committee and our member companies are committed to 
working with Congress to expand and improve telehealth for millions of 
patients in the private sector, and to defeat proposals that would 
impose government mandates that make the situation worse, not better. 
We look forward to working with you to develop and perfect telehealth 
proposals that can be passed in Congress and signed into law by 
President Biden.

                                 ______
                                 
                     Healthcare Leadership Council

                       750 9th St., NW, Suite 500

                          Washington, DC 20001

                              202-452-8700

May 20, 2021

The Honorable Ron Wyden             The Honorable Mike Crapo
Chair                               Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
Washington, DC 20510                Washington, DC 20510

Dear Chair Wyden and Ranking Member Crapo:

On behalf of the Healthcare Leadership Council (HLC), we thank you for 
holding a hearing on, ``COVID-19 Health Care Flexibilities: 
Perspectives, Experiences, and Lessons Learned.''

HLC is a coalition of chief executives from all disciplines within 
American health care. It is the exclusive forum for the nation's 
health-care leaders to jointly develop policies, plans, and programs to 
achieve their vision of a 21st century health-care system that makes 
affordable high-quality care accessible to all Americans. Members of 
HLC--hospitals, academic health centers, health plans, pharmaceutical 
companies, medical device manufacturers, laboratories, biotech firms, 
health product distributors, post-acute care providers, home care 
providers, and information technology companies--advocate for measures 
to increase the quality and efficiency of health care through a 
patient-centered approach.

The COVID-19 public health emergency (PHE) has highlighted significant 
challenges to current models of care delivery. The unprecedented 
cooperation between private and public partners creating innovations in 
care delivery, information sharing and improved coordination have 
served as a guide for future pandemics. HLC thanks Congress and federal 
agencies for their work on providing flexibilities so that stakeholders 
were able to swiftly adjust to a changing environment. HLC encourages 
the Committee to examine lessons learned from the following areas to 
make meaningful improvement to health outcomes after the PHE ends:

Data Sharing

A successful COVID-19 response has required coordination among a 
diverse set of public and private stakeholders. Each of these groups is 
uniquely situated to respond to disaster scenarios. Leveraging their 
individual strengths in a systemic, coordinated manner will lead to 
greater successes. One critical area where such coordination could be 
used is in data access and exchange. Public health officials require 
real-time information on a variety of metrics (e.g., PPE levels, 
hospital bed count, number of individuals vaccinated) so that they can 
tailor their responses as necessary. Private sector health-care 
organizations stand at the ready to provide input to government 
officials on how best to share information in times of emergency to 
support supply chain management and surge redeployment.

Telehealth

One of the greatest lessons from the COVID-19 health pandemic has been 
the opportunity to deliver care through telehealth. State imposed stay-
at-home orders limited access to care to vulnerable populations, but 
increased use of telehealth has helped to deliver care to these 
populations. A recent study found that telehealth use increased over 
3,000% during the 12 month period between October 2019 and October 
2020.\1\ We greatly appreciate the flexibilities permitted by Congress 
and the Department of Health and Human Services (HHS) to expand access 
to telehealth services. These waivers, however, are only temporary and 
are set to expire at the end of the current PHE. HLC encourages the 
Committee to examine regulatory barriers to long-term telehealth use, 
particularly the existing prohibition under Section 1834(m) of the 
Social Security Act that prevents patients from receiving telehealth 
services in their homes and other locations. Limiting where a patient 
can access telehealth unnecessarily reduces care options for patients 
already underserved by the U.S. health-care system. HLC also encourages 
the Committee to examine how to further encourage telehealth use after 
the PHE ends. Patients have been overwhelmingly satisfied with their 
telehealth experiences and imposing additional regulatory barriers 
would limit the ease of such care.\2\ HLC has concerns that adding 
clinically unnecessary in-person requirements as a prerequisite to 
receiving virtual care would limit the ability of providers to meet 
patients where they are and extend access to underserved patient 
populations that do not have an existing relationship with a provider. 
We encourage the Committee to examine the impact on care for vulnerable 
populations before any regulatory guardrails are imposed.
---------------------------------------------------------------------------
    \1\ Iain Carlos, Telehealth claim lines jump 3,000% in 1 year, 
Becker's Hospital Review (January 7, 2021), https://
www.beckershospitalreview.com/telehealth/telehealth-claim-lines-jump-3-
000-in-1-year.html.
    \2\ Telehealth Patient Satisfaction Surges During Pandemic but 
Barriers to Access Persist, J.D. Power Finds, J.D. Power (October 1, 
2020), https://www.jdpower.com/business/press-releases/2020-us-
telehealth-satisfaction-study.
---------------------------------------------------------------------------

Workforce

The PHE has highlighted the need for a robust health-care workforce so 
that it can be quickly scaled and deployed during future disaster 
events. HLC supports legislation that would implement a federal waiver 
of state licensure and allow for practice at the top of the scope of 
license for physicians, nurses, pharmacists, pharmacy technicians and 
other health-care professionals in times of disaster. This should also 
allow health professionals to work in centralized locations to provide 
services, including remote patient monitoring across state lines. We 
also encourage Congress to examine legislation that would expedite the 
visa authorization process for highly trained nurses who could support 
hospitals facing staffing shortages, ensuring hospitals are better able 
to respond to rising COVID-19 caseloads in the months ahead. An 
adequate supply of nursing staff is critical for hospitals to maintain 
services while ensuring that patients are properly cared for during the 
public health emergency. The Healthcare Workforce Resilience Act is 
critical to strengthening health systems' capacity as we continue to 
combat the COVID-19 pandemic, the growing opioid crisis, and other 
significant health challenges.

HLC, through its National Dialogue for Healthcare Innovation (NDHI) 
initiative on Disaster Preparedness and Response has also partnered 
with the Duke-Margolis Center for Health Policy to recommend future 
strategies that will lead to better disaster readiness efforts. In this 
report,\3\ we focus on three different areas: improving data and 
evidence generation, strengthening innovation and supply chain 
readiness and improving care delivery approaches. The report highlights 
many of the current challenges public and private entities have had in 
responding to the COVID-19 health pandemic and makes recommendations on 
how to ease future burdens. HLC has also compiled a compendium \4\ of 
best practices, highlighting the efforts of our members in responding 
to disaster events such as the COVID-19 pandemic as well as natural 
disasters.
---------------------------------------------------------------------------
    \3\ https://www.ndhi.org/files/1816/1281/7553/
disaster_preparedness_report_FINAL.pdf.
    \4\ https://www.hlc.org/wp-content/uploads/2021/02/DP-Compendium-
Final-Final.pdf.

HLC looks forward to working with you on developing lasting 
flexibilities for health-care stakeholders so they can quickly respond 
to disaster events. Please feel free to contact Tina Grande at 
---------------------------------------------------------------------------
[email protected] or 202-449-3433 with any questions.

Sincerely,

Mary R. Grealy
President

                                 ______
                                 
                              HealthEquity

                        15 W. Scenic Pointe Dr.

                            Draper, UT 84020

                            P. 855-437-4727

                            F. 801-727-1005

                     https://www.healthequity.com/

                         [email protected]

May 18, 2021

The Honorable Ron Wyden             The Honorable Mike Crapo
Chairman                            Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
219 Dirksen Senate Office Building  219 Dirksen Senate Office Building
Washington, DC 20510-6200           Washington, DC 20510-6200

Dear Chairman Wyden and Ranking Member Crapo:

We write to you today to thank you for holding a hearing entitled, 
``COVID-19 Health Care Flexibilities: Perspectives, Experiences, and 
Lessons Learned.'' Your attention to this critical issue is appreciated 
by HealthEquity and by the millions of Americans who utilize telehealth 
services.

HealthEquity administers health savings accounts (``HSAs'') and other 
consumer-
directed benefits for more than 12 million accounts on behalf of 
American workers. We partner with employers, benefits advisors, and 
health and retirement plan providers who share our mission to connect 
health and wealth and value our culture of remarkable ``Purple'' 
service.

In response to the COVID-19 pandemic, Congress included temporary 
provisions in the CARES Act (Pub. L. 116-136) permitting an HSA-
eligible high deductible health plan to cover telehealth and other 
remote services without a deductible or before the deductible has been 
met. These temporary provisions providing access to vital care expire 
at the end of 2021.

While these provisions are temporary, the growth in telehealth is 
likely not. Surveys have shown explosive growth in telehealth since the 
pandemic began:

      A study in Health Affairs found that 30.1% of all health care 
visits--a 23-fold increase--were conducted via telemedicine between 
January and June 2020;\1\
---------------------------------------------------------------------------
    \1\ Population of 16.7 million participants with commercial 
insurance or a Medicare Advantage plan. https://www.healthaffairs.org/
doi/abs/10.1377/hlthaff.2020.01786?journalCode=hlthaff.
---------------------------------------------------------------------------
      A coalition of self-insured plan sponsors reported a 28-fold 
increase in telemedicine visits between January and May 2020;\2\ and
---------------------------------------------------------------------------
    \2\ https://www.prnewswire.com/news-releases/patient-
officehospital-visits-down-telemedicine-visits-up-for-non-covid-19-
health-issues-based-on-claims-analysis-by-health-transformation-
alliance-301236052.html.
---------------------------------------------------------------------------
      A major telemedicine company reported a 156% increase in 
appointments for 2020 compared to 2019.\3\
---------------------------------------------------------------------------
    \3\ https://ir.teladochealth.com/news-and-events/investor-news/
press-release-details/2021/Teladoc-Health-Reports-Fourth-Quarter-and-
Full-Year-2020-Results/default.aspx.

These statistics show how critically important telemedicine has become. 
Few observers believe the practice of medicine will return to the way 
it was before COVID. As society and technology evolve, so should health 
---------------------------------------------------------------------------
and tax policy.

We respectfully request that you make the CARES Act telehealth 
provisions permanent and support the millions of Americans who have 
found telemedicine to be a safe and effective means of receiving 
medical care.

Thank you for your attention to this issue. We are happy to be of 
assistance in any way.

Sincerely,

Jody L. Dietel, ACFCI, CAS, HSAe
Senior Vice President, Advocacy and Government Affairs
[email protected]
650-577-6372

                                 ______
                                 
                           Kaiser Permanente

                      One Kaiser Plaza, 27th Floor

                           Oakland, CA 94612

                              510-271-5999

June 3, 2021

The Honorable Ron Wyden
Chair
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510

The Honorable Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510

RE: Kaiser Permanente statement for the record on the committee's May 
19, 2021, hearing, ``COVID-19 Health Care Flexibilities: Perspectives, 
Experiences, and Lessons Learned''

Dear Chair Wyden and Ranking Member Crapo:

On behalf of Kaiser Permanente, we thank you for holding the ``COVID-19 
Health Care Flexibilities: Perspectives, Experiences, and Lessons 
Learned'' hearing on May 19, 2021. We commend the committee for 
addressing these important issues and offer this statement for the 
record.

Kaiser Permanente comprises Kaiser Foundation Health Plan, Inc., the 
nation's largest not-for-profit health plan, and its health plan 
subsidiaries outside of California and Hawaii; the not-for-profit 
Kaiser Foundation Hospitals, which operates 39 hospitals and 724 
clinical facilities; and the Permanente Medical Groups, self-governed 
physician group practices that employ more than 23,000 physicians and 
exclusively contract with Kaiser Foundation Health Plan and its health 
plan subsidiaries to meet the health needs of Kaiser Permanente's 12.5 
million members.

The COVID-19 pandemic has demonstrated the potential of programs that 
provide acute-level care in the home and the inherent value of making 
such programs a durable feature of our health care delivery system. We 
hope that you will find our experiences in implementing our Kaiser 
Permanente Advanced Care at Home programs useful--particularly in the 
dynamic and demanding environment of the COVID-19 pandemic--as you 
consider policies to expand the availability of these beneficial 
innovations to all patients.

Innovating home-based care. Over the past decade, Kaiser Permanente and 
several other prominent, well-respected health-care organizations have 
pioneered care models that enable patients to receive, from the comfort 
of their own homes, care for acute and chronic conditions that 
traditionally has been provided in hospital and other medical facility 
settings. Many patients benefit immensely from this model of care, 
including those with cancer, COVID-19, organ transplants, and chronic 
illnesses such as renal failure. The model brings a range of hospital 
equipment and services into the patient's home. This can include 
infusions; skilled nursing services; medication delivery; and 
laboratory, imaging, behavioral health, and rehabilitation services.

Kaiser Permanente at home. At Kaiser Permanente, we have provided safe 
and effective advanced care at home for more than 500 patients across 
several Kaiser Permanente regions since 2020, and we are working to 
expand availability in the coming years. Leveraging advances in 
technology that support the virtual delivery of health-care services, 
the Kaiser Permanente Advanced Care at Home program temporarily 
installs state-of-the-art technology in patients' homes, and our care 
at home ``command centers'' direct and coordinate care delivered by our 
Permanente Medical Group physicians and care teams. Our specialized 
health-care teams deliver the same high-quality, hospital-level care in 
patients' homes that they would receive during a traditional hospital 
stay.

Through our programs, home-based patients can access their care teams 
around-the-clock by phone and video; have their vital signs monitored 
virtually; receive in-home visits with a nurse practitioner and other 
clinicians such as community paramedics; and have diagnostic testing, 
mobile imaging, and various therapies performed safely in their homes. 
To facilitate patients' connections to their care teams, we also equip 
them with devices and technology, which may include: a computer tablet 
for video visits with their care team, a phone with a direct line to 
their care team, an emergency-response bracelet, remote-monitoring 
devices, and backup Internet access and power supply. Personnel 
entering the home are trained to provide excellent patient care, 
identify and address challenges associated with the social determinants 
of health, and attend to any information technology questions that 
might arise during the course of a medical episode. The command center 
is staffed by physician specialists in hospital medicine, inpatient 
nurses, and program coordinators who can assist patients with the 
logistics of timely delivery of medications, materials, and personnel 
into the home.

Better outcomes for patients. Programs that provide hospital-level care 
at home have been shown to produce better outcomes for patients when 
compared with in-hospital care. Several studies have found that home-
based patients had improved outcomes, including reduced lengths of 
stay, readmissions, and mortality.\1\ These programs also mitigate the 
health risks that patients can face during a traditional 
hospitalization, including those from health care--acquired conditions 
such as nosocomial infections, delirium, and other harm events. 
Hospital care at home takes the infection prevention principles 
afforded by a single room in a hospital to the next level of safety. 
Delirium events can be reduced because elderly patients are not removed 
from their familiar environment.\2\ Nationally, a third of hospitalized 
patients will decline from their baseline functional status after a 
traditional hospitalization.\3\ These patient harms--which can be the 
direct result of hospital stays--are known to be costly, and they can 
be reduced or avoided altogether by enrolling the patient in a program 
that provides hospital-level care at home.
---------------------------------------------------------------------------
    \1\ Johns Hopkins Medicine, ``Hospital at Home,'' 
www.johnshopkinssolutions.com/solution/hospital-at-home; The 
Commonwealth Fund, `` `Hospital at Home' Programs Improve Outcomes, 
Lower Costs But Face Resistance from Providers and Payers,'' 
www.commonwealthfund.org/publications/newsletter-article/hospital-home-
programs-improve-outcomes-lower-costs-face-resistance.
    \2\ Caplan GA, Coconis J, Board N, Sayers A, Woods J. Does home 
treatment affect delirium? A randomised controlled trial of 
rehabilitation of elderly and care at home or usual treatment (The 
REACH-OUT trial). Age Ageing. 2006 Jan;35(1):53-60.
    \3\ Chodos AH, Kushel MB, Greyson SR, et al. Hospitalization-
associated disability in adults admitted to a safety net hospital. J 
Gen Intern Med. 2015; Covinsky KE, Pierluissi E, Johnson CB. 
Hospitalization-associated disability. JAMA Oct. 26, 2011;306(16).

Studies confirm that acute-care-at-home programs can result in cost 
savings. For example, one study determined that the average cost of 
hospital-level care at home was $5,081, compared with $7,480 for acute 
hospital care.\4\ On average, these programs reduced costs by more than 
$2,000, or 32%.\5\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Ibid.

Increased patient satisfaction. Acute care-at-home programs have also 
been shown to enhance patient satisfaction with their care experience. 
Patients overwhelmingly prefer to receive care at home when possible. 
According to one national poll, 77% of Americans over the age of 40 
would prefer to receive care in the familiar surroundings of their 
homes.\6\ In our own experience with Kaiser Permanente Advanced Care at 
Home, patients report satisfaction levels across key areas consistently 
at or above national averages. On a scale of 1 to 100, our surveyed 
patients rated their overall experience with Kaiser Permanente Advanced 
Care at Home at 78 (compared with 73, nationally for all hospitalized 
patients) and their willingness to recommend the program at 78 
(compared with 72, nationally for all hospitalized patients).\7\
---------------------------------------------------------------------------
    \6\ Associated Press and National Opinion Research Center at 
University of Chicago, ``Long-Term Care in America: Expectations and 
Preferences for Care and Caregiving,'' www.
longtermcarepoll.org/long-term-care-in-america-expectations-and-
preferences-for-care-and-caregiving.
    \7\ Internal Kaiser Permanente data.

Advancing health equity. Programs that provide hospital-level care in 
the home also advance health-care equity by enabling additional support 
for more-vulnerable patients. Understanding patients' home environments 
firsthand allows us to better assess patient needs related to social 
determinants of health and enables the care team to treat the whole 
person. When a patient needs additional support, such as healthy food 
or transportation assistance, Kaiser Permanente can integrate this 
critical information into their care plan and connect the patient to 
available community resources to meet these needs, thereby promoting 
better care and outcomes. The care team visiting a patient in the home 
can assess the patient's diet, medication regimen, safety risks, and 
other factors; and, where appropriate, they may intervene in those 
underlying contributors to the medical condition in ways that are not 
possible for facility-based patients. These valuable insights into the 
patient's home environment and our enhanced ability to provide extra 
support for their recovery would not be possible with a traditional 
---------------------------------------------------------------------------
hospitalization.

Investments in advanced care at home. Kaiser Permanente has long been 
an industry leader in developing and implementing home-based care 
models, and we believe that this approach will continue to grow in 
importance. For years we have provided traditional post-acute hospital 
care, home health care, hospice services, and home therapies using 
intravenous medications. Today's technologies now facilitate more 
advanced, real-time monitoring that is scalable and cost effective. The 
regulatory flexibilities issued in response to the pandemic have 
allowed additional practitioners to extend the reach of traditional, 
hospital-based care teams. The future holds tremendous opportunity to 
provide seamless, high-quality, patient-
centered care outside of the four walls of a hospital. Programs that 
safely bring acute care into the home environment are most likely to be 
successful in the context of an integrated care system that manages the 
continuum of care, inclusive of traditional inpatient and outpatient 
services. Kaiser Permanente will continue to leverage our clinical 
expertise in developing and improving these care delivery models for 
our patients and communities and to share our insights for the benefit 
of the health-care system at-large.

Policy investment in home-based care innovation. The COVID-19 pandemic 
has accelerated the revolution in virtual health care, and these 
advancements have been hard-won. In response to the pandemic, the 
Department of Health and Human Services and the Centers for Medicare 
and Medicaid Services implemented key policy waivers--Hospital Without 
Walls and Acute Hospital Care at Home--that enabled providers such as 
Kaiser Permanente to deliver patient-centered, high-quality acute care 
seamlessly and safely in patients' homes. Currently, these waivers are 
set to expire at the end of the public health emergency.

We believe that the time is now to make the investments that those 
waivers have enabled a permanent part of health-care delivery in the 
United States. We look forward to working with Congress, the Department 
of Health and Human Services, and the Centers for Medicare and Medicaid 
Services, including the Center for Medicare and Medicaid Innovation, to 
accelerate the realization of the future of health-care delivery and 
develop a permanent hospital-at-home model for Medicare and Medicaid 
beneficiaries.

We thank you and the committee for your engagement on these critically 
important issues affecting the future of our health care delivery 
system. We would value the opportunity to provide additional 
information to you and your staff. Please do not hesitate to contact 
Laird Burnett in our Washington, DC office by calling (202) 236-7883, 
or to contact either of us.

Very respectfully,

Anthony A. Barrueta                 Stephen Parodi, M.D.
Senior Vice President               Executive Vice President
Government Relations                External Affairs
Kaiser Foundation Health Plan, Inc. The Permanente Federation
Kaiser Foundation Hospitals

                                 ______
                                 
                       Medically Home Group, Inc.

                          133 Brookline Avenue

                            Boston, MA 02215

Chairman Wyden, Ranking Member Crapo, and Members of the Committee, 
thank you for allowing Medically Home the opportunity to submit a 
statement for the record on COVID-19 health-care flexibilities, 
perspectives, experiences, and lessons learned. Particularly, our 
statement will address Hospital Without Walls and Acute Hospital Care 
at Home waivers and their impact on driving patient centered care 
during the COVID-19 public health emergency (PHE).

Medically Home is a Boston-based company that enables hospitals and 
health systems to safely care for acutely ill patients in the comfort 
and safety of their own homes. Many patients benefit from this model of 
care, also referred to as ``Hospital at Home,'' including cancer 
patients, COVID-19 patients, transplant patients, and patients with the 
exacerbation of chronic illnesses that plague millions of Americans 
(e.g., COPD, heart failure, pneumonia, cellulitis, and many other 
conditions acute enough to require inpatient level care and safe enough 
to be provided at home).

Leading medical providers including Mayo Clinic and Kaiser Permanente 
have relied on Medically Home to provide a platform to successfully 
implement Hospital at Home programs that improve patients' health, 
well-being, and experience, while reducing costs at the same time. 
Medically Home's platform achieves these goals by providing clinical 
and technological support to hospitals, and by coordinating the 
delivery of medically appropriate and necessary equipment, medication, 
and supplies to patients' homes on behalf of its hospital customers. 
Our hospital partners, currently operating in 7 States, are using their 
clinicians to provide care to their patients and receive reimbursement 
from public and private payers. Given our unique experience working 
with hospitals/providers to safely shift advanced medical care to the 
home setting before and during the COVID-19 PHE, we believe we can 
provide valuable input on the need to extend the telehealth, Hospital 
Without Walls, and Acute Hospital Care at Home flexibilities on behalf 
of patients across the country.

Unprecedented collaborations driven by COVID-19 and the opportunity to 
expand hospital inpatient care in the home are important to note--
specifically Mayo Clinic and Kaiser Permanente announced last week 
their partnership to enable more patients to receive acute care and 
recovery services in the comfort, convenience, and safety of their 
homes through their investment in, and partnership with, Medically 
Home. Their collective goal is prioritizing the democratization of the 
finest level of care by providing real time access to Hospital at Home 
to rural and underserved communities, including Medicaid beneficiaries. 
Today, Mayo Clinic, using Medically Home's platform is already 
providing patient care in rural Wisconsin, with patients being referred 
by multiple hospitals there, including a critical access hospital.

Perspectives: Background on Hospital at Home

Caring for acutely ill patients in their homes is not a new concept and 
has existed for decades. However, the PHE has heightened and reaffirmed 
the necessity for acute level services in the home. The telehealth, 
Hospital Without Walls, and Acute Hospital Care at Home flexibilities 
alleviated hospital overcrowding and, hence, mitigated the spread of 
COVID-19.

With over 65 clinical trials published on Hospital at Home models, 
previous research on Hospital at Home has indicated that patients who 
received hospital care in the home had improved outcomes including 
reductions in lengths of stay (LOS), readmissions, and mortality, as 
well as increased patient satisfaction.\1\ Studies have also shown that 
providing hospital services in the home has resulted in cost savings 
and lower utilization. More specifically, they found the average cost 
for Hospital at Home care was $5,081 compared to the average $7,480 for 
acute hospital care.\2\
---------------------------------------------------------------------------
    \1\ https://www.johnshopkinssolutions.com/solution/hospital-at-
home/; https://www.common
wealthfund.org/publications/newsletter-article/hospital-home-programs-
improve-outcomes-lower-costs-face-resistance.
    \2\ Ibid.

Prior to the PHE, Hospital at Home had not been widely adopted due to 
current regulatory barriers that limit Medicare reimbursement, and 
therefore, discourage investment in the program. Specifically, the 
interpretation of Section 482.23 of the Medicare Condition of 
Participation for Nursing Services, which requires 24-hour nursing 
services to be provided in person.

 Experiences: Hospital Without Walls and Acute Hospital Care at Home 
                    Waiver

Upon the onset of the COVID-19 pandemic, several leading health systems 
took the initiative to implement Hospital at Home models to address the 
emerging needs of their patients and communities.\3\ CMS announced 
Hospital Without Walls to enable hospitals to provide inpatient 
services outside of traditional inpatient settings, including the 
patient's home. However, the interpretation of Section 482.23 of the 
Medicare Condition of Participation for Nursing Services remained a 
barrier.
---------------------------------------------------------------------------
    \3\ See, e.g., At-Home Care Designed for COVID Likely Here to Stay 
at Cleveland Hospital, available at, https://khn.org/news/at-home-care-
designed-for-covid-likely-here-to-stay-at-cleveland-hospital/; Mayo 
Clinic to Launch National Hospital-at-Home Model, available at, https:/
/l.e.crainalerts.com/rts/go2.aspx?h=686177&tp=i-1NGB-E0-7AV-HEuj8-1n-
1efb-1c-HEsTa-l4mTp
LeEm0-dJjLK; Pandemic Forced Insurers to Pay for In-Home Treatments. 
Will They Now Disappear?, available at, https://
www.leavenworthtimes.com/zz/news/20200616/pandemic-forced-insurers-to-
pay-for-in-home-treatments-will-they-now-disappear.

We applaud HHS for subsequently waiving this requirement via the Acute 
Hospital Care at Home waiver, and we request Congress and HHS to 
consider permanently extending this waiver to allow the 24-hour nursing 
requirement to be fulfilled virtually. According to CMS data,\4\ since 
announced in December 2020, the number of approved waivers has 
increased to 129 hospitals, 56 hospital systems, in 30 states.
---------------------------------------------------------------------------
    \4\ https://qualitynet.cms.gov/acute-hospital-care-at-home/
resources.

Due to this waiver being specific to the COVID-19 PHE and the upfront 
investment (cost, time, etc.) required to operate a Hospital at Home 
program, we believe participation will likely level off in the future 
if there is no long-term extension of the waiver (or worse, without CMS 
participation, some of these hospitals may stop offering the program 
altogether). As well, those currently operating programs will lose 
their investment and no longer receive Medicare payment for hospital 
inpatient care provided in the home.

 Lessons Learned: Regulatory Barriers Continue Outside of Current 
                    Waivers

After the PHE ends, the home will no longer be a permissible 
originating site for telemedicine and telehealth services, as well as 
for acute level of care services. Extending the Hospital Without Walls 
and telehealth flexibilities to allow the home to be a permissible 
originating site for these services is critical to reduce stress on the 
system, allow providers to determine the best and safest setting for 
their patients to receive care, and improve access for patients in 
rural and underserved communities.

We believe these regulatory flexibilities should be made permanent 
beyond the PHE and will be an effective foundation for establishing 
Medicare reimbursement that is specific to Hospital at Home services. 
We applaud HHS for providing these flexibilities to ensure hospital 
services in the home during the PHE, and we encourage Congress and HHS 
to consider extending these flexibilities as a new model of care that 
prioritizes patient safety, patient choice, and patient care needs 
while providing access to those who need it most.

Recommendations: Future of Patient Centered Care Post-PHE

Beyond the PHE, the United States health system should move towards a 
more resilient health-care delivery future where patients are empowered 
to choose their homes as a location for their care because we now have 
the technical and logistical capabilities to make safe and cost-
effective high quality inpatient care in the home a reality nationwide. 
Moreover, equipping patients and hospitals with the flexibility to 
determine the best and safest setting to receive care has been and will 
continue to be critical for access to care and resiliency as hospitals 
address the variations in patient demands, facility capacity, and 
staffing following the PHE.

Maintaining the current waivers and flexibilities beyond the PHE will 
be critical to optimize all efforts by our health-care systems to meet 
the changing needs of their communities. The COVID-19 PHE has changed 
the landscape of health-care delivery. The industry has discussed 
innovations in telehealth and health-care delivery outside of 
traditional care settings for some time, and the PHE has been a 
catalyst for the industry's implementation of these new care delivery 
methods (after all, Hospital at Home is not a new concept in health 
care and has been practiced by some systems for the last 20 years). 
These flexibilities have proven to be effective methods for care 
delivery during the PHE and we are advocating for the extension of 
these regulatory flexibilities to allow the model to fully scale. 
Indeed, these tools make our health-care system more resilient and 
accessible, enabling it to meet the operational and financial 
challenges presented by the pandemic and other potential health 
emergencies.

Extending these waivers is an important step towards advancing the 
future of health-care delivery. Hospital at Home can offer a future 
where patients and their providers can determine the most appropriate 
care settings and provide population-specific targeted approaches to 
care delivery. In 2017, the Physician-Focused Payment Model Technical 
Advisory Committee (PTAC) recommended two Hospital at Home proposals to 
the HHS Secretary for implementation: Mt. Sinai's Hospital at Home Plus 
Model (HaH-Plus) and Marshfield Clinic's the Home Hospitalization: An 
Alternative Payment Model for Delivering Care in the Home (HH-APM). 
Former Secretary Azar had expressed interest in testing home-based, 
hospital-level of care models and agreed with PTAC that these models 
hold promise for testing. To date neither model has been implemented. 
Medically Home and our partners are interested in developing similarly 
proposed reimbursement pathways for Hospital at Home.

Conclusion

Due to the regulatory barriers outlined above, which will return post-
PHE, hospitals have been and/or will again be wary about and 
disincentivized from implementing or scaling hospital at home. This 
includes the access to care for underserved communities, and the 
innovations and superior financial, clinical, and satisfaction outcomes 
of providing acute level care in the home that Hospital at Home 
provides. Therefore, we request Congress and HHS to consider a 
permanent extension of the telehealth, Hospital Without Walls, and 
Acute Hospital Care at Home waivers beyond the PHE to mitigate the 
residual impacts of COVID-19 on public health and encourage broader 
adoption of providing patient centered health-care services in the 
home.

We again thank you for the opportunity to submit a statement for the 
record to the Committee, on behalf of our hospital customers and their 
patients across the country, we look forward to continuing to work with 
Congress and HHS to ensure that access and quality care are available 
to citizens during and beyond the PHE, as well as to further provide 
groundwork for greater innovations in health-care delivery for the 
future.

                                 ______
                                 
                      Moving Health Home Coalition

                           1100 H Street, NW

                          Washington, DC 20005

                     https://movinghealthhome.org/

                              June 2, 2021

The Honorable Ron Wyden
Chair
U.S. Senate
Committee on Finance
Washington, DC 20515

The Honorable Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
Washington, DC 20515

RE: Moving Health Home Testimony for Senate Finance Committee Hearing 
on ``COVID-19 Health Care Flexibilities: Perspectives, Experiences, and 
Lessons Learned''

On behalf of Moving Health Home (MHH), we appreciate your thoughtful 
consideration of the COVID-19 flexibilities that allow clinical care to 
be provided in the home during the Committee's hearing entitled, 
``COVID-19 Health Care Flexibilities: Perspectives, Experiences, and 
Lessons Learned'' held on Wednesday, May 19, 2021. MHH is a coalition 
of pioneering health-care organizations with a bold vision to make the 
home a site of clinical service. We are thankful for the opportunity to 
submit testimony outlining the need for a temporary extension of the 
Hospitals Without Walls (HWW) flexibilities to collect additional data 
and lessons learned. However, a comprehensive Hospital at Home model is 
needed to fully leverage the promise of home as a clinical site for 
care.

We ask that Congress temporarily extend the HWW program for an 
additional two years while simultaneously authorizing a permanent model 
that allows hospitals to deliver inpatient hospital services to 
Medicare beneficiaries at home.

The value of home care was demonstrated during the COVID-19 pandemic, 
as continued to be seen as hospitals leverage temporary waivers to 
offer a greater range of inpatient services in alternate sites of care, 
including the home. To date, more than 100 hospitals have leveraged 
temporary authority to deliver care outside their four walls; 132 
hospitals and 58 health systems across 31 states are delivering care to 
patients in their homes through the Acute Hospital Care at Home (AHCAM) 
waiver.\1\, \2\ Hospital at Home programs have been studied 
for decades both in the United States and internationally. The research 
overwhelmingly demonstrates that Hospital at Home programs are at least 
as safe as traditional in-patient care, improve clinical outcomes and 
patient satisfaction, and reduce the total cost of care.
---------------------------------------------------------------------------
    \1\ https://qualitynet.cms.gov/acute-hospital-care-at-home/
resources.
    \2\ https://www.gao.gov/assets/gao-21-575t.pdf.
---------------------------------------------------------------------------

 Background: Hospitals Without Walls Flexibilities and Acute Hospital 
                    Care at Home Waiver

In March 2020, the Centers for Medicare and Medicaid Services (CMS) 
introduced the Hospitals Without Walls (HWW) initiative, which provided 
broad regulatory flexibility for hospitals to provide services in 
locations beyond their existing walls. This temporary, blanket waiver 
authority is focused on reducing hospital capacity to better address 
COVID-19.

Later that year in November, CMS announced the Acute Hospital Care at 
Home (AHCAH) program that would cover hospital-level care at home for 
Medicare fee-for-service (FFS) beneficiaries at approved sites. This 
temporary, individual waiver requires that prospective health systems 
apply to the program and are subject to approval by CMS based on their 
ability to meet certain requirements. The HWW initiative built the 
foundation for the AHCAH program, operating sequentially.

Comprehensive Hospital at Home Model Is Needed

With the help of nearly 25 leading health-care organizations and 
experts in the field, MHH is advocating for legislation that would 
permanently implement a Medicare Hospital at Home program, which is 
currently in draft form. MHH's proposal is built on decades of research 
and would allow for sustainable, long-term adoption of inpatient 
services at home designed to improve patient experience and outcomes, 
reduce federal spending, and increase access and patient choice.

That said, MHH asks that Congress temporarily extend the HWW program 
for an additional 2 years while simultaneously authorizing a permanent 
model that allows hospitals to deliver inpatient hospital services to 
Medicare beneficiaries at home. While MHH is supportive of a two-year 
extension of the HWW flexibilities, including the AHCAH program, we 
believe it is not the correct long-term solution for broad adoption of 
inpatient services at home for the following reasons:

    -  We Should Not Build Programs Based on Waivers--Temporary waivers 
are a bridge to enable care in the home to continue for a time-limited 
period post-pandemic, but do not fully leverage the promise of home-
based care. They continue to rely on fee-for-service payment, while our 
goal would be to integrate a value-based mechanism into the program.

    -  Hospital at Home Models Reduce Costs--Home care models that 
combine inpatient hospital services with post-acute care post-discharge 
from the home can result in 44 percent lower total cost of care.\3\ In 
general, Hospital at Home programs have realized savings of 30 percent 
or more per admission, while maintaining equivalent or better 
outcomes.\4\
---------------------------------------------------------------------------
    \3\ https://www.carecentrix.com/news/avalere-report-finds-
carecentrix-model-of-post-acute-care-lowers-total-cost-of-care-by-
improving-outcomes-and-reducing-readmissions-ed-visits.
    \4\ https://pubmed.ncbi.nlm.nih.gov/16330791/.

    -  Hospital at Home Models Improve Quality--Quality results for 
care in the home are comparable to or better than those realized for 
facility-based care. Published data of Hospital at Home programs from 
across the U.S. demonstrate reduction in average length of stay by one-
third, readmissions by 24 percent, mortality by 20 percent, 
complications (e.g., delirium and falls), and emergency department 
visits.\5\, \6\, \7\, \8\
---------------------------------------------------------------------------
    \5\ https://www.commonwealthfund.org/publications/newsletter-
article/hospital-home-program-new-mexico-improves-care-quality-and-
patient.
    \6\ https://www.acpjournals.org/doi/10.7326/M19-0600.
    \7\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6143103/.
    \8\ https://pubmed.ncbi.nlm.nih.gov/16330791/.

    -  Consumers Prefer to Receive Care in the Home--The pandemic has 
taught us that home-based care is preferred by many patients. According 
to a recent study, 61 percent of seniors would like to receive health-
care services in their home.\9\ Long before COVID-19, evidence pointed 
to home as a preferred site of care, including a study that found three 
in four adults 50 years and older would prefer to age in their homes 
and communities.\10\
---------------------------------------------------------------------------
    \9\ https://www.signifyhealth.com/blog/for-older-americans-the-
home-must-become-a-choice-for-patients.
    \10\ https://www.aarp.org/research/topics/community/info-2018/2018-
home-community-preference.html.

    -  Pandemic Experience Has Further Demonstrated it Is Safe to 
Provide Care in the Home--The pandemic caused an explosion of home-
based care, in part due to regulatory flexibilities such as the AHCAH 
waiver. Early data comparing pre-pandemic to now show that utilization 
of home- based services, such as home visits, has increased sevenfold 
in some cases.\11\ These experiences demonstrate that care in the home 
is possible and safe.
---------------------------------------------------------------------------
    \11\ https://academic.oup.com/gerontologist/article/61/1/78/
5921231.

Building on the longstanding evidence base, the success of delivering 
more care at home during the pandemic, and patient preference for home-
based care, Congress has an opportunity to act by temporarily extending 
the HWW program for an additional two years while simultaneously 
authorizing a permanent model that allows hospitals to deliver 
---------------------------------------------------------------------------
inpatient hospital to Medicare beneficiaries at home.

Thank you again for holding this important hearing and for your 
thoughtful deliberation on how your committee can enable Americans the 
freedom to choose home as a clinical site of care. We look forward to 
working with you on this critical effort. Please contact Jeremiah McCoy 
at [email protected] with any questions.

Sincerely,

Krista Drobac
Founder

                                 ______
                                 
               National Association of Chain Drug Stores

                      1776 Wilson Blvd., Suite 200

                          Arlington, VA 22209

                              703-549-3001

                             www.nacds.org

           Statement of Steven C. Anderson, FASAE, CAE, IOM, 
                 President and Chief Executive Officer

Introduction

The National Association of Chain Drug Stores (NACDS) appreciates the 
opportunity to submit a statement for the record for the Senate Finance 
Committee's hearing, ``COVID-19 Health Care Flexibilities: 
Perspectives, Experiences, and Lessons Learned.'' NACDS represents 
nearly 40,000 pharmacies (traditional drug stores, supermarkets and 
mass merchants with four or more pharmacies) who employ nearly 3 
million individuals, including pharmacists and pharmacy technicians, 
among others.

NACDS commends the Committee's work to build better health by 
considering flexibilities granted during the Public Health Emergency. 
The nation called on pharmacies to deliver COVID-19 testing, 
vaccination, and other critical preventive care services to communities 
during the pandemic. Pharmacies seamlessly rose to the challenge, in 
large part due to more than a decade of pandemic preparedness and 
collaborative planning. Importantly, the COVID-19 flexibilities granted 
to pharmacies were instrumental in driving better health and fostering 
equity across communities. In reviewing lessons learned with an eye 
toward the future, these flexibilities should be made permanent to 
foster sustained and equitable access to pharmacy care.

 I. A Decade of Pharmacy Preparedness Significantly Strengthened the 
                    Nation's COVID Response

Pharmacies have spent the last decade building upon lessons learned 
from the 2009 H1N1 pandemic, including piloting pharmacy vaccination 
strategies. These planning efforts across industry and government paved 
the way for pharmacy's central position in the nation's COVID-19 
response.

Consider these highlights demonstrating how this preparedness 
translated into results for communities across America:

      Vaccination: Building on years of pandemic planning and 
exercises, the Federal Retail Pharmacy Program (FRPP) was established 
to leverage pharmacy's strengths for public benefit:
          Americans can conveniently get COVID-19 vaccines 
at 40,000 pharmacies nationally thanks to the FRPP, leveraging 21 
national pharmacy chains and independent pharmacy networks.\1\
---------------------------------------------------------------------------
    \1\ https://www.cdc.gov/vaccines/covid-19/retail-pharmacy-program/
index.html.
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          More than 40% of these sites are already in zip 
codes with high social vulnerability--a Centers for Disease Control and 
Prevention (CDC) index identifying communities needing more care.\2\
---------------------------------------------------------------------------
    \2\ https://www.whitehouse.gov/briefing-room/statements-releases/
2021/03/29/fact-sheet-president-biden-announces-90-of-the-adult-u-s-
population-will-be-eligible-for-vaccination-and-90-will-have-a-
vaccination-site-within-5-miles-of-home-by-april-19/.
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          In March, a fraction of these pharmacies provided 
over 5 million vaccinations in just 4 days.\3\ And, recent data show 
that of all FRPP vaccination doses 46% have been administered to people 
of color.\4\
---------------------------------------------------------------------------
    \3\ https://www.politico.com/news/2021/03/29/covid-vaccine-sites-
478233.
    \4\ President Biden Meets Virtually with a Bipartisan Group of 
Governors. Remarks by Dr. Nunez-Smith. May 11, 2021. https://
www.youtube.com/watch?v=e-8oTbbPA94.

      Testing: Pharmacies ramped up across states establishing more 
than 6,000 live testing sites that processed nearly 10 million samples 
under a public-private partnership with the Department of Health and 
Human Services (HHS).\5\
---------------------------------------------------------------------------
    \5\ By the Numbers--Coronavirus Pandemic Whole-of-America Response. 
March 8, 2021. https://content.govdelivery.com/attachments/USDHSFEMA/
2021/03/09/file_attachments/171
7220/By%20the%20Numbers.COVID.FINAL.Mar.%208.2021.pdf.
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          Nearly three-quarters of these sites serve areas 
with moderate to high-social vulnerability.\6\
---------------------------------------------------------------------------
    \6\ https://www.hhs.gov/about/news/2021/01/07/hhs-continues-
community-based-testing-sites-covid-19.html.

      Everyday Care: Beyond providing COVID-19 vaccinations and 
testing, pharmacies kept their doors open throughout the pandemic, 
offering needed preventive care, dispensing critical medications, 
administering routine and catch-up vaccinations to adults and children, 
and providing patients with education and referrals.

 II. Critical Flexibilities Paved Way for Expanded Access to COVID-19 
                    Care at Pharmacies

The significant contributions made by pharmacies in supporting their 
communities throughout the COVID-19 pandemic were largely made possible 
by flexibilities granted during the Public Health Emergency. 
Specifically, federal actions taken under the PREP Act \7\, 
\8\, \9\ leveraged pharmacies to provide enhanced public 
access to COVID-19 testing, COVID-19 vaccines, and routine and catchup 
vaccines for those 3-18 years old. Such actions, along with Congress 
requiring health insurers to cover COVID-19 testing and vaccination 
costs without out-of-pocket expenses,\10\ were monumental. 
Collectively, these actions unleashed pharmacy teams from onerous and 
unnecessary federal and state barriers that have historically 
prohibited them from providing such services to populations more 
broadly. These actions also removed cost barriers for patients.
---------------------------------------------------------------------------
    \7\ U.S. Department of Health and Human Services, August 2020, 
available at HHS Expands Access to Childhood Vaccines during COVID-19 
Pandemic.
    \8\ U.S. Department of Health and Human Services, October 2020, 
available at Advisory Opinion 20-03 on the Public Readiness and 
Emergency Preparedness Act and the Secretary's Declaration under the 
Act.
    \9\ U.S. Department of Health and Human Services. (December 2020). 
Fourth Amendment to the Declaration Under the Public Readiness and 
Emergency Preparedness Act for Medical Countermeasures Against COVID-19 
and Republication of the Declaration, available at https://www.phe.gov/
Preparedness/legal/prepact/Pages/4-PREP-Act.aspx.
    \10\ https://www.healthaffairs.org/do/10.1377/hblog20200326.765600/
full/.

Briefly, a high-level overview of flexibilities that were instrumental 
---------------------------------------------------------------------------
for expanding access to care at pharmacies include:

      COVID-19 Testing at Community Pharmacies: Critical actions taken 
by Congress, HHS, and the Centers for Medicare and Medicaid Services 
(CMS) abolished barriers in a stepwise manner to accelerate 
availability of pharmacy-based COVID-19 testing locations. Effectively, 
this helped spearhead efforts to break down barriers to pharmacy-based 
testing across many states and expand community access to the clinical 
expertise of pharmacies.
          Through multiple actions under the PREP Act, HHS 
authorized pharmacists to order and administer COVID-19 tests, and to 
leverage pharmacy technicians for COVID-19 testing.\11\, 
\12\ HHS further clarified that federal guidance under the PREP Act 
preempts any state or local restrictions.\13\ Additionally, CMS 
released guidance supporting pharmacy enrollment in Medicare as CLIA 
labs \14\ and limiting cost sharing for COVID-19 testing.
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    \11\ Guidance for Licensed Pharmacists, COVID-19 Testing, and 
Immunity under the PREP Act. (April 2020). https://www.phe.gov/
Preparedness/legal/prepact/Documents/pharmacist-guidance-COVID19-PREP-
Act.pdf.
    \12\ U.S. Department of Health and Human Services Office of the 
Assistant Secretary for Health. October 20, 2020. Guidance for PREP Act 
Coverage for Qualified Pharmacy Technicians and State-Authorized 
Pharmacy Interns for Childhood Vaccines, COVID-19 Vaccines, and COVID-
19 Testing. https://www.hhs.gov/sites/default/files/prep-act-
guidance.pdf.
    \13\ https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-
documents/advisory-opinion-20-02-hhs-ogc-prep-act.pdf.
    \14\ See Section 6003 of the Families First Coronavirus Response 
Act and Section 3713 of the CARES Act.

      COVID-19 Vaccinations and Routine Childhood Vaccinations at 
Pharmacies: Similar to testing, the federal government took critical 
actions to clear the pathway for vaccinations at pharmacies throughout 
the pandemic. Doing so removed barriers that otherwise would have 
greatly limited the pharmacy team's ability to serve the public.
          In addition to expanding access to COVID-19 
vaccination, HHS aimed to improve childhood vaccination rates--hindered 
by stay-at-home orders and a decline in provider office visits. This 
was accomplished by expanding the ability for the pharmacy team 
(pharmacists, pharmacy interns, and pharmacy technicians) to provide 
immunizations to children more comprehensively across states.\15\ This 
action was further clarified and reaffirmed by the 
agency.\16\, \17\
---------------------------------------------------------------------------
    \15\ U.S. Department of Health and Human Services. (August 2020). 
HHS Expands Access to Childhood Vaccines during COVID-19 Pandemic.
    \16\ U.S. Department of Health and Human Services. (October 2020). 
Advisory Opinion 20-03 on the Public Readiness and Emergency 
Preparedness Act and the Secretary's Declaration under the Act.
    \17\ U.S. Department of Health and Human Services. (December 2020). 
Fourth Amendment to the Declaration Under the Public Readiness and 
Emergency Preparedness Act for Medical Countermeasures Against COVID-19 
and Republication of the Declaration. https://www.phe.gov/Preparedness/
legal/prepact/Pages/4-PREP-Act.aspx.
---------------------------------------------------------------------------
          Specifically, these actions authorized:
              Pharmacists to order and administer, and appropriate 
pharmacy staff to administer, Advisory Committee on Immunization 
Practices (ACIP)-recommended childhood vaccines for persons 3-18 years 
old; and Food and Drug Administration (FDA)-authorized or FDA-licensed 
COVID-19 vaccinations to persons ages 3 and older.\18\
---------------------------------------------------------------------------
    \18\ https://www.hhs.gov/sites/default/files/third-amendment-
declaration.pdf; https://www.
hhs.gov/sites/default/files/licensed-pharmacists-and-pharmacy-interns-
regarding-covid-19-vaccines-immunity.pdf; and https://www.hhs.gov/
sites/default/files/prep-act-guidance.pdf.

These government actions supporting pharmacy-based immunization and 
COVID-19 testing have been paramount in helping smooth the complex and 
erratic nature of state-by-state rules and regulations. The existing 
patchwork outside of temporary flexibilities can create significant 
patient access barriers, especially in states that have yet to 
modernize their statutory limits. While not all barriers have been 
abolished, pharmacies have leveraged these flexibilities effectively to 
operationalize broader delivery of care services.

 III. Recommended Permanent Changes to Drive Health and Foster Equity 
                    Beyond the COVID-19 Pandemic

Communities have long relied on pharmacies to deliver quality care to 
all populations, including the high-risk and socially 
vulnerable.\19\, \20\ Through the COVID-19 response, the 
nation has built an infrastructure that allows Americans to benefit 
from quality, accessible, and equitable pharmacy care services. As we 
shift to COVID-19 becoming endemic and a return toward a focus on 
routine care services, communities ought to maintain their access to 
pharmacy care. And, as we look ahead to the next pandemic, tremendous 
opportunities exist to transform these flexibilities from temporary to 
permanent, preventing duplicative efforts in the future. NACDS urges 
Congress to retain and build on the existing flexibilities to implement 
permanent pharmacy authority and payment mechanisms. Doing so would 
help Americans continue reaping the benefits of care services at 
pharmacies they know and trust into the future.
---------------------------------------------------------------------------
    \19\ Gaskins RE. Innovating Medicaid: The North Carolina 
Experience, NC Med J. 2017, available at https://www.ncbi.nlm.nih.gov/
pubmed/28115558.
    \20\ Berenbrok LA, Gabriel N, Coley KC, Hernandez I., Evaluation of 
Frequency of Encounters With Primary Care Physicians vs Visits to 
Community Pharmacies Among Medicare Beneficiaries, JAMA Netw Open. 
2020;3(7):e209132, available at doi:10.1001/jamanetworkopen.
2020.9132.
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Conclusion

As we look beyond the COVID-19 pandemic, pharmacies will continue to be 
important care destinations for patients. Health equity will rightfully 
remain a driving force in health care moving forward with care 
destinations, like pharmacies, meeting patients where they are. 
Further, mental health and substance abuse likely will emerge as 
lasting behavioral health impacts of the pandemic. We raise these 
forward leaning issues to say that pharmacies have experience providing 
destigmatizing care and routinely provide for patients essential 
screenings, counseling, treatment, and linkage to care. Oftentimes, 
pharmacies are the entry point for patients into the health-care 
system, further underscoring their value on a patient's health-care 
team. As the COVID-19 response shifts into recovery, pharmacies 
continue to serve their communities on the frontlines to meet their 
evolving health-care needs.

NACDS thanks the committee for the opportunity to offer our support for 
your tremendous work. We implore you to build on these lessons learned 
by transforming temporary flexibilities into permanent pharmacy 
authority and payment mechanisms to support the health and wellness of 
Americans beyond the pandemic. We welcome the opportunity to discuss 
these issues further. Please reach out to NACDS' Chris Krese, Senior 
Vice President of Congressional Relations and Communications at 
[email protected] or 703-837-4650.

                                 ______
                                 
                      National Indian Health Board

                       910 Pennsylvania Ave., SE

                          Washington, DC 20003

Chairman Wyden, Ranking Member Crapo, and Members of the Committee, 
thank you for holding this critical hearing ``COVID-19 Health Care 
Flexibilities: Perspectives, Experiences, and Lessons Learned.'' On 
behalf of the National Indian Health Board (NIHB) and the 574 
federally-recognized sovereign American Indian and Alaska Native (AI/
AN) Tribal Nations we serve, NIHB submits this testimony for the 
record.

 Background--COVID-19 Flexibilities and Impact in Indian Country

As of June 1, 2021, the Indian Health Service (IHS) reported 197,459 
positive COVID-19 cases, with a cumulative percent positive rate of 
8.8% across all 12 IHS Areas.\1\ However, IHS numbers are highly likely 
to be underrepresented because case reporting by Tribally-operated 
health programs, which constitute roughly two-thirds of the Indian 
health system, are voluntary. According to data analysis by APM 
Research Lab, AI/ANs are experiencing the second highest aggregated 
COVID-19 death rate at 51.3 deaths per 100,000. On March 12, 2021, the 
CDC reported that AI/ANs were 3.7 times more likely than non-Hispanic 
white people to be hospitalized and 2.4 times more likely to die from 
COVID-19 infection. Reporting by state health departments has further 
highlighted disparities among AI/ANs
---------------------------------------------------------------------------
    \1\ Indian Health Service. COVID-19 Cases by IHS Area. https://
www.ihs.gov/coronavirus/.

      According to the Centers for Disease Control and Prevention 
(CDC), AI/AN People are 1.7 times (70%) more likely to be diagnosed 
with COVID-19 when compared to non-Hispanic white people.
      According to the CDC, AI/ANs are 3.7 times (370%) more likely to 
require hospitalization when compared to non-Hispanic white people.
      According to the CDC, AI/ANs are 2.4 times (240%) more likely to 
die from COVID-19-related infection when compared to non-Hispanic white 
people.
      There have been 6,206 AI/AN deaths related to COVID-19 
complications since the pandemic was declared. Nearly 60% of these 
deaths are from New Mexico, Arizona, and Oklahoma.\2\
---------------------------------------------------------------------------
    \2\ National Indian Health Board. May 26, 2021. CDC Provisional 
Death Report, 6,533 Deaths, an increase of 51 weekly Deaths. https://
public.tableau.com/app/profile/nihb.edward.fox/viz/
May262021CDCProvisionalDeathReport6533Deathsanincreaseof51weeklyDeaths/
May262021CDC
ProvisionalDeathReport6533Deathsanincreaseof51weeklyDeaths_.
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      In Alaska, 34.8% of the total state's deaths are reported to be 
AI/ANs.\3\
---------------------------------------------------------------------------
    \3\ National Indian Health Board. May 26, 2021. CDC Provisional 
Death Report, 6,533 Deaths, an increase of 51 weekly Deaths. https://
public.tableau.com/app/profile/nihb.edward.fox/viz/
May262021CDCProvisionalDeathReport6533Deathsanincreaseof51weeklyDeaths/
May262021CDC
ProvisionalDeathReport6533Deathsanincreaseof51weeklyDeaths_.
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      The disparity in COVID-19-related death rates is not evenly 
shared across all AI/AN age groups. Young AI/ANs are experiencing the 
most significant disparities. Among AI/ANs aged 20-29 years, 30-39 
years, and 40-49 years, the COVID-19-related mortality rates are 10.5, 
11.6, and 8.2 times, respectively, higher when compared to their white 
counterparts.\4\
---------------------------------------------------------------------------
    \4\ Arrazola J, Masiello MM, Joshi S, et al. COVID-19 Mortality 
Among American Indian and Alaska Native Persons--14 States, January-
June 2020. MMWR Morb Mortal Wkly Rep 2020;69:1853-1856. DOI: http://
dx.doi.org/10.15585/mmwr.mm6949a3external icon.
---------------------------------------------------------------------------
      Across 23 states, the cumulative incidence rate of laboratory-
confirmed COVID-19 infections was 3.5 times (350%) higher among AI/ANs 
persons than non-
Hispanic white persons.\5\
---------------------------------------------------------------------------
    \5\ Hatcher SM, Agnew-Brune C, Anderson M, et al. COVID-19 Among 
American Indian and Alaska Native Persons--23 States, January 31-July 
3, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1166-1169. DOI: http://
dx.doi.org/10.15585/mmwr.mm6934e1.

Unfortunately, the adverse effects of COVID-19 in Indian Country extend 
beyond these sobering public health statistics. Collectively, the IHS, 
Tribal, and Urban health system (known as the I/T/U), has been 
chronicly underfunded since its inception, and has relied on third-
party revenue to stay afloat. Despite its underfunding, Indian Health 
Care Providers (IHCPs) have found innovative ways to provide quality 
care, even during the pandemic. The I/T/U system has taken full 
advantage of the flexibilities that CMS extended, allowing for leverage 
of new technologies; and recouping what would have otherwise been lost 
---------------------------------------------------------------------------
revenue, which is sorely needed.

One key flexibility is the ``Four Walls'' waiver that is extended 
through October 2021.This waiver, while not direcetly a result of the 
pandemic, has been crucial for the I/T/U system in dealing with COVID-
19 This extension allows I/T/U clinics to receive the Medicaid 100% 
Federal Matching Assistance Percentage (FMAP) for services provided to 
an AI/AN Medicaid Beneficiary at sites outside the ``for walls'' of a 
clinic. These external sites can include remote vaccination and testing 
sites that have been commonplace in the public health emergency and 
allow treatment in otherwise underserved communities. These ancillary 
sites for care have long been important to providing quality care 
throughout Indian Country. Still, once this extension expires, an 
essential source of revenue for the I/T/U system will be diminished.

Telehealth has proven to be an invaluable tool to provide quality care 
during the public health emergency, and the flexibilities for its usage 
and reimbursement have been crucial to its expanded adoption. According 
to IHS, since initiating telehealth expansion, the agency has 
experienced an 33-fold increase in telehealth visits.\6\ Additionally, 
the Government Accountability Office (GAO) released a report analyzing 
the federal response to COVID-19, showing IHS allocated $95 million of 
the $1.032 billion in total funding received under the CARES Act toward 
telehealth. While this adoption of telehealth as an alternative to in-
person care is useful, much of Indian Country faces structural 
challenges to leveraging this new technology. Due to a significant lack 
of broadband infrastructure, only 46.6% of houses on Tribal lands have 
access to fixed terrestrial broadband at standard speeds established by 
the Federal Communications Commission (FCC).\7\ Many of our Tribal 
citizens are unable to access necessary telehealth-based care from the 
safety of their homes.
---------------------------------------------------------------------------
    \6\ Todet, R.A.M. (2021, April 28). IHS expanded telehealth to 
provide care during COVID-19 pandemic. Indian Health Service Newsroom. 
https://www.ihs.gov/newsroom/ihs-blog/april2021
/ihs-expanded-telehealth-to-provide-care-during-covid-19-pandemic/.
    \7\ U.S. Department of the Interior. (2020). Expanding Broadband 
Access. Indian Affairs. https://www.bia.gov/service/infrastructure/
expanding-broadband-access. 

Our Tribal communities have endured a great many pandemics and 
tragedies in our history. Our people experience significant historical 
and intergenerational trauma resulting from genocide, forced relocation 
from our homelands, forced assimilation into western culture, and 
persecution of our Native cultures, customs, and languages. As a 
result, AI/ANs experience some of the highest rates of suicide, drug 
overdose, post-traumatic stress, and mental illness compared to all 
other races. While Indian Country remains resilient and committed to 
solutions, the COVID-19 emergency has reignited the historical trauma 
experienced at the hands of historical plagues such as smallpox and 
---------------------------------------------------------------------------
tuberculosis.

Congress reaffirmed the federal trust responsibility for health care 
under the permanent reauthorization of the Indian Health Care 
Improvement Act (IHCIA) when it declared that ``. . . it is the policy 
of this Nation, in fulfillment of its special trust responsibilities 
and legal obligations to Indians . . . to ensure the highest possible 
health status for Indians and urban Indians and to provide all 
resources to effect that policy.''

It is essential to remember that these obligations exist in perpetuity. 
As such, the federal government must ensure that Tribes are 
meaningfully and comprehensively included in any congressional review 
of COVID-19 flexibilities and support. While we appreciate the 
resources and flexibilities allocated for Indian Country thus far--
including the $1.032 billion appropriated to Indian Health Service 
(IHS) under the CARES Act, the $64 million under the Families First 
Coronavirus Response Act, the $1 billion under the Consolidated 
Appropriations Act of 2021, and the $6.094 billion under the American 
Rescue Plan--these one-time additional funding increases and temporary 
regulatory flexibilities are not sufficient to stem the tide of decades 
of underfunding and neglect.

Policy Recommendations

To ensure that the efficiencies in health-care delivery, put in place 
as a response to the public health emergency, are built upon and not 
lost, we urge the committee to pass the following policy priorities.

    1.  Amend the Social Security Act to ensure that all services 
provided through an Indian health-care program are eligible for 
reimbursement at the OMB all-inclusive rate.

In 2016, CMS issued a Dear State Health Official (SHO) letter 
explaining that only services rendered within the Four Walls of an IHS 
or Tribal (I/T) clinic are eligible for Medicaid reimbursement at the 
all-inclusive rate (100% FMAP). CMS's interpretation means that if a 
service is rendered outside the Four Walls of a clinic by an IHS or 
contracted provider, the provided health service is not eligible for 
the same reimbursement under Medicaid. It is common practice within the 
Indian health-care system to use an ancillary site (like a school) or 
send providers into the community to deliver health-care services. In 
the SHO letter, CMS offered a solution that requires two actions, one 
by the Indian health program and another by the State Medicaid Agency. 
If IHS or Tribal clinics want to receive the ``clinic'' rate for 
Medicaid services provided outside the four walls, the I/T facilities 
must first convert to Federally Qualified Health Centers (FQHC). The 
state also needs to file a State Plan Amendment (SPA) to grant the 
Tribal FQHCs authority to bill at the ``clinic'' rate. With CMS 
approval, the Indian health program can receive the encounter rate, and 
the state is automatically paid at the 100% FMAP--increasing 
reimbursement to the I/T clinics while reducing the state's 
contribution to Medicaid

This presents multiple issues--first, Indian health programs may not 
want to convert to FQHCs for reasons other than to receive the 
reimbursement, as the conversion itself is burdensome. Second, not all 
States have good working relationships with the Tribes, and if no 
relationship (or a poor one) exists, the state may not see the benefits 
of amending its Plan. (One advantage is that Medicaid services to AI/
ANs are reimbursed at 100 percent FMAP). Because this reimbursement 
depends on the state's action, it adds to the uncertainty for the 
Tribes, and in some ways, undermines the Tribes' status as sovereign 
governments.

This year CMS authorized an extension to its four walls grace period 
through October 31, 2021, to allow more I/T clinics to convert to 
Tribal FQHCs. One can expect that another extension will be requested 
given the CMS solution's onerous burden. The solution CMS proposed in 
its SHO letter and subsequent Frequently Asked Questions (FAQs) was 
only a band-aid. The agency's actions do not sufficiently address the 
reimbursement parity Tribes seek for delivering Medicaid services in a 
community-centered way. NIHB and other Tribal Organizations have 
advocated for a permanent fix to CMS's Four Walls issue for more than 
three years.

    2.  Expand the Medicaid 100% FMAP to Urban Indian Organizations.

The COVID-19 pandemic has created significant financial hardships for 
IHCPs. While I/T/U clinics receive 100% FMAP for services provided to 
AI/AN Medicaid beneficiaries, this FMAP does not permanently extend to 
Urban Indian Organizations (UIOs). In the American Rescue Plan, signed 
into law on March 11th, the 100% FMAP was expanded to UIOs for two 
years. While this temporary extension is crucial in providing 
additional federal dollars to UIOs to provide quality care, this FMAP 
increase must be made permanent to fulfill the Federal Government's 
trust responsibilities to AI/AN individuals.

    3.  Increase flexibility in Medicare Definition of Telemedicine 
Services.

COVID-19 has demonstrated the importance of telehealth to increase 
access to providers during the pandemic. But it has also demonstrated 
it can increase access to needed primary, specialty, and behavioral 
health services, particularly in rural areas. The telehealth 
flexibilities Medicare has made available during the public health 
emergency should be made permanent to the maximum extent possible. In 
addition, much of Indian Country is located in rural areas and lacks 
access to more advanced audio and video real-time communication 
methods. As a result, Medicare should allow telehealth to be provided 
through audio-only telephonic and two-way radio communication methods 
when necessary, and grant maximum reimbursement for services rendered 
through these modalities.

    4.  Expand access to telehealth in the Indian Health System through 
increased funding and technical fixes.

Limitations in the availability of AI/AN-specific COVID-19 data are 
contributing to the invisibility of the adverse impacts of the pandemic 
in Indian Country within the general public. Senior IHS officials, 
including Chief Medical Officer Dr. Michael Toedt, have stated publicly 
that existing deficiencies with the IHS health IT system are inhibiting 
the agency's ability to adequately conduct COVID-19 disease 
surveillance and reporting efforts.\8\ Lack of health IT infrastructure 
has also seriously hampered the ability of IHS and Tribal sites to 
transition to a telehealth-based care delivery system. While mainstream 
hospitals have been able to take advantage of new flexibilities under 
Medicare for the use of telehealth during the COVID-19 pandemic, IHS 
and Tribal facilities have not because of insufficient broadband 
deployment and health IT capabilities. The IHS Tribal Budget 
Formulation Working Group previously outlined the need for a roughly $3 
billion investment to fully equip the Indian health system with an 
interoperable and modern health IT system. It is critical that Congress 
provide meaningful investments in health IT technologies for the Indian 
health system to ensure accurate assessment of AI/AN COVID-19 health 
disparities and equip IHCPs with the tools to seamlessly provide 
telehealth-based health services.
---------------------------------------------------------------------------
    \8\ Toedt, R.A.M. (2021, May 21). Testimony from RADM Michael Toedt 
on Examining the COVID-19 Response in Native Communities: Native Health 
Systems One Year Later before Senate Committee on Indian Affairs. 
HHS.gov. https://www.hhs.gov/about/agencies/asl/testimony/2021/04/14/
examining-covid-19-response-native-communities-native-health-systems-
one-year-later.html.

---------------------------------------------------------------------------
    5.  Permanently Extend Waivers under Medicare for Use of Telehealth

CMS has temporarily waived Medicare restrictions on the use of 
telemedicine. Yet, for many Tribes that lack broadband and/or 
telehealth capacity and infrastructure, it is not financially feasible 
to purchase expensive telehealth equipment for a short-term authority. 
Making the telehealth waivers permanent would ensure that the 
telehealth delivery system remains a viable option for delivering 
essential medical, mental and behavioral health services in Indian 
Country, and helps close the gap in access to care.

Conclusion

The federal government's trust responsibility to provide quality and 
comprehensive health services for all AI/AN Peoples extends to every 
federal agency and department. As the only national Tribal organization 
dedicated exclusively to advocating for the fulfillment of the federal 
trust responsibility for health, NIHB is committed to ensuring the 
highest health status and outcomes for those affected with COVID-19 and 
all Indian Country. We continue to appreciate your dedication to Indian 
health priorities and remain committed to working with you to protect 
and preserve the mental, physical, behavioral, and spiritual health of 
Indian peoples in the future.

                                 ______
                                 
                                98point6

                           701 5th Ave, #2300

                           Seattle, WA 98104

                             (866) 657-7991

                       https://www.98point6.com/

U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510-6200

RE: Hearing held Wednesday, May 19, 2021, ``COVID-19 Health Care 
Flexibilities: Perspectives, Experiences, and Lessons Learned''

To Members of the Senate Finance Committee:

98point6 is pioneering a new approach to primary care. By pairing 
artificial intelligence (AI) and machine learning technology with 
board-certified physicians, our vision is to make primary care more 
accessible and affordable, leading to better health outcomes. 98point6 
believes in meeting patients where they are by offering private, modern 
communication-enabled diagnosis and treatment via a HIPAA-compliant 
mobile application to increase primary care utilization and enable 
earlier medical intervention with reduced costs of overall care. As 
Congress debates lessons learned from the COVID-19 pandemic, we believe 
there are two changes that should become long term policy improvements: 
(1) making telehealth benefits an ``excepted benefit'' under Employee 
Retirement Income Security Act (ERISA), which is consistent and in-line 
with a current Tri-Agency (Department of Labor (DOL), Department of 
Health and Human Services (HHS), and Department of Treasury) temporary 
relief; and (2) making permanent a waiver that allows a high deductible 
health plan (HDHP) to retain its status as an health savings account 
(HSA)-qualified HDHP--wherein participants may make contributions to a 
HSA--if telehealth coverage is provided before the deductible. These 
changes will allow for continuity of coverage and access to virtual 
care for many individuals.

During the COVID-19 medical demand surge, 98point6 clinic volume 
exceeded 200% growth from the start of the year, with COVID-related 
concerns accounting for over 40% of all patient visits. The physician 
team at 98point6 and our technology-assisted approach to care enabled 
quality care delivered expediently, with the platform incorporating 
standards based on research, outcomes, and clinical quality monitoring 
of pandemic guidelines. Telehealth services offer a transformative 
paradigm shift for the uninsured, underinsured, and populations with 
limited access to physician care to readily access quality, inexpensive 
basic medical and primary care services. Amid the COVID-19 pandemic, 
telehealth has emerged as a viable and cost-effective solution across 
all demographic groups, including racial and ethnic minorities and 
rural populations lacking access to brick and mortar medical 
facilities.

Health disparities among racial and ethnic minority populations have 
been both highlighted and exacerbated by the COVID-19 pandemic. 
Disproportionately represented among ``essential worker'' categories, 
racial and ethnic minorities experience lower rates of employer-
provided or other private health-care coverage. Employers representing 
more than three million part-time, non-benefits-eligible employees 
stand ready and willing to provide telehealth or virtual care benefit 
options at no cost to these employees, but are prohibited from doing so 
without exposure to penalties under, for example, the ERISA.

Under current law, when telehealth or virtual health-care services are 
provided by an employer, the benefit is considered a ``group health 
plan'' under ERISA (subject to mandates absent an exception, which 
trigger per-day penalties). ERISA Sec. 733 and DOL regulations (29 CFR 
Sec. 2590.732)--and conforming Internal Revenue Service (IRS) and HHS 
statutes and regulations--do not include telehealth or virtual care as 
an excepted benefit under ERISA. On June 23, 2020, DOL, HHS, and 
Treasury jointly issued an FAQ pertaining to the Families First 
Coronavirus Response Act, the Coronavirus Aid, Relief, and Economic 
Security Act (CARES) and other health coverage issues related to COVID-
19, that provided temporary relief from most group market reforms under 
part 7 of ERISA, title XXVII of the Public Health Service Act, and 
chapter 100 of the Internal Revenue Code to employers wishing to 
provide telehealth or other remote care services to employees 
ineligible for any other employer-sponsored group health plan. This 
temporary relief has proven to be beneficial as a short-term fix, 
subject to the public health emergency, but a permanent solution is 
required to ensure long-term benefits of telehealth services can be 
accessed, across the spectrum of Americans in need.

Telehealth and remote care services should be an ERISA-excepted benefit 
when paid entirely by the employer or other plan sponsor. To that end, 
Representative Jackie Walorski (R-IN) introduced legislation in the 
116th Congressional session, the Telehealth Benefit Expansion for 
Workers Act, to permit telehealth services offered under a group plan 
or group health insurance coverage as ERISA-excepted benefits (by 
adding, ``Benefits for telehealth services'' to Section 2791(c)(2)). 
This legislation is expected to be re-introduced in the current 
Congressional session.

In addition, the CARES Act clarified in Section 3701 that a HDHP 
retains its status as an HSA-qualified HDHP--wherein participants may 
make contributions to a savings account (HSA)--if telehealth coverage 
is provided before the deductible. This exception ends December 31, 
2021. Most employers have taken advantage of this provision to waive 
fair market value charges for telehealth and remote care services 
through December 31, 2021, further enabling the policy goal of health-
care access and inclusivity.

As employers begin preparing for coverage requirements and changes 
affecting off-calendar year plan years, however, potential mid-year 
changes may subject unwitting participants to billing inconsistencies 
upon termination of the CARES Act telehealth deductible waiver 
(impacting HDHP/HSAs). Similarly, employers utilizing calendar year 
plans are now considering how and when to communicate the impending 
elimination of the CARES Act telehealth or other remote care services 
waiver. Elimination of the waiver will require employees to pay the 
fair market value for telehealth benefits if the employees participate 
in a HSA-qualified HDHP. To address this irregularity and the fact that 
employees' out-of-pocket expenses are increased, the Internal Revenue 
Code should be amended to provide a permanent exemption for telehealth 
services by adding, ``or telehealth and other remote care,'' to Section 
223(c)(1)(B).

Permanent relief for telehealth services under ERISA penalties and HDHP 
waivers would enable employers to continue to provide important access 
to safe, high-quality health care for many of the 21 million part-time 
workers in America as well as the 28 million uninsured. Provision of 
telehealth services will improve health outcomes across the demographic 
spectrum, with highest gains among ethnic and racial minorities and 
those most impacted by the COVID-19 pandemic. Telehealth is estimated 
to save the health-care system up to $6 billion, factoring preemptive 
care and early detection, as well as ensuring communities have a 
lifeline to reliable health information. The statutory corrections 
requested would neither add to the federal budget nor be subject to a 
Congressional Budget Office score, as the telehealth services 
contemplated would continue to be employer-funded.

The COVID-19 pandemic has illustrated the immense benefits of 
telehealth services. The technology is available now to ensure that 
more Americans, including part-time ``essential'' workers--and the 
racial and ethnic minorities disproportionately comprising this 
category--as well as rural Americans without ready access to medical 
care, can access quality basic medical and primary health-care 
services.

Telehealth has proven benefits and public policy should reflect the 
technological shifts and consumer preferences that incentivize 
employers to provide telehealth services for expanded groups of 
employees (part-time workers) and at lower employee cost (in HDHP/HSA 
models). These two minor changes would bring significant benefits 
across the U.S. public health landscape.

Sincerely,

Robbie Cape
CEO and co-founder

                                 ______
                                 
                             Ochsner Health

                         1514 Jefferson Highway

                         New Orleans, LA 70121

                          phone (504) 842-3000

                            www.ochsner.org

Hon. Ron Wyden                      Hon. Mike Crapo
Chairman                            Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
219 Dirksen Senate Office Building  219 Dirksen Senate Office Building
Washington, DC 20510                Washington, DC 20510

Re: May 19th Hearing: ``COVID-19 Health Care Flexibilities: 
Perspectives, Experiences, and Lessons Learned''

Dear Chairman Wyden and Ranking Member Crapo:

On behalf of Ochsner Health (Ochsner), our physicians, nurses, and 
other health professionals and the tens of thousands of patients and 
communities we serve in Louisiana and Mississippi, we thank you for 
this opportunity to submit to you and your Senate Committee on Finance 
colleagues comments regarding the May 19th hearing on ``COVID-19 Health 
Care Flexibilities: Perspectives, Experiences, and Lessons Learned.'' 
We commend you for your recognition to take time now to hold a hearing 
to examine the impact of telehealth on the COVID-19 response, and how 
those lessons learned may inform future federal policy with respect to 
telehealth.

We thank you in advance for your attention to our recommendations and 
the comments that may be submitted by our colleagues from associations 
representing health and hospital systems. Making permanent a number of 
the current federal telehealth waivers and other policy changes, 
expanding coverage and payment for telehealth and digital medicine 
services and devices, and otherwise supporting and facilitating the 
utilization of virtual care will help ensure that more patients have 
access to care, not just during emergency circumstances. These much-
needed changes will help facilitate access to care for individuals from 
underserved and/or rural communities, and enable better access for 
those with mobility, transportation, and other challenges.

We stand ready to share our lessons learned over the past 14 months as 
we have addressed the myriad challenges associated with COVID-19 and 
how we have successfully deployed telehealth and digital medicine to 
care for patients with COVID-19 as well as maintain continuity of 
primary and specialty care for patients, families, and communities 
during this challenging and unprecedented time. We welcome the 
opportunity to be a resource to you, your staff, and Finance Committee 
members as you examine this critically important topic.

Summary of Policy Recommendations

We know that the topic of telehealth is an incredibly important and 
time sensitive issue and as such, wish to draw your immediate attention 
to our policy recommendations below, which can be found in further 
detail on pages 6-10 of this document. Background on Ochsner and our 
digital medicine and telehealth programs can be found on pages 2-5. Our 
COVID-19 telehealth and virtual care lessons learned are enumerated on 
pages 5-6.

The following provides a summary of the policy changes we urge Congress 
and CMS to support. These recommendations are informed by our 
experience in providing care throughout the public health emergency 
(PHE) and, in particular, being an early ``hot spot'' for the pandemic. 
With these changes, patients will have improved access to the primary, 
specialty, urgent, and emergency care they need and deserve.

      Make permanent the range of waivers associated with the 
provision of telehealth. Specifically, make permanent the flexibilities 
associated with: patient location, relationship between patient and 
provider, and the types of services that can be provided via 
telehealth. Further, maintain reimbursement for telehealth services at 
the in-person rate and permanently waive the application of copayments 
to remote patient monitoring services and other non-face-to-face 
services.
          Given the significant focus during the hearing on audio-only 
telehealth, we wish to note that the provision of audio-only telehealth 
services is an important aspect of telehealth, particularly for 
individuals who may not have access to broadband, smart devices, or 
other technology that enable a video-visit. Audio-only telehealth can 
help bridge the health care digital divide, address equity, and 
otherwise expand access to care for certain individuals and 
communities. Audio-only also is a clinically appropriate way to conduct 
low acuity visits, communicate with established patients, and 
coordinate care with patients as part of a remote patient monitoring 
program. To that end, we urge that reimbursement for audio-only 
telehealth be maintained under traditional Medicare (fee-for-service) 
beyond the PHE.
      Ensure that during a PHE cross jurisdictional licensure can be 
automatic, presuming certain conditions are met.
      Modify the Emergency Medical Treatment and Labor Act (EMTALA) to 
allow new types of medical screenings, such as pre-screenings that use 
technology that can help divert non-emergent cases to other, 
appropriate settings.
      Expand covered remote monitoring services to allow for 
beneficiary participation and Medicare coverage and reimbursement for 
more than one program, which will increase access, ease patient day-to-
day care, and improve health outcomes.
      Provide digital medicine and telehealth tools/devices to 
Medicare patients at no cost to increase patient uptake of these 
services.
      Ensure patient access to TeleStroke services by establishing 
separate Medicare payment for providers giving both TeleStroke consult 
and same day inpatient care to Medicare beneficiaries experiencing 
acute stroke.
      Expand Medicare beneficiary access to non-stroke telehealth 
services for acute neurological conditions.
      Expand access to intensive care unit (ICU) telehealth.
      Provide payment to providers who are offering additional levels 
of remote monitoring for patients through programs such as TeleStork.

About Ochsner

Ochsner, headquartered in New Orleans, is one of the nation's leading 
integrated not-for-profit academic health systems. Ochsner--as a leader 
in value-based care and delivery system innovation--provides a 
comprehensive range of services through its clinically integrated 
network of a combination of owned, managed and affiliated hospitals, 
and nearly 200 total sites of care located throughout Louisiana and 
Mississippi. We are proud that our innovative partnership model through 
the Ochsner Health Network (OHN) allows many communities to maintain 
local ownership and control of their hospitals, while bringing to bear 
the benefit of the experience and breadth of the Ochsner clinical and 
operational teams. Ochsner offers a wide array of specialized and 
nationally ranked services with its 4,500 affiliated physicians, 
including more than 1,600 employed physicians practicing in over 90 
specialties and subspecialties, and more than 30,000 employees. Each 
year Ochsner and its physician partners serve over 1 million individual 
patients who come from every state in the nation and more than 70 
countries.

Louisiana regularly ranks near the bottom of the United States in 
nearly all health indicators, with a population that has a high 
prevalence of a number of risk factors for poor health outcomes, 
including obesity, tobacco use, poverty, diabetes, and cardiovascular 
disease. More than five years ago, Ochsner leaders recognized that it 
would take innovative strategies and deployment of new technologies and 
interventions to tackle these myriad challenges.

In response to the demand for better care at a lower cost and greater 
convenience to patients, Ochsner created an innovation lab, 
innovationOchsner (iO) to improve health through innovation with the 
following quadruple aim: improve the patient experience of care, 
improve the health of populations, reduce the per capita cost of health 
care, and improve the work life of the provider of care. The strategies 
to achieve these goals are: operational efficiency, differentiate 
product or service, create customer intimacy, and improve quality and 
safety. We are proud that our investment and focus in this area has 
resulted in ground-breaking innovations, which are measurably improving 
patient care and outcomes, and are reducing inefficiencies and costs.

iO has developed numerous digital medicine programs, particularly for 
those affected by chronic disease, in particular hypertension and 
diabetes, that are transforming the patient experience, enhancing 
health, and well-being, while reducing costs. More than 19,000 patients 
have been cared for in the Digital Medicine program, 80% of which are 
still enrolled. In addition, Ochsner provides more than 100 telehealth 
services to more than 185 hospital and clinic partners. Further, 
Ochsner continues to innovate in the direct-to-consumer market, with 
offerings such as Ochsner Anywhere Care for primary and urgent care 
needs.

Ochsner's innovative digital medicine approach using wearable 
technologies, remote monitoring, and virtual provider visits is 
substantially improving patient health outcomes at a lower cost. 
Particularly for patients who are managing complex diagnoses and 
chronic disease we are easing the patient care experience by allowing 
them to receive the care they need, when and where they need it. And, 
critically, our pioneering telehealth program is meaningfully 
increasing patient access to medical services in rural areas of 
Louisiana and Mississippi where, in certain cases, no such access 
existed before. For many--and a growing population of our patients--
telehealth and digital medicine are the standard of care and a 
preferred way in which they interface with the health-care system.

Examples of Ochsner Digital Medicine Offerings \1\
---------------------------------------------------------------------------

    \1\ To learn more about Ochsner's digital medicine programs see the 
following article: Washington Post: https://www.washingtonpost.com/
business/economy/these-louisiana-physicians-can-monitor-your-blood-
pressure--and-you-dont-even-have-to-leave-your-living-room/2018/07/11/
6d57f198-7beb-11e8-93cc-6d3beccdd7a3_story.html.

Ochsner's Hypertension Digital Medicine (HTNDM) program uses a 
connected blood pressure cuff to transmit blood pressure readings from 
the patient's home to be monitored by an Ochsner care team, which 
includes a pharmacist and health coach. This program has been shown to 
be three times more effective than traditional care at having patients 
achieve blood pressure control over 180 days, while also increasing 
patients' medication adherence and patient activation, and reducing the 
---------------------------------------------------------------------------
total cost of care.

An analysis by Blue Cross Blue Shield found that participants in the 
HTNDM medication adherence program led to an overall decrease in 
emergency department visits and inpatient hospital stays. The same 
analysis also found that the program saved $77 per member, per month, 
based on claims data and total cost of care.

Our Digital Diabetes Medicine (DDM) program uses a prescription, 
Bluetooth-
enabled digital glucometer to monitor a patient's blood sugar levels 
and other health indicators. This program also has achieved results 
that are better than traditional care methods, including reductions in 
A1C, decreases in hypoglycemic events and diabetes distress, and 
increases in adherence to recommended health maintenance activities.

The Connected Maternity Online Monitoring (MOM) program provides 
pregnant patients with a Bluetooth-enabled blood pressure cuff and 
scale that interfaces with the electronic health record. This allows 
patients to perform remote monitoring during pregnancy, and as 
appropriate, decrease the number of in person prenatal visits, while 
increasing the frequency of monitoring for potential pregnancy 
complications. Analysis of data from early implementation of the 
program demonstrates that not only does it allow for earlier detection 
of hypertension in pregnancy, but also increases compliance with post-
partum blood pressure monitoring in the initial days and weeks 
following delivery.

Examples of Ochsner's Telehealth Offerings

Ochsner deploys telehealth to deliver specialty, primary, and urgent 
care to patients near and far. We are proud to have created a network 
of hundreds of physicians who reside out of state and who--through 
multi-state licensure and the telehealth licensure compact--can deliver 
high quality care to our patients via telehealth, helping to ensure 
better access to care for underserved communities.

Access to specialty care has been expanded through the utilization of 
physicians with multi-state licensure who can treat patients via 
telehealth. Our ``hub'' and ``spoke'' model allows us to leverage our 
specialty physician workforce and expertise located in New Orleans to 
locations throughout Louisiana and Mississippi. For example, Ochsner 
provides emergency virtual psychiatric services, cutting emergency room 
wait times for psychiatric care at our partner sites by 50%. Telehealth 
can meaningfully increase patient access to telepsychiatry and 
telebehavioral health services for many patients in rural and 
underserved areas who are currently without access to such care.

Ochsner's TeleStroke program provides 24-hour/7-days per week coverage 
by vascular neurologists who--through telehealth--are immediately 
available to emergency department physicians in rural hospitals to help 
them quickly diagnose and treat patients presenting with symptoms of a 
possible stroke. The program has been instrumental in successfully 
treating thousands of patients (more than 300 patients per month) in a 
timely manner, and allows these facilities to remain open and 
successfully caring for patients in their own communities. Seventy 
percent of TeleStroke patients now stay local; prior to the program's 
implementation, nearly all patients were transferred.

Ochsner's TeleStork program, using live streaming of maternal and fetal 
health records, provides 24/7 monitoring to laboring mothers. Rapid 
detection of labor distress and maternal or fetal decompensation and 
facilitating early interventions by our specialty care team is helping 
reduce adverse maternal and neonatal outcomes. Since initiated in 
August 2016, there has been a 50% decrease in term unexpected Neonatal 
Intensive Care Unit (NICU) admissions in TeleStork facilities. Not only 
are the interventions effective in improving outcomes, but they have 
also been successful in driving changes in clinical practice that 
result in a decrease in the need for interventions, all of which 
ultimately lead to improvements in birth outcomes of newborns within 
the program.

In 2019, we announced a partnership with Tyto Care, the health-care 
industry's first all-in-one modular device for remote medical exams. 
This partnership expands Ochsner's current telehealth offering, a 
consumer-facing virtual visit platform called Ochsner Anywhere Care, 
which is powered by national telehealth leader American 
Well'. The Ochsner Anywhere Care Health Kit, powered by Tyto 
Care, is a portable health kit that enables patients to capture 
physical examination data at home using a handheld device with a 
digital camera and various attachments and then share it with a 
provider using the Ochsner Anywhere Care app. It is designed to 
replicate the exams performed during an in- office visit, by providing 
high-quality digital sounds of the heart and lungs, digital images and 
video of the ears, throat and skin, and body temperature. Special 
adaptors are included for examining the ears, throat, skin for taking 
body temperature, and listening to heart and lung sounds. To see a 
demonstration video visit: https://ochsner.tytocare.com/.

Since the pandemic began, we have sold thousands of Ochsner Anywhere 
Care Health Kits and through their deployment expanded access to 
primary and urgent care, allowing these patients to have access to care 
from the safety of their own homes. It is important to note that an 
Ochsner Anywhere Health Kit is not required for an Ochsner Anywhere 
Care or other telehealth visit, but it does provide tools to capture 
and share exam data, which can prove to be helpful for a provider 
making a diagnosis and treatment recommendation.\2\ This offering has 
potential to expand access to care, particularly for individuals with 
mobility limitations, including disabilities and transportation 
challenges, as well as provide access to individual and families in 
rural and underserved communities. Further, through funding we received 
through the Federal Communications Commission (FCC) COVID-19 Telehealth 
Program, we have been able to purchase and are actively disseminating--
at no cost to patients--nearly 12,000 devices to support patients in 
participating in our HTNDM, DDM, and Connected MOM programs.
---------------------------------------------------------------------------
    \2\ The Ochsner Anywhere Health Kit, powered by Tyto Care, retails 
for $299 with $10 flat shipping if ordered online at www.ochsner.org/
healthkit. It is also available for purchase at Ochsner pharmacy 
locations https://www.ochsner.org/services/pharmacy/, O Bar retail 
stores https://www.ochsner.org/shop/o-bar, Ochsner Fitness Centers 
https://www.ochsnerfitness.
com/, and Ochsner Total Health Solutions https://www.ochsner.org/
locations/ochsner-total-health-solutions. Some insurance providers may 
provide a discount or partial reimbursement; it is recommended that 
consumers contact their insurance provider for more information.

Having additional resources allowed us to expand the reach of our 
digital medicine programs, which in turn, supported our ability to 
maintain continuity of care--and in some cases begin important health 
monitoring--of patients with hypertension and/or diabetes as well as 
support our patients during an important time during their pregnancy. 
With the availability of the FCC telehealth device funding, we are 
particularly pleased that we have been able to expand enrollment of 
Medicare and Medicaid beneficiaries in our digital medicine programs, 
as making the devices available free of charge has removed a 
significant participation barrier for many patients.

Lessons Learned from COVID-19

Prior to the COVID-19 PHE, Ochsner had long-advocated that Congress, 
the U.S. Department of Health and Human Services (HHS), and the Centers 
for Medicare and Medicaid Services (CMS) expand coverage and 
reimbursement for telehealth and digital medicine services and 
associated connected devices. We theorized that improvement in how 
these services and the associated devices are covered and reimbursed 
would accelerate their adoption, increase access to care, and in turn, 
leverage their potential in supporting patient engagement, expand 
provider access to more accurate and timely patient data, and enhance 
the patient experience.

Now, more than a year into the pandemic, we have real world experience 
and have seen this theory come to fruition. These technologies and care 
delivery modalities are making a difference in the lives of people 
diagnosed with COVID-19, those suspected as having COVID-19, and for 
patients who need access to non-COVID-related primary or specialty 
care. Fully deploying telehealth and digital medicine to our Medicare, 
Medicaid, and commercially insured patients has helped to maintain 
continuity and coordination of care, as well as allowed for expanded 
access to care to patients who previously had been underserved. In many 
cases, Ochsner has been able to reach patients who previously have had 
limited or no access to such services--particularly in rural and 
underserved areas where health-care disparities persist.

Over the course of the COVID-19 pandemic, Ochsner has observed in 
patient reported data a significant increase in utilization of 
telehealth services by minority populations, particularly among Blacks, 
where the percentage of patients completing virtual visits doubled. At 
the height of the COVID-19 outbreak in the ``hot spot'' state of 
Louisiana, Ochsner delivered more than 60 percent of visits to patients 
via telehealth--making Ochsner the leading health-care system in the 
South in the delivery of telehealth during the public health crisis. 
From the March to December 2020 period, we are proud to have deployed 
virtual visits in a robust manner to sustain continuity of care and 
reduce the risk of COVID-19 exposure for patients, family members, and 
providers. Specifically, during this period:

      We provided an estimated 291,100 total virtual visits to adult 
and pediatric patients;
      Virtual visits were delivered across all primary, medical and 
surgical specialties, with the bulk of care being primary care, 
behavioral health, and medical specialties;
      Approximately 30% (87,389) of our virtual visits were with 
Medicare beneficiaries; and
      Almost 40,000, or 14%, of virtual visits were with people with 
Medicaid coverage.

While Ochsner was able to quickly and adeptly expand our telehealth and 
digital medicine offerings due to our existing programs and 
infrastructure, other hospitals, health systems, and providers required 
significant time, resources, equipment, and training--of health 
professionals and patients--to scale up their remote care offerings, 
which in turn, caused some delay in patients receiving health-care 
services and outpatient treatment. We feel strongly that the nation's 
health-care system must maintain these advances during non-pandemic 
times to ensure that the infrastructure, practice, familiarity, and 
resources are in place so irrespective of what threat may emerge--
natural disaster, bioterrorism, or infectious disease--that we have a 
strong, existing system so physicians, nurses, and hospitals can 
continue to provide health-care services across the care continuum.

Ochsner Policy Recommendations

The telehealth waivers granted by HHS and CMS have been critical to 
Ochsner's quick expansion and implementation of telehealth and digital 
medicine services. Since the start of the PHE and the advent of the 
waivers, in our telehealth program, we have seen an 89% increase in 
Louisiana patients from rural areas, as defined by the Health Resources 
and Services Administration. This increase is due to numerous factors, 
including a significant boost in patient interest in remote care and 
quick patient adoption to remote care. We commend HHS and CMS for 
providing these flexibilities and respectfully request that the 
Congress work with CMS and HHS to enact legislation and modify 
regulations, as applicable, to make these waivers permanent and ensure 
that we do not lose the gains made in telehealth and virtual care.
Telehealth Waivers Prioritized for Permanent Change
While all of the telehealth waivers provided by HHS and CMS have 
enhanced our ability to serve patients throughout the COVID-19 public 
health crisis, Ochsner believes that the following waivers, in 
particular, have enabled and fostered successful deployment of 
telehealth services to patients and these policy changes should be 
maintained once the pandemic has abated so that more patients--
especially those in rural and underserved areas--can access treatment 
and receive more comprehensive and coordinated care.

    1.  Patient location: The ability of patients to receive telehealth 
services from any location, including their homes, has given patients 
access to services where in many cases they could not have accessed 
care. Telehealth has reduced the need to travel for patients who are 
not as mobile and provides scheduled or on demand care and support 
through difficult stages of well-being. For example, telehealth has 
allowed patients in rural and remote areas without reliable 
transportation to more easily receive treatment by eliminating travel 
burden. For those patients with limited resources, telehealth has 
eliminated the cost of travel time and additional time away from work 
to receive an in-person visit. Further, for institutional-based 
patients such as those residing in skilled nursing facilities (SNFs), 
telehealth has given them the ability to remain in their care setting, 
minimizing both health risk and burden. Hence, making permanent the 
waiver permitting patients to receive telehealth from any location will 
eliminate a significant barrier for many patients who, before the 
telehealth expansion, faced challenges in accessing the services they 
need to get well and stay healthy.

    2.  Reimbursement at the in-person visit rate: Reimbursing for 
telehealth visits at the in-person rate has enabled Ochsner to offer 
services to patients in a financially sustainable and scalable manner. 
Adequate reimbursement for telehealth at the in-person visit rate 
ensures that providers receive appropriate payment for the full range 
of care they provide in the context of a remote visit. For example, 
often patients submit photographs, videos, and other medical 
information (e.g., blood pressure readings, blood sugar data, etc.) in 
advance that their providers take time to review and analyze prior to--
or following--a telehealth encounter. In a face-to-face encounter this 
often is done in real time and is reflected in the in-person payment 
amount. Further, providing reimbursement at the same rate as in-person 
care recognizes that the provision of telehealth services requires 
resources, such as technology and other infrastructure.

    3.  New services eligible for telehealth delivery: The significant 
expansion in the types of health-care services that can be delivered 
via telehealth has given Ochsner a way to reach patients previously not 
possible in many instances. For example, delivering occupational, 
speech/language, and physical therapy services via telehealth to 
patients in their homes or in SNFs has given patients new or increased 
access to care that improves quality of life and health outcomes. Pain 
management and palliative care and hospice patients and families have 
also benefited from the ability to connect with their providers through 
telehealth.

    4.  No required established relationship between practitioner and 
patient: Without the requirement of an established relationship between 
the patient and provider, Ochsner has been able to immediately serve a 
wider population of patients and address their care needs. Many 
patients living in rural and underserved communities do not have a 
regular source of health care and therefore do not have an established 
relationship with a provider. Making this waiver permanent will remove 
a significant barrier in access to treatment, especially for those many 
patients in rural and underserved communities who in many cases 
historically have received fragmented care.

    5.  Waiver of Medicare remote patient monitoring and other non-
face-to-face services copayments: The HHS Office of the Inspector 
General (OIG)'s waiver of the Anti-Kickback Statute (AKS) for cost-
sharing obligations for non-face-to-face services furnished through 
various modalities, including remote patient monitoring, remote monthly 
care management, virtual check-ins, and telehealth visits has 
eliminated a substantial barrier in patient access to care where, in 
many cases, patients simply do not have the resources to pay for 
services that are not immediate care needs but who could benefit from 
the care provided.

For example, as noted earlier, primary and secondary preventive 
services like Ochsner's DDM and HTNDM programs have reduced unnecessary 
emergency department visits, decreased inpatient admissions, increased 
medication adherence, and improved annual screening compliance, but 
unfortunately have been hindered by copayment barriers. Given the 
demographics of the Ochsner patient population, affordability of care 
is a serious impediment to our ability to manage chronic disease for 
too many of our patients. According to Kaiser Family Foundation, 
approximately 20% of Medicare beneficiaries in fee-for-service have no 
type of supplemental coverage, which makes paying out-of-pocket costs 
more challenging. Coinsurance often stands in the way of patients 
seeking and receiving the care they need, particularly for Medicare 
patients with limited resources.

Remote monitoring, such as our hypertension program, typically involves 
a monthly ``charge'' to cover the costs of having the data reviewed by 
the health-care team and additional involvement by the physician should 
any adjustments to treatment or the care plan need to be made. We know 
from our clinical experience that for many beneficiaries the cost of 
the monthly out-of-pocket fee caused them to decline the opportunity to 
enroll in a digital medicine program. Yet, over the past 14 months, 
with the copayments waived, we have noted a significant increase in 
enrollment and participation among patients who need these programs, 
which in turn will help improve their health and reduce costs over 
time. Permanently waiving the copayment requirement for these non-face-
to-face services will meaningfully improve access and much better 
enable Ochsner to more effectively and comprehensively care for 
patients, especially for patients in rural and underserved areas where 
significant disparities in care remain and must be addressed.
Other Waiver Related Policy Recommendations
In addition to the telehealth waivers enumerated above, HHS and CMS 
have provided additional waivers during the PHE that have strengthened 
our ability to continue to provide health-care services and outpatient 
treatment during the pandemic. Based on our experience with these 
waivers, we recommend that Congress and CMS work together to address 
the following:

    1.  Cross jurisdictional licensure in the event of a PHE: In the 
event of a PHE, there should be automatic allowance of CMS physician or 
non-physician practitioner licensing requirements when the following 
four conditions are met: (1) must be enrolled as such in the Medicare 
program; (2) must possess a valid license to practice in the state, 
which relates to his or her Medicare enrollment; (3) is furnishing 
services--whether in person or via telehealth--in a state in which the 
emergency is occurring in order to contribute to relief efforts in his 
or her professional capacity; and (4) is not affirmatively excluded 
from practice in the state or any other state that is part of the 
emergency area. This change would have no effect on state licensure 
requirements.

    2.  Modify EMTALA: The 1135 emergency waiver authority has allowed 
the Secretary to waive enforcement of EMTALA. In response to the 
current PHE the Secretary allowed hospitals to redirect patients who 
present at the emergency department to an alternative screening site 
and to transfer individuals with an unstable emergency medical 
condition. To use these waivers, many health systems relied on 
technology to screen patients upon emergency department arrival. 
Outside of a PHE, such screening tools would not typically meet the 
medical screening requirements under EMTALA.

        While EMTALA is necessary to ensure that all patients have 
access to emergency medical care, we urge Congress to revise the 
statute to allow for new types of medical screenings. Specifically, 
many health systems hope to employ pre-screenings that use technology 
that can help divert non-
emergent cases to other settings. The current medical screening 
requirements are so extensive that patients remain in the full queue of 
emergency department patients before it is determined that they could 
be diverted to another setting of care. More often than not, the 
patient is treated in the hospital after long wait times rather than 
being directed to nearby outpatient departments or physician practices, 
where the patient could have received appropriate care in a timelier 
manner and at lower cost to the patient and health-care system. We 
envision appropriate guardrails could be put in place by requiring 
hospitals to have their pre-screening approaches approved by CMS and 
requiring additional data submissions on patient diversion.

Other Policy and Payment Recommendations

    1.  Expand covered remote monitoring services to allow for 
beneficiary participation and Medicare coverage and reimbursement for 
more than one program, which will increase access, ease patient day-to-
day care, and improve health outcomes: Federal health programs should 
permit patients to participate in as many remote monitoring programs as 
their health needs dictate. A significant number of patients have more 
than one chronic condition (e.g., hypertension and diabetes) that would 
benefit from remote monitoring. Currently, Medicare only provides 
payment for one remote monitoring program/initiative, generally 
resulting in the provider receiving reimbursement for the program to 
which the patient consents first. Ochsner treats patients who would 
benefit from being enrolled in both our HTNDM and DDM programs because 
they have both hypertension and diabetes. For example, in Louisiana 
among Medicare beneficiaries aged 65 and older 65.63% have hypertension 
and 27.99% have diabetes.\3\ Hypertension is twice as common among 
people with diabetes as those without it and an estimated two-thirds of 
people with diabetes have elevated blood pressure and/or are treated 
for hypertension.\4\ Among the population we treat at Ochsner, an 
estimated 75% of patients with diabetes also have hypertension. Many 
chronic care Medicare beneficiaries have multiple comorbid conditions. 
CMS data for Louisiana show that 28.63% of Medicare beneficiaries in 
the state have 2-3 chronic conditions and annual Medicare per capita 
spending for this group of patients is $5,999.\5\ As such, the Medicare 
program and patients could benefit from allowing providers to offer a 
variety of remote monitoring services at the same time for all 
applicable documented diagnoses. Federal health programs should permit 
providers to bill for all remote monitoring services applicable to a 
patient's diagnoses to foster increased patient access to more 
coordinated and more comprehensive care, ultimately, resulting in 
improved patient health outcomes at a lower total cost-of-care.
---------------------------------------------------------------------------
    \3\ https://portal.cms.gov/wps/portal/unauthportal/
unauthmicrostrategyreportslink?evt=20480
01&src=mstrWeb.2048001&documentID=69E5BACC452E9CC0D72D6DA872A90AF6&visMo
de=
0&currentViewMedia=1&Server=E48V126P&Project=OIPDA-
BI_Prod&Port=0&connmode=8&ru
=1&share=1&hiddensections=header,path,dockTop,dockLeft,footer.
    \4\ https://www.hopkinsmedicine.org/health/conditions-and-diseases/
diabetes/diabetes-and-high-blood-pressure.
    \5\ https://portal.cms.gov/wps/portal/unauthportal/
unauthmicrostrategyreportslink?evt=20480
01&src=mstrWeb.2048001&documentID=69E5BACC452E9CC0D72D6DA872A90AF6&visMo
de=
0&currentViewMedia=1&Server=E48V126P&Project=OIPDA-
BI_Prod&Port=0&connmode=8&ru
=1&share=1&hiddensections=header,path,dockTop,dockLeft,footer.

    2.  Provide digital medicine and telehealth tools/devices to 
Medicare patients at no cost to increase patient uptake of these 
services: Patients often need technology or tools to support their 
health and well-being and allow for better care management by their 
provider team. As explained above, Ochsner's successful digital 
medicine programs require the use of connected smart devices that 
communicate with the care team. Patients must purchase these devices--
in some cases entirely out-of-pocket and in other cases with some cost-
sharing and some coverage. Unfortunately, as noted above, out-of-pocket 
expenses often preclude patients from accessing to the care, services, 
and tools they need to stay healthy and prevent catastrophic episodes 
of care. In our experience, approximately 10% of patients decline to 
participate in our digital medicine programs when they learn they have 
to pay for the device out-of-pocket. Therefore, Congress should expand 
Medicare payment policy to include full coverage of digital medicine 
devices (e.g., Bluetooth-enabled blood pressure cuff, Bluetooth-enabled 
digital scale, Bluetooth-enabled digital glucometer) and telehealth 
devices (e.g., Tyto Anywhere Care kit) and do so without any cost-
sharing requirements. The overwhelming response to the Congressionally 
established COVID-19 Telehealth Program at the FCC has demonstrated the 
need for a funding mechanism for these devices. Ochsner has seen 
firsthand the willingness of patients to participate in these 
beneficial programs when they have affordable access to them. Expanding 
access to these important patient engagement and support tools will 
help providers leverage the full value and improved patient health 
---------------------------------------------------------------------------
outcomes that digital medicine and telehealth care can offer.

    3.  Ensure patient access to TeleStroke services by establishing 
separate Medicare payment for providers giving both TeleStroke consult 
and same day inpatient care to Medicare beneficiaries experiencing 
acute stroke: Ochsner commends the Congress for expanding Medicare 
beneficiary access to TeleStroke services as part of the Bipartisan 
Budget Act (BBA) of 2018. To foster further Medicare beneficiary access 
to TeleStroke services, Congress should permit Medicare to make two 
separate payments to a single provider for both a TeleStroke consult 
and the work of a subsequent stroke admission on the same day if the 
admitting hospital both provides the initial TeleStroke consult and 
later admits the patient after transfer due to the acuity level of the 
patient's stroke.

    4.  Expand Medicare beneficiary access to non-stroke telehealth 
services for acute neurological conditions: Patients in rural and 
underserved communities typically have significantly less access to 
treatment for acute neurological diseases. To build on the important 
expansion of TeleStroke care, Ochsner requests that Medicare provide 
unrestricted telehealth coverage for other non-stroke acute 
neurological conditions that typically require consultations with 
emergency departments to achieve optimal patient health outcomes. These 
include diagnostic questions of numbness, weakness, vertigo, confusion, 
headache, tremors and seizures, leading to treatment of complications 
of spinal cord injury, nerve compression, brain tumors, Multiple 
Sclerosis (MS), Parkinson's disease, Alzheimer's disease, epilepsy, 
Amyotrophic Lateral Sclerosis (ALS), and many other conditions. Similar 
to the request for TeleStroke above, Congress should allow Medicare to 
make two separate payments to a single provider for both a non-stroke 
telehealth consult of an acute neurological condition and the work of a 
subsequent inpatient admission on the same day related to that 
condition if the admitting hospital provides both the initial 
telehealth consult and later admits the patient after transfer due to 
the acuity level of his or her neurological condition. Patient access 
to acute neurological telehealth services should not be limited by 
geographic or originating site requirements in the original Medicare 
telehealth statute.

    5.  Expand access to intensive care unit (ICU) telehealth: In many 
cases, patients in rural and underserved areas have to travel 
significant distances to receive emergency care. Through Ochsner's 
innovative telehealth offerings, we can give telehealth ICU consults 
that save meaningful time to treatment in many instances where 
immediate access to care can result in the likelihood of significantly 
better patient health outcomes. Congress should provide unrestricted 
Medicare coverage for telehealth ICU consults (i.e., no originating or 
geographic site limitations) so that all beneficiaries can access the 
emergent care they need as quickly as possible.

    6.  Provide payment to providers who are offering additional levels 
of remote monitoring for patients through programs such as TeleStork. 
Offerings like TeleStork provide an additional level of specialized 
monitoring and clinical support to providers who are caring for 
maternity patients who may be at higher-risk for poor maternal and 
fetal outcomes. Because the care is not delivered directly to the 
patient there is no reimbursement provided for the service, yet in our 
experience it is cost-effective and cost-saving.

Conclusion

The federal waivers outlined above have allowed Ochsner's telehealth 
and virtual care programs to operate at their full potential, and in 
doing so, have demonstrated that telehealth and virtual care are high 
quality, efficient, and effective ways to treat patients safely both 
inside and outside of the clinic and hospital settings. Ochsner urges 
the permanent extension of these critically important waivers; making 
these changes permanent will allow us to continue providing care to 
patients that may otherwise go unserved.

Further, we thank you for considering our additional recommendations 
for ways to modify federal coverage and reimbursement policy to 
facilitate the provision of virtual care and patient monitoring in a 
cost effective and convenient manner and in a way that also reduces 
patients' unnecessary exposure to infectious disease, such as COVID-19. 
We believe that by strengthening our nation's telehealth, virtual care, 
and digital medicine infrastructure we will be able to maintain the 
access to care gains made over the past year and support hospitals and 
providers in continuing to provide care throughout the PHE and 
otherwise.

We thank you for your consideration of our recommendations and stand 
ready to serve as a resource. Sincerely,

Will Crump
Director of Public Health Policy

                                 ______
                                 
              Partnership for Employer-Sponsored Coverage

                    1212 New York Avenue, Suite 1100

                          Washington, DC 20005

The Partnership for Employer-Sponsored Coverage (P4ESC) appreciates the 
Senate Finance Committee holding this hearing to discuss options for 
continuing health-care delivery and policy flexibilities implored 
during the COVID-19 pandemic. P4ESC believes that the time is ripe to 
modernize laws to increase access to telehealth services as patients, 
health providers, and coverage plan sponsors adapted to remote working 
and social distancing measures by utilizing this care delivery method 
and benefit offered by many employers.

As an advocacy alliance of employment-based organizations and trade 
associations representing businesses of all sizes and millions of 
Americans who rely on employer-sponsored health coverage every day, 
P4ESC is working to ensure that employer-sponsored coverage is 
strengthened and remains a viable, affordable option for decades to 
come.

P4ESC appreciates the COVID-related policies adopted over the last year 
to help employees and businesses, including expanding telemedicine 
availability to employees. Congress should build on this policy to 
provide employers with the ability to enhance employee coverage 
permanently. P4ESC is eager to work on bipartisan legislation to expand 
employee access to telemedicine, including enabling employers to offer 
a telehealth service plan to all employees regardless of their 
enrollment in the employer's medical coverage.

P4ESC supports: (1) treating telehealth services as an excepted benefit 
which would enable employers to offer this type of coverage to part-
time and variable workforces, and other employees not enrolled in the 
employers' medical plan; (2) reforming licensure requirements to enable 
services to be offered across state lines; (3) establishing a national 
set of standards for telemedicine services to address state-based 
requirements that have not kept pace with technology, practice site and 
remote working advances, including eliminating originating site and 
prior provider relationship requirements; and (4) clarifying that CARES 
Act telemedicine provisions are effective for plan years on or after 
January 1, 2019 (employer plan years vary between non-calendar and 
calendar year basis).

According to the Society for Human Resource Management's (SHRM) 
Navigating COVID-19: Impact of the Pandemic on Mental Health,\1\ ``the 
COVID-19 pandemic has put unprecedented strain on workers' mental 
health the research finds that a majority of employees are experiencing 
symptoms of depression, but very few are receiving care.'' Findings 
include:
---------------------------------------------------------------------------
    \1\ https://www.shrm.org/hr-today/trends-and-forecasting/research-
and-surveys/documents/
shrm%20cv19%20mental%20health%20research%20presentation%20v1.pdf.

      Two out of three employees report experiencing symptoms of 
depression sometimes amid widespread lockdowns
      More than two in five employees feel burned out, drained, or 
exhausted by work
      37 percent of employees have not done anything to cope with 
depression-related symptoms and only 7 percent have reached out to a 
mental health professional

The pandemic has offered employees the ability to receive mental and 
behavioral health services via telemedicine, and we strongly support 
making this access permanent. As noted in testimony before the House 
Education and Labor Committee hearing \2\ on April 15, 2021, James 
Gelfand of the ERISA Industry Committee (ERIC) stated ``[w]hen COVID-19 
caused many employers to shift to remote work or reduced employee 
presence onsite, many worksite clinics went virtual, offering mental 
and behavioral health via telehealth. Some clinics expanded eligibility 
to other employees in the same state, who may not be based at the same 
site. This helped create continuity for employees undergoing care, and 
a new access point for many others.''
---------------------------------------------------------------------------
    \2\ 04-15-21 ERIC Testimony--E&L Mental Health Hearing [Final].pdf.

Further, in an op-ed published in The Hill \3\ on May 28, 2020, SHRM's 
Emily M. Dickens, Chief of Staff, Head of Government Affairs and 
Corporate Secretary, wrote ``[g]reater access to telemedicine, 
including telepsychiatry, will provide the resources for employees to 
navigate all health-care options and privately seek the help that they 
need. The convenience of this offering will benefit employers and their 
employees because such services can be received at home and after work 
hours during a time when personal and professional schedules are 
anything but definite for so many workers.''
---------------------------------------------------------------------------
    \3\ https://thehill.com/opinion/healthcare/500017-assist-mental-
health-of-workers-by-increasing-access-to-telemedicine.

In the employer benefits space, telehealth services come in different 
forms, such as: the ability for employees to be treated by a health 
provider or practice, with whom they already have a relationship, in a 
telemedicine setting instead of through a traditional in-office visit; 
and access to a telehealth service vendor which is included in a 
benefits package offering, similar to a dental or vision plan, that is 
separate from the medical plan but provides the ability to be connected 
---------------------------------------------------------------------------
to a physician or health professional for a consultation.

In the later example, the separate telehealth vendor program can 
legally be provided to full-time employees enrolled in the employer 
medical plan but not to other groups of the workforce. Part-time and 
seasonal employees, and full-time employees who declined the employer 
medical plan cannot access the telehealth vendor program because this 
type of stand-alone benefit would violate the coverage rules under the 
Affordable Care Act's (ACA) employer mandate. P4ESC supports 
legislation to enable employers to offer these excepted benefit 
telehealth service plans to all employees, regardless of their 
eligibility for or enrollment in an employer's medical plan. Offering 
this type of telehealth service to employees is not at all meant to 
circumvent an employer's responsibility to offer a medical plan to 
full-time employees under the ACA's employer mandate.

Additionally, as the Committee considers ways to improve access to 
telehealth services, P4ESC urges you to also consider network access 
and availability of behavioral and mental health providers. Employers 
and employees face challenges in finding available and affordable 
behavioral and mental health-care providers. Some behavioral and mental 
health providers--particularly those in rural areas--decline to 
participate in health insurance networks. In the case of most self-
insured plans under the Employee Retirement Income Security Act of 1974 
(ERISA), employers rent insurance carriers' provider networks. The 
decision to join a network lies with the provider, subject to network 
standards.

Because so many behavioral and mental health providers choose not to go 
in-
network, employees can often face large out-of-network bills for care 
sought. It is important to stress that efforts to evaluate the 
availability of behavioral and mental health providers in health 
insurance networks must also consider whether these providers make 
themselves available and affordable to employees. Coverage requirements 
and civil monetary penalties on employers and insurance carriers are 
counterproductive, particularly regarding access and affordability, 
unless there is a countervailing requirement enforced by equal 
penalties for providers to participate in one or more networks.

The Partnership for Employer-Sponsored Coverage welcomes the 
opportunity to provide input and speak in further detail. Benefits 
offerings and coverage plans in the employer-sponsored system are as 
diverse as employers themselves. There is no one-size-fits-all employer 
plan, and the functionality of a business is centered around a 
productive, thriving, and healthy workforce. As a coalition 
representing businesses of all sizes, we have the unique ability to 
provide operational input across the full spectrum of the employer 
system--from the smallest family business to the largest corporation.

American Health Policy Institute

American Hotel and Lodging Association

American Rental Association

Associated Builders and Contractors, Inc.

Associated General Contractors of America

Auto Care Association

Business Group on Health

The Council of Insurance Agents and Brokers

The ERISA Industry Committee (ERIC)

FMI--The Food Industry Association

HR Policy Association

National Association of Health Underwriters

National Association of Wholesaler-Distributors

NFIB--National Federation of Independent Business

National Restaurant Association

National Retail Federation

Retail Industry Leaders Association

Society for Human Resource Management

                                 ______
                                 

                              Premier Inc.

                444 North Capitol Street, NW, Suite 625

                          Washington, DC 20001

                             T 202-393-0860

                             F 202-393-6499

                      https://www.premierinc.com/

The Premier health-care alliance appreciates the opportunity to submit 
a statement for the record on the Senate Finance Committee hearing 
titled ``COVID-19 Health Care Flexibilities: Perspectives, Experiences, 
and Lessons Learned'' on May 19, 2021. We applaud the leadership of 
Chairman Wyden and Ranking Member Crapo and members of the Committee 
for holding this hearing to evaluate the lessons learned during the 
pandemic and what the important flexibilities that have played in 
safely expanding access to care during the pandemic and options to 
extend telehealth capabilities into the future.

Many of the waivers and temporary regulatory changes granted during 
this period have significantly improved health-care providers' ability 
to combat the epidemic. These actions have also highlighted key 
opportunities to modernize health-care delivery by removing outdated 
regulations. Premier's hope is that by identifying temporary policies 
that proved successful in improving and innovating health care for 
Americans during this challenging time, we can pinpoint changes that 
should be made permanent or implemented on a broader scale beyond the 
pandemic.

Safely Treating Patients through Telehealth

Premier greatly appreciates Congress acting to broadly expand permitted 
uses of telemedicine and telehealth during the public health emergency 
in the Coronavirus Preparedness and Response Supplemental 
Appropriations Act and the Coronavirus Aid, Relief, and Economic 
Security (CARES) Act. These provisions have allowed beneficiaries 
beyond just those in rural areas to receive telehealth services in 
their home from an expanded set of providers, including through audio-
only communications, and provided payments to match in-office rate for 
clinicians who typically provide care in an office. As such, telehealth 
has provided a lifeline during the pandemic for individuals in all 
geographic areas who still need access to health care when traditional 
care delivery approaches are interrupted.

Premier data for more than 30,000 ambulatory providers nationwide shows 
that the use of virtual visits in the outpatient space have averaged 
14.2 percent since the pandemic (an increase of nearly 30X compared to 
pre-pandemic) with a 31 percent better no-show rate than in-person 
visits. With this concentrated experience over the past year, providers 
have learned how to best deploy telehealth and patients are 
overwhelmingly reporting high satisfaction with their virtual care 
visits. As a result, it is now seen as a valuable and potentially cost-
effective addition to health-care delivery.

As health systems and providers continue to support their communities 
and navigate a new normal after the pandemic, they are concerned that a 
retreat to prior rules will limit provider care delivery innovation for 
Medicare beneficiaries. A permanent expansion of telehealth policies 
will require appropriate guardrails. Recognizing more time is needed to 
determine the best approaches for permanent telehealth expansion in 
fee-for-service, Premier urges Congress to permanently extend to all 
alternative payment models (APMs) the telehealth coverage and payment 
policies that were operationalized under the public health emergency. 
Providers in APMs are incented to use telehealth only when it is most 
appropriate as they are responsible for the cost of care and improving 
quality. A survey \1\ conducted by Premier found that providers 
participating in accountable care organizations (ACOs) drew heavily on 
their population health capabilities to manage COVID-19 cases and keep 
people staying at home healthy, including by quickly ramping up the use 
of telehealth.
---------------------------------------------------------------------------
    \1\ https://www.premierinc.com/newsroom/press-releases/premier-inc-
survey-clinically-integrated-networks-in-alternative-payment-models-
expanded-value-based-care-capabilities-to-manage-covid-19-surge.

We believe Congress should immediately start with allowing greater 
flexibility around the types of technology that can be used, adopting 
additional services, and exploring additional telehealth flexibilities 
through Center for Medicare and Medicaid Innovation (CMMI) models and 
other Medicare APMs. While telehealth waivers are available for APMs, 
they are far more limited than the waivers provided during the public 
health emergency. The greatest flexibility should be awarded in models 
in which providers bear downside risk, such as in global budgets and 
capitated payments. Providing greater telehealth flexibility in models 
will be a tremendous incentive for providers to transition from fee-
for-service to value and total-cost-of-care and other risk-based 
---------------------------------------------------------------------------
models.

As Congress considers how to make expanded telehealth a permanent part 
of our health-care system, we also encourage lawmakers to explore 
increasing telehealth access across all of Medicare fee-for-service and 
Medicare Advantage by granting Centers for Medicare & Medicaid (CMS) 
greater authority to set regulation on allowable health services and 
payment for telehealth services.

With appropriate guardrails, Congress should also take action to:

      Provide temporary state licensing reciprocity for telehealth 
during the pandemic by passing the Temporary Reciprocity to Ensure 
Access to Treatment (TREAT) Act (S. 168/H.R. 708).\2\,\3\
---------------------------------------------------------------------------
    \2\ https://www.congress.gov/bill/117th-congress/senate-bill/168.
    \3\ https://www.congress.gov/bill/117th-congress/house-bill/708.

      Ensure audio-only telehealth continues to be an effective source 
of health care for all seniors during the course of the COVID-19 public 
health emergency by passing the Ensuring Parity in MA for Audio Only-
Telehealth Act (S. 150).\4\ This bill would count diagnoses obtained 
from audio-only telehealth services for risk adjustment purposes under 
the Medicare Advantage program to ensure that health costs are 
adequately covered while providing the information care teams need to 
manage patient care.
---------------------------------------------------------------------------
    \4\ https://www.congress.gov/bill/117th-congress/senate-bill/150.
---------------------------------------------------------------------------

Ensuring Continued Movement to Value-Based Care

The pandemic has required greater care coordination across the 
traditional health-care silos as providers work to manage infected 
patients in the most effective settings. According to a Premier 
survey,\1\ leading health systems and providers operating in value 
models were able to rapidly implement strategies to respond to COVID-
19, expanding care management, call centers and remote/home monitoring 
and other capabilities to respond to COVID-19. Moreover, if we had made 
more progress in value-based care prior to COVID-19, with more entities 
in global budgets or capitation, we could have avoided the financial 
challenges many providers faced. We urge Congress to support a 
continued emphasis on movement to value by:

      Incenting providers to move to downside risk arrangements by 
extending the Advanced APM bonus by five years and giving CMS the 
authority to set the thresholds to qualify for the bonus;
      Fixing a perverse flaw in the Medicare Shared Savings Program 
that penalizes organizations in certain communities that are achieving 
savings for the Medicare program by including their ACO population in 
their spending benchmark calculation; and
      Removing risk adjustment caps from value models so that the 
complexity of patients is recognized in the benchmark.

Conclusion

In closing, the COVID-19 public health emergency has illuminated the 
need to allow more flexibility in Medicare payment and delivery system 
models so that providers can tailor care to the specific needs of 
beneficiaries and their communities. This is especially true for 
providers serving rural and underserved communities. Congress and the 
Administration can build on the limited flexibilities for telehealth 
and APMs granted during the public health emergency and make other key 
changes to open doors to providers who are seeking to better serve 
their Medicare populations through accountable delivery system models 
that focus on care coordination, improved outcomes and value.

The Premier health-care alliance appreciates the opportunity to submit 
a statement for the record on the Senate Finance Committee hearing on 
COVID-19 health-care flexibilities. Premier is available as a resource 
and looks forward to working with Congress as it considers policy 
options to continue to address this very important issue.

If you have any questions regarding our comments or need more 
information, please contact Blair Childs, Senior Vice President of 
Public Affairs, at blair--childs@
premierinc.com.

                                 ______
                                 
                     Psychiatric Medical Care, LLC

                         8 Cadillac Drive, #230

                          Brentwood, TN 37027

                              May 19, 2021

Dear Chairman Wyden and Ranking Member Crapo:

Psychiatric Medical Care (PMC) appreciates the opportunity to submit a 
statement for the record to the Senate Finance Committee on ``COVID-19 
Health Care Flexibilities: Perspectives, Experiences, and Lessons 
Learned.'' PMC applauds the members of the Finance Committee for their 
rapid action to expand access to telehealth services during the COVID-
19 pandemic and strongly believes this expansion of health-care access 
should be maintained to address other health issues, such as America's 
ongoing behavioral health needs.

Founded in 2003 and headquartered in Nashville, TN, PMC is a leading 
behavioral health-care management company. Focused on addressing the 
needs of rural and underserved communities, PMC manages inpatient 
behavioral health units, intensive outpatient programs, and telehealth 
services in more than 25 states. The company's services provide 
evaluation and treatment for patients suffering from depression, 
anxiety, mood disorders, memory problems, post-traumatic stress 
disorder, and other behavioral health problems.

Critical Access Hospitals (CAHs) have provided outpatient hospital 
services via telecommunications technology during the COVID-19 pandemic 
by leveraging the Center for Medicare and Medicaid Services (CMS) 
waiver of the provider-based regulations described in ``Hospitals: CMS 
Flexibilities to Fight COVID-19.''\1\ CMS clarified that hospitals 
could use this flexibility to designate a patient's home as provider-
based and treat services rendered to such a patient in their home via 
telecommunications technology as if they were being performed in-
person.\2\ This flexibility to leverage virtual care to its full 
potential has proven crucial to meeting surging behavioral health needs 
during the COVID-19 pandemic. However, even after the COVID-19 public 
health emergency comes to an end, America's behavioral health crisis 
will continue.
---------------------------------------------------------------------------
    \1\ https://www.cms.gov/files/document/covid-hospitals.pdf.
    \2\ 85 Fed. Reg. 27750, 27563 (May 8, 2020).

Unfortunately, public health experts expect that the opioid crisis 
public health emergency, which has been exacerbated by the COVID-19 
pandemic and further compounded the country's behavioral health 
challenges, will also continue. Indeed, in the months since COVID-19 
brought the nation to a standstill, more than 40 states have recorded 
increases in opioid-related deaths.\3\ Additionally, approximately 20 
percent of the rural population experiences mental illness \4\ and are 
disproportionally impacted by the opioid epidemic (SUD often co-
occurring with mental illness).\5\ Approximately 48,000 people die by 
suicide every year--the 10th leading cause of death in the United 
States.\6\ These suicide rates were 40 percent higher in rural areas 
than in large urban areas (and are increasing at a faster rate).\7\
---------------------------------------------------------------------------
    \3\ https://www.ama-assn.org/system/files/2020-10/issue-brief-
increases-in-opioid-related-overdose.pdf.
    \4\ Rural Health Reform Policy Research Center (2014). The 2014 
update of the rural-urban chartbook, available on Gateway at https://
www.ruralhealthresearch.org/publications/940.
    \5\ Keyes KM, Cerda M, Brady JE, Havens JR, Galea S. Understanding 
the rural-urban differences in nonmedical prescription opioid use and 
abuse in the United States. Am J Public Health. 2014;104(2):e52-e59.
    \6\ National Vital Statistics System--Mortality Data (2018) via 
CDC, www.cdc.gov/nchs/fastats/suicide.htm.
    \7\ National Advisory Committee on Rural Health and Human Services, 
Policy Brief and Recommendations, ``Understanding the Impact of Suicide 
in Rural America,'' December 2017.

These challenges are particularly acute for Medicare beneficiaries. 
Approximately 33 percent of widowers become depressed--and while 
elderly adults represent only 13 percent of the population, they 
represent approximately 20 percent of all suicide 
deaths.\8\, \9\ At the same time, approximately 68 percent 
of elderly adults have little awareness about how to recognize and be 
treated for depression.\10\
---------------------------------------------------------------------------
    \8\ National Institute of Mental Health, The Many Dimensions of 
Depression in Women: Women at Risk (1999).
    \9\ National Institute of Mental Health, Older Adults: Depression 
and Suicide Fact Sheet (1999).
    \10\ Depression in Older Adults: More Facts, Mental Health America 
(n.d.). Retrieved from http://www.mentalhealthamerica.net/conditions/
depression-older-adults-more-facts.

In addition to maintaining access to critical services, the ability of 
CAHs to furnish outpatient behavioral therapy via telehealth has also 
improved continuity of care by easing some of the transportation 
barriers intrinsic to rural settings, which are invariably exacerbated 
during the winter months even in the absence of COVID-19. In other 
words, CAHs serve communities defined by barriers in accessing medical 
care, and CMS' flexibilities have enabled CAHs to not only maintain 
access to outpatient behavioral therapy during the COVID-19 period of 
health emergency, but these flexibilities have also driven CAHs to 
identify and implement more efficient and clinically appropriate 
---------------------------------------------------------------------------
delivery of care models that leverage telecommunications technology.

These rural behavioral health challenges are both a moral and economic 
imperative for communities across the nation. These are exactly the 
issues that Congress intended CAHs to address as providers of essential 
services in rural communities, and the telecommunications flexibilities 
granted during the COVID-19 pandemic that enable these facilities to 
meet these challenges should continue.

Why CAHs Are Different

As you know, CAHs receive their designation because they are viewed as 
critical health-care hubs within their rural areas and communities. 
This designation excludes CAHs from the outpatient prospective payment 
system (OPPS) for outpatient services unless they elect otherwise, 
because Congress understood that payment under the OPPS would generally 
not be adequate. Under the standard payment methodology for CAHs, a CAH 
receives payment for outpatient services under a reasonable (``fair 
market'') cost-based methodology. More specifically, many CAHs as an 
institution receive payment for outpatient hospital services they 
furnish to patients and then pay the medical staff according to their 
own internal policies.

However, the telehealth statute is currently structured to provide fee 
schedule payment to ``physicians'' and ``practitioners,'' not 
reasonable cost payment to institutions like CAHs. Specifically, with 
respect to telehealth services under section 1834(m) of the Medicare 
statute, section 1834(m)(2) requires that the payment for telehealth 
services be made ``to a physician or practitioner located at the 
distant site . . .''. Further, the terms ``physician'' and 
``practitioner'' are defined in statute and may not generally include 
the state-licensed health-care professionals that CAHs rely on, by 
virtue of their rural location and scarce labor market, to provide 
outpatient behavioral therapy to their patients.

Unless Congress preserves CAH's existing reasonable cost payment 
methodology under which they receive payment for behavioral health 
services furnished via telecommunications technology during the PHE, 
CAHs will be unable to provide these services after the end of the PHE 
because Medicare cannot pay CAHs as an institution for ``telehealth'' 
services under a reasonable cost methodology. For a CAH to be able to 
furnish behavioral health services via ``telehealth,'' it would need to 
affirmatively elect to bill under the OPPS for all outpatient services, 
which undermines the reimbursement flexibility Congress intended to 
provide to CAHs in the first place. Even then, the CAH would not be 
paid reasonable costs, and instead the ``physician'' or 
``practitioner'' would be paid by Medicare the Medicare fee schedule 
amount for their professional services. Moreover, as discussed above, 
CAHs rely on state-
licensed providers to furnish behavioral health services, and many of 
these providers may not be eligible to bill as ``physicians'' or 
``practitioners'' under the Medicare program. These limitations would 
leave many Medicare beneficiaries in rural communities served by CAHs 
without mental health services, and would represent a significant 
decrease in our national capacity to address rural mental health needs.

Recommendation

Psychiatric Medical Care requests that the Senate Finance Committee 
take action to ensure that this important strengthening and expansion 
of rural behavioral health capability is preserved at the end of the 
public health emergency.

      Our preferred action in response to this problem would be a 
change to section 1834(g)(1) of the Social Security Act.i 
This approach would retain the standard billing structure that CAHs use 
and understand, while allowing the Centers for Medicare and Medicaid 
Services the flexibility to continue the delivery of virtual care by 
these facilities under that provision (rather than 1834(m)). CMS would 
retain its authority to make evidence-based decisions as to the 
services covered under this recommendation.
      Psychiatric Medical Care would also support a two-year extension 
of CMS's Hospital Without Walls flexibilities that are currently 
allowing the delivery of these telehealth services by CAHs, so that the 
Finance Committee can better understand the importance of these 
services--particularly with respect to the delivery of behavioral 
therapy services to seniors in rural areas.

Finally, it is important to understand that while Congress passed 
legislation allowing the Medicare program to cover the provision of 
mental health services offered in the patient's home through telehealth 
in December 2020, that legislation did not make permanent the 
flexibilities afforded under the ``provider-based'' waivers that 
currently allow CAHs to bill telehealth services as if they were 
furnished in-person during the PHE. Without this flexibility, many CAHs 
will have significantly reduced capacity to provide behavioral health 
services through telehealth after the PHE expires.

We strongly encourage the members of the Finance Committee to Act to 
preserve these services for rural seniors. We look forward to 
continuing to work with you to expand access to health care for 
Americans.

Sincerely,

J.R. Greene, FACHE

_______________________________________________________________________

i Legislative Text for Consideration
(a) EXPANDING TELEHEALTH FOR CRITICAL ACCESS HOSPITALS. Section 
1834(g)(1) of the Social Security Act (42U.S.C. 1395m) is amended to 
read as follows:
        `` (1) IN GENERAL.--The amount of payment for outpatient 
critical access hospital services of a critical access hospital is 
equal to 101 percent of the reasonable costs of the hospital in 
providing such services, unless the hospital makes the election under 
paragraph (2).
         ``(A) SPECIAL PAYMENT RULE FOR TELEHEALTH SERVICES.
                 ``(i) IN GENERAL. Notwithstanding subsection (m) 
critical access hospitals may receive payment under this paragraph for 
outpatient critical access hospital services that are furnished via 
telecommunications technology, which may include the use of audio or 
visual equipment permitting two-way, real-time interactive 
communication between the patient and health-care professional at the 
critical access hospital.
                 ``(ii) INITIATION OF OUTPATIENT CRITICAL ACCESS 
HOSPITAL SERVICES VIA TELECOMMUNICATIONS TECHNOLOGY. Services described 
in clause (i) may also be initiated via telecommunications technology 
as long as such services complement a plan of care that includes in-
person care at some point, as may be appropriate.''
(b) EFFECTIVE DATE. The amendments made by this section shall apply to 
covered outpatient critical access hospital services furnished on or 
after January 1, 2022.

                                 ______
                                 
                                TechNet

                     805 15th Street, NW, Suite 708

                          Washington, DC 20005

                         Telephone 202-650-5100

                            Fax 202-650-5118

                            www.technet.org

                              May 19, 2021

U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510

RE: ``COVID-19 Health Care Flexibilities: Perspectives, Experiences, 
and Lessons Learned''

Chairman Wyden and Ranking Member Crapo:

Thank you for the opportunity to submit a statement for the record 
regarding the Senate Committee on Finance Hearing titled ``COVID-19 
Health Care Flexibilities: Perspectives, Experiences, and Lessons 
Learned.'' We appreciate the efforts you are making to prioritize 
greater access to health-care services through telehealth as the nation 
recovers from the devastating COVID-19 pandemic, and we wanted to share 
with you TechNet's federal policy principles on telehealth.

TechNet is the national, bipartisan network of technology CEOs and 
senior executives that promotes the growth of the innovation economy by 
advocating a targeted policy agenda at the federal and 50-state level. 
Our diverse membership includes dynamic American businesses ranging 
from startups to the most iconic companies on the planet and represents 
over three and a half million employees and countless customers in the 
fields of telehealth, information technology, e-commerce, the sharing 
and gig economies, advanced energy, cybersecurity, venture capital, and 
finance.

Telehealth has fundamentally altered how patients experience care. New 
communication technologies allow health-care professionals to provide 
patients with medical care and services in convenient, affordable, and 
accessible ways. TechNet supports efforts that affirmatively enable the 
use of technology neutral, innovative systems to treat patients 
remotely and ensure the physician-patient relationship can be 
maintained and strengthened. The COVID-19 pandemic has demonstrated how 
critically important this is, as an increasing number of patients need 
to access safe, timely, and effective care. For example, the number of 
patients reporting at least one telehealth visit has increased by 57 
percent since the start of the pandemic (Doximity).

With the onset of the pandemic, Congress provided the authority for 
Centers for Medicare and Medicaid Services (CMS) to lift the antiquated 
restrictions that conditioned eligibility for telehealth services on 
the location of a patient and the site of care. CMS also significantly 
expanded telehealth by approving more than 80 services eligible for 
reimbursement under traditional Medicare while allowing Medicare 
Advantage plans to use telehealth for the purposes of risk adjustment. 
These are only a few of the regulatory flexibilities Congress 
authorized to increase and enhance virtual care, and we believe that 
many of these temporary measures should be made permanent. Telehealth 
should be supported as a tool to practice medicine and ensure patients 
have access to affordable health-care options despite their proximity 
to health-care facilities or personal barriers restricting 
accessibility.

We look forward to working with you on this and other critical issues 
facing our nation. Please don't hesitate to reach out if we can be a 
resource on these important issues or if you have any questions. I can 
be reached at [email protected] or (202) 372-7000.

Best regards,

Carl Holshouser
Senior Vice President

                                 ______
                                 
                          Teladoc Health, Inc.

                          2 Manhattanville Rd.

                           Purchase, NY 10577

                              June 2, 2021

The Honorable Ron Wyden             The Honorable Mike Crapo
Chair                               Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
Washington, DC 20515                Washington, DC 20515

RE:  Teladoc Health Statement on the U.S. Senate Committee on Finance 
Hearing, ``COVID-19 Health Care Flexibilities: Perspectives, 
Experiences, and Lessons Learned''

Dear Chairman Wyden and Ranking Member Crapo,

Teladoc Health welcomes the opportunity to submit a statement for the 
record for the May 19, 2021, U.S. Senate Committee on Finance hearing, 
``COVID-19 Health Care Flexibilities: Perspectives, Experiences, and 
Lessons Learned.'' We appreciate your interest in leveraging telehealth 
and virtual care services to improve outcomes, expand access, address 
disparities, and reduce health-care costs for all Americans.

Founded in 2002, Teladoc Health is the world's only integrated virtual 
care system for delivering, enabling and empowering whole-person 
health--from wellness and prevention to acute care to complex health-
care needs. The integrated services from Teladoc Health include 
telehealth, expert medical services, AI and analytics, and licensable 
platform services. With more than 2,400 employees, the organization 
delivers care in 175 countries and in more than 40 languages, 
partnering with employers, hospitals and health systems, and more than 
50 health plans in the U.S. to transform care delivery. Teladoc Health 
serves more than 40 percent of Fortune 500 employers, as well as 
thousands of small businesses, labor unions, and public-sector 
employers, which offer our virtual care services to their employees.

More than 70 million Americans access high-quality health-care support 
through Teladoc Health and our providers. In 2020, Teladoc Health 
Medical Group clinicians and therapists delivered more than 10.6 
million unique virtual visits. Our hospital and health system clients 
completed more than 3.5 million patient visits using our technology 
platform. Additionally, more than 600,000 members use Livongo solutions 
to manage a range of chronic conditions. Our behavioral health solution 
saw an increase in use by over 500 percent in 2020.

While clinicians have used telehealth and virtual care services for 
decades, many Americans were unable to access virtual care due to 
overly restrictive and outdated policies at the state and federal 
level. In many cases, these barriers disproportionately impacted urban 
and underserved communities that rely on Medicare and Medicaid.

Yet, during the COVID-19 pandemic, telehealth proved to be a lifeline--
providing Americans with access to critical health-care services while 
keeping vulnerable patients out of clinics and hospitals. Now, across 
the United States, at unprecedented levels, clinicians are leveraging 
virtual services to extend access to mental health, chronic condition 
management, primary and specialty care, and other critical services for 
patients who otherwise would not be able to see a physician in person. 
In terms of our services, Teladoc Health expects total patient visits 
to be between 12.5 million and 13.5 million for 2021 and we expect 
similar patient volume growth for our hospital and health system 
clients as they move to virtualize more aspects of care delivery post 
pandemic.

From a policy perspective, increased use of telehealth services was 
augmented by several key policy changes that Congress helped enable 
through the Families First Coronavirus Response Act (FFCRA) and the 
Coronavirus Aid, Relief, and Economic Security (CARES) Act and which 
the Centers for Medicare and Medicaid Services further encouraged by 
waiving restrictions on exactly how, where, and who can access and 
deliver virtual care services.

Prior to the pandemic, only 13,000 Medicare beneficiaries accessed a 
telehealth service per week. Leveraging emergency flexibilities, 
providers delivered care to more than nine million beneficiaries via 
telehealth from March through June 2020. This alone underscores the 
critical role that virtual care can play in providing expanded, high-
quality, convenient, and cost-effective access to many in-demand 
health-care services.

Without additional legislative changes, many of the temporary 
flexibilities implemented during the current public health emergency 
will expire, and patients, including beneficiaries enrolled in 
traditional fee-for-service Medicare, will continue to face 
substantial, outdated barriers to obtaining critical virtual care 
services.

            Concerns With Respect to In-Person Requirements 
                    for Medicare Telehealth Services

As you and your colleagues consider the path forward for telehealth, we 
urge you to consider the unintended consequences of relying on in-
person requirements as a policy tool. Given the bipartisan objectives 
of the Committee with respect to Medicare, we believe that restricting 
telehealth coverage for seniors using mandated prior in-person visits 
is not a viable strategy and would control costs in much the same 
manner as the existing statutory restrictions--by arbitrarily 
restricting access to care for America's seniors. Restrictions on 
telehealth that mandate a prior in-
person relationship are clinically unnecessary, exacerbate health 
inequities, and would conflict with existing safeguards at the state 
level that would add to the existing regulatory morass that providers 
must navigate when delivering care virtually.
Health Equity and Racial Disparities
      As of 2019, 23% of Americans report not having a relationship 
with a doctor or health-care provider.\1\
---------------------------------------------------------------------------
    \1\ KFF. ``Adults Who Report Not Having a Personal Doctor/Health 
Care Provider by Race/
Ethnicity,'' October 13, 2020. https://www.kff.org/other/state-
indicator/percent-of-adults-reporting-not-having-a-personal-doctor-by-
raceethnicity/.

          23% of Black and 39% Hispanic Americans do not 
---------------------------------------------------------------------------
have a pre-existing relationship with a health-care provider.

          In Oregon, 42% of Hispanic Americans do not have 
a pre-existing relationship with a health-care provider.

          Nearly 30% of all Idahoans do not have a pre-
existing relationship with a health-care provider.
States Regulate the Practice of Medicine and Have Implemented Robust 
        Safeguards
The use of technology does not alter the ethical, professional, and 
legal requirements around the provision of appropriate medical care by 
clinicians. The role of Medicare is to regulate and establish payment 
and coverage for Medicare physician and non-physician provider 
services, not to regulate the practice of medicine or nursing, which 
has long been the prerogative of the states.

Over the past decade all 50 states and DC have passed legislation to 
remove requirements for prior in-person consultations to establish a 
valid physician-patient relationship, so long as the standard of care 
is upheld. Today, not a single state in the U.S. mandates a prior in-
person consult to establish a relationship. The evidence has been clear 
for some time that in-person requirements were, and remain, unnecessary 
and have no clinical basis of support. In fact, in 2014, the Federation 
of State Medical Boards (FSMB), the association of state regulators 
that oversee standards of medical care, issued guidance and model 
policy to state medical boards on regulating telehealth, that included 
safeguards to ensure providers are required to meet the appropriate 
standards of care when delivering care using technology.\2\
---------------------------------------------------------------------------
    \2\ https://www.fsmb.org/siteassets/advocacy/policies/
fsmb_telemedicine_policy.pdf.
---------------------------------------------------------------------------
Patient Choice and Continuity of Care
In the past, some state medical associations have expressed concern 
that telehealth would allow other providers to ``come between a patient 
and their doctor.'' In response, nearly all states have incorporated 
requirements into their telehealth statutes to ensure continuity of 
care by requiring that patients' medical records from telehealth 
consults be shared with each patient's primary care provider (with 
patient consent) or be readily and easily accessible to a patient to 
provide to their primary care provider or specialist.

The solution to enhancing continuity of care is to redouble efforts 
toward patient-centered health data interoperability rather than 
mandate that a patient sees a provider in person. The 21st Century 
Cures Act, the ONC Cures Act Final Rule, and the CMS Interoperability 
and Patient Access rule have accelerated the ability for a patient to 
access their personal health information and as implementation 
proceeds, will facilitate nationwide access to health records for 
patients, health-care providers, and payers.

Patients should have the choice to see any provider. Survey data from 
the pandemic shows that more than 70 percent of patients using 
telehealth saw their own doctor. The remaining 30 percent represent the 
millions of Americans who did not have a pre-existing relationship with 
a provider due to widespread Primary Care and Mental Health workforce 
shortages but were able to use telehealth to establish a relationship 
and receive care from a provider licensed in their state.

We cannot ignore the importance of providing all Americans, regardless 
of whether they have a medical provider with whom they have an 
established relationship, the opportunity to access health care. For 
years Congress has urged patients and consumers to make smart decisions 
about their health-care spending. Telehealth is simply a modality and 
is a safe and economical way to access quality health care with the 
patient in the driver's seat.
Antitrust Issues
The U.S. Federal Trade Commission (FTC) and the US Department of 
Justice have conducted numerous investigations into anti-competitive 
behavior from state medical societies and state medical boards that 
have used regulatory requirements for a prior in-person visit to 
restrict access and limit patient choice.

In fact, FTC staff recently submitted comments to CMS and addressed in-
person requirements for Medicare telehealth services, noting the impact 
on competition, innovation, choice, and price:

        As discussed in a number of FTC staff advocacy comments, in-
        person examination requirements prevent licensed health-care 
        providers from providing telehealth care that they otherwise 
        would deem appropriate. Such restrictions potentially reduce 
        competition, innovation, consumer choice, and the supply and 
        quality of care, and may also increase price. Accordingly, FTC 
        staff advocacy comments have opposed proposed laws and 
        regulations that prohibit the use of telehealth for initial, as 
        well as subsequent evaluations. Rather, FTC advocacy has 
        favored flexible provisions that allow the licensed 
        practitioner in the best position to weigh access, health, and 
        safety considerations to decide whether to use telehealth. Such 
        policies, which allow the patient-practitioner relationship to 
        be established by telehealth and typically hold the 
        practitioner to an in person standard of care, are supported by 
        several physicians' organizations.
Program Integrity
Antifraud enforcement and investigations of waste and abuse in federal 
health programs must be a priority. However, Congress must not allow 
program integrity concerns to inappropriately limit Medicare 
beneficiaries' access to needed care. Arbitrarily restricting 
telehealth coverage for seniors, including mandated prior in-
person visits, is not a viable program integrity strategy.

In fact, in a recent statement, Principal Deputy Inspector General 
Christi A. Grimm stated unequivocally that bad actors using 
telecommunication services to perpetrate ``telefraud'' should not be 
conflated with the legitimate practice of telemedicine or imply that 
telehealth services are at greater risk of abuse than in-person 
services under Medicare.

Inspector General Grimm's statement is consistent with an HHS-OIG 2018 
audit that found that the limited number of improper telehealth 
payments were the result of deficiencies in Medicare claims forms or 
the result of providers who inadvertently billed for telehealth 
delivered to beneficiaries outside of the 1834(m) geographic site 
restrictions.

Comprehensive anti-fraud statutes exist at both the federal and state 
level. HHS OIG and CMS have extensive program integrity policies and 
procedures in place to leverage existing authorities to address all 
fraud, waste, and abuse, including improper payments. However, Congress 
must ensure HHS and CMS have the necessary tools to combat bad actors 
and provide robust funding for critical antifraud programs.

Bipartisan consensus exists across a range of telehealth and digital 
health issues. We have presented recommendations in the appended white 
paper intended to provide a framework for how best to advance 
telehealth and virtual care both in preparation for future public 
health emergencies and on a permanent basis to ensure expanded access 
to quality care in the U.S. As detailed there, and noted previously in 
this letter, these changes can, and should, be made without 
unnecessarily limiting patient access to clinically appropriate care.

Thank you for the opportunity to provide a statement for the record. If 
you have any questions or would like to further discuss our 
recommendations, please do not hesitate to contact me.

Sincerely,

Claudia Duck Tucker
Senior Vice President
Government Affairs and Public Policy

                                 ______
                                 

 Expanding Access to Care Through Proven, Quality, and Cost-Effective 
                       Digital Health Technology

                     Federal Policy Recommendations

January 2021

Overview

Health-care providers have long used telehealth and remote technology 
to provide timely access to needed health services, enhance the patient 
experience, improve health outcomes and reduce costs. During the COVID-
19 pandemic, telehealth has proven to be a lifeline--providing 
Americans with access to critical health-care services while keeping 
vulnerable patients out of clinics and hospitals. Now, across the 
United States, clinicians are leveraging virtual services and platforms 
to extend access to mental health, primary and specialty care, and 
other critical services for patients who otherwise would not be able to 
see a physician in person. More Americans than ever have engaged with a 
provider through synchronous real-time video or asynchronous 
technologies to access lifesaving prescriptions, receive follow-up care 
after an in-person procedure, or avoid high-cost ER and urgent care 
clinics for minor conditions.\1\ Providers in underserved communities 
are deploying telehealth solutions to ``beam'' in specialists from 
across the country to rapidly respond and treat critical stroke 
patients, augment and support ICU's and NICU's, and use remote 
technologies to monitor long-term care patients and help patients 
overcome chronic diseases.
---------------------------------------------------------------------------
    \1\ ``Synchronous'' means an exchange of information regarding a 
patient occurring in real time. ``Asynchronous'' means an exchange of 
information regarding a patient that does not occur in real time, 
including the secure collection and transmission of a patient's medical 
information, clinical data, clinical images, laboratory results, or a 
self-reported medical history, https://www.americantelemed.org/wp-
content/uploads/2020/10/ATA-_Medical-Practice-10-5-20.pdf.

        These rapid advances in virtual care were made possible, in 
        part, because federal policymakers advanced a number of 
        legislative and regulatory changes to enhance patient access 
---------------------------------------------------------------------------
        during the COVID-19 public health emergency.

For example, Congress provided the Department of Health and Human 
Services (HHS) authority to waive Medicare's longstanding geographic 
and originating site restrictions on telehealth.\2\ HHS and the Centers 
for Medicare and Medicaid Services (CMS) also leveraged emergency 
authority to waive many of the in-person requirements for services 
across Medicare programs while allowing Medicare Advantage plans to add 
new virtual care benefits and use telehealth for risk adjustment 
purposes.\3\, \4\ Congress also allowed high-deductible 
health plans (HDHP) with a health savings account (HSA) to cover 
telehealth services prior to a patient reaching their deductible.\5\
---------------------------------------------------------------------------
    \2\ Section 3703, H.R. 748, CARES Act.
    \3\ https://www.cms.gov/about-cms/emergency-preparedness-response-
operations/current-emergencies/coronavirus-waivers.
    \4\ Centers for Medicare and Medicaid Services. Applicability of 
diagnoses from telehealth services for risk adjustment. April 10, 2020, 
https://www.cms.gov/files/document/applicability-diagnoses-telehealth-
services-risk-adjustment-4102020.pdf.
    \5\ Section 3701, H.R. 748, CARES Act.

These and other temporary COVID-19 policy changes have, overnight, 
opened the door to virtual care services that were previously 
unavailable to many patients in the U.S. In response, Teladoc has 
worked alongside our clients and partners--health systems, health 
plans, and employers--to help meet new demand as Americans have 
---------------------------------------------------------------------------
embraced virtual care on an unprecedented scale.

As of 2020, more than 70 million Americans have paid access to high-
quality health-care support through Teladoc Health clinicians and 
therapists. In 2020, Teladoc Health Medical Group clinicians and 
therapists delivered more than 10.6 million unique visits. Our hospital 
and health system clients completed more than 3.5 million patient 
sessions using our technology platform. Additionally, as of Q3 2020, 
more than 540,000 members use Livongo solutions for chronic conditions. 
Overall, Teladoc Health has seen utilization of services stabilize at a 
level that is 40% higher than before the COVID-19 pandemic with total 
visits expected to exceed 10 million for 2020.

In terms of Medicare, prior to the pandemic, only 13,000 beneficiaries 
accessed a telehealth service per week. Leveraging emergency 
flexibilities, providers delivered care to more than 9 million 
beneficiaries via telehealth from March through June 2020. This alone 
underscores the critical role that virtual care can play in providing 
expanded, high-quality, convenient, and cost-effective access to many 
in-demand health-care services.\6\
---------------------------------------------------------------------------
    \6\ Early Impact of CMS Expansion of Medicare Telehealth During 
COVID-19, Health Affairs Blog, July 15, 2020, https://
www.healthaffairs.org/do/10.1377/hblog20200715.454789/full/.

        This experience has made clear that there is no clinical basis 
        for the long-standing restrictions that have prevented Medicare 
        beneficiaries from accessing services via telehealth from their 
        homes, and it is time for Congress to finally take action to 
---------------------------------------------------------------------------
        permanently extend access to virtual care.

As policymakers look to the future, it is important to note that 
telehealth is not a separate care delivery system. From a patient and 
provider perspective, telehealth is a tool to deliver health-care 
services by a licensed health-care professional to a patient at a 
different location. Since health care and the practice of medicine are 
primarily regulated at the state level, state legislatures and 
professional boards determine how and when clinicians can deliver care 
remotely. This provides federal policymakers with the opportunity to 
leverage federal health programs to incentivize and promote access to 
virtual care.

As Congress and the Administration work to expand access to care, 
efforts to harmonize federal and state requirements must be a priority 
to prevent fracturing an already complex patchwork regulatory landscape 
that has long hindered the uptake and adoption of virtual care. For 
example, in all 50 states, state law allows physicians to establish a 
relationship with a patient virtually.\7\ However, in recent years some 
legislative proposals to expand Medicare telehealth services would 
require a patient to see a provider in-person before they are eligible 
for telehealth benefits. Not only are such in-person requirements 
clinically unnecessary, but they are also out of step with a decade of 
telehealth reform at the state level and would exacerbate the patchwork 
regulatory environment that hinders patients' access to virtual care.
---------------------------------------------------------------------------
    \7\ https://www.ama-assn.org/system/files/2018-10/ama-chart-
telemedicine-patient-physician-relationship.pdf.

In short, the challenges and shortcomings revealed by the pandemic have 
exposed a fragile and inflexible U.S. health-care delivery system. 
Without additional legislative changes at the state and federal level, 
many of the temporary flexibilities implemented during the current 
public health emergency will expire, and patients, including 
beneficiaries enrolled in traditional fee-for-service Medicare, will 
continue to face substantial, outdated barriers to obtaining critical 
---------------------------------------------------------------------------
virtual care services.

        As Congress and the Biden Administration take stock of recent 
        temporary COVID-19 policy changes and consider the important 
        role that virtual care has played in improving care delivery 
        during the pandemic in the U.S., efforts should focus on:

        1.  Determining if the authorities put in place by Congress and 
the Administration are sufficient for future public health emergencies, 
including pandemics.
        2.  Identifying and permanently extending certain flexibilities 
and authorities made available during the public health emergency.

As policymakers work to answer these questions, we encourage continued 
engagement with stakeholders to ensure that post-pandemic policies 
reflect the preferences of patients and the realities of those on the 
front lines of care delivery. Bipartisan consensus exists across a 
range of telehealth and digital health issues. The recommendations 
proposed in this document are intended to provide a framework for how 
best to advance telehealth and virtual care both in preparation for 
future public health emergencies and, perhaps most importantly, on a 
permanent basis to ensure expanded access to quality care in the U.S.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


Teladoc Health is empowering all people everywhere to live 
healthier lives by transforming the health-care experience. Recognized 
as the world leader in whole-person virtual care, Teladoc Health 
leverages clinical expertise, advanced technology and actionable data 
insights to meet the evolving needs of consumers and health-care 
professionals.

For more information, please visit teladochealth.com or follow 
@TeladocHealth on Twitter.

 Enhance Health-care Access, Convenience, and Outcomes

Virtual care technology can serve as a powerful equalizer by 
eliminating the barriers of time, distance, and geography and 
empowering patients to overcome the challenges and limitations of 
accessing in-person health care. Post pandemic, federal health programs 
must ensure that patients can access high-quality telehealth services 
anywhere, including the home. For a wide range of health-care services, 
providers utilizing telehealth have demonstrated the ability to provide 
the same level of care as in-office visits and shown that, in both 
rural and urban underserved areas, telehealth serves as the only means 
by which patients can quickly and conveniently access quality care.

Before the waiver authority granted through the Families First 
Coronavirus Response Act (FFCRA) and expanded under the Coronavirus 
Aid, Relief, and Economic Security (CARES) Act, traditional Medicare 
allowed seniors and individuals with disabilities covered under the 
program to receive telehealth services only when located in certain 
rural areas of the country and at an eligible ``originating site''--
usually a clinic or hospital. This regulatory imbalance between in-
person care and telehealth prevented the health-care system from 
leveraging the agility and convenience of virtual care with no clinical 
basis of support. These unnecessary and outdated restrictions were 
waived during the COVID-19 pandemic but will require action from 
Congress to be eliminated permanently.

     Recommendation 1.1: Congress must reform 1834(m) of the Social 
Security Act and permanently eliminate the geographic and originating 
site requirements to enable Medicare beneficiaries to access telehealth 
services outside of federally designated rural areas and, importantly, 
from home.\8\
---------------------------------------------------------------------------
    \8\ Social Security Act, Pub. L. No. 104-321. Codified at 42 U.S.C. 
Sec. 1320b-5.

     Recommendation 1.2: Under current authority, CMS should 
permanently allow Medicare Advantage organizations to use telehealth, 
including both real-time interactive video and audio, for the purposes 
---------------------------------------------------------------------------
of risk adjustment.

     Recommendation 1.3: Section 1135 of the Social Security Act 
provides HHS with authority to waive many of the requirements that 
could potentially limit the provision of virtual care during a national 
emergency, including EMTALA, Physician Self-Referral, HIPAA, and 
requirements that a provider be licensed in the state of the patient as 
a condition of participation in federal health programs. Under FFCRA 
and the CARES Act, Congress gave HHS additional authority to waive 
restrictions on telehealth during the COVID-19 pandemic. However, the 
waiver authority is limited to the COVID-19 PHE determination. Congress 
should ensure HHS and CMS can act quickly during future pandemics and 
natural disasters by granting permanent waiver authority for all public 
health emergencies under Section 1135 of the Social Security Act.

Incentivize 21st Century Virtual Care

Federal health programs should incentivize the expansion of virtual 
care and reimburse providers for all forms of telehealth. In addition, 
patients and payers should have more flexibility to use account-based 
plans and innovative coverage arrangements to help finance care. 
Private payers should compensate health-care providers for delivering 
virtual care; however, a provider and health plan should have the 
ability and flexibility to agree to reimbursement rates based on market 
conditions.

     Recommendation 2.1: Congress should permanently allow pre-
deductible coverage for telehealth and other remote care services for 
high-deductible health plans (HDHPs) paired with a health savings 
account (HSA).

     Recommendation 2.2: CMS has historically taken a conservative 
approach to expanding telehealth services under traditional Medicare 
FFS. In response to COVID-19, CMS broadly expanded the list of eligible 
telehealth services available to beneficiaries for the duration of the 
PHE. COVID-19 has demonstrated that providers are able to responsibly 
deliver care remotely, and CMS should seek to broadly expand the list 
of eligible Medicare telehealth services that are demonstrated to be 
safe, effective, and clinically appropriate. For services that CMS 
needs additional evidence before initiating permanent coverage, the 
agency should create an additional pathway that would cover telehealth 
services on a temporary basis and allow providers to develop the 
evidence that the agency believes necessary for adding a service on a 
permanent basis.

     Recommendation 2.3: Under Medicare FFS, there are two payment 
rates for many physicians' services based on the site of service: the 
facility rate; and the non-facility, or office, rate. For telehealth 
services, Medicare has historically reimbursed the billing provider at 
the facility rate since the costs (i.e., staff and equipment) for the 
telehealth service were borne by the originating site where the patient 
is located, not by the provider at the distant site. This payment 
methodology has worked for delivery models where networked, affiliated 
hospitals and practices share costs. However, when the home is made an 
eligible originating site, payment rates must adequately compensate 
providers so as not to incentivize and favor in-person visits over 
virtual.

     Recommendation 2.4: While reforming Medicare FFS to allow for 
telehealth must remain a priority, the power of telehealth to address 
costs and improve outcomes is best leveraged within risk-bearing 
payment arrangements. As CMS continues to pilot and expand value-based 
care models, expanding flexibility to use virtual care must be a 
cornerstone of key payment reform initiatives moving forward.

     Recommendation 2.5: Congress should ensure Medicare enables 
virtual chronic condition prevention and management, including virtual-
only providers in the Diabetes Prevention and the Diabetes Self-
Management and Training Programs.

     Recommendation 2.6: Congress should designate standalone 
telehealth as an ERISA excepted benefit to ensure that virtual services 
can be offered as a supplement to employees and dependents who are 
eligible for traditional group health coverage and to employees--and 
their dependents--who are ineligible for employer group health 
coverage.

Ensure Patient Choice and Provider Autonomy

The paradigm for health care has shifted in response to the rapid 
growth and ubiquity of digital technology. Prior to COVID-19, patients' 
expectations for how care is delivered had already significantly 
changed, and the pandemic further accelerated these trends. Given the 
speed and proliferation of digital health, patients should be afforded 
the ability to choose the technology by which they want to interact and 
engage with their health-care provider. To expand patient choice, 
health-care services accessed and delivered remotely should not be held 
to a different standard than services provided in-person. The form of 
communication, or modality, should be determined by clinicians, in 
consultation with their patients, provided that it is sufficient to 
evaluate and diagnose the condition and meet the standard of care.

As the COVID-19 pandemic has demonstrated, Americans that do not have 
access to high speed Internet or broadband have challenges in accessing 
a provider through real-time video, and have come to rely on telephone 
and interactive audio visits to access care. A clinically appropriate 
telehealth encounter--when it includes informed consent, affirmative 
identification of patient and treating provider, a patient evaluation 
and diagnosis in accordance with the standard of care, and an 
appropriate treatment plan--should not be limited by arbitrary 
legislative or regulatory restrictions. Policymakers should pursue a 
technology neutral approach and allow health-care providers to 
determine what technology is best to treat patients. Telehealth should 
not have clinicallyunsubstantiated barriers to technologies if it is 
safe, effective, appropriate, and complies with HIPAA and all related 
state privacy requirements.

     Recommendations 3.1: As Congress seeks to address the outdated 
geographic restrictions in traditional Medicare FFS, it should avoid 
imposing requirements for a prior in-person visit or limits on the type 
of technology that may be used for a telehealth encounter.

     Recommendations 3.2: Congress should not limit Medicare 
beneficiaries' access to telephone-based communications, which has 
proven safe and effective across a range of use cases during the COVID-
19 pandemic.

     Recommendations 3.3: Congress and CMS should expand support for 
asynchronous telehealth technologies, including remote patient 
monitoring, to ensure beneficiaries are not limited to accessing 
virtual care via real-time video.

     Recommendations 3.4: To address the ongoing substance abuse 
crisis, Congress must ensure that DEA finalizes the telemedicine 
special registration rule which would allow DEA-registered 
practitioners to prescribe controlled substances, such as certain kinds 
of medication-assisted treatment, without an in-person medical 
evaluation. The DEA has temporarily waived requirements during the 
COVID-19 PHE; however, the agency will need to promulgate and finalize 
the rule to ensure providers can continue to treat and prescribe 
controlled substances to patients post-pandemic.

 Address Digital Literacy and Expand Telehealth Access to Underserved 
                    Communities

Underserved rural and urban communities, tribal nations, racial and 
ethnic minorities, and vulnerable patient populations all have higher 
prevalence of chronic conditions and should have equitable access to 
telehealth and digital health services. The pandemic has revealed that 
connectivity is a critical health-care resource and a prerequisite for 
expanding access to high-quality care. A patient should not be denied 
access to virtual care because they live in a community that lacks 
sufficient broadband access, cannot afford the appropriate technology, 
or are not comfortable using a computer or device. Underserved patient 
populations deserve the same savings, convenience, and access to care 
as patients elsewhere. Health disparities must be accounted for in 
federal health programs, and virtual care reform efforts should be 
coupled with targeted federal investment to help bridge the digital 
divide and help ensure autonomy and access for all seniors and 
caregivers that want to use it.

     Recommendation 4.1: To address racial, ethnic, and income-based 
disparities while ensuring Americans in both rural and urban 
communities are not left behind, Congress must advance a national 
strategy toconnect all Americans via broadband and 5G, with robust 
investments targeted toward underserved areas of the US.

     Recommendation 4.2: Building on the investments made in recent 
COVID-19 relief legislation, Congress should continue to invest in 
telehealth and remote care infrastructure for health systems that serve 
vulnerable patient populations, Federally Qualified Health Centers 
(FQHC), Rural Health Clinics (RHC) and Community Behavioral Health 
Centers (CCBHC), expand existing HRSA telehealth grant and technical 
assistance programs, and task HHS with developing a national strategy 
to support community health workers (CHW) to identify and work with 
high-risk patients who need help with understanding how to use 
technology to ensure all Americans can access virtual care.

     Recommendation 4.3: HHS and CMS should work with stakeholders to 
develop education and training resources that account for age, socio-
economic, geographic, cultural and linguistic differences in how 
beneficiaries interact with technology and ensure seniors and Medicaid 
beneficiaries can fully leverage digital health technologies.

     Recommendation 4.4: Congress and the Administration should revisit 
cost-
sharing requirements for digital health. Monthly recurring copays for 
remote patient monitoring and other virtual care solutions can serve as 
a deterrent to those living with chronic and complex conditions that 
may benefit most from ongoing care management solutions.

Ensure Patient Privacy and Address Cybersecurity Risks

The protection of patient privacy and personal data are critical to the 
expansion of virtual care. Balanced federal health data privacy and 
cybersecurity policy are necessary to support innovation; however, 
telehealth and digital health technologies must be required to mitigate 
cybersecurity risks and protect patients' privacy and personal health 
data. Coordinated disclosure, information sharing, patient and provider 
education, and the development of consensus standards must remain the 
cornerstone of cybersecurity policy for regulated devices, mobile 
applications, and related health-care products to ensure that risks to 
patients and providers are mitigated.

     Recommendation 5.1: Post-pandemic, the HHS Office of Civil Rights 
(OCR) should swiftly end the current COVID-19 PHE HIPAA enforcement 
discretion policy and ensure virtual care and telehealth encounters are 
conducted via secure HIPAA-compliant platforms designed to protect PHI. 
Patients should be assured that health-care providers are complying 
with HIPAA's privacy, security, and breach notification requirements 
when receiving care virtually.

     Recommendation 5.2: While the Federal Trade Commission (FTC) has 
some authority to regulate organizations that are not considered 
covered entities under HIPAA, the FTC's authority is limited to 
practices that are ``unfair or deceptive.'' To better protect patients 
and consumers and address the patchwork privacy framework for health 
data in the U.S., Congress should establish a Commission to study and 
issue recommendations for the protection of individual privacy that 
balances the need to preserve innovation, with clear rules of the road 
for the appropriate use of health information by mobile application and 
platform developers.

     Recommendation 5.3: The Food and Drug Administration (FDA), HHS, 
and other health-care regulators already have broad authority to 
strengthen the cybersecurity requirements for regulated devices and 
products that could potentially be exploited by bad actors. Federal 
agencies must prioritize the recognition, promotion, and direct 
participation in the development of private sector consensus standards 
to ensure manufacturers and developers have a consistent framework for 
implementing cybersecurity safeguards. Given today's dynamic threat 
landscape, Congress and relevant agencies should also facilitate 
collaboration with health-care delivery organizations, medical device 
manufacturers, independent security experts, and academia through 
public-private partnerships to ensure that these stakeholders are able 
to quickly address and resolve emerging cybersecurity threats to 
patients and providers.

 Expand Patient Health Data Portability and Ensure Interoperability of 
                    Digital Health Technology

The COVID-19 pandemic has demonstrated the importance of patients and 
providers having access to health-care data when and where they need 
it. Over the past decade, progress has been made to incentivize the 
adoption of technologies that are capable of exchanging electronic 
health information; however, data remains siloed and inaccessible 
across much of the health-care system. Congress and the Administration 
must remain committed to advancing a patient-centered interoperable 
health-care system that empowers patients and enables providers to 
deliver safe and efficient care.

     Recommendation 6.1: CMS and ONC should remain committed to 
implementing the 21st Century Cures Act, including robust enforcement 
of the CMS Interoperability and Patient Access Final Regulation and the 
ONC Interoperability and Information Blocking Final Regulation--both of 
which will advance the uptake of patient access application programming 
interfaces (APIs) and facilitate greater provider-to-provider and 
payer-to-payer data exchange. COVID-19 has placed an unprecedented 
burden on the nation's health-care system, and the agencies should 
extend implementation deadlines in line with the COVID-19 PHE.

Protect Patients and Taxpayers

The economic benefits of robust antifraud and abuse enforcement under 
existing federal law are much larger than monetary settlements when 
accounting for deterrence effects, including long-lasting changes in 
physician behavior and wasteful medical procedures.\9\ Antifraud 
enforcement and investigations of waste and abuse in federal health 
programs must be a priority. However, Congress must be cautious about 
letting program integrity concerns dictate virtual care policy in 
traditional Medicare FFS. Arbitrarily restricting telehealth coverage 
for seniors, including mandated prior in-person visits, is not a viable 
program integrity strategy for Medicare. Such a strategy would cause 
Medicare Advantage and private health plans members to receive more 
robust telehealth benefits and could exacerbate health-care 
disparities. As virtual care is expanded, the federal agencies tasked 
with protecting federal health programs--and ultimately beneficiaries 
and taxpayers--must be appropriately equipped to maximize and leverage 
currently available technologies and strategies to audit claims and 
enhance fraud investigations.
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    \9\ Howard, David H, and Ian McCarthy. ``Deterrence Effects of 
Antifraud and Abuse Enforcement in Healthcare.'' Working Paper. Working 
Paper Series. National Bureau of Economic Research, October 2020, 
https://www.nber.org/papers/w27900.

        HHS OIG and CMS must continue to invest in innovative 
        strategies, appropriate private sector best practices, and 
        leverage artificial intelligence and predictive analytics 
        rather than rely on policies that would restrict access to 
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        virtual care.

     Recommendation 7.1: HHS OIG and CMS have extensive program 
integrity policies and procedures in place to address fraud, waste, 
abuse, and improper payments. Congress should ensure HHS and CMS have 
the necessary tools to combat bad actors and provide robust funding for 
critical antifraud programs. Teladoc Health believes that the existing 
public-private partnership codified under Sec. 124, Public-Private 
Partnership for Health Care Waste, Fraud, and Abuse Detection, H.R. 
133, Consolidated Appropriations Act, 2021 can significantly advance 
efforts to mitigate and prevent telehealth from being utilized as an 
avenue for fraud and abuse. We recommend strengthening the public 
private partnership by ensuring experts with experience in virtual care 
are included and represented on the executive board.

     Recommendation 7.2: States should maintain responsibility for 
regulating the practice of medicine to ensure the full resources of the 
state are available for the protection of any patients that receive 
services that fall short of the standard of care. Federal policy should 
support and incentivize the adoption of interstate licensure compacts 
and other related licensure portability policies to ensure that 
clinicians can treat patients safely across state lines.

Infuse Innovation into Federal Health-care Programs

More than seven million federal employees have access to Teladoc Health 
solutions through their Federal Employees Health Benefit Program. There 
is great potential to empower those in federal service through 
contracting opportunities with entities like the Department of Veterans 
Affairs, the Department of Defense and the Indian Health Service. 
Supporting and caring for federal health beneficiaries with chronic 
conditions is a complex process that draws on many clinical and 
financial resources from across the federal government. From devices 
and supplies to care management, nutrition, clinic visits, and 
specialist consults, the points of contact for a beneficiary, and the 
associated agency cost/payment flows, are numerous.

Modern digital disease management solutions offer the potential to make 
things easier and meet federal health beneficiaries where and when they 
need support the most. Connected data can be combined with intelligent 
support and empathetic coaching that is available all day every day. 
Unfortunately, most federal beneficiaries with chronic conditions have 
little access to management tools such as this. Depending on their 
disability status, federal beneficiaries receive various levels of care 
from appointments to medications and testing. Across Medicare/Medicaid, 
VA, and IHS, beneficiaries are now receiving video visits via 
telehealth, as well as a small number receiving home-based remote 
monitoring. This piecemeal approach does not allow for scale or 
comprehensive cost analysis and is complicated for both beneficiary and 
federal agency alike.

     Recommendation 8.1: Congress must continue to invest and ensure 
that federal health-care program beneficiaries through the Office of 
Personnel Management (OPM), the Department of Veterans Affairs (VA), 
the Department of Defense (DoD) and the Indian Health Services (IHS) 
have access to telehealth and other innovative virtual care offerings 
to manage their health and wellness.

     Recommendation 8.2: As hospital systems, health plans, and 
employers, are seizing on modern virtual care methods to support their 
patients and beneficiaries with chronic conditions, VA, DOD, and IHS 
should create pathways to pursue Alternative Payment Models (APMs) for 
chronic conditions and diabetes management.

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