[Senate Hearing 117-792]
[From the U.S. Government Publishing Office]
S. Hrg. 117-792
STATE OF TELEHEALTH: REMOVING BARRIERS
TO ACCESS AND IMPROVING PATIENT OUTCOMES
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON COMMUNICATIONS, MEDIA,
AND BROADBAND
OF THE
COMMITTEE ON COMMERCE,
SCIENCE, AND TRANSPORTATION
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
__________
OCTOBER 7, 2021
__________
Printed for the use of the Committee on Commerce, Science, and
Transportation
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available online: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
54-261 PDF WASHINGTON : 2023
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SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
MARIA CANTWELL, Washington, Chair
AMY KLOBUCHAR, Minnesota ROGER WICKER, Mississippi, Ranking
RICHARD BLUMENTHAL, Connecticut JOHN THUNE, South Dakota
BRIAN SCHATZ, Hawaii ROY BLUNT, Missouri
EDWARD MARKEY, Massachusetts TED CRUZ, Texas
GARY PETERS, Michigan DEB FISCHER, Nebraska
TAMMY BALDWIN, Wisconsin JERRY MORAN, Kansas
TAMMY DUCKWORTH, Illinois DAN SULLIVAN, Alaska
JON TESTER, Montana MARSHA BLACKBURN, Tennessee
KYRSTEN SINEMA, Arizona TODD YOUNG, Indiana
JACKY ROSEN, Nevada MIKE LEE, Utah
BEN RAY LUJAN, New Mexico RON JOHNSON, Wisconsin
JOHN HICKENLOOPER, Colorado SHELLEY MOORE CAPITO, West
RAPHAEL WARNOCK, Georgia Virginia
RICK SCOTT, Florida
CYNTHIA LUMMIS, Wyoming
Melissa Porter, Deputy Staff Director
George Greenwell, Policy Coordinator and Security Manager
John Keast, Republican Staff Director
Crystal Tully, Republican Deputy Staff Director
Steven Wall, General Counsel
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SUBCOMMITTEE ON COMMUNICATIONS, MEDIA, AND BROADBAND
BEN RAY LUJAN, New Mexico, Chair JOHN THUNE, South Dakota, Ranking
AMY KLOBUCHAR, Minnesota ROY BLUNT, Missouri
RICHARD BLUMENTHAL, Connecticut TED CRUZ, Texas
BRIAN SCHATZ, Hawaii DEB FISCHER, Nebraska
EDWARD MARKEY, Massachusetts JERRY MORAN, Kansas
GARY PETERS, Michigan DAN SULLIVAN, Alaska
TAMMY BALDWIN, Wisconsin MARSHA BLACKBURN, Tennessee
TAMMY DUCKWORTH, Illinois TODD YOUNG, Indiana
JON TESTER, Montana MIKE LEE, Utah
KYRSTEN SINEMA, Arizona RON JOHNSON, Wisconsin
JACKY ROSEN, Nevada SHELLEY MOORE CAPITO, West
JOHN HICKENLOOPER, Colorado Virginia
RAPHAEL WARNOCK, Georgia RICK SCOTT, Florida
CYNTHIA LUMMIS, Wyoming
C O N T E N T S
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Page
Hearing held on October 7, 2021.................................. 1
Statement of Senator Lujan....................................... 1
Statement of Senator Thune....................................... 3
Statement of Senator Wicker...................................... 4
Statement of Senator Schatz...................................... 29
Statement of Senator Cantwell.................................... 33
Statement of Senator Moran....................................... 35
Statement of Senator Blumenthal.................................. 39
Statement of Senator Blunt....................................... 41
Statement of Senator Tester...................................... 42
Statement of Senator Cruz........................................ 44
Statement of Senator Peters...................................... 46
Statement of Senator Blackburn................................... 47
Statement of Senator Warnock..................................... 49
Statement of Senator Rosen....................................... 51
Statement of Senator Klobuchar................................... 53
Statement of Senator Young....................................... 56
Witnesses
Sterling N. Ransone, Jr., MD, FAAFP, President, American Academy
of Family Physicians........................................... 5
Prepared statement........................................... 7
Hon. Brendan Carr, Commissioner, Federal Communications
Commission..................................................... 12
Prepared statement........................................... 13
Deanna Larson, President, Avel eCare; Founder, American Board of
Telehealth; Executive Secretary, American Telemedicine
Association.................................................... 16
Prepared statement........................................... 18
Dr. Sanjeev Arora, President and Founder, Project ECHO/ECHO
Institute; Distinguished and Regents' Professor of Medicine,
University of New Mexico Health Sciences Center (UNMHSC)....... 21
Prepared statement........................................... 22
Appendix
Alliance for Connected Care, prepared statement.................. 61
Response to written questions submitted to Dr. Sterling Ransone
by:
Hon. Ben Ray Lujan........................................... 64
Hon. Amy Klobuchar........................................... 65
Hon. Kyrsten Sinema.......................................... 66
Minority Committee Members................................... 68
Response to written questions submitted to Hon. Brendan Carr by:
Hon. Ben Ray Lujan........................................... 69
Hon. Kyrsten Sinema.......................................... 69
Hon. Ron Johnson............................................. 71
Hon. Roger Wicker............................................ 74
Hon. Shelley Moore Capito.................................... 74
Hon. Mike Lee................................................ 75
Hon. Dan Sullivan............................................ 76
Response to written questions submitted to Deanna Larson by:
Hon. Maria Cantwell.......................................... 78
Hon. Kyrsten Sinema.......................................... 79
Response to written question submitted to Dr. Sanjeev Arora by:
Hon. Ben Ray Lujan........................................... 80
Hon. Kyrsten Sinema.......................................... 81
Hon. Dan Sullivan............................................ 82
STATE OF TELEHEALTH: REMOVING
BARRIERS TO ACCESS AND
IMPROVING PATIENT OUTCOMES
----------
THURSDAY, OCTOBER 7, 2021
U.S. Senate,
Subcommittee on Communications, Media, and Broadband,
Committee on Commerce, Science, and Transportation,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:01 a.m., in
room SR-253, Russell Senate Office Building, Hon. Ben Ray
Lujan, Chairman of the Subcommittee, presiding.
Present: Senators Lujan [presiding], Cantwell, Klobuchar,
Blumenthal, Schatz, Peters, Tester, Rosen, Hickenlooper, Thune,
Wicker, Blunt, Cruz, Moran, Blackburn, Young, and Johnson.
OPENING STATEMENT OF HON. BEN RAY LUJAN,
U.S. SENATOR FROM NEW MEXICO
Senator Lujan. Well--and we very much appreciate all of our
panelists who are here today. Over the past year and a half,
the COVID-19 pandemic has changed so much about how we live our
lives. To stay safe, we changed how we worked, how we see
friends, and how we connect with family. But nothing changed so
fundamentally as our relationship with health care.
Staying safe became a daily question. At times, hospitals
and emergency rooms were full, leaving patients with nowhere to
go. Doctors needed new ways to care for their patients that
wouldn't further expose them to a virus that could threaten
their health and well-being. To solve this problem, many
doctors and patients turned to telehealth at the start of the
pandemic.
From February to May 2020, the U.S. Department of Veterans
Affairs reported weekly appointments on their telehealth
applications surged from 10,000 to 120,000 a week. Nationwide,
weekly telemedicine visits increased over 2,300 percent. The
number of telemedicine appointments are now 23 times higher
than they were before the pandemic. Nearly one in three health
care visits now use telehealth services. Not only did usage go
up, the landscape of American health care changed.
According to data by the Department of Health and Human
Services, before the pandemic, over half of all community
health centers were not equipped to provide telemedicine
services. Today, that number is under 5 percent. Physicians
have found ways to incorporate telehealth, including audio only
options into their practice, and patients have seen benefits
from the convenience and accessibility that these services have
offered. These services kept Americans safe when ICU beds ran
low in Dona Ana County in New Mexico.
Local, public, and private partners rapidly assembled a
remote telehealth monitoring program. This allowed many
patients to recover in their own homes while still under the
supervision of trained medical staff. The program freed up beds
and saved lives. I want to thank Ranking Member Thune for his
partnership and willingness to engage in this discussion, and
also to Chair Cantwell and Ranking Member Wicker for their
leadership in making historic investments in telehealth over
the last few years.
We all see the urgency here. Congress appropriated $450
million to the COVID-19 telehealth program in the CARES Act and
the Consolidated Appropriations Act to increase telehealth
services. Thanks to Acting Chair Rosenworcel's leadership, the
Federal Communications Commission continues to support
essential connections for telehealth. The Commission helps
fund, secure confidential remote medical consultations,
especially for those living in rural areas. That is why we are
here today.
Over the past year, New Mexico received over $1 million to
help connect patients. This funding will help improve health
care in the Presbyterian Medical Services in Santa Fe and
Albuquerque, and First Choice Community Health Care South
Valley Family Health Commons. These programs are essential, but
our work is just beginning. Digital divide is standing in our
way of connecting all Americans to this vital service.
According to the FCC, 14.5 million Americans lack even a low
speed broadband connection. These communities are effectively
cutoff from many of the benefits of telehealth.
Native American and Hispanic communities are less likely to
have access to high speed broadband and are less likely to take
advantage of telehealth services. Rural areas continue to face
higher costs for broadband infrastructure. We must connect
every American to high quality, affordable, resilient
broadband. Without it, the current patterns of inequality will
continue to grow. The bipartisan Infrastructure Investment and
Jobs Act includes $65 billion to increase broadband access and
adoption.
We urgently need to deliver this relief to communities
across the country. Families must be able to talk to their
doctor without worrying about hitting a data cap. Critical
remote monitoring systems must remain online during network
outages, bad weather, and natural disasters. These are
priorities that I have long advocated for, and I will continue
to lead the fight in many of these areas and work with my
colleagues to solve these challenges.
Finally, to ensure every American has access to telehealth,
we must focus on solutions that work for underserved and
unserved communities, underserved by broadband, underserved
without access to critical health care. The solution must
include access to affordable broadband Internet service,
support for connected devices, and access to digital literacy
programs.
We have a distinguished panel of experts today to discuss
the state of telehealth in the country, consider existing
barriers, and explore solutions. I want to introduce them
before I turn this over to our Ranking Member as well.
Dr. Arora, he saw a critical gap in specialized care in New
Mexico almost 20 years ago. Since then, Project Echo has
reached over 1 million participants. Commissioner Carr has
traveled across the Nation gathering stories and evidence of
the need for rural health--rural telehealth access and turn
that into policy initiatives. Ms. Larson has made a career of
her passion to provide better access to quality health care and
specialty services for residents of rural communities.
And Dr. Ransone has seen firsthand how telehealth can
enhance the patient-physician relationship, taking up that
charge as President of the American Academy of Family
Physicians.
And I look forward to their discussion today. And I want to
recognize Ranking Member Thune for opening remarks.
STATEMENT OF HON. JOHN THUNE,
U.S. SENATOR FROM SOUTH DAKOTA
Senator Thune. Good morning, and thank you, Chairman Lujan,
for holding this hearing. As a resident of a rural state, I
have long been a proponent of telehealth for the access it
gives to rural communities. If you live in a major city, you
usually don't have to think too much about where you will find
a doctor if you need one. But that is not always the case for
Americans in rural areas.
In the smallest towns in America, access to specialty care
can be a challenge. The only providers may be primary care
providers, nurses, pharmacists. These providers are essential
to rural families, and there are times when specialty care is
needed. And when there isn't a specialist close by, telehealth
can help get patients to the medical care they need from a
remote location through the use of technology. Telehealth
services are also critical in nursing home facilities.
In my state, we have strong programs designed to bring on
demand support into facilities to help avoid unnecessary
emergency department transfers. By reducing unnecessary senior
hospitalizations--I should say, my Reducing Unnecessary Senior
Hospitalizations Act, or the RUSH Act, would help facilitate
more arrangements like we have in South Dakota, allowing
medical groups to collaborate with nursing homes, provide
telehealth services through a Medicare alternative payment
model.
I am also pleased to support the bipartisan Connect for
Health Act, which aims to expand telehealth services through
Medicare and is supported by more than half of the U.S. Senate.
The bipartisan CARES Act played an important role in further
expanding access to telehealth throughout the COVID-19
pandemic, and I look forward to continuing the conversation
with my colleagues at the Senate Finance Committee on the path
forward for Medicare reimbursement post-pandemic.
In my role on this committee, I will continue to advocate
for the expansion of broadband services, which has allowed more
patients in rural areas to take advantage of telehealth
services. It is critical that any additional broadband funding
goes to truly underserved areas so we can expand the reach of
next generation services like telehealth. The Federal
Communications Commission plays an important role to help
expand telehealth services through a number of programs.
Congress, acting in a bipartisan manner, provided a
significant amount of funding for the FCC's COVID-19 telehealth
program through the CARES Act and the year-end coronavirus
relief package. Several health care providers in all 50 states
have been able to participate in this important program. In my
home state, there are a number of excellent health care
providers expanding access to telehealth services by
participating in this program. The Community Health Care
Association of the Dakotas received funding for equipment
necessary to expand remote patient monitoring and other
telehealth services in community health centers.
Sanford Health was able to utilize funding to secure
wireless access points, which is necessary to conduct
confidential telehealth appointments. And Avera Health and its
affiliated Avel eCare represented on this panel today to
receive funding for a number of services, including remote
monitoring equipment and software to provide care for
chronically ill patients in their homes. In addition to the
FCC's COVID-19 telehealth program, the FCC's Universal Service
Fund provides support for the Rural Health Care Program and for
the Connected Care Pilot Program, which was spearheaded by
Commissioner Carr.
I appreciate Commissioner Carr taking the time to speak
with us today about these programs. It is my hope that we will
see you again soon before this committee, as there are many
other important issues at the FCC of interest to members here.
And last, I would like to extend my thanks to Ms. Deanna
Larson, who is President of Avel eCare, for joining us today.
As President of Avel eCare, Ms. Larson has helped advance
telehealth services across many areas in the Midwest. Thank you
to all of the witnesses for being here today, and I look
forward to hearing from you. Thank you, Mr. Chairman.
Senator Lujan. Now, recognize Ranking Member Wicker for
opening remarks.
STATEMENT OF HON. ROGER WICKER,
U.S. SENATOR FROM MISSISSIPPI
Senator Wicker. Thank you very much, Chairman Lujan and
Senator Thune for convening this important hearing on
telehealth. We have got someone here from South Dakota. We have
someone here from New Mexico. And us folks in Mississippi kind
of think that Brendan Carr is an honorary Mississippian. So
please to see him here. And of course, he is the leading voice
for telehealth on the FCC. Telehealth is becoming an
indispensable part of our health care system.
The COVID-19 pandemic only accelerated the expansion of
telehealth as more aspects of our lives moved online. Today,
millions of Americans, particularly in rural and underserved
communities, rely on telehealth for real time and continuous
access to medical care. Telehealth is highly cost effective and
convenient for both doctors and patients. Doctors are able to
monitor their patients' conditions from afar, collaborate
quickly with other health care professionals, and provide
faster diagnosis and treatment.
Telehealth also helps patients to manage their own health.
Patients can track their symptoms; send vital information to
doctors, set up medication reminders, and much more. These
services are especially helpful to rural Americans, veterans,
and other underserved populations who routinely face doctor
shortages and hospital closures. I once supported the expansion
of telehealth. In 2018, Commissioner Carr and I visited the
University of Mississippi Medical Center to unveil the FCC's
new Connected Care Pilot Program. UMMC Center for Telehealth is
a national leader in telehealth, providing high quality care to
thousands of Mississippians and Americans across the country.
The FCC's Connected Care Pilot Program is currently
studying how investments from the Universal Service Fund can
support patient and provider use of Connected Care services,
and how that support can improve health outcomes and reduce
costs. I am proud to have led efforts to include $450 million
in the FCC's COVID-19 telehealth program in the CARES Act and
the Consolidated Appropriations Act.
These funds help reimburse providers for the connectivity
and devices they need to keep telehealth available during the
pandemic. Ultimately, we will not realize the full benefits of
telehealth without reliable broadband access. Senator Lujan, in
his statement, correctly said, ``we must conquer the digital
divide in order to have effective telehealth,'' and he is
correct there. More than 14 million Americans lack access to a
broadband connection.
And a vast majority of those Americans, 11 million, live in
rural areas. Our Nation's rural communities should have access
to the range of benefits that come from having a broadband
connection, including telehealth. The broadband investments we
are making both at the FCC and through the bipartisan
infrastructure bill will help achieve that goal.
Today's hearing is an opportunity to discuss our progress
in making telehealth more accessible, and I appreciate the
leadership of the Subcommittee in forwarding this issue. Thank
you, Mr. Chair.
Senator Lujan. Thank you, Ranking Member Wicker. And next
we will recognize our witnesses for their testimony. We are
first going to hear from Dr. Sterling Ransone, the President of
the American Academy of Family Physicians and a practicing
physician coming to us from Deltaville, Virginia. Dr. Ransone.
STATEMENT OF STERLING N. RANSONE, JR., MD, FAAFP, PRESIDENT,
AMERICAN ACADEMY OF FAMILY PHYSICIANS
Dr. Ransone. Thank you. Chairman Lujan, Ranking Member
Thune, and members of the Committee, I am Dr. Sterling Ransone,
President of the American Academy of Family Physicians, and I
am honored to be here today representing the 133,500 physician
and student members of the AAFP.
In addition to my leadership role at the AAFP, I am the
Physician Practice Director at Riverside Fishing Bay family
practice in Deltaville, Virginia, and Assistant Clinical
Professor of Family Medicine and Population Health at Virginia
Commonwealth University. I have practiced in a rural community
for more than 20 years with my wife, who is a pediatrician, and
I have seen firsthand how telehealth can be used as a tool to
enhance the patient-physician relationship, increase access to
care, improve health outcomes by enabling timely care
interventions, and decrease costs when utilized as part of a
patient's medical health.
Full success of telehealth cannot be achieved without
significantly improving our Nation's broadband infrastructure.
The ongoing pandemic has highlighted the importance of
broadband for access to many primary care services, especially
in the areas of mental and behavioral health care. Broadband
access must be recognized as a social determinant of health.
The COVID-19 pandemic has underscored the strong link between
digital equity and health equity.
In order to realize the potential of telehealth and address
health disparities, Congress must invest in efforts to ensure
universal access to affordable broadband services for all
individuals and their health care providers. The AAFP supports
the FCC's Rural Health Care Program, which has helped many
rural clinicians obtain high-speed broadband connections. This
has allowed practices like mine to implement telehealth
services onsite, which can in turn provide patients access to
tertiary care by connecting them and me to remote specialists.
However, to provide virtual primary care to patients at
home, both the clinician and the patient need access to
broadband. Many of my patients, particularly those enrolled in
Medicaid, are unable to afford high-speed Internet at home,
which affects their ability to use telehealth services and
limits my engagement with them outside the office. Beyond
virtual visits, the lack of broadband access is also limiting
the potential of other digital health tools, such as patient
portals and remote patient monitoring. It is not enough simply
to expand access to broadband.
Congress must ensure that patients in need of access, end-
user devices such as tablets or computers, we need them to
connect to digital health tools, and we should invest in
training and assistance so patients can confidently use those
tools to ensure that they are not further marginalized. For
many small physician practices, the cost of telehealth
technology can be prohibitive. In addition to hardware costs,
many telemedicine vendors charge setup fees up to $3,000 and
recurring subscription and transaction fees.
Congress should ensure that small practices are adequately
supported, either by making them eligible for funding through
existing FCC telehealth programs or by creating a new program.
Supporting telehealth adoption within these offices will
improve equitable and timely access to health care and promote
competition by enabling smaller practices to remain
independent.
As this committee is acutely aware, our Nation has a long
way to go before all Americans have high-speed broadband and
the tools and knowledge to leverage it for virtual video health
care visits. Further, there may be times that an old fashioned
phone call is the best way for a clinician to access and treat
a patient. Therefore, it is critical to preserve access to
audio only telehealth services provided by a patient's usual
source of care. Coverage and payment policy should support
patients and clinicians' ability to choose the most appropriate
modality of care.
As a family physician, I am a highly trained professional
and I adhere to the standards of care. I also truly know my
patients have formed--truly know my patients and have formed
trusted relationships with them over the years. No two patients
or cases are alike, and I should be able to choose how to best
care for them based on my clinical judgment, not based on
arbitrary insurance rules. Telehealth benefit expansions must
increase access to one's own physician and promote high
quality, comprehensive continuous care.
Expanding telehealth services in isolation without regard
for previously existing patient-physician relationships,
knowledge of medical history, or the eventual need for a
follow-up, hands-on physical exam can undermine the basic
principles of the medical home, increase fragmentation of care,
and lead to the patient receiving suboptimal treatment.
Telehealth can't fully replace in-person care. Federal
policy should support physician practices like mine in adopting
and sustaining telehealth availability so that we can serve our
patients both virtually and in the pandemic. The COVID-19
pandemic has illustrated that telehealth can be an essential
part of health care, but more needs to be done to ensure that
every person in every community of our country has access to
high quality virtual care as part of their medical home.
I appreciate the opportunity to discuss our recommendations
with the Committee. Thank you.
[The prepared statement of Dr. Ransone follows:]
Prepared Statement Sterling N. Ransone, Jr., MD, FAAFP, President,
American Academy of Family Physicians
Chairman Lujan, Ranking Member Thune and members of the Committee:
I am Dr. Sterling Ransone, president of the American Academy of Family
Physicians (AAFP), and I am honored to be here today representing the
133,500 physician and student members of the AAFP.
In addition to my leadership role at the AAFP, I am the physician
practice director at Riverside Fishing Bay Family Practice in
Deltaville, Va., and an assistant clinical professor of family medicine
and population health at Virginia Commonwealth University.
Having practiced in a rural community for more than 20 years with
my wife, who is a pediatrician, I have seen firsthand how telehealth
can enhance the patient-physician relationship; increase access to
care; improve health outcomes by enabling timely care interventions;
and decrease costs when utilized as a component of, and coordinated
with, continuous care. Telehealth services during the pandemic have
allowed patients and families to maintain access to their usual source
of primary care, ensuring care continuity.
Full success of telehealth cannot be achieved without significantly
improving our Nation's broadband infrastructure. The ongoing pandemic
has highlighted the utility and importance of broadband for access to
primary care, mental and behavioral health care, education, remote
work, applications for support programs, and public health information.
Without broadband, many rural, tribal, and urban areas lack
critical resources, and physicians face greater difficulty serving
these communities. Recent research found that lack of access to high-
speed Internet was a primary barrier to equitable telehealth access for
patients in rural areas, and stories from family physicians confirm
that too many people have been left out as telehealth has grown during
the COVID-19 pandemic.\1\ We must make sure that, moving forward, we
have policies and programs in place that enable equitable telehealth
access and utilization.
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\1\ Kelly A Hirko, Jean M Kerver, Sabrina Ford, Chelsea Szafranski,
John Beckett, Chris Kitchen, Andrea L Wendling, Telehealth in response
to the COVID-19 pandemic: Implications for rural health disparities,
Journal of the American Medical Informatics Association, Volume 27,
Issue 11, November 2020, Pages 1816-1818, https://doi.org/10.1093/
jamia/ocaa156
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As Congress considers investments in our Nation's broadband
infrastructure and policies to expand telehealth access beyond the
public health emergency, the AAFP offers the following recommendations.
Invest in efforts to ensure universal access to affordable
broadband services for individuals and health care providers.
Invest in programs that provide end-user devices and digital
literacy training and assistance to patients in need.
Expand and target Federal telehealth programs to support
small physician practices.
Preserve access to audio-only telehealth.
Adopt coverage and payment policies that support physicians'
and clinicians' ability to choose the most appropriate modality
of care.
Adopt telehealth policies that enhance the physician-patient
relationship rather than disrupt it, and also incentivize
coordinated, continuous care provided by the medical home.
Monitor the impact of telehealth and broadband on health
care access and equity by ensuring that data collection and
evaluation include race, ethnicity, gender, language, and other
key factors.
Broadband access must be recognized as a social determinant of
health. The COVID-19 pandemic has underscored the strong link between
digital equity and health equity. Having access to broadband,
especially in times of pandemic and disaster, is vital for connecting
people to the most basic necessities, such as health care, education,
and employment. It is estimated that 42 million Americans don't have
the ability to purchase broadband Internet service.\2\ And rural
Americans are 10 times more likely to lack broadband access than their
urban counterparts.\3\ Additionally, rural areas tend to rely on older
broadband technologies such as DSL, satellite internet, or cellular-
based fixed wireless access. These broadband technologies are useful
for limited web-browsing, but typically are not reliable enough to
support telehealth services. In order to realize the potential of
telehealth and address health disparities, Congress must invest in
efforts to ensure universal access to affordable broadband services for
individuals and health care providers.
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\2\ Busby, J., Tanberk, J., & Cooper, T. (2021, August 29).
BroadbandNow estimates availability for all 50 states; confirms that
more than 42 million Americans do not have access to Broadband.
BroadbandNow Research. Retrieved October 2, 2021, from https://
broadbandnow.com/research/fcc-broadband-overreporting-by-state.
\3\ Congressional Research Service. (2019, March 22). Broadband
loan and grant programs in the USDA's rural utilities service.
Retrieved October 2, 2021, from https://sgp.fas.org/crs/misc/
RL33816.pdf.
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The AAFP supports the Federal Communications Commission's (FCC)
Rural Health Care (RHC) Program, which has helped bridge the digital
divide for many rural health care providers by allowing them to obtain
high-speed broadband connections similar to their urban and suburban
counterparts. These broadband connections have allowed rural practices
like mine to implement telehealth services on-site, which can provide
patients with timely access to comprehensive care by connecting them
and me to remote specialists. However, to provide virtual care to
patients at home, both the clinician and the patient need access to
broadband.
Lack of broadband Internet is associated with fewer telehealth
visits, and rural and low-income urban populations are less likely to
have broadband internet.\4\,\5\ Affordability remains one of
main barriers to broadband adoption. The lack of reliable and
affordable Internet access is especially severe in rural communities,
where only two out of every three people say they have broadband
access.\6\ I have seen many of my patients, particularly those enrolled
in Medicaid, who are unable to afford high-speed Internet at home,
which affects their ability to use telehealth services and limits my
engagement with them outside the office.
---------------------------------------------------------------------------
\4\ Wilcock, A. D., Rose, S., Busch, A. B., Huskamp, H. A., Uscher-
Pines, L., Landon, B., & Mehrotra, A. (2019, July 29). Association
Between Broadband Internet Availability and Telemedicine Use. JAMA
Intern Med, 179(11), 1580-1582. https://jamanetwork.com/journals/
jamainternalmedicine/article-abstract/2739054
\5\ Velasquez, D. & Mehrotra, A. (2020, May 8). Ensuring The Growth
Of Telehealth During COVID-19 Does Not Exacerbate Disparities In Care.
Health Affairs Blog. https://www.health
affairs.org/do/10.1377/hblog20200505.591306/full/
\6\ Vogels, E. (2021, September 10). Some digital divides persist
between rural, urban and Suburban America. Pew Research Center.
Retrieved October 2, 2021, from https://www.pewre
search.org/fact-tank/2021/08/19/some-digital-divides-persist-between-
rural-urban-and-suburban-america/.
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The FCC's Lifeline Program has been critical in helping low-income
Americans access broadband; however, it is used almost exclusively for
mobile, rather than in-home, broadband services. Mobile services have
significant value, but broadband at home creates additional public
benefits--including the ability to connect with your physician via
telehealth. Additionally, mobile or wireless broadband connections may
not have sufficient bandwidth depending on the telehealth platform. We
urge Congress to expand and reform the Lifeline Program so it can also
provide broadband access in homes and in turn expand access to
telehealth.
Beyond virtual visits, the lack of broadband access is limiting the
potential of other digital health tools, such as patient portals and
remote patient monitoring. Patients who cannot access the online
patient portal cannot view their own or a family member's health data,
message securely with their physician, schedule appointments online, or
request prescription refills online. Remote monitoring devices can feed
real-time patient data, such as vitals, to clinicians and allow them to
adjust medications and treatment regimens as needed without bringing
the patient back into the office; however, these devices work only with
a strong, reliable Internet connection. I have a patient with
congestive heart issues who drives more than an hour each way to see me
and who would benefit tremendously from this technology, but we can't
use it because of poor bandwidth.
A 2020 report found that access to broadband for Black and Hispanic
Americans is an estimated 10 years behind that of white Americans.\7\
As stated in our joint principles for telehealth policy in partnership
with the American Academy of Pediatrics and the American Colleges of
Physicians, equitable access to broadband is critical to reducing
health disparities and addressing many social determinants of health,
including education and employment.
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\7\ Walia, A. (2020, September 3). America's Racial Gap & Big
Tech's closing window. Deutsche Bank Research. Retrieved October 2,
2021, from https://www.dbresearch.com/PROD/RPS_EN-
PROD/America%27s_Racial_Gap_%26_Big_Tech%27s_Closing_Window/
RPS_EN_DOC_VIEW
.calias?rwnode=PROD0000000000464258&ProdCollection=PROD0000000000511664.
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The COVID-19 pandemic has reinforced how lack of access to
broadband and end-user devices perpetuates digital health inequity, and
limited access to virtual health information worsens the digital
divide.\8\,\9\ It is not enough to simply expand access to
broadband. Congress must ensure that patients in need can access end-
user devices, such as tablets, to connect to digital health tools and
invest in training and assistance so patients can confidently use those
tools to ensure we don't further marginalize and disenfranchise them.
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\8\ Rowlands, G. (n.d.). Digital Health Literacy. World Health
Organization. Retrieved October 2, 2021, from https://www.who.int/
global-coordination-mechanism/activities/working-groups/17-s5-
rowlands.pdf.
\9\ Nelson, H. (2021, February 4). Lack of access to health
information threatens digital divide. Patient Engagement HIT. Retrieved
October 2, 2021, from https://patientengagementhit.com/news/lack-of-
access-to-health-information-threatens-digital-divide.
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One out of three households headed by someone over the age of 65
does not have a computer, and more than half of people over the age of
65 do not have a smartphone.\10\ 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 with 14 percent of
whites.\11\ Digital literacy also varies with age, income, and
ethnicity. Many of our members have shared the challenges their
patients have faced during the COVID-19 pandemic in accessing
telehealth services and their patient portal. In my practice, I have
seen that seniors have a significant learning curve when accessing
these tools unless they have a younger family member to help them log
on or troubleshoot technology issues.
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\10\ Ryan, C. & Lewis, J. M. (2017, September). Computer and
Internet Use in the United States: American Community Survey Reports.
United States Census Bureau. https://www.census.gov/content/dam/
Census/library/publications/2017/acs/acs-37.pdf
\11\ Child Trends. (2018, December 13). Home Computer Access and
Internet Use. https://www.childtrends.org/ indicators/home-computer-
access
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To achieve the full promise of telehealth, Congress must act to
address these structural barriers to virtual care. The AAFP has called
for 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 robust evaluation to
demonstrate how the interventions have addressed gaps in care or
increased access for underserved populations.
I applaud Congress' and the FCC's efforts and recognition that
closing the digital divide, especially during a pandemic, is critical
to ensuring that Americans continue to have access to care via
telehealth. Programs such as the COVID-19 Telehealth Program and
Connected Care Pilot Program have increased telehealth adoption among
community health centers and hospitals serving communities most in
need. The COVID-19 Telehealth Program has also helped ensure patients
have the connected devices they need to benefit from comprehensive
telehealth and remote monitoring services. Unfortunately, these have
largely excluded primary care practices, for which the startup and
ongoing costs of telehealth impede adoption.
For many small physician practices, especially those that serve a
disproportionate number of Medicaid and uninsured patients, the costs
of telehealth technology can be prohibitive. Many telemedicine vendor
solutions charge setup fees ranging from $400 to $3,000 dollars, in
addition to recurring subscription or transaction fees. Congress should
ensure that small practices are adequately supported, either by making
them eligible for funding through existing telehealth programs or by
creating a new program. Supporting telehealth adoption within these
practices will improve equitable and timely access health care and
promote health care competition by enabling smaller practices to remain
independent.
The AAFP supports the Connected Care Pilot Program's focus on
improving equitable access to quality telehealth services for low-
income patients by addressing the high cost of broadband connectivity,
including equipment and information services, and urges the FCC to
extend and expand this program.
As this Committee is acutely aware, our Nation has a long way to go
before all Americans have high-speed broadband and the tools and
knowledge to leverage it for virtual video health care visits. Further,
there may be times that an old-fashioned phone call is the best way for
a clinician to treat a patient. Therefore, it is critical to preserve
access to audio-only telehealth services provided by a patient's usual
source of care.
A survey of AAFP members conducted in May 2020 found that audio-
only telephone was the most commonly used tool for conducting virtual
visits, and a follow-up survey in September 2020 found that 80 percent
of respondents were still using telephone visits.\12\ From my own
experience, and talking with other family physicians, I can tell you
that the reasons for this are lack of reliable, high-speed Internet
connection; patients' inability to navigate complex technology required
for video visits; and the challenge for physicians of adopting or
perfecting a video-visit platform.
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\12\ AAFP Virtual Care Survey, May 2020
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A comprehensive review of literature comparing the effectiveness of
video conference versus telephone in the delivery of health care found
that patient outcomes were generally comparable between video
conference and phone, with no consistent differences in patient
mortality or satisfaction.\13\ These findings underscore that telephone
can be an effective and appropriate means of providing telehealth care.
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\13\ Rush, K. L., Howlett, L., Munro, A., & Burton, L. (2018,
October). Videoconference Compared to Telephone in Healthcare Delivery:
A Systematic Review. Int J Med Inform, 118, 44-53. https://
pubmed.ncbi.nlm.nih.gov/30153920/
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However, face-to-face interactions between a physician and a
patient are important components of a patient's care that allow a
physician to gather a comprehensive understanding of the patient and
their needs and build trust and communication. Unlike video visits,
telephone visits do not allow physicians the benefit of being able to
visually examine a patient or read body language and facial
expressions. AAFP members sharing their experiences with telehealth
said they feel much more comfortable evaluating patients they know over
the phone. To protect patient safety and reduce potential for fraud, it
may be prudent to limit coverage of telephone visits to established
patients.
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. Preserving access to audio-only telehealth
services is important for ensuring equitable access to care.
Coverage and payment policies 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 family physician, I am highly trained and
adhere to standards of care. I also know my patients and have formed
trusted relationships with them over years. No two patients or cases
are alike, and I should be able to choose how to care for them based on
my clinical judgement, not based on arbitrary insurance rules.
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, 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.\14\
---------------------------------------------------------------------------
\14\ Welch, B. M., Harvey, J., O'Connell, N. S., & Mcelligott, J.
T. (2017). Patient preferences for direct-to-consumer telemedicine
services: A nationwide survey. BMC Health Services Research, 17(1).
doi:10.1186/s12913-017-2744 https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC57
04580/
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Telehealth cannot fully replace in-person primary care. Researchers
at the Robert Graham Center recently conducted an analysis of National
Ambulatory Medical Care Survey (NAMCS) data to estimate what proportion
of primary care visits can be provided via telehealth.\15\ They found
that two-thirds of all primary care visits in 2016 required at least
one in-person service. The study also revealed how crucial primary care
practices are in providing preventive and chronic care: 95 percent of
immunizations and annual wellness visits, one-third of pap tests, 70
percent of foot exams and more than half of neurological and retinal
exams. Equally important, according to the Graham Center analysis, more
than 90 percent of all rapid strep tests and throat cultures occurred
in a primary care office setting, and one in four casts/splints/wraps
were performed by primary care physicians. While telehealth can expand
the reach of primary care by making it more convenient and accessible
to patients in their homes, it is clear that virtual-only providers
cannot offer fully comprehensive primary care. This underscores the
importance of Federal policymakers supporting physician practices like
mine in adopting and sustaining telehealth so that we can offer our
patients both in-person and virtual care.
---------------------------------------------------------------------------
\15\ Jabbarpour, Y., et al., Not Telehealth: What Primary Care
Visits Need In-Person Care?. Journal of American Board of Family
Medicine. https://www.jabfm.org/sites/default/files/COVID_20-
0247_Man.pdf
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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 suggested 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. With respect to broadband, more accurate information
can help Federal agencies direct funds to those households truly in
need, and in turn will help address the digital divide. As Congress
seeks additional studies to inform the direction of permanent
telehealth policies and additional broadband investments, you should
ensure the collection and reporting of data stratified by race,
ethnicity, gender, language, and other key factors.
In closing, the COVID-19 pandemic has illustrated that telehealth
can and should be an essential part of health care. But more needs to
be done to ensure that everyone in this country has access to high-
quality virtual care as part of their medical home. Thank you for the
opportunity to discuss our recommendations with the Committee.
Founded in 1947, the AAFP represents 133,500 physicians and medical
students nationwide. It is the largest medical society devoted solely
to primary care. Family physicians conduct approximately one in five
office visits--that's 192 million visits annually, or 48 percent more
than the next most-visited medical specialty. Today, family physicians
provide more care for America's underserved and rural populations than
any other medical specialty. Family medicine's cornerstone is an
ongoing, personal patient-physician relationship focused on integrated
care. To learn more about the specialty of family medicine, the AAFP's
positions on issues and clinical care, and for downloadable multimedia
highlighting family medicine, visit www.aafp.org/media. For information
about health care, health conditions, and wellness, please visit the
AAFP's award-winning consumer website, www.familydoctor.org.
Senator Lujan. Thank you, Dr. Ransone. Next, we are going
to hear from Commissioner Brendan Carr of the Federal
Communications Commission. Commissioner, floor is yours.
STATEMENT OF HON. BRENDAN CARR, COMMISSIONER, FEDERAL
COMMUNICATIONS COMMISSION
Mr. Carr. Thank you. Chairman Lujan, Ranking Member Thune,
Ranking Member Wicker, distinguished members of the Committee,
thank you for the invitation to testify. I would like to begin
by commending the Subcommittee for convening this important
hearing on telehealth, and for the leadership that members here
have shown in supporting these vital offerings and extending
Internet connectivity to more Americans.
Expanding access to telehealth has been a top priority for
me, and it is one that has long benefited from bipartisan
support at the agency and here in Congress. In fact, I have had
the chance to see firsthand the benefits that telehealth brings
to communities across the country. In New Mexico, on a visit to
the Mescalero Apache Reservation, I met with the team at the
Mescalero Indian Hospital. Thanks to a high speed connection,
community members can now have one-on-one video sessions with
world class mental and behavioral health specialists located
all the way back in Albuquerque.
Without telehealth, this type of care would be out of reach
for many people in that community. I have seen similar benefits
in remote parts of South Dakota. In Pine Ridge, I toured a
smart emergency room that connects hundreds of miles away back
to Sioux Falls. A team of emergency room specialists there can
walk the generalists at Pine Ridge through complicated
emergency procedures in cases where there is no time to
transfer a patient to a more specialized facility. This
important form of telehealth, connecting one facility to
another, is vital.
With rural hospitals closing, a shortage of specialists,
and the challenges of traveling long distances for care, we
must continue to support this mode of telehealth. At the same
time, there is a complementary trend emerging. Whether you call
it remote patient monitoring or connected care, patients are no
longer limited to receiving care in-person at a brick and
mortar facility.
I first learned about this new trend on a visit to the
Mississippi Delta with Senator Wicker a few years back, and
that is where I heard about an innovative program that sent
diabetes patients home with a blood glucose monitor and a
connected tablet. The constant monitoring and feedback improved
outcomes for those patients, and I thought we should build on
that model back at the FCC.
So I worked with my colleagues to create a $100 million
connected care pilot program. We stood that up last year and so
far awarded a total of $58 million. Of course, COVID-19 only
underscored the importance of telehealth. As the pandemic
emerged, Congress passed the CARES Act, which provided the FCC
with $200 million in additional telehealth funding. We used
that to stand up a new COVID-19 program that built off the
Connected Care model. We awarded all of that funding by July
2020, and Congress then provided the agency with an additional
$250 million. So far, the FCC has committed $80 million of that
round two funding.
All told, I have had the chance to visit with 44 health
care providers in 22 states, including many of the FCC
awardees, and those visits have brought home the unprecedented
spike in telehealth over the last 2 years. In Parsons, Kansas,
a provider just told me their visits jumped from close to zero
before the pandemic to about 1,200 a month. At the University
of Michigan, doctors there saw a 75 fold increase in telehealth
visits.
And just yesterday in Florida, a pediatrics department told
me that their telehealth visits grew from 25 a day to 1,800 a
day. The data also confirm the significant benefits from
telehealth. Yet barriers remain from legal and regulatory to
connectivity challenges. For instance, there have long been a
range of licensing and reimbursement issues.
HHS eliminated some of those hurdles last year through
waivers, but those are set to expire when the pandemic ends,
and we simply can't afford a return to the status quo. That is
why I have supported many of the bills that members of this
subcommittee introduced. Including the bipartisan Connect for
Health Act that would extend those waivers. There is more the
FCC should do too. For one, connectivity is key to telehealth,
so we need to continue our work of closing the digital divide.
That means more spectrum and further streamlining of
infrastructure rules. For another, we need to ensure that our
telehealth programs deliver on their important goals.
This means quickly finalizing the award of the remaining
portions of telehealth funds. We are taking another good step
in that direction later this month at our open meeting, so I
want to thank Acting Chair Rosenworcel for bringing a vote
forward on that issue.
This also means working with stakeholders on a long term
solution to funding these types of initiatives, and this means
ensuring that our rural health care program provides the
sufficient and predictable level of support necessary to meet
the needs of rural providers. It has fallen short before, and I
have been working with my FCC colleagues on fixing those
shortcomings. I look forward to making more progress on that.
In closing, I want to thank you again for the opportunity
to testify today. I look forward to taking your questions.
[The prepared statement of Mr. Carr follows:]
Prepared Statement of Hon. Brendan Carr, Commissioner,
Federal Communications Commission
Chairman Lujan, Ranking Member Thune, Chair Cantwell, Ranking
Member Wicker, distinguished Members of the Subcommittee, thank you for
the invitation to testify. It is a privilege to appear before you
today.
I would like to begin by commending the Subcommittee for convening
this hearing on telehealth and for its Members' leadership in
supporting these vital services as well as the broadband connections
that are necessary to power these offerings. Expanding Americans'
access to telehealth services has been a top priority for me at the
FCC, and I can say that it is an endeavor that has long benefited from
broad and bipartisan support at the agency and here in Congress. In
fact, for years, the FCC has supported the buildout of high-speed
Internet services to health care facilities through the Universal
Service Fund, which Congress authorized through the Telecommunications
Act of 1996.
I have had a chance to see firsthand the benefits that these
telehealth services can bring to communities across the country. New
Mexico is just one example. On a visit to the mountainous Mescalero
Apache Reservation last year, I met with the talented team at the
Mescalero Indian Hospital. Thanks to a high-speed Internet connection,
community members can now have one-on-one video sessions with world-
class mental and behavioral health specialists that are located
hundreds of miles away in Albuquerque. Without that connection, this
type of mental and behavioral health care--care that we need to expand
access to in this country--would be out of reach for many people in
that community.
I have seen similar benefits in remote parts of South Dakota as
well. In the southwest corner of the state, I visited Pine Ridge two
years ago. That's where I toured a ``smart emergency room'' that
connects via an Internet-powered video and audio feed all the way back
to Sioux Falls, which is almost 400 miles away. A team of talented
emergency room specialists located there at Avel eCare can walk the
generalists at Pine Ridge through complicated, emergency procedures in
cases where there is no time to transfer a patient to a larger or more
specialized facility. The high-speed fiber enabling that connectivity
was built with support from the FCC's Rural Health Care (RHC) Program.
This important type of telehealth--connecting one facility to
another or what is often referred to as a hub and spoke model--is
vital. With rural hospitals closing, a lack of specialists in many
remote communities, and the challenges and costs of traveling long
distances for care, we must continue to support this form of
telehealth. The FCC is committed to doing just that.
At the same time, there is an emerging and complimentary trend in
telehealth. The delivery of high-tech, high-quality care is no longer
limited to the confines of connected, brick-and-mortar facilities. With
remote patient monitoring and mobile health applications that can be
accessed right on a smartphone or tablet, health care workers now have
the technology to deliver high-quality care directly to patients,
regardless of where they are located.
I first learned about this new trend on a visit to the Mississippi
Delta a few years ago. It's a part of the country with a deep and rich
history. And it is not exempt from the many health care challenges that
Americans face in communities around the country. Take Ruleville,
Mississippi, which sees diabetes rates about twice the national
average. It also has some of the highest poverty rates in the country,
only adding to the difficulty in finding adequate health care.
In Ruleville, I met Miss Annie, a patient at the North Sunflower
Medical Center. Miss Annie woke up one morning with blurred vision, and
after seeing her doctor found out she had advanced diabetes. She tried
treating it through traditional methods of care but didn't see much
progress. She then signed up for a ground-breaking telehealth program
being run in conjunction with the University of Mississippi Medical
Center (UMMC). She was sent home with a tablet and a wireless-powered
blood glucose monitor. Every morning, Miss Annie's tablet would chime
as a reminder, she would prick her finger, and the tablet would then
display her glucose number, which was reported back via a wireless
connection to her doctors.
Based on that reading, an app on the tablet suggested appropriate
actions--from a particular food or exercise, to watching a relevant
video. If she forgot, she would get a call from a nurse. With this
technology, her A1C levels went down, and Miss Annie says she has never
felt better. I had the chance to visit Ruleville again just a few
months ago with Senator Wicker and reconnect with Miss Annie. She is
doing great and is a strong advocate for expanding telehealth.
After that first visit to the Mississippi Delta a few years ago, I
started working with my FCC colleagues to create a nationwide, $100
million Connected Care Pilot Program that builds on the one UMMC
pioneered. We were able to stand that program up in April of 2020. So
far, we have awarded a total of $58 million to more than 50 entities in
30 states and the District of Columbia.
While there has long been value in telehealth, COVID-19 further
underscored the importance of care at a distance. As stay at home
recommendations spread across the country, everyday tasks that used to
be carried out in person moved online. It became critically important
that patients receive treatment remotely. In response, the FCC quickly
waived certain telehealth rules and boosted funding to our RHC Program
to make it easier for broadband providers to support telehealth during
the pandemic.
Congress also came together and passed the CARES Act, which
provided the FCC with an additional $200 million in emergency
telehealth funding. Within days of Congress passing that law, we used
that support to stand up a new COVID-19 Telehealth Program. We awarded
all $200 million by July 2020, and at the end of that year, Congress
provided the Commission with an additional $250 million for a second
round of funding. So far, the agency has committed $80 million of that
Round 2 funding.
I have had the chance to visit with many of the awardees and other
health care providers that have greatly expanded their telehealth
offerings, including in New Mexico, South Dakota, Washington,
Mississippi, Florida, Kansas, Michigan, Ohio, and Pennsylvania.
One thing these visits have brought home is the unprecedented spike
in telehealth visits over the past two years. In Parsons, Kansas, I
recently met with a health care provider that saw telehealth visits
jump from close to zero before the pandemic to about 1,200 each month.
At the University of Michigan, I met with doctors that saw a 75-fold
increase in telehealth visits per month--increasing from 400 a month
pre-pandemic to more than 30,000 at its height. Near Miami, Florida,
one provider went from zero telehealth visits in 2019 to 90,000 in
2020. All of these facilities said that they were able to ramp up their
technology infrastructure to meet this surge in demand thanks to the
FCC's congressionally-funded COVID-19 Telehealth Program.
More broadly, the data on telehealth and remote patient monitoring
show significant benefits too--both in terms of health outcomes and a
reduction in costs. For instance, the Veterans Health Administration's
remote patient monitoring program resulted in a 25 percent reduction in
days of inpatient care and a 19 percent reduction in hospital admission
for more than 43,000 veterans. It also cost $1,600 per patient compared
to more than $13,000 per patient for VHA's home-based primary services.
Another remote patient monitoring initiative showed a 46 percent
reduction in ER visits, a 53 percent reduction in hospital admissions,
and a 25 percent shorter length of stay. Analysts estimate that the
widespread use of remote patient technology and virtual doctor visits
could save the American health care system $305 billion annually.
While the benefits of telehealth are clear, barriers remain--from
legal and regulatory to connectivity challenges. For instance, there
have long been a range of licensing and reimbursement issues that held
back telehealth. In early 2020, the Department of Health and Human
Services (HHS), with urging from Members of this Subcommittee, helped
facilitate greater access to telehealth services through the issuance
of key waivers. For example, HHS has allowed more types of providers to
bill Medicare for telehealth services and granted waivers for the
reimbursement of audio-only telehealth services. While these waivers
are set to expire at the end of the COVID-19 public health emergency
declaration, we cannot afford a return to the status quo once the
pandemic ends. We have made too much progress to move backwards.
For this reason, I fully support the bipartisan CONNECT for Health
Act reintroduced this year by Senator Schatz, Ranking Member Wicker,
and many other Members of this Subcommittee. This important legislation
would take a number of steps to ensure that more people have access to
telehealth, including by removing geographic restrictions on telehealth
services, allowing health centers and rural health clinics to provide
telehealth services on a continued basis after the pandemic ends, and
giving the Secretary of Health and Human Services additional authority
to waive telehealth restrictions after the pandemic ends. Similarly,
the Telehealth Modernization Act and the Protecting Rural Telehealth
Access Act--championed by Members of this Subcommittee--are valuable
pieces of legislation that would extend many of these same waivers.
Ranking Member Thune's bipartisan RUSH Act of 2021 would also take
important steps to facilitate greater use of telehealth in skilled
nursing facilities, like the one I visited in Lennox, South Dakota.
This legislation would reduce unnecessary hospitals visits and stays
and, in turn, decrease the risk of COVID-19 or other virus
transmission.
There's more the FCC can and should do, as well. For starters,
connectivity is key to telehealth. And on this front, we have made
significant progress towards the goal of ensuring that every American
has access to an affordable, high-speed connection over the past few
years. Since 2016, Internet speeds have more than tripled. Competition
has increased too, with the percentage of Americans with more than two
options for high-speed service jumping by 52 percent between 2016 and
2018 alone. And the digital divide has been cut significantly as both
new cell sites and high-speed fiber builds accelerated over the past
few years.
Yet there remain too many Americans without access to affordable,
high-speed connections. And this prevents them from realizing the
benefits that telehealth and other online services can deliver. So the
FCC must continue to deliver results.
On the spectrum front, we must keep moving the airwaves needed for
5G and other high-speed connections into the commercial marketplace. On
infrastructure, we need to build on the reforms we put in place over
the past few years and continue to modernize and streamline our
regulations.
And there is more the FCC can do to ensure that our telehealth
programs deliver on their important goals. For one, we should quickly
finalize the award of the remaining portions of the COVID-19 Telehealth
Program and the Connected Care Pilot Program funding. We are taking
another good step in that direction later this month when we will vote
on a new round of awardees at our October Open Meeting. So I want to
thank Acting Chair Rosenworcel for moving that forward. For another, we
need to work with stakeholders on a long-term solution to funding these
types of initiatives. The Connected Care Pilot Program for instance is
a three-year initiative. One goal for the program is to provide
additional evidence regarding the value that flows from connected care
technologies. In my view, the portions of the health care industry that
benefit from these technologies and their associated reductions in
health care costs should be the ones that support them in the long run.
Now is the time to work towards that transition.
Finally, the FCC needs to take additional steps to ensure that our
RHC Program provides the sufficient and predictable level of support
necessary to meet the needs of rural health care providers. I have
worked with my FCC colleagues towards this goal over the past few
years, including on the issuance of a January 2021 waiver that
addressed anomalies in a rates database--anomalies that would likely
have contributed to an inadequate and inconsistent level of support for
Alaskan health care providers. I also worked with my colleagues to add
additional rates into that database and otherwise on relief that
ensures greater flexibility. There are additional steps we can take to
improve the administration of the FCC's initiatives, including by
imposing firmer deadlines on funding decisions, and I look forward to
continuing to work with my FCC colleagues and stakeholders on those
improvements.
* * *
In closing, I want to thank you again Chairman Lujan, Ranking
Member Thune, Chair Cantwell, Ranking Member Wicker, and Members of the
Subcommittee for holding this hearing and for the opportunity to
testify. I look forward to continuing to work with the Subcommittee to
accelerate the buildout of broadband networks to facilitate the greater
use of telehealth services. I welcome the chance to answer your
questions.
Senator Lujan. Thank you very much, Commissioner Carr.
Next, we are going to hear from Ms. Deanna Larson, the Chief
Executive Officer at Avel eCare in Sioux Falls, South Dakota.
STATEMENT OF DEANNA LARSON, PRESIDENT, AVEL eCARE; FOUNDER,
AMERICAN BOARD OF TELEHEALTH; EXECUTIVE SECRETARY, AMERICAN
TELEMEDICINE ASSOCIATION
Ms. Larson. Good morning, Chairman Lujan, Ranking Member
Thune, and Ranking Member Wicker--good morning, Chairman Lujan,
and Ranking Member Thune, and Ranking Member Wicker. Very happy
to be here this morning. Honored to represent the many
stakeholders and the providers of telemedicine who are using
this modality to deliver health care across the Nation. Being
based in Sioux Falls, South Dakota, for the last decade and a
half, telemedicine has given us a lot of experience in rural
care. We now have locations--sub-locations in Michigan and in
Texas.
I have the honor also of serving on the board of the ATA,
so we hear a lot from many members across the Nation about
issues and great outcomes as well. And by way of background, we
began providing telemedicine services in 1993, really providing
specialty care clinic to clinic for patients and individuals
who couldn't make into the--out of the rural settings into
tertiary. We now provide acute care for ICU, hospital medicine
and emergency medicine, behavioral health services, specialty
clinics, school health, as well as in skilled nursing
facilities.
So essentially, we are a virtual health care center,
augmenting care in rural locations. So how did we get to use
the FCC funds? We were very excited about the opportunity.
During the pandemic, there was pandemonium in health care. It
is usually a fairly very--excuse me, it is usually a very
controlled environment, and all of a sudden all of the--
everything was not controlled. So overnight, we developed
training and moved out. Telemedicine has been earlier described
both to clinicians and residents. Brick and mortar closed.
People were needing access to care. So, we know we are needing
to extend those services using now--providing the funds from
the COVID telehealth relief program. We were able to extend
those services in emergency settings, skilled nursing
facilities, and in home monitoring.
84 communities in 7 states. We were very grateful to
receive those funds. It all went directly to expansion of that
equipment. On behalf of those customers, we were really
grateful for all of that work, but we know that there are still
a lot of opportunity. There are still underserved communities
as it relates to broadband. We have experience where we haven't
been able to get into communities for up to 2 years of time, up
to 2 years of time in Montana, where individuals are seeking
care, telemedicine services, and there is no access, there is
no way for us to get to them. While we are very grateful, we
know there is a lot more to do.
So, it is really important broadband for us. It is the
essential piece, as we really made a shift during the situation
and the kind of pandemonium of telemedicine, we made a shift
with providers. The paradigm moved. Clinicians all of a sudden
understood the power of telemedicine. Patients were willing to
accept it. Now we need that critical vehicle of broadband
everywhere to make that happen.
An example of that is, you know, the use of broadband too,
I want to mention, it has been brought up before, you know, is
it telephone? Is it video? Is it store and forward? You know,
that is like asking a physician, you can't use--you can only
use a flat X-ray or CT scan or MRI. Should we be making that
decision, or should we leave that in the hands of physicians or
clinicians who can make that decision? Which use cases most--
treats their patients in the best way?
And we also are involved in the Federal initiative, the
National Emergency Telemedicine Critical Care Network, that has
been sponsored federally. It is called NETCCN. We are working
with HHS, Asper, and the Department of Defense to provide
critical care expertise to hospitals, municipalities struggling
still with the COVID-19 surges. Over the last year, we have
been deployed over a dozen times to care for thousands of
patients in the communities, ICUs, community hospital units,
and also in patients homes. We know we have been part of saving
lives in those situations.
We have supported health systems, alleviating bed
shortages, and really supporting those vulnerable clinician
workforce that now is out there. And there is a very big
scarcity in the workforce situation. I know important strides
have been made to improve access, and we are very grateful in
the broadband situation. I would urge the committee to continue
to support new and innovation projects and initiatives that
might alleviate these physical challenges we see like in
Montana. Let's keep an eye on Starlink and the satellite
opportunities that might be coming around for us to have very
affordable and continuous access.
The Telehealth Flexibility Program, I urge every member on
this committee in the Administration to continue to extend the
telehealth regulatory flexibilities created during the COVID-19
pandemic, or better yet, let is just make them permanent.
Without this support, patients can lose access. We will go back
to the great divide, if you will, or as ATA calls it, the
telehealth cliff.
We will create again underserved communities that will no
longer have access. The ability to provide this modality-
neutral telemedicine, such as again, the phone only or
asynchronous care, remote patient monitoring really has proven
to be essentially valuable. We also are very grateful for the
FCC funding USEC program. We use it very well in many of these
remote and rural programs. They are very grateful to receive
those funds.
It has been my experience over the course of my career to
find telemedicine makes a great difference. It improves the
overall quality of care. They are reaching patients. It serves
the community well. We often can keep patients in their small
rural community. Keeping the money in that community. We are
able to support and retain physicians, clinicians in that
community. All of that immediate care where it is needed can
de-escalate the illness and reduce the cost of that care
overall.
Again, I am very happy to be here and represent this and
look forward to your questions.
[The prepared statement of Ms. Larson follows:]
Prepared Statement of Deanna Larson, President, Avel eCare; Founder,
American Board of Telehealth; Executive Secretary, American
Telemedicine Association
Chairman Lujan, ranking member Thune and members of the committee,
thank you for the invitation to speak to you today on behalf on such an
important topic--the state of telehealth. My name is Deanna Larson, CEO
of Avel eCare based in Sioux Falls, S.D., and Executive Secretary,
American Telemedicine Association. By way of background, Avel eCare
began in 1993 as a means to take care of patients in very rural areas,
providing these communities with 24/7 access to care using
telemedicine.\1\ Since then, we have expanded and our services now
reach patients served by more than 600 facilities in 32 states across
the Nation.
---------------------------------------------------------------------------
\1\ See Addendum (page 5)
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How has Avel eCare Leveraged FCC COVID-19 Telehealth Program Funds?
During the past year-and-a-half, Avel has developed new services
and solutions for the challenges brought on by the pandemic. From
ramping up virtual visits, to augmenting long-term care, to virtual
physician rounding in the hospital, we have leveraged telemedicine to
meet real needs and in doing so, have saved lives, reduced cost of
care, and supported our clinical workforce.
As part of this work, we applied for the Federal Communication
Commission's COVID-19 Telehealth Program. The funds received--totaling
nearly $804,000--supported eCare emergency services brought much needed
care to emergency rooms, hospitals, senior care facilities, and patient
homes, impacting 84 communities spanning seven states.
On behalf of our customers and the hundreds of providers and
companies around the country who received these funds, I want to thank
this committee and the FCC for offering this important program. The
dollars went directly to acquiring new equipment, ultimately,
delivering exceptional care to patients and their families during a
difficult time.
Importance of Broadband Access, Connectivity
A critical component to providing telemedicine care is broadband
connectivity and access. Telemedicine can help bring care to
underserved communities by eliminating travel, accessibility, and
scheduling concerns. This utilization of telemedicine services by
underserved groups is significant, and depends largely on their access
to reliable, high-speed internet. Without convenient access to
broadband connectivity enhances, our ability to reach patients with
augmented, high-touch care is greatly restricted.
Take for example our work with COVID-19 patients. One life-
threatening symptom that requires immediate care is the shortness or
loss of breath that can often accompany a severe case of COVID. This
can be an unsettling and traumatic experience for patients and
caregivers. By having access to video telemedicine services, clinicians
can more fully assess the severity of illness to determine the best
course of treatment. They can reassess frequently throughout the day if
needed. Patients have direct visual contact with a trusted clinician
who can talk through the treatment options, discuss alternatives, and
provide a calming presence. The ability to effectively manage
significant COVID illness at home has been invaluable to patients, the
health care system and to payers. But, access to reliable, fast
Internet is critical to the availability of these types of programs.
In another federally funded initiative, the National Emergency
Tele-Critical Care Network, or NETCCN, we are working with HHS and the
DOD to provide critical care expertise to hospitals and municipalities
struggling with COVID-19 surges. Over the last year, we have been
deployed a dozen times to support the care of thousands of patients in
community ICUs, COVID hospital units, and at patients' homes. We know
we have saved lives, supported the healthcare system, and alleviated
burnout of our vulnerable clinical workforce. The ability to deploy
this telemedicine support to communities in stress requires speed,
regulatory relief, and importantly, reliable broadband even during
times of high network demands.
Important strides have been made to improve access to broadband,
and I urge this committee to continue to support new and innovative
projects and initiatives which can alleviate the physical challenges to
delivering broadband. For example, our work with a rural Montana site
was delayed for more than a year due to the logistical and physical
difficulties of bringing in fiber to this remote community. If our
provider partner had an alternative method to access high-speed
internet, they could have brought in this life-saving care much sooner.
Telehealth Regulatory Flexibility
In addition to support for connectivity, I urge every member of
this committee and the administration to continue to extend telehealth
regulatory flexibilities created during the COVID-19 pandemic, or
better yet make them permanent. Without this support, patients will
lose access and we could run the risk going over the ``telehealth
cliff.'' The ability to provide modality-neutral telemedicine, such as
phone-only care, asynchronous care, and remote patient monitoring, has
proven especially valuable. We have learned we can trust clinicians to
choose the right modality to work with their patients effectively.
Conclusion
In closing, I would again like to thank the committee for the
invitation to speak, and express gratitude on behalf of telemedicine
providers to the FCC for providing funding to support the delivery of
care to millions of patients. The funding available through USAC and
the COVID-19 Telemedicine Program have delivered much needed access,
but there is still work left to be done to address the disparity that
still exists in the system.
It has been my experience over the course of my career that
telemedicine improves overall quality of care while reducing cost. We
serve patients in the communities where they live. We provide resources
and access to help reduce rural clinician burnout and stabilize local
workforces. Most importantly, we save lives. Again, thank you for the
invitation to speak and I look forward to your questions.
Addendum
Senator Lujan. Thank you so very much, Ms. Larson, and
thank you for your challenge in our call to action as well.
Next, we are going to hear from Dr. Sanjeev Arora, founder of
Project Echo and Distinguished Professor at the University of
New Mexico Health Sciences Center in Albuquerque, New Mexico.
Dr. Arora.
STATEMENT OF DR. SANJEEV ARORA, PRESIDENT
AND FOUNDER, PROJECT ECHO/ECHO INSTITUTE;
DISTINGUISHED AND REGENTS' PROFESSOR OF MEDICINE,
UNIVERSITY OF NEW MEXICO HEALTH SCIENCES CENTER (UNMHSC)
Dr. Arora. Chairman Lujan, Ranking Member Thune, and
members of the Committee. My name is Sanjeev Arora, and I am
the Director and Founder of the Project Echo at the University
of New Mexico. Thank you for inviting me to testify. As we have
seen in the pandemic, we have exposed what we all knew
instinctively, we need to fundamentally reorient our health
care system to enable patients to get the care they need, when
they need it, where they live. Last year, I testified before
the HELP committee and shared a patient is story from almost 20
years ago.
A 43-year-old widow and mother had been diagnosed with
hepatitis C eight years earlier. Yet she was just now seeking
treatment for the first time. When I asked her why she had
waited so long, she said her doctor told her that the treatment
would require her to make a dozen trips to Albuquerque over a
year, and she couldn't afford to take the time off work. Now
the pain was too much for her to bear, but it was too late to
save her. She died 5 months later from advanced liver cancer.
We had the medicines and the expertise to treat her, but she
didn't have the resources to get to us, and no doctor in the
community had the knowledge to treat her disease.
That is why I started Project Echo, to get the right
information to the right place at the right time, to save and
improve lives. Now we must enable telehealth of all kinds.
Improving broadband will support all three domains of
telehealth: remote monitoring, telemedicine, and telementoring.
All three can advance health equity in rural and underserved
communities. Remote monitoring gives us a unique window into
the life of a patient. Picture an elderly woman wearing a
wireless remote device that can alert us if her gait is
unsteady and allows us to intervene earlier and prevent a fall
and hip fracture.
Telemedicine allows us to bridge a geographic divide and
connect a specialist with a patient who would otherwise be
forced to travel a long distance or go without care completely.
Both remote monitoring and telemedicine are critical and needed
and will be significantly enhanced by ensuring broadband
connectivity to every household in America. But an additional
serious constraint remains. The lack of specialists is not just
in rural areas.
Most urban areas also have an insufficient number of
experts. There are simply not enough experts anywhere to serve
all that need their help, and patients everywhere have to wait
weeks and months to see a specialist. And that is where the
mentoring to build workforce capacity comes in. They all teach,
all learn Echo model works like this. Teams of experts at
regional medical centers called hubs use one to many video
conferencing to engage with local health care providers, the
spokes, in ongoing weekly sessions with knowledge sharing and
case based learning to ensure that clinicians already on the
ground in communities have the latest best practices mentoring
and support they need to treat patients.
Hubs and spokes learn from each other. Everyone is
knowledge is constantly improving. Based on the tremendous
need, Echo has grown and is now embedded at more than 250
organizations in all 50 states across the U.S. Many of these
are major academic health centers, like the University of
Washington, University of Hawaii, M.D. Anderson, the University
of Mississippi, and many, many more. And we know the model
works. A study published in the New England Journal of Medicine
on Hepatitis C work in New Mexico showed that patients got the
same quality of care they would get if they went to a
specialist.
There are now more than 400 papers published to demonstrate
the effectiveness of the model. We had long believed that the
Echo model could be put to work in a pandemic, and in 2020 it
was put to the test. Since the onset of COVID-19, we have
deployed our entire national and global network in response to
the pandemic. Here are two quick examples. We worked with the
agency for Healthcare Research and Quality and Institute for
Health Care Improvement to launch the Nation's most
comprehensive and successful effort to reduce the spread of
COVID-19 in nursing homes. More than 9,000 nursing homes and
more than 30,000 health care workers participated.
We partnered with the Assistant Secretary for Preparedness
and Response at Health and Human Services to run a national
program for frontline providers focused on COVID-19. Every
week, some 400 to 1,700 clinicians log on to this virtual
community. More than 50,000 have participated. How can these
lessons help us reshape our health care system to move
lifesaving information more quickly and efficiently?
First, expanding access to high quality, high speed
broadband connectivity is critical. It is a prerequisite for
the success of any telehealth model in rural communities and
urban underserved areas. Second, the FCC should explore any
additional opportunities under its purview to support
telehealth to improve care in rural and underserved
communities.
Finally, although mostly outside the purview of this
committee, I hope Congress will commit to exploring longer term
changes to health care financing for approaches like
telementoring that can support our health care workforce. I am
committed to working with you to help realize the promise of
telehealth in our country. Thank you for this opportunity and I
look forward to your questions.
[The prepared statement of Dr. Arora follows:]
Prepared Testimony of Dr. Sanjeev Arora, President and Founder, Project
ECHO/ECHO Institute; Distinguished and Regents' Professor of Medicine,
University of New Mexico Health Sciences Center (UNMHSC)
Chairman Lujan, Ranking Member Thune and Members of the Committee.
My name is Sanjeev Arora. I'm here today both as a practicing liver
disease specialist and as Director and Founder of Project ECHO at the
University of New Mexico, Health Science Center.
Thank you for inviting me to testify at today's hearing focused on
exploring the state of telehealth and removing barriers to access and
improving patient outcomes, particularly in the context of COVID-19.
The pandemic exposed what we all knew instinctively long before the
first COVID cases were diagnosed. We need to fundamentally reorient our
healthcare system. Instead of placing the burden on patients to find
us--the medical experts who can treat and cure them--we need to bring
the care to them.
We need to enable patients to get the care they need, when they
need it, where they live.
And technology can help us get there. It can't do it all--but,
increasingly, it's a critical underpinning to our work.
In June of last year, I testified before the Senate HELP Committee
at a hearing on telehealth, and I shared the story of one of my
patients from almost 20 years ago.
A 43-year-old widow and mother of two small children, she had been
diagnosed with hepatitis C eight years earlier. Yet she was just now
seeking treatment for the first time.
When I asked her why she had waited so long, she said that her
doctor told her that treatment would require her to make at least a
dozen trips to Albuquerque over the course of a year--and she couldn't
afford to take the time off work.
Now the pain was too much for her to bear. But it was too late to
save her. She died five months later from advanced liver cancer.
We had the medicines and the expertise to treat her. But she didn't
have the resources to get to us. And no doctor in her community had the
knowledge to treat her disease.
That's why I started Project ECHO. We have the knowledge to reduce
so much human suffering, but we need to move it out into communities
where it's needed most.
Now flash forward two decades and imagine another rural patient
diagnosed with COVID-19 last year. The first in her community. Was her
local medical team ready? Did they have the knowledge they needed to
treat her?
We need to leverage telehealth to quickly move new information and
best practices from top experts at academic health centers to providers
at the frontlines caring for patients in communities. The COVID-19
pandemic has only underscored the urgency with which we need to tackle
this challenge.
To enable telehealth of all kinds, we need to ensure that providers
and patients in rural and underserved communities have access to
broadband and high-speed internet.
Improving broadband will support all three domains of telehealth--
remote monitoring; telemedicine; and telementoring. And all three have
the potential to expand access to best practice treatment and advance
health equity in rural communities and urban underserved areas.
But telehealth is much more than technology.
Technology can help us bridge wide geographic divides in ways we
wouldn't have imagined possible twenty years ago. But technology is
simply a tool that enables essential human interaction.
For example, technology allows us to have the virtual hearing we're
participating in today, but it's not the technology that makes this
discussion valuable. What matters is what the technology enables--the
discussion we're having, the expert testimony, the answers we provide
to your questions, and, most importantly, how it all informs the
decisions you make going forward. Likewise with telehealth, the
technology enables us to interact in ways that ultimately improve
health and save lives.
In the case of remote monitoring, technology gives us a unique
window into the life of a patient. Picture an elderly woman wearing a
wireless remote device that can alert us if her gate is unsteady and
allows us to then intervene earlier and prevent a fall and a possible
hip fracture.
In telemedicine, technology allows us to bridge a geographic divide
and connect a specialist with a patient who would otherwise be forced
to travel a long distance or go without care completely. The technology
enables the communication to happen, creating the opportunity for a
patient-physician relationship that might never have existed.
Both remote monitoring and telemedicine are critical and needed and
will be significantly enhanced by ensuring broadband connectivity to
every household in America.
But an additional constraint remains. In addition to the lack of
specialists in rural areas, most urban areas also have an insufficient
number of experts. Patients everywhere in the country have to wait
weeks and sometimes months to see a specialist. Even if we can power up
rural and underserved communities with high-quality, high-speed
broadband or 5G, we're still woefully short of enough specialists to
provide care, virtually, to patients in these communities. A workforce
training and development solution is needed to enhance the capacity of
the healthcare professionals.
And that's where telementoring models come in.
Efforts like Project ECHO leverage technology, including
videoconferencing platforms such as Zoom, to ensure that clinicians
already on the ground in communities have the latest best practices,
mentoring and support they need to treat patients. They involve a
specialist or team of specialists in a specific disease area connecting
to many teams of community providers in an ongoing virtual learning
community.
Again, each of these telehealth approaches is needed and valuable.
But for the purpose of my testimony, I will be primarily focused on
telementoring, which is the area I know best.
When I started Project ECHO to treat hepatitis C in my home state,
I realized that in order to convince clinicians in rural clinics to
treat this complicated disease, I needed to create something that
mimicked the grand rounds experience of their residencies. We needed to
bring the experts to these rural clinicians over video to share up-to-
date best practices--and the clinicians needed to present their own
cases and get ongoing guidance and mentorship from experts.
We launched 21 new centers of excellence to treat hepatitis C in
rural communities across the state. Each center was run by a primary
care clinician. We shared our treatment protocols with them, and they
connected with us all together once a week on video to discuss cases.
Soon they became experts and the wait in my clinic fell from 8 months
to 2 weeks. Tens of thousands of patients got treatment. We knew we had
an effective model, so we expanded it by training other academic health
centers around the United States to deploy ECHO for a wide range of
common and complex diseases and conditions. The ``all teach, all
learn'' ECHO model works like this:
Teams of experts at regional medical centers (called ``hubs'') use
one to many videoconferencing to engage with local healthcare providers
(the ``spokes'') in weekly ongoing knowledge-sharing, case-based
learning, and telementoring.
Hub and spokes learn from each another, Everyone's knowledge is
constantly improving.
Based on the tremendous need, ECHO has grown from addressing a
single disease in a single state to over 600 training centers
addressing over 75 different health conditions with learners connecting
in from more than 180 different countries around the world.
There are now ECHO projects at more than 250 organizations in all
50 states across the U.S. . alone, many of these at major academic
health centers like the University of Washington, the University of
Hawaii, MD Anderson, the University of Minnesota, and many more.
And we know the model works. A study published in the New England
Journal of Medicine and funded by the Agency for Healthcare Quality and
Research focusing on our hepatitis C work in New Mexico showed that
patients treated by an ECHO-trained community provider got the same
quality care they would get if they went to a specialist. There are now
more 300 papers published on different aspects of the model,
demonstrating that ECHO can help implement best practices at speed,
scale, with fidelity, at substantially lower cost.
We had long believed that the ECHO model could be put to work in a
meaningful way in a pandemic. And in 2020, it was put to the test.
Since the onset of COVID-19 we have deployed our entire national
and global networks in response to the pandemic:
Launched in October 2020, the National Nursing Home COVID-19
Action Network was the Nation's most comprehensive effort to
reduce and prevent the spread of COVID-19 in nursing homes. At
the time, COVID-19 was surging across the country,
disproportionately affecting people living and working in
nursing homes--which accounted for nearly 40 percent of all
deaths from COVID-19. Despite the terrible pressures under
which they were operating, more than 9,000 of the Nation's
15,000 nursing homes joined the Network, a partnership of the
Agency for Healthcare Research and Quality (AHRQ), Project
ECHO, and the Institute for Healthcare Improvement. More than
30,000 healthcare workers were mentored as part of this
initiative as part of one of 326 weekly virtual learning
communities.
We partnered with the Office of the Assistant Secretary for
Preparedness and Response (ASPR) at HHS to run a national
program serving extremely rural locations for EMS and other
emergency frontline workers focused on COVID-19 that continues
to this day. With new best practices emerging every week we
used ECHO to get that knowledge into the hands of frontline
health workers across the U.S. Every week, some 400 to 1,700
clinicians log on to navigate the challenges of COVID-19
together.
Our ECHO networks active with the Indian Health Service, the
CDC, and other Federal agencies all shifted to get up-to-date,
best-practice knowledge about COVID-19 into the hands of the
health workers in rural and underserved communities who needed
it most.
In addition, to underscore the interconnection of different
telehealth approaches, multiple ECHO projects are now using the ECHO
model to train providers on how to do telemedicine effectively. We need
ongoing learning communities to ensure that the doctors, nurses and
other health professionals who were thrown into a world of virtual
medicine, almost overnight, get access to best practices and the
guidance to implement them.
What does this all mean for going forward? How can lessons from
COVID-19 and the experience of telehealth during this pandemic help us
to reshape our healthcare system to move life-saving information more
quickly and efficiently?
First, expanding access to high-quality, high-speed broadband
connectivity is critical. It's a prerequisite for the success of any
telehealth model in rural communities and urban underserved areas.
Broadband connectivity will help us address one of the biggest
challenges in our healthcare system--that almost no one has access to a
specialist on a timely basis regardless of whether they're being
treated for COVID, cancer, or autism. And rural communities and urban
underserved areas are at highest risk with either no access at all;
long waits; or when they do get access, they have to travel long
distances.
Second, the Federal Communications Commission should explore any
additional opportunities under its jurisdiction to support telehealth
to improve care in rural and underserved communities.
Steps that Congress and others have taken in areas like increasing
broadband access in rural communities and expanding coverage for the
virtual services clinicians can provide are critical--and we need to
explore more pathways to making this happen quickly.
But we also need to continue to move beyond the emphasis on the
technology part of telehealth to the health part. Again, like the
hearing today, it's what's being virtually delivered across the
medium--and--how that allows us to take action that will optimize
health outcomes.
While mostly outside the jurisdiction of this Committee, I hope the
Congress will commit to exploring longer-term changes to healthcare
financing that would create sustainable and ongoing funding for
effective telehealth approaches like telementoring that can bring much
needed care to the people in communities who need it the most.
If not continued COVID-19, the lives of rural and urban underserved
populations will be disproportionately affected by the opioid epidemic,
cancer, HIV, diabetes, autism or many other diseases or conditions.
I am committed to working with you to help realize the promise of
telehealth, and ultimately seeing the day when a mother's survival
doesn't rest on her ability to take a five-hour car ride twelve times a
year.
Thank you for providing me with the opportunity to testify before
you today. I look forward to answering your questions.
Senator Lujan. Thank you, Dr. Arora. We will now move to
questions of our distinguished panel. I recognize myself for 5
minutes. At this moment, the U.S. Congress stands at a critical
juncture. We are on the cusp of a historic bipartisan
infrastructure package that invest $65 billion in broadband
infrastructure and broadband affordability.
This investment has the opportunity to improve connectivity
and access to education, jobs, and critically lifesaving
treatments. To start us off here, I have a simple yes or no
question for each of the witnesses. Does access to high quality
broadband contribute to better health outcomes? Dr. Ransone.
Dr. Ransone. Yes, sir. Absolutely.
Senator Lujan. Ms. Larson.
Ms. Larson. Resounding yes.
Senator Lujan. Commissioner Carr.
Mr. Carr. Yes.
Senator Lujan. Dr. Arora.
Dr. Arora. Yes.
Senator Lujan. Thank you. And I think we all agree here
that we must connect every American and ensure those networks
are built to live up to the critical role they will play in our
health and well-being. Dr. Arora, you are the Director of a
nationwide leader in telementoring project, but you are also
still a practicing physician who has served the people of New
Mexico for nearly 30 years. I am deeply grateful for your
tireless work that you have done for our home State of New
Mexico. You have touched thousands of lives in Albuquerque and
across our state and across America, and skilled that knowledge
to provide expert care across the world. Thank you.
A state like New Mexico faces many unique challenges in
accessing health care. Many of my constituents live hours from
the nearest community health center or hospital. For many,
telehealth is the only way they can get care without having to
take a day off of work or find someone to care for their kids.
Dr. Arora, how can we ensure future investments in
telehealth meet the needs of states like New Mexico, South
Dakota, and Mississippi--and Hawaii? I am going to get in
trouble over here--and Kansas. So, I am going to get in trouble
as I look around. Dr. Arora?
Dr. Arora. Thank you, Chairman Lujan, for the question. The
problem you have identified is present in every state in the
United States. Many, many of our patients and health care
providers in the most rural areas don't have access to
adequate, high quality broadband. So, of course, that would be
enabling every different aspect of health care and produce
equity in a health care system, if we were able to fulfill the
vision that you articulated of getting good broadband to every
household and every health care provider in New Mexico. The
biggest problem, Senator Lujan, that I see in the United States
today is that in every state, there are such a long wait to see
a specialist.
Take the example of a dermatology consult in New Mexico. 30
percent of our land area has no dermatologist, there are only
33 dermatologists in the State of New Mexico, when we need more
than 120. Even in Albuquerque and Santa Fe, the wait to see a
dermatologist can be six to 8 months. It is not possible for
this person to do a lot of telemedicine because he or she is so
busy seeing patients all day long in Albuquerque and Santa Fe.
And so telemedicine will overcome a geographic divide, but it
does not overcome the biggest problem of a capacity constraint
in our health care system.
We need task shifting so we can enable physician
assistants, nurse practitioners, primary care doctors, family
doctors to provide fundamental dermatologic care in their local
communities. In a state where we have one of the highest skin
cancer rates, our patients cannot access dermatology care.
And so I think the combination of all three types of
telehealth that we talked about, remote monitoring,
telemedicine, and telementoring with projects like Echo can be
a solution not just for New Mexico, not just for every rural
state, but for the entire United States.
Senator Lujan. Thank you so much, Dr. Arora. Commissioner
Carr, the Connected Care Pilot Program identified a critical
need within the telehealth system. The Connected Care Program
is designed to serve a critical need by targeting telehealth
funding to communities that most need support. What is the
future of Connected Care with the program, and do you recommend
we move it beyond a pilot into a permanent program?
Mr. Carr. Thank you--thank you--I always do that. Thank
you, chairman, for the question. The Connect Care Pilot is set
to run for 3 years, and part of the original idea was to get
more data on how beneficial telehealth is. Well, the reality is
with COVID, we stood up before it, the emergency COVID-19
program, so we have even more data now. So long term, yes, we
need to make sure that this type of service is available. There
are questions about how to fund that, but absolutely, we need
to make sure we maintain support for these types of telehealth
services.
Senator Lujan. I look forward to hearing more about that
during the hearing today and in the future. Appreciate that. I
now recognize, Mr. Thune, for five minutes.
Senator Thune. Thank you, Mr. Chairman. Ms. Larson, how did
the FCC's COVID-19 telehealth program help expand the reach of
Avel eCare, and I used to know it as Avera eCare, but Avel
eCare Telehealth services? And is there anything that we should
know as policymakers about the program? What worked well and
what didn't?
[Technical problems.]
Ms. Larson. We used the funds to create another situation
of telehealth and more emergency settings, more skilled nursing
facilities, and specifically in that home settings. So, the
funding really works very well for us. Some of the things that
worked very well and were difficult at the same time, was very
quick notice. You know, it seemed like we had to be first in
line. And so, we applied within 24 hours, which is no small
feat when you are trying to collect all of those tools. But
nonetheless, we were very happy to apply. I think that worked
very well. We were able to get equipment out and we were
actually able to get equipment out quickly.
The reimbursement for that equipment took nearly 12 months.
So due to the paperwork and processes that are in place--and
again, it wasn't, you know, could have been part of our issue
too, but that is part of how do we streamline that so that we
aren't using extra time to try to make those things work very
efficiently. I do believe it was a great program and it funded
what we needed to have to extend our programs. We did not apply
for the second one. Not sure. Remember, there was a lot of
unknowns during that time. Not sure when funding the
reimbursement would be coming.
And then again, the notice to get ready so quickly. We
deeply appreciated in that we are able to impact hundreds and
hundreds of lives through the funding we received.
Senator Thune. Well, it seems like we ought to be able to
improve on a 12-month reimbursement rate, even for
organizations as inefficient as the Federal Government.
Commissioner Carr, can you talk about some of the lessons
learned from the COVID-19 telehealth program and what other
initiatives are underway at the FCC to support telehealth
services?
Mr. Carr. Well, I think one the most interesting lessons
learned is how much uptake there was for these services. We
talked about the 75fold increase, depending on the facility.
People found this very easy to use, preferable to use. Health
outcomes improved. So, we do need to move down this path, and I
think finishing the award of funds from our existing programs
would help. And looking at how do we sustain this from a
payment perspective long term are some important steps we need
to take.
Senator Thune. Tell me about--we know telehealth services
have dramatically expanded with the improvement of broadband
services in rural America. You all have testified to that. What
steps has the FCC taken to expand reliable and affordable
broadband services to unserved areas? And what needs to be done
to make sure all the broadband funding provided by Congress
goes to truly unserved areas?
Mr. Carr. Well, there are a lot of steps we took over the
last couple of years to streamline infrastructure rules. A lot
of it was looking at some of the legislation that you all have
been working on. We pushed a lot of spectrum out, building off
of the MOBILE NOW bill that you all introduced. And going
forward, we need more of the same. One, we need to continue to
streamline infrastructure rules. Two, we need to continue to
get spectrum out there, put a spectrum calendar out that would
make sure we do that.
And importantly, we have a lot of funding right now in the
pipeline that we need to get out the door, whether it is RDOF
phase one, which we will have a couple of percentage points of
the total award moved out the door yet. So we have funding in
the pipeline that we need to get going, because as I did a
visit with Senator Wicker, there is broadband builders that won
funding that are ready to go, they are just waiting on those
dollars to get to them.
Senator Thune. And what does it take to get them going
faster?
Mr. Carr. Well, I am not sure. We are behind schedule in
terms of the CAF II, which is an analogous program, in terms of
the percentage of funds that we got out the door. So, we have
got to keep moving on that. Obviously, long term, the maps are
going to be key. We have got to complete those maps. That is
what is going to let us go to RDOF phase two, 5G fund, and get
more support for broadband builders in rural communities.
Senator Thune. It comes always comes back to the maps,
doesn't it? Been working on the maps for a long time. Ms.
Larson, how have you seen expanded broadband services improve
patients' and health care providers' experience in areas that
have lacked sufficient health care services, particularly
specialty care services? Can you talk about that?
Ms. Larson. You know, I think a great example of this is
the care and services, especially to the opportunity with the
COVID relief pieces. We were able to provide, in two of the IHS
areas, both the Billings area and the Great Plains area.
Previously, you know, there hadn't been enough access for us to
provide care. And having broadband available, the last one was
in the Billings area, we were actually able to reach another
tribal location and a service unit area. We increased--through
the relief, we were able to increase the behavioral health
services response. So able to provide care in the home through
behavioral health versus having to go to a clinic. The no-show
rate of those individuals reduced by up to 40 percent.
So now, we are reaching 40 percent more of the individuals
coming on a telehealth visit, receiving behavioral health
services. So, you know, the availability of that in the home
setting and because broadband was now brought out there, they
could actually use their phones in their home situation to have
behavioral health services. Huge extension. And the clinicians
and the behavioral health arena specifically are very
comfortable on video or on phone.
I mean, we have many physicians in many specialty areas
that are comfortable at this point, but it is especially
interesting that individuals with behavioral health needs are
more comfortable in a location, not always in a clinic setting,
maybe in their home setting. Also, the providers and behavioral
health are telling us they can learn more. The patients are
more comfortable in their home setting. They also can see the
environments behind them or around them to help them understand
maybe what is happening with the individual, which is not
something you can get if the individual comes in and is not
able to really communicate easily in the clinic setting.
So taking broadband out across the reservation areas has
enabled physicians. I have mentioned behavioral health. There
is also dermatology. There is endocrinology. We know the
situation with diabetes in that population. Able to manage and
control that with individuals not always in the clinic setting
but making broadband available in that setting also gives our
specialists the ability to be in the clinic and work remotely
with those clinic physicians.
Senator Thune. Thank--thank you. Thank you, Chairman.
Senator Lujan. Thank you so much. Next will recognize,
Senator Schatz, for questions.
STATEMENT OF HON. BRIAN SCHATZ,
U.S. SENATOR FROM HAWAII
Senator Schatz. Thank you, Mr. Chairman. And thank you to
the Chair of the whole committee for deferring to me. Mr.--Dr.
Ransone and Ms. Larsen, as you know, we are facing a telehealth
cliff because the authority that has expanded Medicare's
coverage of telehealth expires when the COVID-19 public health
emergency ends.
And unless Congress acts, we will go back to the stone
ages, with very limited access to telehealth, and I think
people are sort of underestimating the shock that will occur
across communities if we don't deal with this cliff. I have
introduced a bill, the Connect for Health Act. It has the
support of more than 60 Senators on a bipartisan basis that
would make this expanded coverage permanent.
So Dr. Ransone, first and then Ms. Larson, could you speak
to the disruption in health care delivery if we don't fix this?
Dr. Ransone. Thank you, Senator. There will be an
incredible disruption in my ability to take care of my patients
when we reach this cliff. For family physicians nationwide,
prior to the pandemic, about 15 percent of our members provided
telehealth services. And because we were concerned about the
safety of our patients at the beginning of the pandemic, we
quickly transitioned to approximately 6 weeks later, over 90
percent of our members provided telehealth services to our
patients.
It is critically important that we are allowed to have
funding to help us take care of these patients in a virtual
environment. The concerns that I have are multiple should that
funding evaporate. Number one, virtual care has allowed me to
expand my house call services. I have done physical house calls
for years. However, because of patient safety, because of
distance, and because of I am in a rural area, allowing me to
access the patients that I have known for years in their home
has allowed me to keep many of my patients out of the hospital.
So this is a big cost savings for our entire health care
system. When we can go, we can monitor our patients closely.
We can keep them from going downhill and we can keep them
out of the hospital. So continued funding is incredibly
important. I would also like to put in a little push for
continued funding of audio only telehealth services. I see many
geriatric patients. And rarely do I see a patient over 75 who
is not there with someone who is younger. Typically, they have
a family member who is there helping them bridge that digital
divide, helping them use the technology that is there.
And more frequently, my patients 80 and over just don't
have that technology. A flip phone is considered very advanced
for them. So, they have used audio only telemedicine services,
and I use that to help monitor them and help keep them healthy.
I think keeping that availability of audio only telemedicine
services and funding thereof is incredibly important to help me
take good care of my patients. Thank you.
Senator Schatz. Ms. Larson.
Ms. Larson. So I would echo a few of those comments. It is
very important to us that the geography is not limiting where
we can really see individual patients. Workforce is an issue.
You know, we have to remember that physicians are clinicians
having to travel to locations to see--in our rural states, they
may travel 60 miles 1 day or more just to get to a clinic to
see patients. Can I not do--can I have that in a skilled
nursing facility? You know, really making sure that location is
not a barrier. And in the home, ensuring that that same
clinician doesn't have to take the time, unnecessary time to
travel where they can actually see the patient in their home.
Not to mention, remember, many of these individuals don't
have the ride that was just earlier mentioned. They will forego
it. They won't ask their daughter or their son to take the day
off, to take them to the nearest setting, when we can be right
in their home with them. That is a huge and important--it
will--absolutely, people will fall through the cracks if we are
not able to continue to see them in their home.
Senator Schatz. Right. And for the technicians, you know,
who develop these statutes and the people who work at CMS, and
people on the Finance committee, we talk about that as the home
as an originating site. But the practical implication is really
significant. It is a matter of life and death. It is a matter
of whether or not you can get care. Because if you still have
to go to your car and get into some--either public
transportation or get a ride, and schlep someplace, it defeats
the purpose, at least partially of telehealth in the first
place.
Ms. Larson. It absolutely does. And you know, the
spiraling--remember that since COVID too, many families are
trying to care for their senior family members in their home,
which means they are not in skilled nursing facilities today.
So even in skilled nursing facilities, but now in the home, we
see escalation of illness that there is delay.
So, what does that cost--what does that cost us? So if we
can't immediately see an individual when they start to feel ill
or have a situation going on, if we are waiting, now that
individuals is going to be seen probably in an emergency
department with an escalated illness and maybe even
hospitalized. We can prevent much of that.
Senator Schatz. Thank you. One final question I will submit
for the record, but I am very interested in the behavioral
health piece, especially for adults in the community with
severe and persistent mental illness. I used to run a nonprofit
that provided services to people with severe and persistent
mental illness, and a lot of our case management was just
finding the client--physically locating the client. And
technology has advanced to the point where we can make sure
that those--and oftentimes it is billable hours.
It is a fee-for-service arrangement, but a lot of those
billable hours we are chasing someone and trying to locate
them. And this is a problem that telehealth can solve and make
sure that the system is efficient and delivering care, not just
activities related to trying to deliver care. So thank you. I
will submit that for the record. Thank you.
Senator Lujan. Thank you, Senator Schatz. Next, Ranking
Member Wicker.
Senator Wicker. Thank you very much. Commissioner Carr,
when do you think the FCC will have the new maps ready?
Mr. Carr. Well, it is a good question. It is a bit of a
black box, but I don't think it should be. Back in March, I
said we should get them done by this fall, at least a targeted
set of maps that lets us go forward with RDOF II and 5G fund. I
heard that they may get done this summer, but there are no maps
at this point.
Senator Wicker. Is there a sense of urgency in the FCC?
Mr. Carr. I am sure there is. And so I don't know what the
difficulty is. Obviously, getting these maps together is a very
complicated process, but we obviously do need to get them done.
Senator Wicker. OK, so is this a staff problem or do you
need to get back to us on that?
Mr. Carr. I am happy to--you know, we obviously got almost
$100 million from Congress at the end of last year to get this
done, and we need to because it is holding up the distribution
of funds that could further bridge the digital divide.
Senator Wicker. OK. Well, pass along that I would like to
see a sense of urgency from everybody within the FCC, and I
hope I get some amens up and down the dais on that.
Commissioner, USF is funded by contributions from
telecommunications providers who pass the cost to consumers.
The contribution rate, which is a tax, has climbed. I have
a bill called the Fair Contributions Act, which directs the
FCC, which would direct the FCC to study whether big tech
should also contribute to the USF fund because these companies
overwhelmingly benefit from broadband. So how can--do you think
that would be a good way to ensure that Universal Service Fund
is on a stable and sustainable path?
Mr. Carr. Well, thank you, Senator. I think that is a great
bill and it tackles an important issue. There is a 30 percent
charge that we add to the telephone portion of consumers'
bills. A study that came out a couple of weeks ago said that
that could spike to 75 percent if we don't do something
different.
And your legislation would have us to look at what I think
is a much more fair way of doing that. Just looking to the
large tech companies that benefit to the tune of trillions of
dollars from these investments in the network, they should
start contributing a fair share. So I think the FCC should move
forward, consistent with that legislation.
Senator Wicker. Seems to me we ought to just use that bill
this afternoon. Members of the Senate can get back to me on
that. One other thing Commissioner, the FCC has reviewed
applications for both COVID-19 Telehealth Program and the
Connected Care Pilot Program beginning in April 2020. The
applications were either granted or denied based solely on FCC
staff review, without public comment on their applications.
Commissioner, is this a fair criticism, and has the selection
process for both COVID and Connected Care Pilot Program been
open and transparent?
Mr. Carr. Thanks for the question. It sounds like there is
room for improvement on that front. We have tried to put some
guardrails in place at the Commission level and then move
quickly at the staff level to move those through. But I take
the point that we could bring some greater transparency to that
to make sure that we are getting the dollars where it is needed
most.
Senator Wicker. OK, so what needs to be done? What would be
the next step there?
Mr. Carr. We can work with my colleagues and see if there
is more that we need to do to get common input on those
applications that are pending.
Senator Wicker. OK, well, you know, I will tell you what I
think I would like to ask you to do is check with your
colleagues and maybe you can respond on the record. A
comprehensive answer there. Ms. Larson, you agree with me about
maps. We don't we don't want to duplicate where we already have
service. We need to make sure where the new broadband is
needed. Do you agree on the importance of maps?
Ms. Larson. Absolutely agree on the importance of maps.
What I want to make sure and maybe indicate here when we--the
comprehensive maps. There are urban settings where there is not
enough access. So, you know, let us be sure it is comprehensive
and that we really understand where this broadband is
absolutely needed for access for all.
Senator Wicker. Well, you have a young man sitting right
next to you there, who I am sure is listening. Besides the
existence of broadband, are there regulatory barriers in
telehealth that you would like to bring or other barriers
besides just the availability of broadband you would like to
bring to our attention?
Ms. Larson. So I will start with broadband. You know, it is
interesting when we go to different locations, you know what
the cost of broadband access is for a different remote
location. And certainly the USAC funds have tried to address
that. And you know, it is--I think we have talked about this
before. I know I have talked it with Commissioner Carr.
Application is--when you are a small critical access hospital,
and you know, you have--the IT person is also the quality
control person, maybe infection control and a few other things,
the application process is difficult and that can actually--and
it is not that it is not accurate.
It is not that it is not--that the information is not
needed, but it is a lot of due diligence that we often try to
help with. So that piece of access again and the funds that are
available, if there is any way we can make that more readily
available for those most in need. We have come into
organizations who just a small critical access facility who
site monthly fees of up to $15,000 for broadband access.
You know, that is it is an incredible amount of money when
you are that size of the facility. But with USAC, we typically
can, you know, cut that down to much, much, much less than
that. So, that is an important feature.
Senator Lujan. Thank you, Ranking Member Wicker. And I
think there is a lot of interest in what you have identified,
not just with legislation you have introduced, but looking at
modernizing how we are able to fund these initiatives. And also
the editorial piece, the opinion piece that was written by you,
Commissioner Carr, which I know received a lot of attention. I
certainly appreciate it as well. Next, we are going to hear
from the Chair of the Full Committee, Senator Cantwell.
STATEMENT OF HON. MARIA CANTWELL,
U.S. SENATOR FROM WASHINGTON
The Chair. Thank you, Mr. Chairman. Thank you for this
important hearing. You and Senator Thune have done a good job
of outlining these important issues. Senator Thune and I both
serve on the Finance committee, and I guarantee you these are
constant issues before the Finance Committee, and we just have
to figure out solutions. But thank you for your leadership
because your understanding of our infrastructure as it relates
to the utility sector and these solutions is very, very much
appreciated.
And I want to--I think the Ranking Member is reminding us
how important it is that we actually get the information on
these maps now. I have seen a lot of data provided by the
private sector already on this, and I think that some of the
private sector data is outlining just what Ms. Larson said,
that while access in some parts of the United States is
challenging, affordability is a bigger problem. It is in sheer
numbers what is preventing us from delivering something on
telehealth. So, we need to do both, and hopefully we can do
both. And hopefully this committee can play a larger role in
communicating to our colleagues what are some burgeoning
technology solutions that I think could expedite us, obviously,
once we see the data and information.
Although I think there is a lot of data and information
that is already there that should point us in the right
direction. On this specificity this morning, Commissioner Carr,
I think you recently visited the Whitman-Walker Health Center
in D.C. Acting Chair Rosenworcel happened to be in the
Northwest in 2019, where we visited an actual stroke victim
gentleman, one of the San--basically had been on the San Juan
Islands. Was able to then be helicoptered, I think, over to one
of the Bellingham hospitals.
And then because of tele-stroke care, immediately, they
knew--they knew, immediately. Actually, it might have been even
before he left one of the San Juan Islands, they knew, and they
said, get him down to Seattle for care. So, that is the kind of
system that we want, and obviously we have to have that
connectivity to help in making those kinds of assessments in
those rural areas. But I am also interested in this issue of
the system just in the availability of specialists. It is
almost as if we could open up rural parts or hard-to-serve
parts of our health care delivery system to the kind of care
you don't have to drive to Seattle to see the specialist or you
can get some of the information or the help and support.
The reason I mention that is because we have so many
shortages in primary care physicians, unbelievable amounts of
shortages of primary care, and hopefully we can do something
about that. But we also have tremendous shortages in specialty
care.
So Ms. Larson, what do you think we should be doing to try
to identify and help? What kind of savings we would have in the
health care system if we were able to hook up some of our most,
you know, I think places in my state, north of Spokane, in
other parts that are just hard to get to see a specialist?
Ms. Larson. It is a great question. And workforce is an
issue. You know, we have to understand, and I have been saying
for a long time that telehealth is part of the solution of
workforce. You know, we don't have enough specialists. And
where they are located may not--they may, even as a
subspecialist, not have enough population to even fill their
profiles.
So we need to think about a broader cast of network of
providers who can cross State lines. You can have access to a
child in rural South Dakota who has rheumatoid arthritis. There
is no reason for a peds rheumatologist to be in South Dakota.
There is not enough patients for him to take or her to take
care of. But in a neighboring state, maybe two or three of
those States in the Midwest, they could do a great amount of
care if they were able to get through the licensing issues to
provide telemedicine support to the family practice provider,
who would collegially take care of that individual, that child
through that growth over time.
It is a--you know, today medicine, they are trained to work
collegially. Primary care providers are trained through their
residency to understand the specialties and how to work with
them. But if they work in a remote location, that is not
available to them or the individual's family. And as you say,
you know, sometimes it could only--it could be close by, but it
is still not available to them because of a distance travel.
You talk about Spokane and some of the places, you are talking
about airlifting. You know, and it is just not available for
everyone. But telehealth can be available.
And what we find in our environment--you know, we are often
working with nurse practitioners where through telemedicine, we
are intubating patients who are at the end of their life,
guiding the hands of the nurse practitioner, placing chest
tubes. These are very technical types of things. So take that
and move that over to a peds rheumatologists working with the
primary care in a very calm clinical setting. These clinicians
know how to do this. They know how to work collegially.
We need to give them the tools set, move some of the
restrictions in the licensing across the states, and let them
build a broad network to help each other and support the
constituents.
The Chair. I think this is why I say there is overlap here,
particularly with the--well, not just with us at the Federal
level like on the Finance Committee, but states too, because a
lot of these licensure issues are at the State level. And so,
then how do you figure out how to get some sort of global
agreement?
And so, I would like for the record, if you could, just
tell me, you can submit it for the record, what are those, you
know, top three or four areas that you think would best be
served by having--you mentioned rheumatoid arthritis, but like
what are the three or four things where we are seeing a lot of
activity, where a licensure and telehealth delivery system
could make a big dent in delivering care? And you can take that
for the record, but--unless, you know, right off the top. But I
don't want to----
Ms. Larson. Well, I will take it for the record, but I will
also mention you will for sure see behavioral health.
The Chair. Pardon me?
Ms. Larson. You will for sure see behavioral health be a
part of that.
The Chair. Behavioral health. Yes. Well, my colleagues, I
am sure every one of my colleagues could go a long time on
sections of their State who have like no behavioral health
services, like counties and counties. Thank you. Thank you, Mr.
Chairman.
Senator Lujan. Thank you so much, Chair Cantwell. And Dr.
Arora, I think it would be important to hear from you on that
question from Chair Cantwell as well. So we will make sure we
submit that to the record for you as well. And next, we are
going to hear from Senator Moran.
STATEMENT OF HON. JERRY MORAN,
U.S. SENATOR FROM KANSAS
Senator Moran. Chairman Lujan, thank you very much and
thank you to our witnesses for their participation today. Let
me start, I think, with Dr. Ransone. First of all, I want to
highlight a piece of legislation as many of my colleagues have
done. And also second, what Senator Wicker said about maps,
Commissioner Carr. We have introduced, several of us have
introduced Protecting Rural Health Telehealth Access Act. It
is--there is a number of pieces of legislation.
I am involved in most of them, but this is the only one
that includes a provision to allow payment parity for audio
only telehealth. And I wanted to ask you, doctor, from a
physician's perspective, why is the continuation of audio only
telehealth important, particularly as it relates to rural
communities?
Dr. Ransone. Thank you, Senator. I can say that AAFP did
support that piece of legislation. It does support it. Audio
only telehealth is incredibly important, especially for my
older and geriatric patients. There is a in the--part of the
digital divide is just a competency and confidence in using
technology.
And a lot of my older patients just do not feel confident
in using it. A lot of them feel that if they do anything to the
computer, it will break and they won't have the availability to
do it, and so they don't feel confident in doing it. And we
need to meet--we need to meet these patients where they are. A
lot of them don't have computers or tablets or anything in
their home, and what they have is a telephone. They feel
confident with that type of technology, and they know how to
use it.
So because they have been using it for 90 years. So, when
we see those folks, a way that we can get to them is the audio
only or telephonic consultation. In the time of the pandemic, I
spent a lot of my time trying to keep my patients into an
environment that was safest for them and frequently that was
not going out in public and potentially exposing themselves to
the virus. So I needed to find ways that I could get to them to
help manage their chronic disease.
Telemedicine was my answer for a lot of patients to be able
to get to them to give them the best quality of care, and I
continue to use that. I think that in the future, after the
public health emergency has abated, I will still use and will
still need to use audio only services in order to reach those
patients. Thank you.
Senator Moran. Thank you for that testimony. That
confirmation of the value. Commissioner Carr, you mentioned
audio only. Anything you want to add to the doctor's response
to my question?
Mr. Carr. I think he is exactly right. And as my testifying
friend here said, we need to give doctors every tool in the
toolkit and audio is a big piece of that. I think your
legislation would make a lot of progress on telehealth.
Senator Moran. Commissioner, thank you for your recent
visit to Kansas. Parsons may be the most per capita the
Commissioner visited community in the country. And I was not
able to join you on your visit, which only means that you have
to return to Kansas in the near future. Commissioner, you are
aware that the FCC, USDA, and NTIA announced a memorandum of
understanding to share information and coordinate the
distribution of broadband deployment Federal funds. Can you
bring us up to date on what has transpired? Is there the
necessary coordination occurring?
Mr. Carr. I am concerned there is not the necessary
coordination for a couple of reasons. One, the agreement that
you referenced only covers some agencies that have broadband
dollars and then some of the broadband dollars at the agencies
that signed it have. If you step back, you can argue that there
is about $800 billion across various agencies right now that
could go to broadband infrastructure. It could go to other
infrastructure as well. And I am not confident that we are in a
situation where we are coordinating across agencies.
And unfortunately, we saw what can happen back in 2009, we
had the BTOP program, which is a lot of people here probably
remember, was plagued by waste, fraud, and abuse. And I am very
worried that we have hundreds of billions of dollars right now
that we aren't focusing enough on implementing those existing
dollars, because there is enough money now potentially to
bridge the digital divide, and I don't want to see that money
go to waste.
So, we need more focus on coordinating across agencies that
have portions of these hundreds of billions of dollars.
Senator Moran. I think that is a really important comment
that you made, and I share the concern. We do spend a lot of
time talking about the importance of maps so that we are
putting the money where it belongs. But if the consequence
because of lack of coordination between various Federal
agencies and others is so lacking, the coordination is lacking,
that we are spending money that doesn't need to be spent, that
is also a sin as well. And so, we need to make certain that
that coordination is occurring.
And I would encourage you to ask us, ask Congress, for any
assistance that would be helpful in that regard. I would
highlight for you, Commissioner, there was another memorandum
of understanding for planning a rural telehealth initiative. I
would be glad to hear any update on that. I don't have enough
time to take your answer.
The last thing I wanted to say is--actually the second to
last thing, but I only have time for one more. That is, I have
some responsibilities in the world of the Department of
Veterans Affairs, and they have a significant telehealth
program.
Any of our witnesses have any suggestions or comments that
we should know, as we try to improve the access of care within
the Department of Veterans Affairs for those who served our
nation?
Mr. Carr. Well, for my part, I will add that the VA has
been on the front edge of a lot of telehealth adoption, and
that has been very good to see. Digging beneath that
observation, I would leave it to others.
Ms. Larson. You know, we still experience latency in
getting local providers eligible to provide specialty service
at the VA. If they are not members of or getting again, a
credential to be on, VA staff as a provider is difficult. And
so, we still have that barrier.
Senator Moran. Ms. Larson, I am not sure, and my time is
expired, but I am not sure what you are telling me because the
VA has the opportunity to provide, in fact, as the requirement
to provide, community care in the community for those veterans
who can better be cared for in the community. And I don't know
whether you are telling me--that those providers are not being
allowed to provide care in the community or you are not being
able to get the necessary credentialed people at the VA?
Ms. Larson. Yes, I am telling you physicians have
difficulty meeting the requirements to be credentialed at those
facilities.
Senator Moran. Community facilities or the VA hospital
itself?
Ms. Larson. All VA settings.
Senator Moran. Thank you. Thank you, Chairman.
Senator Lujan. Thank you, Senator Moran. And Dr. Ransone
and Dr. Arora, Senator Moran's questions is very important. If
we could hear from both of you as well in regards to care for
veterans in that VA setting.
Dr. Ransone. Thank you, Senator. I see numerous veterans in
my clinic, and I share many of my veteran patients with the
nearest VA hospital. I have two, each of which are probably 1
hour and 20 minutes to an hour and 30 minutes drive from my
office.
I have not heard of any program where I am able to access a
VA Administration specialist via telemedicine. I think that is
a wonderful idea. I take care of these folks and I try to keep
them out of the hospital. But any time that I could teleconsult
with a specialist in the VA system, it would be beneficial for
our veteran patients. Thank you.
Senator Lujan. Dr. Arora.
Dr. Arora. Thank you, Mr. Chairman. You know, the VA has an
extraordinarily great shortage of specialists to take care of
veterans. Most veterans living in rural areas don't have
adequate access. We at Echo, have partnered with the VA system,
and they have run more than 30 networks on a variety of
diseases, including mental health disorders, hepatitis C, etc.
But there is the same problem that exists in nursing homes in
the VA hospitals, that is in our health care system financing,
there is no real methodology to incent specialists to
democratize their knowledge and enable primary care clinicians
across this country and in the veterans admission system to
operate at the highest level of their license.
All VAs that I am aware of have very long waits for
specialists and therefore these veterans have limited access.
But this can be solved if we were able to measure productivity
in the health care system differently. For example, could we
account for a time a specialist at the VA spends in mentoring
other primary care providers in rural areas in the VA system,
in the VBOCs, outpatient clinics to provide the care locally.
That is not happening because our measurement systems are
all outside the VA and inside the VA focused on a fee for
service system where the specialist only gets reimbursed for
seeing the patient themselves. And that, in turn, exacerbates
this enormous shortage of knowledge that exists in rural areas.
And I think there is a potential in the VA system to change
that.
Senator Lujan. Thank you, Doctor. And Senator Moran to
respond. And then, we will go to Senator Blumenthal.
Senator Moran. Chairman Lujan, thank you for highlighting
the importance and allowing the other two witnesses to testify.
I appreciate your interest in this topic. The Mission Act,
which many of us were intimately involved in, allows for the
Department of Veterans Affairs and I said earlier requires
where it is in the best interest of a veteran, he or she is
entitled to have care outside the VA. It is not really outside
the VA, it is within the VA, but it is a community care
provider network. And I just would highlight for particularly
both of the doctors and what they just said.
First of all, we expect the VA--and they tout their
capabilities within the capability of providing telehealth to
veterans across the country. What you are telling me is they
lack the necessary professionals, particularly in specialty
areas, to meet the needs. That is one area in which the
Department of Veterans Affairs can reach veterans is through
their own telehealth program.
But the other is community care authorized, required by the
Mission Act, which says if it is in the best interests of a
veteran, determined by his or her--him, her, the veteran and
his or her provider, then the VA must provide that care within
the community. It doesn't solve the specialty care, probably
because there is not that many specialists--we don't have the
necessary specialists in our communities, but particularly when
it comes to primary care, there is an opportunity for veterans
to be cared for in the community separate from telehealth.
And this is not a feature that should be forgotten and
needs to be highlighted within our physician community.
Senator Lujan. Well, said Senator Moran. Thanks so much.
Senator Blumenthal.
STATEMENT OF HON. RICHARD BLUMENTHAL,
U.S. SENATOR FROM CONNECTICUT
Senator Blumenthal. Thanks very much, Mr. Chairman, and
thank you for having this hearing during National Digital
Inclusion Week. Very fitting time to have it. Broadband, in
other words, high speed, affordable broadband is really an
essential need. It is not a convenience or a luxury. I think
every one of our witnesses knows the COVID-19 pandemic has only
increased digital divide, including the homework gap. But that
divide can mean a life or death difference to underserved
communities. On Monday, I visited East Hartford to join in the
announcement of East Hartford Fiber City, a project that will
bring in all fiber Internet networks to every home, business,
and town owned facility. It can reach speeds of 10 gigabytes
per second.
I want to highlight this project in particular because it
brings broadband to an underserved urban area. It is not the
solution for the whole State of Connecticut or the whole
country because it relies primarily on private money, even
though it is a public-private partnership, but we do need more
projects across the state and country that provide that kind of
Internet access, including telehealth. So I wonder whether our
witnesses can explain how underserved communities really suffer
as a result of the digital divide, and in particular, low
income communities and communities of color, which face the
largest barriers in accessing telehealth? I will begin with
you, Commissioner Carr.
Mr. Carr. Thank you, Senator, for the question. We have
done some mapping historically at the FCC, and you are exactly
right. We see poor health outcomes, lack of affordable access
to internet, low income. Those things tend to cluster together.
And that is why if we can get affordable Internet
connectivity out there, we can extend the benefits of
telehealth and it literally can save lives. That is why the
Connected Care Pilot we have been working on focuses on low
income Americans and veterans. To your point, COVID-19 only
underscored the value of Internet connection and the value of
telehealth, and we can't afford to go back to the way we did
telehealth before COVID-19.
Senator Blumenthal. Ms. Larson.
Ms. Larson. You know, I think it is really essential to say
that communities do need health care. And the connectivity with
telehealth, what it does is actually helps us keep dollars in
that community, commerce in the community, as we can retain
patients in that local clinic setting, have all of their lab
work and other follow up care retained in the small rural
community versus going to the next level of care. We are
keeping commerce in that community, helping it stay alive.
Senator Blumenthal. I want to ask a question that troubles
me after hearing that we had yesterday in this committee about
data security. It was the second in a series of hearing that is
focused on finding a path toward consumer privacy and
protecting that privacy. I think that my colleagues and I all
agree that we need to see real change to protect consumer
privacy rights.
And I wonder if you could tell me, and I am going to ask
Dr. Arora, Dr. Ransone, and Ms. Larson, what specific actions
do you think ought to be taken to ensure privacy? And then
Commissioner Carr may not have time, so I may ask you to
provide the answer in writing, what the FCC does to verify
telehealth providers in the area of privacy? Ms. Larson, maybe
begin.
Ms. Larson. So there are several options, as you know,
for--especially during the early COVID time where clinicians
were allowed some opportunities to go on different aspects of
providing telemedicine. As a health care provider, we do not
allow that. So all of our--all of the connectivity we have is
HIPPA compliant and we do, of course, comply with that as a
health care requirement.
Senator Blumenthal. Dr. Arora.
Dr. Arora. Mr. Chairman, Senator--Mr. Chairman, Senator
Blumenthal in the Echo Project, your state has taken a
leadership role in democratizing the knowledge of the Yale
University Community Health Center Inc. and many other
organizations. We have taken special precautions for data
security that when a patient is presented on the Echo project
as a telementoring case study, no patient identifying data is
ever shared. So, the Echo model inherently protects the data of
individuals.
Let me give you an example of the nursing home project that
we recently launched. You know, we had almost 500,000 deaths at
one point in the pandemic and 30 to 40 percent of them were in
nursing homes in the United States. So, we at Echo launched 326
networks to connect many in Connecticut to connect these
nursing homes in cohorts of 30 to these academic medical
centers and other organizations.
So, in South Dakota, what happened was there was a nursing
home where there were 40 people residing and 30 got infected
with COVID-19. Two of them were over 100 years old. We had
taught this nursing home using Echo how to use the antibody and
bam, and essentially, of the 30, 28 survived. Two of them who
were over 100 survived. This was almost unheard of in nursing
homes where COVID-19--but the right knowledge at the right
place saved their lives.
And no data security issue came along because no patient's
name was ever discussed, ever in this entire network. Thank
you.
Senator Blumenthal. Thank you. Dr. Ransone, do you have
any----
Dr. Ransone. Yes, sir. I would like to say that we take the
digital privacy and security--we think that is incredibly
important. The concern that we have is the affordability of
HIPPA compliant platforms. Typically, they tend to be more
expensive, and trying to support the smaller, rural practices
is difficult just because of the cost issue. One thing I would
like to jump on that you said earlier, Senator, was regarding
your all fiber network. I only got wired Internet in my home
about 3 years ago, and this was after 2 years of fighting with
a company in order to get it to our area.
Before that, I was considered to have broadband because I
had a cell phone and I had 3G coverage. Unfortunately, that
type of coverage is not anywhere near good enough to allow me
to access my advanced electronic health record at the office.
And so there, I might have been considered to have broadband.
But it was not broadband that was usable and affordable for
most folks. So thank you very much.
Senator Blumenthal. Thank you. Excellent testimony. Thanks
again, Mr. Chairman, for having this hearing.
Senator Lujan. Thank you so much, Senator Blumenthal. Next,
we are going to hear from Senator Blunt.
STATEMENT OF HON. ROY BLUNT,
U.S. SENATOR FROM MISSOURI
Senator Blunt. Thank you, Chairman. On the topic of how we
deliver, Commissioner Carr, you said in your testimony that all
the benefits of telehealth are clear. Barriers remain from
legal and regulatory to connectivity challenges. We seem to be
moving as quickly as we are able to, though seems slower to
most of us than it should be for connectivity. But on the other
authorities, I am concerned we are not moving as quickly as we
need.
Senator Murray and I, along with the House Representatives
Lara and Dingell, introduced a bill, the Treat Act, to try to
deal with some of the regulatory challenges. You know, Missouri
is--we have seven states that touch our state. Our two biggest
population centers are right on the edge of the state. Lots of
people drive from other states to come to Missouri for health
care.
But when it is telemedicine and they are dealing with the
doctor they have always dealt with, they are in a state where
that doctor may not have--may have some challenges because of
the barriers to becoming licensed in that state. Do you--any
anybody on the panel, starting with Commissioner Carr, have any
thoughts on that problem and the importance of solving it?
Mr. Carr. Well, thank you, Senator. I think the Treat Act
is a great step in the right direction to eliminate some of
those geographic restrictions that are unnecessary in a
telehealth world. Speaking of Missouri, though, I also want to
say that you know, one of the challenges on the connectivity
side is workforce and make sure we have the telecom crews
capable of building this out.
And I just had a visit to Lynn, Missouri. They have got
State tech there, which is a wonderful program, training up
young people to get good paying jobs building out this
infrastructure. And as a country, any infrastructure plan that
doesn't include a plan for workforce shortage that we have is
itself falling short. I think that type of a program in Lynn,
Missouri is a great model we need to continue to build on.
Senator Blunt. Right. Well, I agree with that. But in fact,
in our state, the University of Missouri has had extension
opportunities. Early on, very much Ag focused, but later that
focus expanded in every single county. And one of the things
they are doing right now is trying to be sure that there is at
least one location in every county that someone could go to for
a telemedicine opportunity. Often your behavioral health
provider is further away than your other health provider.
And you know, that is something you don't want to let get
away. But if anybody has any thoughts on the challenges. Last
year we saw kids in college in a different situation than they
had been before. Maybe these were people that had had a
behavioral health, people that they would relied on at home,
but suddenly they are five states away. How important is it
that we figure out how to deal with that problem? Ms. Larson.
Ms. Larson. You know, I would speak to licensing is really
a barrier. As you talk about these specialists, they can
provide--there is always a place that is needing them. And you
know, if there are a lot of barriers to getting not only
licensed in the State and the time that that takes--some states
require them or want them to come into the State and be
fingerprinted.
You know, the duplication of that for an individual
physician who is very busy to get all of that done across
several State lines is difficult. Not to mention, typically at
least the way we provide telemedicine, we become--we did a
credentialing or appointment, if you will, with whoever the
local providers are. That means that medical staff, through the
conditions of participation, are required to have medical staff
appointment criteria.
Each of them are different. I have ED, emergency physicians
who are appointed in 200 locations across the U.S., 200
different sets of bylaws that they have to be accountable to
achieve and accomplish and keep up in 200 different facilities.
That is just the governance at the local site that is required
by the conditions of participation.
Senator Blunt. Well, I think I am running out of time here.
We are--I think this is something we have to deal with. I had a
meeting, a Zoom meeting this week with a group, the American
Connection Project, 170 different members, big companies and
others. The Treat Act is the first piece of legislation they
have ever endorsed, and so they endorsed it this week.
And I hope we can deal with that because if we have
telemedicine, we are going to have to have connection to the
doctors and other health care professionals that you want to be
connected with and that you often are connected with when you
get in your car and drive.
But all of our--every state has somewhere in the State that
someone from another state drives to see their doctor now, and
we need to figure out how they can have that telemedicine visit
as well with the--I think you can make considerations as the
Treat Act does, for State regulators to still have authority if
things are not going the way they should, but some sort of
understood reciprocity or something is really important here.
Thank you, Chairman.
Senator Lujan. Thanks, Senator Blunt. Next, we are going to
hear from Senator Tester.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Chairman Lujan. I like the sound
of that. You know, Commissioner Carr, before I get into my
remarks here, I just want to say, I hope you heard what Dr.
Ransone said. And at that, you know, we give a lot of money out
to folks who are supposed to put broadband in the ground, and
they turn around and say, you know, he has already got
coverage, when he has got crap for coverage. I mean, this is
unbelievable.
And so I think depending on you, Commissioner, to put the
boost of these guys when they don't do what they say they are
supposed to do because we are putting out billions of dollars.
And telehealth is really important. I live in Montana. Weather,
distance, those all make telehealth a winner. And I have heard
from patients that they believe it is a winner. And quite
honestly, I wasn't sold on it from a mental health standpoint
in the beginning.
But I have heard from veterans because I serve as chairman
of the Veterans Affairs committee--from veterans that say
telehealth is actually better than in-person visits in a lot of
cases. So, there is just a lot of positive things out there for
telehealth, and we have done a lot to help push the ball
forward as the Senators know, through the CARES Act and through
the December Consolidated Appropriations Act that we passed in
2020. Montana health care providers received nearly $1.9
million. That is real money. And it came through Commissioner
Carr's FCC telehealth program, to purchase telemedicine
software devices, remote monitoring equipment, and more--
ultimately delivering more quality care to Montanans.
Because of this funding, Montanans, you know, they can do
it at home. They can do it at a local hospital that may not
have the kind of level of expertise there that some hospital
always away would have. So, it is a real positive thing in a
State like Montana. And I know that for those folks who don't
know how to use a computer or don't want to use a computer or
don't have the up to date computer, there is also audio
options. And quite honestly, those provide some benefits too.
I am going to start with you, Dr. Ransone. From an audio
standpoint, I don't know if you do any audio telehealth, but if
you do, could you talk to me about its effectiveness, because I
do know the video telehealth is very effective. And correct me
if I am wrong on that. You are the pro.
Dr. Ransone. No, sir. The video is very effective. And
being able to see a patient and being able to have them hold
their broken finger up or whatever it might be in front of a
camera, it is quite beneficial for me and making a diagnosis
and developing a treatment plan. Audio only is quite effective.
Especially the most effective tool is one that we can use,
right. And so, if my patient can't use video, it is of no good
to me and their care. So, the most effective thing is what they
can use. And audio only is incredibly effective, especially for
my older patients. I can ask a lot of questions, and a lot of
times I can decide, do I actually need to bring this patient
down to see me?
And an audio consultation can give me the needed data that
I have in order to do that. I would like to jump in and just
say that, when my patient--we know that the best care of these
patients is in the patient-centered medical home. And when we
have our patients who travel, they go to college, they do other
things like you mentioned, specifically if they are out of
state, I think I can give them the best care because I have
known the patients since they were an infant.
Frequently, when my patients go to college, I can call
them. We can do mental or telehealth visits regarding
behavioral health, frequent medication refills and things like
that. So, we do think we need to crack that-of interstate
commerce or interstate consultation, but we support the
Interstate Medical Licensure Act.
We think that it is incredibly important that there is
still some state control for safety reasons over the physicians
in that Act, though we think it needs to be less burdensome to
apply in other states and less costly to apply in other states.
We think it is incredibly important to allow that patient to
stay within their medical home so we can give them the best
services, be it audio or video. Thank you.
Senator Tester. No, thank you for that input. This is a
very simple question, and because I only got about 40 seconds
left. And we put it in a bunch of waivers because of the
pandemic on telehealth. Number one, do you think that those
waivers should be made permanent, or should we just extend
them? What is your view on the waivers, and have they been
effective?
Dr. Ransone. I think the waivers have been effective and I
would be supportive of making them permanent. I think that we
have entered a brave new world of virtual communication, and
this is the best way for me to help take care of my patients in
their medical home.
Senator Tester. Alright, thank you, Mr. Chairman. I want to
thank you all. It is a good hearing. Thank you very much.
Senator Lujan. Thank Senator Tester. Next, Senator Cruz.
STATEMENT OF HON. TED CRUZ,
U.S. SENATOR FROM TEXAS
Senator Cruz. Thank you, Mr. Chairman. Ms. Larson, the
Biden Administration has issued a number of COVID-19 vaccine
mandates. One of them compels Medicare and Medicaid providers,
such as hospitals and medical practices to in turn force their
employees to get vaccinated or risk losing their job. These
mandates violate individual liberty, they violate the health
care privacy of the employees, they are not authorized by law,
and they could force people to receive a vaccine, even if doing
so is contrary to the medical advice of their own doctor.
For the first 12 months of the pandemic, Republicans and
Democrats together praised health care workers, praised
doctors, nurses, physicians, assistants, technicians,
pharmacists, other medical professionals for working
tirelessly, and despite personal risk for their own safety and
health, to treat Americans who contracted COVID-19. We all
agreed that medical professionals were heroes.
But for President Biden and for Senate Democrats,
yesterday's heroes are today's Government subjects who must
submit. The message from Joe Biden and Senate Democrats is, do
as the Government says with your own health care or lose your
job. Lose the ability to make a living, lose the opportunity to
provide for your family. That is the Biden Administration's
unlawful vaccine mandate. It is ironic that Senate Democrats
are holding a hearing today about access to care, even though
they are perfectly willing to let President Biden impose a
policy that will cause medical professionals to lose their jobs
and in turn diminish America's access to care.
Ms. Larson, what are you hearing from medical professionals
about their intention to submit to this mandate? And are there
medical professionals who are not going to comply with this
Government mandate?
Ms. Larson. What I would like to speak to is the
application of telemedicine within this. So what I do hear from
individuals are because we are reaching patients a thousands of
miles away, and it is the same clinicians, physicians, nurses,
pharmacists, will we be requiring--you know, the question is,
what are we doing? And you know, we will be in compliance with
what our customers in this case want.
So, in some cases, a receiving facility of telemedicine is
saying all clinicians who are accepted on the medical staff
need to be in compliance. And so, it is interesting in that
situation we have to be careful that we aren't subduing care,
taking care away from them by not being compliant with the
bylaws of the medical staff. And individual physicians will be
taken off medical staff if they aren't compliant with the
requirements.
So right now, you know, we are hearing a mix. There is--you
know, just like the Nation, there is a mix of who is doing--you
know, who wants to provide care or who wants to get a COVID
vaccine and who doesn't. And we are in this situation of trying
to be in compliance so that we aren't taking care away from any
organization.
Senator Cruz. Dr. Ransone, do you know how many doctors,
how many nurses, how many health care providers have been fired
because of the Biden Administration's vaccine mandate?
Dr. Ransone. No, sir. I don't have any numbers as far as
termination of employment. The American Academy of Family
Physicians does support the vaccination of health care workers
for----
Senator Cruz. The mandatory vaccination, regardless of
whether they want to or not?
Dr. Ransone. We support what is best and safest for our
patients, Senator.
Senator Cruz. Does that mean the mandatory vaccination,
whether they want to or not, and whether their own doctor
advises it or not?
Dr. Ransone. I think in a health care environment, each
office, each hospital should be able to make their own decision
about what is safest for the patients that come into their
building or interact with their staff. And I support their
freedom to make a decision on what, how they want their
building or system to operate.
Senator Cruz. So I agree with you they should have that
freedom and they are not being given that freedom right now
because the Biden Administration is forcing them upon it. I
will read to you a headline from the New York Times this week.
This week, on October 4th of this week, New York's largest
health care provider fires 1,400 unvaccinated employees.
It is astonishing, after we spent a year celebrating the
heroes of health care, the Joe Biden solution is we are going
to use Government power to force you to submit, and as a
consequence, fire any doctor, fire any nurse who dares make a
different decision. That is an abuse of Government power. It is
contrary to law, and it is bad policy for America.
Senator Lujan. Senator Peters.
STATEMENT OF HON. GARY PETERS,
U.S. SENATOR FROM MICHIGAN
Senator Peters. Well, thank you, Mr. Chairman. And thank
you to each of our witnesses for a very insightful hearing.
Thank you for being here today. You know, I live in a very
diverse state. The State of Michigan has some densely populated
areas, as well as some incredibly beautiful rural areas in
Northern Michigan in particular, in the Upper Peninsula. And
what all of my folks require is access to quality health care
that they can afford. And certainly telehealth brings state-of-
the-art technology into homes, regardless of where they live.
It is incredibly transformative. But the University of Michigan
recently put out a report that found that patients who are
African-American or folks who may need an interpreter or use
Medicaid as a primary insurance, or certainly if they live in a
low broadband area, are much less likely to access video
visits.
For example it has been estimated that only 10 percent of
African-Americans and 12 percent of Medicaid beneficiaries were
less likely to access video visits compared to audio only
visits. So, we have seen these kinds of health disparities
certainly play out across the pandemic.
And my question for you, Dr. Ransone, is in what ways can
we support telehealth services to our underserved communities
that currently are not able to utilize these technologies or
for various reasons may find it difficult to use these
technologies?
Dr. Ransone. Thanks. I think that the connectivity issue is
twofold, it is access and affordability. I think that we need
to work on digital literacy for a lot of our patients,
especially the elderly. And I think that potentially putting
out pilot programs or things such as digital health navigators
to help people understand the technology will be incredibly
beneficial to help them be able to interact with me as their
physician. I think that we have seen that non-native English
speakers and folks who have limited English proficiency don't
use telemedicine platforms to access their physicians.
A lot of it has to do with just the inability to understand
the instructions on their iPad or their phone. And I know that
with when we first started with a telemedicine program to reach
out to our patients at the beginning of the pandemic, I had to
have extra staff time in order to help my patients learn how to
connect with a digital platform.
One of my front office staff would spend approximately 25
to 30 minutes with each patient just trying to get them to
connect so that I could have my office visit, and that takes
time away from their regular duties in the office. So I think
any type of digital health navigators to help these patients
access and bridge that digital divide would be incredibly
beneficial for them. Thank you.
Senator Peters. Well, I appreciate that. And a follow up
question, you mentioned also the ability to have resources to
pay for these services so that it is available. You said access
is about technology, but it is also affordable. We know that
during the pandemic, HHS allowed certain services to be covered
under Medicare, but those waivers are about to expire. Could
you tell this committee why it is important to have both
flexibility for billing, for telehealth services, why we need
to continue to be focused on that going forward?
Dr. Ransone. Thank you. Well, I spend a lot of time with
each visit, be it an in-person visit, be it a video visit, be
an audio visit beforehand, reviewing charts or viewing patient
history and trying to prepare in order to see that patient to
give them the most efficient and best care that I can give
them. Once these waivers run out, I will be doing a lot of work
for services for which I am not going to be reimbursed.
So, it is pushing people more toward an in-person visit
because that is the old paradigm in patient care, as you see a
patient in person and you treat them. Where when we get to more
advanced ways of seeing patients for some of the advanced
models of patient care, it is--when we, let's say we were to
make global payments to physician offices, we can allot our
time.
We can be paid for what we do to get ready for these
visits. But it takes a lot of time to prepare and then follow
up from any of the three types of visits mentioned. Thank you.
Senator Peters. Alright, well, thank you, doctor. Thank
you, Mr. Chairman.
Senator Lujan. Thank you so much, Senator Peters. Senator
Rosen while you are next, we don't have any other Republicans
that are currently in the queue. Senator Warnock does have to
leave now at noon, and I was just checking to see if we might
be able to go to Raphael next----
Senator Blackburn. Mr. Chairman, you do have a Republican
in queue virtually.
Senator Lujan. I appreciate that, Senator Blackburn. So,
Ms. Rosen, you would follow Ms. Blackburn. But just checking to
see if that might be OK.
Senator Blackburn. OK. Are you ready for me, Mr. Chairman?
Senator Lujan. No, a Democratic member is next, Ms.
Blackburn.
Senator Blackburn. OK.
Senator Lujan. Or I apologize. Ms. Blackburn, you are next.
STATEMENT OF HON. MARSHA BLACKBURN,
U.S. SENATOR FROM TENNESSEE
Senator Blackburn. OK. Thank you, Mr. Chairman, and thank
you for the hearing. As you all can see, there is a lot of
interest in this hearing. I enjoyed sitting in the hearing room
until I had to step out and move on to another quick little
meeting. Commissioner Carr, I wanted to come to you first. Last
year, the FCC did such a good work setting up the telehealth
program, the Connected Care Pilot Program that you all did. So
we have talked a little bit during the course of this hearing
about, you know, funding and grants and workforce, and a little
bit about regulation, things that would inhibit moving forward
with this program, growing it.
And of course, we have talked about using it for veterans.
And Dr. Ransone, thank you for your comments that are there.
Ms. Larson, you have talked some about serving the underserved.
So let me know if there are any legislative or legal hurdles
that we need to move out of the way so that we can continue to
grow this program. What do you see?
Mr. Carr. Well, thank you, Senator, for your leadership on
telehealth. First, I would say the Connected Care Program is
funded out of the FCC's Universal Service Fund. And as a
statutory matter, there are some threats to the stability of
that fund, and that is why I have put forward the idea of
looking for legislation that would help us expand the base of
contributors into that to include big tech. I think the other
statutory issue that comes to mind is the HHS waivers. I know
you personally were involved in helping to secure those waivers
last year that paid dividends for really so many Americans. I
think statutorily addressing those waivers and sometime of
longer term basis is a key step going forward.
Senator Blackburn. OK, thank you for that. And Ms. Larson,
as we were discussing the waivers with Senator Tester, I could
see you wanted to weigh in on that. And as Commissioner Carr
just said, this is one of the first things I did when we had
the pandemic at its beginning, in the earliest stages, I asked
President Trump to give that temporary relief and those waivers
for telehealth provisions.
We had had this legislation for about 3 years and people
didn't seem to think it was a necessity. But of course, COVID
has proven that it is a necessity for individuals with complex
medical conditions and who are not in proximity to a health
care provider. So, I want to give you an opportunity to weigh
in on why these waivers need to be made permanent.
Ms. Larson. Well, thank you for your leadership in all of
those waivers. It has been essential for us to be able to
provide the telehealth services in many locations. And I will
just emphasize, you know, if HHS were able to untie their hands
a bit to determine appropriate telehealth practices and
services and providers, it would be tremendous--you know, the
many of the rules and regulations are written prior to this
type of technology.
And so, if we could look at that in a more global way and
untie their hands, allowing them to do what is appropriate
today. And then also, you empower the safety net providers, the
federally qualified health centers, as well as rural health
clinics, making sure that we can have telehealth services
continue in those locations, in those remote geographies.
Senator Blackburn. OK. Yes, we have the legislation that
would allow the across state line utilization of telehealth.
Tennessee is a state that borders eight states, and we have
areas where those physicians are located inside Tennessee, and
then other areas against the state line where it is across that
state line. So, we do think that that is vitally important.
Dr. Arora, one quick question for you on the Echo program.
Vanderbilt has done a really admirable job on its own Echo
program, which really does help in training those providers on
caring for our adults on the spectrum, as well as providers to
treat patients with opioid abuse, disorders, pediatric
behavioral health.
So talk for just a moment about flexibility, why
flexibility is important to the success of this program and the
role that you see for public-private partnerships as we look to
grow this program.
Dr. Arora. Yes, Mr. Chairman and Senator Blackburn, thank
you for your question. In addition to Vanderbilt and all of
their amazing Echo programs East Tennessee State University
also runs an Echo program for children's care. And these
programs have an extraordinarily powerful impact on bringing
care for children with autism in all over Tennessee. But there
is a challenge for Vanderbilt and East State University. All
our current Echo programs are funded through one time grants or
support from the Executive Branch through a short amount of
money or funding or philanthropic support is a very major way
Echo's--we currently have close to 800 such networks operating
in the United States.
And in the United States alone, in 2020 alone, more than
500,000 health care providers participated. Yet the entire
network is operating on philanthropy or Federal grants, et
cetera. We need policy change so that each of these academic
medical health centers, large not-for-profits are actually
incented and funded to democratize their knowledge so every one
of the members of Dr. Ransone's community of family physicians
has the ability to be mentored to provide best practice care in
their local community, and that requires significant policy
change.
And Senator Blackburn, I would greatly enjoy the
opportunity to work with you to bring this policy change so
such universities can be supported.
Senator Blackburn. My time has expired. We will follow up
with you. And Mr. Chairman, thank you.
Senator Lujan. Thank you, Senator Blackburn. And I also
want to thank Senators Rosen and Hickenlooper for their
indulgence. Senator Warnock, you are next.
STATEMENT OF HON. RAPHAEL WARNOCK,
U.S. SENATOR FROM GEORGIA
Senator Warnock. Thank you so very much, Chairman Lujan.
And it is great to serve alongside you on your subcommittee.
COVID-19 has put a strain on all of us, and it has been
particularly challenging to our health care systems. But one
consequence of that is that it has forced advances in
telemedicine that otherwise would have taken decades. In
response to the pandemic, for example, CMS allowed telehealth
flexibilities and encouraged Medicaid programs to follow suit.
So, this is some innovation that is a consequence of the
challenge. This has allowed patients to remain in the safety of
their homes while receiving care. It has allowed providers to
safely provide high quality care and to be reimbursed for it.
However, due to the politics of health care coverage in our
country, Medicaid nonexpansion states like Georgia have left
some 4.4 million Americans in the coverage gap.
And in the case of Georgia, there are 500,000 Georgians who
cannot access these services. This means that Georgians are
forced to delay lifesaving treatment in the midst of a
pandemic. Dr. Ransone, can you tell me what it would mean to
patients and providers and hospitals--by the way, we have had
10 hospitals in Georgia close in 10 years because of our
refusal to expand Medicaid.
What would it mean for these communities and other--the
other 11 nonexpansion states were we to expand Medicaid?
Dr. Ransone. Well, thank you for the question, Senator. I
am from Virginia, and we were a state that delayed expansion of
Medicaid, and when we eventually did expand it. It allowed us
to see over 400,000 new patients in our health care systems
across the Commonwealth. By allowing these folks to receive
coverage, we have been able to save lives. We have been able to
initiate care sooner and we have been able to prevent the
disease. Medicaid expansion has been essential for us to
deliver equal and equitable care across the citizens of our
Commonwealth. Thanks.
Senator Warnock. Can you speak specifically to the impact
of this for rural communities in your state? When I moved
around Georgia, especially with the refusal to expand Medicaid,
it seems to me that it is the rural communities that have been
most hard hit by the politics of health care. Can you talk
about the impact, particularly on rural communities?
Dr. Ransone. Yes, sir. Living in a rural community, I have
gotten many patients who were uncovered prior to the expansion
of Medicaid. One patient in particular, his name was Sam,
delayed coming to see me after he lost his job. He did not have
Medicaid because his wife worked, and he delayed coming in to
see me by approximately 9 to 10 months. By the time he came in,
he was quite jaundiced or yellow in color, and we got him in.
We got the services done under some--under some provisions of
care for folks who were uninsured.
But unfortunately, he ended up passing away from a
cholangiocarcinoma, which is a cancer of the gallbladder and
gallbladder duct. I think if we had been able to get him in
sooner when he first had symptoms, we would have been able to
save his life or at least ease a tremendous amount of suffering
that he had near the end of his life. Medicaid expansion in our
area has been incredibly important to get folks into our
office. My wife, as I said, is a pediatrician. About 50 percent
of her patients have Medicaid.
I have probably doubled the number of Medicaid patients
that I have been able to see in my office since we have had
expansion, and it has enabled me to give them better care
because they will actually come in when they first start seeing
symptoms. Thank you.
Senator Warnock. Thank you. So you see firsthand, given
your position as President of the American Academy of Family
Physicians, the ways in which this is an equity issue around
health care. Generally, we have got Medicaid in 38 states.
Imagine having Medicare in 38 States or Social Security in just
38 states. But this issue around the digital divide is also an
equity issue. About 1 in every 11 locations in Georgia lacks
reliable broadband services, and 75 percent of these unserved
locations are in rural areas.
Commissioner Carr, we are working right now, and I was
proud to join Chairman Lujan and others to champion increased
broadband funding in the bipartisan infrastructure package. I
hope the House will pass it soon. But even if that bill were
signed into law today, it could take many years before some of
these areas are served with high speed internet. Commissioner
Carr, what are some short-term solutions that Congress, and the
FCC can pursue to expand telehealth access in areas that
currently lack broadband?
Mr. Carr. Well, one thing we can do very quickly is we have
about $326 million that is slated to come to Georgia as part of
our RDOF initiative over 10 years. That could bring service to
about 179,000. We need to accelerate the process of getting
that money that Georgia broadband builders who won at the end
of last year actually out the door. So, I think implementing
the existing funds because there are billions and billions out
there that we can put into the ground. I think that is
important while the discussions go on about additional
broadband funding.
Senator Warnock. Thank you so much. Thank you, Chairman.
Senator Lujan. Thank you, Senator Warnock. And again,
Senator Rosen, thank you so very much. You are next.
Senator Warnock. Thank you, Senator Rosen.
STATEMENT OF HON. JACKY ROSEN,
U.S. SENATOR FROM NEVADA
Senator Rosen. Of course. Of course. Thank you both, the
chairman--all the gentlemen for being here, women for being
here, everyone, all the witnesses for being here today. It is a
really important topic. Senator Peters, Senator Warnock, and
others have talked about rural areas. I just want to add that
in Nevada, 280,000 citizens of Nevada, my constituents that
live in rural areas, barely 10 percent of our population.
So it is really, really important to us. But I want to
actually talk a little bit about provider shortages because
earlier this year, Senator Murkowski and I introduced the
bipartisan Improving Access to Health Care in Rural and
Underserved Areas Act. It is going to bring specialists in
person or through telemedicine like we are discussing today to
health centers and rural clinics. So, Dr. Ransone, can you talk
to me about how we can use telemedicine to leverage the
providers that we have now, because we are facing severe
provider shortages.
And what can we do actually in conjunction with that, maybe
having our EMTs, our mobile clinics, home visits by nurses, but
there are shortage of providers everywhere we go, and we know
we need to increase them. But how we can--how can we potentiate
with other things we do in rural or remote underserved areas?
Dr. Ransone. Well, Senator, I am a big believer in team
based care. And I am a believer that the physician-led team
based care consisting of nurse practitioners, physician
assistants, potentially EMTs and so forth can greatly expand
our access to patients in need. I have had telemedicine visits
where I had a home health nurse in the home of one of my
patients, where I could connect via a virtual video visit where
the RN in that patient's home acted as my eyes and ears in
looking at the patient.
The reason we had to do that is because the patient was
about an hour away and wasn't able to be transported. We don't
have--in our rural environment, we have no public
transportation. And they had no way to get to me, but I could
get on the services to them. And that allowed me to take what I
consider to be great care of that patient. And again, it was
within our medical home. We could have people acting as our,
again, our eyes and ears to help take care of that patient. One
thing that--when you were speaking, it made me think, wouldn't
it be a great thing--we know that physicians tend to settle
within a certain radius of where they train.
Wouldn't it be a great thing to be able to get young
physicians, potentially rather than physicians out into rural
and underserved areas where they are able to communicate with
their attending physician via medicine, via telemedicine, so
that they know in the area we can get them there before they
have completed their training and potentially keep them in
those underserved areas after they graduate.
Senator Rosen. Yes. I couldn't agree more, and I agree with
you on the team approach. We talk about connectivity or
technological issues. Maybe people don't have an iPad, or they
don't have the right technology to connect. This is where
someone coming to their home can really help and get the
services that they need. And speaking of other services we are
talking about, so many of my colleagues, the access for mental
health for our K-12 students. They really suffered so much
during the pandemic with tele-education, trying to learn,
missing their friends, all of that nationwide.
We just know that there are in rural areas in particular,
there is no licensed psychologist or there is such a shortage.
94 percent of counties actually have no licensed psychologists.
So, telemedicine again can help fill this provider gap.
And so, what other things do you think, Dr. Arora, that--
what we can do about pediatric mental health care, access
again, using this approach to get into people's homes somehow
with maybe a provider on the other end of the line?
Dr. Arora. Yes, Mr. Chairman, Senator Rosen, thank you for
your question. Your State of Nevada, University of Nevada, Reno
has done a tremendous amount of work with the Echo model to
bring access to care to rural and underserved areas. They work
in the area of opioid use disorder, medication assisted
treatment, mental health, antimicrobial stewardship, and even
in sports medicine. And I think that the problem you
highlighted is one of the biggest problems of the health care
system, the shortage.
One potential way to ameliorate the problem, not completely
solve it, is the idea of what we call task shifting. Dr.
Ransone mentioned this briefly, but there are physician
assistants, nurse practitioners, nurses. If they are mentored
in a telementoring model in which all teach, all learn, we have
demonstrated in hundreds of publications now that we can
upskill them so that they can provide the care where patients
live. Now this upskilling occurs in a method which we call
``all teach, all learn,'' where these physician assistants and
nurse practitioners learn from each other, they learn from
experts at the university, and together discuss cases
ultimately with the idea that they become experts in this
situation.
I will give you an example, out of this country in India,
where the leading academic center in Punjab in India was
treating 1,500 hepatitis C patients and they adopted the Echo
model in every district hospital, and now have treated more
than 90,000 patients with a cure rate of 93 percent just by
upskilling and task shifting of the kind that you can do.
Effective task shifting requires three things: a
multidisciplinary team of experts, case-based learning, and
mentor/mentee relationships. And with current expansion of
broadband capacity that we are talking about here, we can
achieve those objectives in this country. Thank you, Senator.
Senator Rosen. Thank you. I really appreciate all the
thoughtful answers today and look forward to working with you
on positive solutions. Thank you.
Senator Lujan. Thank you, Senator Rosen. Senator Klobuchar.
STATEMENT OF HON. AMY KLOBUCHAR,
U.S. SENATOR FROM MINNESOTA
Senator Klobuchar. Well, very good. Thank you so much,
Senator Lujan, for your leadership on this, as well as other
issues related to getting information out to your constituents,
the people in this country, and certainly telehealth. Our
states may be a little different for temperature, Chairman, but
we both have significant rural areas and know how important it
is to get health care in innovative ways. And I also want to
thank Senator Thune. He and I actually led a bill on telehealth
before it was cool, like years ago when no one was talking.
And part of that was we have major health care systems
based in our states and one in South Dakota, obviously, Mayo in
Sanford, Mayo in Minnesota, and they have wanted to reach rural
areas and trying to figure out how best they do that. So, I
think I will start out with you, Commissioner Carr. You
testified highlighted in your testimony some of the challenges
that rural communities face.
What kind of investments, and you all know we just did, in
the bipartisan infrastructure bill that we are very proud of
that passed the Senate $65 billion when it came to broadband?
And that is getting to these very areas that may not have an
expert in a certain medical field next door, so it goes hand in
hand. But do you want to talk about how important it is to get
the broadband to make all the telehealth work?
Mr. Carr. Yes. Thank you, Senator, for the question. You
know, we do need billions and billions of dollars to finish the
job of bridging the digital divide. And I think the most
important challenge at the moment is implementation because we
have a lot of dollars, for instance, already spread out across
Department of Ag, Commerce, Education, Treasury.
We have got to make sure we move in a coordinated way, so
we are not putting money on top of other dollars, or wasting
because this issue is just too important to quickly bridge the
divide to not fully coordinate on this. I think that is going
to be the biggest challenge is less so than the dollar amount
right now, given the desire to invest in it, but is the
implementation of those dollars.
Senator Klobuchar. Good point. And I think part of this is
mapping, as you know. And Senator Wicker, and we have talked
about that. We actually had, in Minnesota, witness where we
were commended for some of our mapping, but it is also about
the accountability.
You know, this issue where it goes out to a big telephone
company, they don't actually build out. And one of the things I
like about the bipartisan infrastructure bill is a lot of that
is going to be focused out of Commerce with Secretary Raimondo.
I had her in my--we had a long discussion about the claw backs
and like if they are not actually doing it, that the money can
be clawed back. And I think that accountability piece of it, it
is going to be really important.
And as you point out, Commissioner, there is also other
funds and other things, but just getting it out there. Ms.
Larson, the Universal Service Fund Rural Health Care Program
funds modern telecom broadband services. In your view, how can
the FCC work with Government partners and the private sector to
coordinate the integration of telehealth?
Ms. Larson. The USAC funds, as we have mentioned earlier,
are very important to our rural geographies. And you are right,
the local telecoms often don't have the circuit to build out.
So how do we make sure that that circuitry is built and
available to our rural communities. And ease of a collaborative
application for USAC funding would be really well embraced by
our rural communities.
Senator Klobuchar. Very good. And the other question of you
and then maybe Dr. Arora. The pandemic has shown about how we
need to connect with family and friends. You know, we lost my
dad this year, but during the pandemic, he was in assisted
living, and that was one of the only ways of course, I could
talk to him was through the internet. And we had some very
interesting things with iPhones that they are trying to hold up
with him. He had Alzheimer, so you can imagine suddenly this
voice is coming on the thing.
And it did make me think about how having a, you know, some
of these facilities, getting them or making sure they have the
screens in the way you can do this for people to be seeing
their loved ones in a bigger way. And that is why Senator
Capito, and I introduced the Access Act to expand telehealth
support for seniors for virtual visits. Of course, it was
pandemic based.
But really, the same thing applies for out-of-town
relatives and all kinds of things you would like to use it for.
Ms. Larson, in your view, how will sustained telehealth,
sustained, coupled with in-person care, bolster health services
for elderly communities?
Ms. Larson. You know, it is very important to understand
that our telehealth can be the end of the clinical service
requirement, and intervention can be ordered, and implemented
via the phone or video, and, or it can be noted--you can note
that this individual needs to come into a clinic visit face to
face, maybe for an advanced tele--or non-telehealth, an
advanced in-person visit. What is really important about that
is that you need both to really get early access to the
individual.
And our seniors, again, with mobility issues and just not--
you know, we have understood that being home and sequestered a
bit, not being exposed to viruses or other situations, and they
really are more comfortable in their home. Can we retain the
telehealth visit in the home where they are comfortable, they
are accessible and then only bring them out of their
comfortable environments into clinic environments as needed?
Senator Klobuchar. Very good. Dr. Arora, you want to
quickly add anything?
Dr. Arora. Sure. Mr. Chairman, Senator Klobuchar, your
state has been a leader in the telementoring Echo platform out
of the University of Minnesota----
Senator Klobuchar. I know there was a reason I ended with
you, Dr. Arora. Now, continue on. Yes.
[Laughter.]
Dr. Arora. Thank you. Mayo Clinic, Hennepin Healthcare,
Catholic Health Initiative St. Gabriel, they have used Echo for
opioid addiction, viral hepatitis. And the Nursing Home Echo
Project was amazing in that they, Hennepin Health System,
mentored nursing homes in the entire State of Minnesota so that
patients could get the best possible care there. But the
challenge again, Senator Klobuchar, is the same.
All these institutions are working either in philanthropy
or, in this case, the Nursing Home Project, a Federal contract
that we got from AHRQ, which we passed on to Minnesota. But
there is no long term, sustainable way to support these
institutions, to democratize their expertise so that every
citizen of Minnesota can get the care they need, because every
provider, nurse, doctor, community health worker is mentored
with the best care, best knowledge. Thank you.
Senator Klobuchar. Yes. Thank you. And I would note we have
one of the lower death rates for seniors from COVID, and I
think a lot of this was a coordination. And Dr. Ransone, I will
put a question on the record. Thank you for your good work.
Thank you.
Senator Lujan. Thank you so much, Senator Klobuchar.
Commissioner Carr, I wanted to follow up on a line of
questioning from Senator Wicker. Is the Connected Care Pilot
Program established by law or regulation?
Mr. Carr. Connected Care looks to our general Universal
Service Authority and then we stood up a rulemaking procedure
to stand it up, and then applications come in. And so, at that
point, it is a blend of adjudication, rulemaking, but it is a
regulatory program we stood up pursuant to the Telecom Act.
Senator Lujan. And did the FCC under Chairman Pai increase
the Universal Service Fund contribution factor to collect the
additional $100 million to support the Connected Care Pilot
Program?
Mr. Carr. The $100 million comes out of the General
Universal Service Fund, yes.
Senator Lujan. And do you believe that the Rural Health
Care Program established by law has adequate funding?
Mr. Carr. Yes and no. No, we have hit the cap in years
before. We added some additional funding to it. We also allowed
the rollover of funds to address it, but without getting into
the weeds of it, the answer is we need to devote more resources
to this to make sure we have the sufficient, predictable level
of support needed. And if that is more money than it is more
money, because that is what the statute requires.
Senator Lujan. And while you have spoken out publicly with
the next question and responded to Senator Wicker here as well,
I still think it is important to hear from you on this in the
hearing. How should the contribution factor be reformed to
ensure that all programs under the Universal Service Fund have
adequate resources?
Mr. Carr. I think there is a couple of ways to do it. What
we do now is we assess a 30 percent charge roughly on the
telephone portion of consumers' bills, not the Internet
portion. Some people have said we should just shift that charge
over to the Internet bill, which would effectively increase the
price of Internet at a point in time when we are all very
focused on the affordability challenges. The idea that I have
thrown out that is also reflected in that legislation is we
should look to some set of large technology companies to begin
to contribute into that fund to help stabilize it.
One way you could do it in a sort of targeted way is
looking at digital advertising services revenues, which is an
over $100 billion a year in revenues. So, you could eliminate
that 30 percent charge from customers' bill and replace it with
a single digit percent charge on the digital advertising
revenues, and it is much more difficult charge when placed
there for it to actually find its way back into hitting a
consumer directly.
Senator Lujan. I just wanted to thank you for raising this.
I want to recognize the Chair and Ranking Member Wicker for the
work he has done in this space, and it is something I certainly
agree with. What we have heard today are many ideas that have
strong bipartisan support. The affordability piece here is one
that is going to be critically important. Chair Cantwell
reminded us 90 million people across America today don't have a
connection because they can't afford it. That is why the
emergency broadband benefit mattered. It is why the inclusion
of affordability in the bipartisan infrastructure bill matters.
But we have got to fix this other one.
And I don't believe people should be paying that surcharge
for long distance calls. I don't think people should be paying
for long distance calls. I am often at my mother's home and I
have shared this with several, and I was going to call a family
member that lives out of state, and she picks up her landline.
So, you know, mom, use your mobile and she, oh yes, you know.
It turns out it doesn't cost you anything extra to use your
mobile device if you have a connection. It is an old revenue
stream.
And when we can modernize in a bipartisan way to make
affordability real and support the other programs in a way that
does not directly hit the consumer but goes after the
advertising funding that it turns out those companies benefit
from, then more people are connected. It is in their interest.
So, I am hopeful that we can find a strong bipartisan approach
in that particular area.
There are some other questions that I have today, but I
will submit them into the record. And oh, very good. Well,
before we closed the hearing, I want to recognize one of our
colleagues who joined as well. And I will turn this over to
Senator Young.
STATEMENT OF HON. TODD YOUNG,
U.S. SENATOR FROM INDIANA
Senator Young. Well, thank you so much. I appreciate that,
and I think----
[Technical problems.]
Senator Lujan. Senator Young, we may have a bad connection
there. We are going to check with your office. One second, sir.
Senator Young. OK. OK, thank you.
Mr. Carr. I see that the FCC still has work to do.
Senator Lujan. It appears that we have a better connection.
Senator Young, you are recognize.
[Technical problems.]
Senator Lujan. It appears that we do have a bad connection
with Senator Young right now. I don't know that we will be able
to get him back on. I will ask one follow up here as we go, and
we will see if we get Senator Young back. If not, we will close
out the hearing.
The other questions that I had, were along the lines of,
because of the conversation we have had today and the data that
we know from care that constituents patients are receiving
across America, benefiting from telemedicine--now, whether it
is a patient to their provider or it is provider to provider,
telelementary services, there is data caps out there as well.
And there needs to be a real conversation about data caps,
so I think it is an old technology, it is an old revenue
stream, but nonetheless, especially when it comes to
telehealth, people should not be timed out when they are
accessing care, especially what we have learned from veterans.
The VA took this on and there were some benefits that we saw
because of it.
So rather than asking those questions in this hearing, I
want to have a follow up conversation about this and see if
there is a way that we can get some bipartisan support in
looking at this as we are modernizing, especially with the
investment across America. One last check for any of our other
colleagues. We are trying. Well, very good Senator Young. You
are recognized, sir.
Senator Young. Alright. Thank you, Chairman. I really
appreciate it and it is good to be with our panelists. And I
would like to ask a question of Commissioner Carr.
Incidentally, it is good to see you again, Commissioner. So, my
question, I will lead into it by laying the groundwork about
Indiana and our maternal mortality rate. So unfortunately, our
State has one of the worst maternal mortality rates in the
country, although it has improved somewhat in recent years.
Hoosiers aren't alone in facing maternal health issues.
According to the CDC, severe maternal morbidity impacted
more than 50,000 women in the United States in 2014, and the
rate of severe maternal morbidity increased nearly 200 percent
from 1993 to 2014. Now this is a trend you would expect to hear
about in a Third World country, and it is one that we have to
reverse here in the U.S. So earlier this year, I have worked
with some of my colleagues on both sides of the aisle, Senators
Rosen and Fischer and Schatz and myself introduced the Data
Mapping to Save Moms Lives Act. This was swiftly reported out
of the Commerce committee.
Our legislation would utilize data mapping to show where
high rates of poor maternal health outcomes overlap with lack
of access to broadband services. And the objective here is to
help identify where improved access to telehealth services can
be most effective. The 2020 annual report from the Indiana
Maternal Mortality Review Committee specifically identifies
increased access to pre- and post-partum medical and social
work telehealth services as a recommendation to prevent
maternal mortality.
So Commissioner Carr, with that lead in, what steps do you
believe we must take to increase access to telehealth services
to address maternal health and other important health care
issues?
Mr. Carr. Well, thank you, Senator, for your leadership on
this. I think your legislation would go a long way toward that.
And I think as contemplated by the bill, we could include that
in these maps that the FCC is working on right now. And to your
point, that would help us to direct resources in the right
direction to make sure we provide connectivity.
I have visited a health care clinic in Virginia that
addressed some of these issues and would send expectant mothers
home with a connected blood pressure monitors and other
devices, and they saw significant benefit. So, if we get
connectivity and allow these telehealth services to be funded
to provide it to these moms to be, we can literally save lives
as your legislation lays out.
Senator Young. Well, that is what myself and some of my
colleagues who have helped champion this effort believe, and I
am encouraged to hear you say that. Commissioner, how close,
and you may have covered this earlier, but how close is the FCC
to producing these new, more granular maps as directed by the
Broadband Data Act?
Mr. Carr. I don't know, Senator. I think that is a problem.
It is--as indicated earlier, it is a bit of a black box. We
have got the funding from Congress, I believe at the end of
last year. In March of this year, I said the FCC should set the
goal of finishing those maps at least targeted versions this
fall. I don't expect it is going to happen this year.
Obviously, there are a lot of people the FCC that are
working very hard on this, but we have to get those maps done.
If it means paring back what is included in the first version,
then we should do that, but we have to get targeted maps out.
It is the key to unlocking that additional funding from RDOF
II, which is key to getting the 5G fund going, and is key to
making sure as we have these billions of dollars across
agencies that that funding can go through these completed maps
so that we don't have overbuilding.
But unless those maps are done, we are going have to hold
back some of those billions of dollars that other agencies
have, or it is going to go out there and uncoordinated manner.
Senator Young. Well, I hope you will let myself and other
members of the Committee know if there is anything we can do to
expedite the process. Commissioner Carr, once again last time
we dialoged within the committee, the FCC had just recently set
up your $100 million Connected Care Pilot Telehealth Program.
Can you provide us just a brief update on the program and
lessons learned or notable takeaways thus far?
Mr. Carr. I think the most surprising thing has been the
uptake in telehealth generally, particularly with COVID-19. It
has been less of a user issue, less of a technical issue, and I
think what have been holding things back were regulatory and
legal barriers and to some extent funding. And so, I think
these programs are making a big difference.
So far, Indiana has received about $6.7 million in
telehealth funding, not from the Connected Care Pilot yet, but
from the emergency COVID-19 programs. And so, I am very excited
to see the data come in that I am confident is going to show
improved health outcomes.
Senator Young. I believe that will be the case as well. So,
thank you so much. Back to you, Chairman.
Senator Lujan. Senator Young, thank you so very much for
being a part of this important hearing today. Dr. Ransone, Ms.
Larson, Commissioner Carr, and Dr. Arora, thank you for being
here today. And your testimony helped illustrate how the
digital divide is standing in the way of connecting all
Americans to essential telemedicine, remote health monitoring,
and telementoring. Now we have a lot of work to do.
Rural, Native American, Hispanic communities, whether you
are living in big cities or in the most rural parts of our
country, so many people are effectively cutoff from many of the
benefits of telehealth. And we all understand the urgency and
the importance of connecting every American to high quality,
affordable, resilient, fast broadband. Without it, the current
patterns of inequality will continue to grow, and we urgently
need to deliver this relief to communities across the country.
Families must be able to talk to their doctors without
worrying about hitting a data gap or getting cutoff, so there
are many other challenges we have to solve. In the end,
critical remote monitoring systems must remain online during
network outages, bad weather, and natural disasters. And under
the leadership of Acting Chairwoman Rosenworcel, the Federal
Communications Commission has been able to make progress here,
even with a two, two Commission.
Now, imagine the progress that the FCC can make if there
were five members. It is simply unacceptable and inexcusable
that there is no urgency from this Administration to nominate a
fifth Commissioner. And I would say nominate Acting Chairwoman
Rosenworcel, not just for another term, but to be the full
chair of the Commission. I don't understand why this has not
happened. I just want to close with this.
I want to urge President Biden to renominate Acting
Chairwoman Rosenworcel to nominate a fifth FCC Commissioner and
a permanent head of NTIA. We have heard from many Senators
today about the importance and the urgency to get these dollars
into communities, expand capacity with telemedicine. The
funding that was made available through spectrum auctions to
get this back into communities, $1 billion that was
appropriated to NTIA in the previous Congress for Native
American connectivity, CARES Act, American Rescue Fund, the
bipartisan infrastructure.
If we are going to get this right, we need all of these
positions filled and we are running out of time. If there is
not urgency in appointing a fifth FCC Commissioner,
renominating Commissioner Rosenworcel, there is going to be
three FCC Commissioners instead of five in January. It is
unacceptable. We all have to work to expand these programs, but
we need these positions filled. These are priorities I have
long advocated for, and I am going to continue to raise my
voice in that fight.
Now, the hearing record will remain open for two weeks
until Thursday, October 21, 2021. Any Senators that would like
to submit questions for the record for the witnesses should do
so by that date. We ask that your responses be returned to the
Committee by November 4, 2021. That concludes today's hearing.
[Whereupon, at 12:23 p.m., the hearing was adjourned.]
A P P E N D I X
Prepared Statement from Alliance for Connected Care
The Alliance for Connected Care appreciates the opportunity to
submit testimony for this hearing examining the importance of access to
telehealth services, and the role that broadband plays in the public
health response.
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.
We believe telehealth has the potential to broaden access to care
and improve patient engagement, and we agree it demands thoughtful
consideration to ensure all Americans are provided equal and equitable
access. As highlighted by the COVID-19 pandemic, access and
affordability of broadband is an important aspect to accessing health
care services, including telehealth services.
Broadband is essential to expanding access to telehealth. Without
it, we will never reach populations who need access to behavioral
health, primary care, specialty consults and more. We must invest in
broadband alongside changing coverage policy for telehealth.
The inequities in broadband access across geography, race, and
income are clear. According to a 2021 Pew Research Center survey, home
broadband use varies significantly across demographic groups, including
race and income levels. Nearly all Americans with annual household
incomes above $75,000 reported having a broadband connection at home,
compared to just half of households making less than $30,000 a year.
Similar stark contrasts can be seen between races and geography, with
80 percent of Whites having access, compared to just 70 percent and 65
percent of Blacks and Hispanics, respectively. Additionally, more than
35 million rural Americans lack access to broadband.
In January, the Federal Communications Commission (FCC) released
their fourteenth annual Broadband Deployment Report finding progress in
closing the digital divide. For example, the gap between urban and
rural Americans with access to high-speed broadband service has been
nearly halved, falling from 30 percentage points at the end of 2016 to
just 16 points at the end of 2019. Despite significant progress being
made, tens of millions of Americans do not have access to broadband.
Estimates range from roughly 14.5 million to 42 million Americans in
total, with the lowest coverage levels experienced in Tribal and rural
areas.
Below we summarize recommendations designed to support and maintain
both patient and provider availability and affordability of broadband:
Congress should invest in efforts that support broadband
affordability for patients and providers.
Congress must continue to coordinate with other Federal
agencies to ensure improvements are being made to our taxpayer-
funded programs, and that all patients deserving of these
benefits are being afforded access.
Congress must make permanent the Emergency Broadband Benefit
program.
Congress must continue to address anticompetitive behaviors
in all industries, and explore solutions that support patients.
Congress should invest in efforts that support the
deployment of broadband for all Americans, including those
living in rural areas, on Tribal lands and to our Nation's
health care providers and centers.
Congress must maintain access to audio-only services for
patients who, in the interim, continue to lack broadband access
and/or affordability.
Congress should pass the Data Mapping to Save Moms' Live Act
(S. 198/H.R. 1218) in the 2022 Consolidated Appropriations
package.
Congress should consider addressing antiquated licensure
requirements that impeded access to care to address gaps in the
delivery system and provide high-value care directly to
consumers in rural or underserved areas.
1. Congress should invest in efforts that support broadband
affordability and use for patients and providers.
For digital health technologies to truly transform the way
Americans obtain and receive access to health care services, we must
address affordability and usability of the technology supporting that
access.
Telehealth has been a critical lifeline during the pandemic and
public health emergency flexibilities have 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 from the Centers
for Medicare & Medicaid Services (CMS) show that between mid-March and
mid-October 2020, over 24.5 million out of 63 million beneficiaries and
enrollees received a Medicare telemedicine service. Finally, an HHS
Office of the Assistant Secretary for Planning and Evaluation (ASPE)
Medicare fee-for-service (FFS) telehealth report 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 versus less than 1
percent before the COVID-19 pandemic.
Despite all of these advancements in telehealth usage, many
households lack the ability to benefit from these digital services.
This is partly due to the United States having one of the highest
broadband prices among OECD countries.
Congress must continue to coordinate with other Federal agencies to
ensure improvements are being made to our taxpayer-funded
programs, and that all patients deserving of these benefits are
being afforded access.
FCC's Lifeline program helps low-income consumers afford the
high cost of telecommunications services, including phone and
broadband. The program has helped millions of Americans connect
with the internet. However, as the COVID-19 pandemic took full
force and much of our in-person services were shutdown,
challenges and shortcomings of the program came to light.
In April of 2020, Senators Klobuchar (D-MN) and Durbin (D-
IL) and Representatives Fudge (D-OH) and Eshoo (D-CA), along
with 140 colleagues in both the House and Senate, urged the FCC
Chair at the time to ensure that the millions of Americans
eligible for the Lifeline Program are informed of their
eligibility status. ``The Lifeline program provides critical
connectivity for those who need it most. Informing consumers
about their Lifeline eligibility is a necessary step to help
close the digital divide and is clearly something we should
continue doing even after the pandemic ends,'' the members
wrote.
Congress must continue to coordinate with other Federal
agencies to ensure improvements are being made to our taxpayer-
funded programs, and that all patients deserving of these
benefits are being afforded access.
Congress must make permanent the Emergency Broadband Benefit program.
The Alliance for Connected Care supported efforts to
establish the Emergency Broadband Benefit, a program that
bolsters access to broadband Internet services for low-income
and minority individuals. Passed in the Consolidated
Appropriations Act of 2021, Congress appropriated $3.2 billion
to the FCC to help low-income households pay for broadband
service and connected Internet devices.
The Emergency Broadband Benefit program has proven to be a
successful entry point for tackling some of the inequities that
exist in access to broadband and Internet services. In
September, FCC Acting Chair Rosenworcel announced that the FCC
has enrolled over six million low-income households into the
country's largest broadband affordability program.
Additionally, nearly 1,200 broadband providers have agreed to
take part in the program.
Congress must make permanent the Emergency Broadband Benefit
program. Without a permanent, government-funded structure for
this program, funds will expire and Americans will lose access
to this vital program. Similar programs like the Supplemental
Nutrition Assistance Program (SNAP) and other Federal programs
have proven to be effective models to deliver assistance. The
Emergency Broadband Benefit program should be treated the same.
Congress must continue to address anticompetitive behaviors in all
industries, and explore solutions that support patients.
A provision later omitted from President Biden's
infrastructure plan would have promoted price transparency and
competition among Internet providers, including by lifting
barriers that prevent competition, and requiring Internet
providers to clearly disclose the prices they charge.
Similarly, the Alliance for Connected Care supported the
Community Broadband Act, which would prohibit banning or
limiting the ability of any state, regional, or local
governments to build broadband networks and provide Internet
services.
According to a 2020 Institute for Local Self-Reliance report
which analyzed data from the FCC, more than 20 million
Americans live in broadband monopolies, whereby they have
access to only one broadband provider. Another roughly 100
million Americans live in areas with access to only two
broadband service providers.
A lack of affordable broadband is a significant barrier to
not only virtual health care access, but also other important
social determinants of health such as education and employment
opportunities. Congress must ensure that Americans are not at
the detriment of corporate business, and that access to these
services takes precedent over corporate interests.
2. Congress should invest in efforts that support the deployment of
broadband for all Americans, including those living in rural
areas, on Tribal lands and to our Nation's schools and health
care providers.
Congress should expand and extend the FCC's COVID-19 Telehealth Program
and Connected Care Pilot Program
The Alliance for Connected Care has been supportive of
calling for additional FCC funding to help health care
providers and others provide telemedicine. In June,
Representatives Spanberger (D-VA), co-leads Johnson (R-SD),
Matsui (D-CA) and Curtis (R-UT)--plus 31 bipartisan members of
Congress--sent a letter to House and Senate leaders emphasizing
the demand in their districts for reliable telehealth services
during the COVID-19 pandemic and the need to strengthen the
FCC's COVID-19 Telehealth Program.
We applaud Congress' and the FTC's continued efforts to
close the digital divide and ensure health care providers have
the appropriate tools to take care of their patients in an
ever-evolving virtual world. The COVID-19 Telehealth Program
and Connected Care Pilot Program have remarkably increased
telehealth adoption among health care providers and health
centers serving those in need. Health care providers in each
state, territory, and the District of Columbia have received
funding.
The Alliance for Connected Care urges FCC to extend these
programs, and for Congress to appropriate additional funding to
support such efforts.
Congress must continue coverage for audio-only services beyond the
COVID-19 public health emergency.
Our nation has only just begun to make strides recognizing
and addressing broadband inequities. As we continue to reach
for 100 percent broadband coverage for all, Congress must
recognize and support policies that maintain coverage and
access where broadband is lacking.
The Alliance believes that audio-only telehealth has been a
critical tool for many clinicians and patients during COVID-19,
especially when considering providing equitable access to care
for patients facing broadband, affordability and other
barriers. While we believe that audio-video communication is
the preferred modality for most telehealth, we strongly support
continued flexibility for audio-only--when clinically
appropriate and when meeting the need or request of the
patient.
Congress must maintain access to audio-only services for
patients who in the interim continue to lack broadband access
and/or affordability.
Congress should pass the Data Mapping to Save Moms' Lives Act
The Data Mapping to Save Moms' Lives Act (S. 198/H.R. 1218)
would use data mapping to identify areas of the country where
poor maternal health rates overlap with a lack of broadband
access, to better deploy telehealth services there.
The United States is one of the only countries in the
developed world with a rising maternal mortality rate. The
problem is especially prevalent in rural communities and
amongst women of color who continue to experience
disproportionately high rates of maternal and infant mortality.
This bill will give our Nation one more tool to combat the
devastating rising maternal mortality rate in this country. We
urge Congress to pass the Data Mapping to Save Moms' Lives Act
in future legislation, including considering inclusion of the
bill in the year-end appropriations package.
Congress should consider policies that drive greater flexibility for
clinicians to provide care across state lines.
State lines create artificial barriers to the delivery of
care--complicating access for patients and creating additional
burden on clinicians. These lines sometimes split major urban
areas and hamper the ability of telemedicine providers to fill
in gaps in the delivery system and provide high-value care
directly to consumers in rural or underserved areas.
Current efforts to expand interstate licensure have been
insufficient to meet the needs of patients and the clinicians
seeking to better serve them. One of the most effective
utilizers of telehealth networks to support the delivery of
care across state lines, the U.S. Department of Veterans
Affairs, supported 900,000 veterans though telemedicine visits
in Fiscal Year 2019--a majority of which were for mental health
care. The program demonstrated growth of 17 percent over the
prior Fiscal Year.
As our entire ecosystem works to address inequities, we urge
Congress to consider addressing antiquated licensure laws that
impeded access to care, and the value of cross-state care in
providing greater access to health care and specialty medicine,
addressing provider shortages in rural and medically
underserved communities, improving follow-up and continuity of
care, and providing patients with more choice in the providers
they wish to see.
Thank you for your consideration. We look forward to working with
you on this important effort. Please contact Crystal Wallace at 301-
742-5240 or crystal
[email protected] with any questions.
Sincerely,
Krista Drobac,
Executive Director,
Alliance for Connected Care.
______
Response to Written Questions Submitted by Hon. Ben Ray Lujan to
Dr. Sterling Ransone
As you stated, there is a clear link between digital equity and
health equity. It's critical we support all providers providing the
best care for their patients.
Question 1. What can the FCC do to ensure better telehealth
access--particularly among independent physician practices?
Answer. FCC programs such as the COVID-19 Telehealth Program and
Connected Care Pilot Program have increased telehealth adoption among
community health centers and hospitals serving communities most in
need. The COVID-19 Telehealth Program has also helped ensure patients
have the connected devices they need to benefit from comprehensive
telehealth and remote monitoring services. Unfortunately, these have
largely excluded primary care practices, for which the startup and
ongoing costs of telehealth impede adoption.
For many small physician practices, especially those that serve a
disproportionate number of Medicaid and uninsured patients, the costs
of telehealth technology can be prohibitive. Many telemedicine vendor
solutions charge setup fees ranging from $400 to $3,000 dollars, in
addition to recurring subscription or transaction fees. Congress should
ensure that small practices are adequately supported, either by making
them eligible for funding through existing telehealth programs or by
creating a new program. Supporting telehealth adoption within these
practices will improve equitable and timely access health care and
promote health care competition by enabling smaller practices to remain
independent.
The AAFP also supports the Connected Care Pilot Program's focus on
improving equitable access to quality telehealth services for low-
income patients by addressing the high cost of broadband connectivity,
including equipment and information services, and urges the FCC to
extend and expand this program.
Lastly, the FCC's Lifeline Program has been critical in helping
low-income Americans access broadband; however, it is used almost
exclusively for mobile, rather than in-home, broadband services. Mobile
services have significant value, but broadband at home creates
additional public benefits--including the ability to connect with your
physician via telehealth. Additionally, mobile or wireless broadband
connections may not have sufficient bandwidth depending on the
telehealth platform. We urge Congress to expand and reform the Lifeline
Program so it can also provide broadband access in homes and in turn
expand access to all telehealth services.
Question 2. How can digital health navigators break down barriers
to ensure telehealth is reaching everyone who needs it?
Answer. AAFP members have shared the challenges that their patients
have faced during the COVID-19 pandemic in accessing telehealth
services and their patient portals, including not having access to
technology such as a smartphone, tablet or computer and not
understanding how to navigate the technology or specific digital health
platform. In my practice, many seniors have struggled to access these
tools unless they have younger family members to help them log on or
troubleshoot technology issues.
To achieve the full promise of telehealth, Congress must act to
address these structural barriers to virtual care. The AAFP has called
for the creation of a pilot program to fund digital health navigators;
develop digital health literacy programs; and deploy digital health
tools that provide interpretive services at the point of care. These
should be available in non-English languages, easily and securely
integrate with third-party applications, and include assistive
technology. Such a pilot should include robust evaluation and metrics
to demonstrate how the interventions have addressed gaps in care or
increased the access for underserved populations.
______
Response to Written Questions Submitted by Hon. Amy Klobuchar to
Dr. Sterling Ransone
Supporting Small Physician Practices. Broadband connectivity is
essential for telehealth. But in rural areas of my state, about 16
percent of households lack access to broadband at baseline speeds. That
means 144,000 Minnesota households don't have adequate access to the
internet.
Question 1. In your testimony, you note that we should be
implementing Federal telehealth programs to support small physician
practices. In your view, what can Congress do to better support local,
rural providers?
Answer. For many small physician practices, especially those that
serve a disproportionate number of Medicaid, uninsured, and
disadvantaged patients, the costs of telehealth technology can be
prohibitive. Many telemedicine vendor solutions charge setup fees
ranging from $400 to $3,000 dollars, in addition to recurring
subscription or transaction fees. Congress should ensure that small
practices are adequately supported, either by making them eligible for
funding through existing telehealth programs or by creating a new
program. Supporting telehealth adoption within these practices will
improve equitable and timely access health care and promote health care
competition by enabling smaller practices to remain independent.
While many of these practices have adopted telehealth due to the
pandemic, the AAFP saw adoption rise from 13 percent before the
pandemic to 94 percent during the pandemic, they have done so in ways
which are hard to sustain and to support a robust digital experience
for their patients. Additionally, the scope of services that are and
can be delivered with sustained payment reforms has grown
significantly. These practices need training and support to transition
from telehealth during a pandemic to sustained long-term telehealth
delivery. Funded by the Health Resources and Services Administration
(HRSA), Telehealth Resource Centers across the Nation provide practices
with information and support around telehealth. Such Federal programs
should be continued and expanded to help rural areas sustain and grow
telehealth in their communities.
As this Committee is acutely aware, our Nation has a long way to go
before all Americans have high-speed broadband along with the tools and
knowledge to leverage it for virtual video health care visits. Further,
there may be times that an old-fashioned phone call is the best way for
a clinician to treat a patient. From my own experience in a rural
community, and talking with other family physicians, I can tell you
that the reasons for this are lack of reliable, high-speed Internet
connection; patients' inability to navigate complex technology required
for video visits; and the challenge for physicians of adopting or
perfecting a video-visit platform. Therefore, it is critical to
preserve access to audio-only telehealth services provided by a
patient's usual source of care.
Rural Telehealth Funding. During the pandemic, we have worked to
bolster the telehealth system across the country. The Federal
Communications Commission (FCC) has awarded local health care providers
in Minnesota nearly $2 million to expand telehealth services to
increase access to care and services during the COVID-19 pandemic.
Question 2. In your testimony, you highlight that telehealth can
improve the quality and comprehensiveness of patient care. What should
we do to capitalize on investments the Federal government is making in
telehealth to advance care in the post-pandemic environment?
Answer. Broadband access must be recognized as a social determinant
of health. The COVID-19 pandemic has underscored the strong link
between digital equity and health equity. Having access to broadband,
especially in times of pandemic and disaster, is vital for connecting
people to the most basic necessities, such as health care, education,
and employment. To realize the potential of telehealth and address
health disparities, Congress must invest in efforts to ensure universal
access to affordable broadband services for individuals and health care
providers.
Telehealth benefit expansions must promote high-quality,
comprehensive, continuous care and increase access to those services.
Telehealth, when implemented thoughtfully, can improve the quality and
comprehensiveness of patient care and expand access to that care for
under-resourced communities and vulnerable populations. As outlined in
our Joint Principles for Telehealth Policy, 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. Telehealth should also enable higher-
quality, more personalized care by making services more convenient and
accessible for patients.
Coverage and payment policies should support both 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 or tactile examination. No two patients or cases are alike,
and family physicians should be able to choose how to best care for
them based on clinical judgement, not based on arbitrary insurance
rules.
While telehealth can expand the reach of some primary care services
by making it more convenient and accessible to patients in their homes
or offices, it is clear that virtual-only providers cannot offer fully
comprehensive primary care. This underscores the importance of Federal
policymakers supporting physician practices in adopting and sustaining
telehealth so that we can offer our patients both in-person and virtual
care as part of the patient's medical home. As Congress seeks
additional studies to inform the direction of permanent telehealth
policies and additional broadband investments, you should encourage the
collection and reporting of data stratified by race, ethnicity, gender
identity, language, and other key factors to help ensure health equity.
______
Response to Written Questions Submitted by Hon. Kyrsten Sinema to
Dr. Sterling Ransone
Infrastructure Investment and Jobs Act. The bipartisan
Infrastructure Investment and Jobs Act includes $65 billion for
broadband deployment, rural and tribal broadband, digital equity, and
affordability in Arizona and throughout the country.
Question 1. How will this historic investment in broadband enable
more Arizonans to access telehealth services, including Arizonans in
rural and tribal areas?
Answer. Full success of telehealth cannot be achieved without
significantly improving our Nation's broadband infrastructure. The
ongoing pandemic has highlighted the utility and importance of
broadband for access to primary care, mental and behavioral health
care, education, remote work, applications for support programs, and
public health information. The $65 billion investment for broadband in
the bipartisan infrastructure bill, which the AAFP supports, is a
significant step to enable equitable telehealth access and
utilization--particularly for rural and underserved communities.
Medicare Coverage of Telehealth Services. Congress expanded the
ability of Medicare of cover telehealth services in the midst of the
COVID-19 pandemic. I have joined my colleagues from both parties to
support legislation, the Creating Opportunities Now for Necessary and
Effective Care Technologies (CONNECT) for Health Act of 2021, that
would make Medicare coverage of many telehealth services permanent.
Question 2. How would the CONNECT for Health Act enable more
Arizonans to access health care services?
Answer. The AAFP has not taken a position on the CONNECT for Health
Act but it includes several provisions we support such as expanding the
definition of originating site to include the home, permanently
removing all geographic restrictions on telehealth services within the
medical home, and permanently adding federally qualified health centers
and rural health clinics as eligible distant site providers. These
changes would help ensure physicians and patients can continue to use
telehealth services beyond the pandemic and help to standardize
coverage and payment of telehealth services across payers.
Question 3. What would happen if telehealth services currently
eligible for Medicare coverage were no longer covered by Medicare?
Answer. In response to the pandemic, family physicians across the
Nation have dramatically transformed and made significant investments
in new technologies and care delivery models, not only to meet COVID
driven patient demand, but to prepare for America's future health care
needs. Many of the telehealth flexibilities are temporary and limited
to the duration of the COVID-19 public health emergency. Without action
from Congress, Medicare beneficiaries will abruptly lose access to
nearly all recently expanded coverage of telehealth when the COVID-19
PHE ends. This would have a chilling effect on access to and continuity
of care across the health care system.
We also have a long way to go before all Americans have high-speed
broadband along with the tools and knowledge to leverage it for virtual
video health care visits. There may be times that an old-fashioned
phone call is the best way for a clinician to treat a patient. Many
physicians routinely use telephone translation services to provide
linguistically appropriate care, and these services can be more
seamlessly integrated into telephone visits. Preserving access to
audio-only telehealth services beyond the PHE is important for ensuring
equitable access to care.
With so many patients accessing care virtually, expectations for
the future of our health care system have shifted significantly.
Virtual care has provided unprecedented access for patients, but
uncertainty as to the future of many telehealth policies will halt or
reverse further adoption--to the detriment of both patients and
physicians. The AAFP urges Congress to act before the PHE ends to
ensure that patients continue to have access to their family physicians
via telehealth services.
Mental Health. The pandemic illustrated the importance for people
of all ages to have access to mental health services, especially during
periods of limited social interaction. Arizona's Teen Lifeline saw the
volume of text messages received by its suicide prevention hotline
increase over 450 percent during the pandemic.
Question 4. How does telehealth provide more opportunities for
patients to receive mental health services? Does the virtual nature of
a telehealth appointment encourage some patients to reach out for help
who may not otherwise?
Answer. Telemedicine for mental health care is a growing interest
in primary care and telehealth initiatives for these services are
expanding rapidly. While the research is limited on this topic, there
are a growing number of studies assessing the benefits, comparative
effectiveness with face-to-face visits, and cost comparisons. At the
beginning of the COVID-19 pandemic, telehealth visits increased by 135
percent compared to that time period in 2019, and 93 percent of those
visits were for non-COVID concerns. In addition, mental health concerns
increased rapidly during the pandemic. Other trends show a
disproportionate effect on the mental health concerns of communities of
color, mothers, and essential workers.
The AAFP is supportive of efforts to expand access to mental health
services via telehealth and encourages Congress to address the
legislative barriers outlined in previous testimony to the Senate
Finance Committee and Joint Principles for Telehealth Policy. In
particular, 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. Telehealth for
mental health services can help address the shortage of over 6,000
mental health professionals in the U.S., particularly for rural and
underserved areas that face a disproportionate impact of the shortage.
Mental Health for Veterans. Nearly half a million veterans live in
Arizona. The COVID-19 pandemic and recent events in Afghanistan have
led to an increase in the number of veterans seeking mental health
treatment.
Question 5. How can telehealth services help veterans receive the
mental health care they need before a veteran faces a mental health
crisis?
Answer. The Department of Veterans Affairs is responsible for
providing health care to the Nation's 18.2 million veterans, serving
more than 9 million veterans every year. However, many veterans often
face challenges when seeking care. A recent study shows veterans often
have to wait longer to receive care compared to non-VA facilities.
Additionally, many veterans live in rural areas where the nearest VA
health care facility may be hours away.
Veterans often deal with both mental and physical health issues,
and unfortunately, long wait times and limited VA resources can often
impede veterans' access to care. Continued investments in VA telehealth
programs, such as the telehealth tablet program, can increase health
care access and strengthen the patient-physician relationship.
______
Response to Written Questions Submitted by Minority Committee Members
to Dr. Sterling Ransone
Question 1. As we evaluate what telehealth flexibilities to make
permanent, do you agree the removal of the originating site restriction
on telehealth is valuable, especially for frontier and tribal
communities given the high prevalence of chronic conditions?
Answer. 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 to pathogens 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 the
comfort of their home and observe things they normally cannot see
during an in-office visit. This helps us to identify social and
environmental factors that may be affecting their health, and to
develop more personalized treatment plans.
Question 2. Dr. Ransone, could you discuss how remote monitoring is
used today, in addition to telehealth, to help in the care of those
living with chronic conditions like diabetes or hypertension? What
steps should we consider to support Americans ability manage their
chronic conditions more effectively when they are outside of a health
care facility?
Answer. The lack of broadband access is limiting the potential of
many digital health tools, such as remote patient monitoring and
patient portals. Remote monitoring devices can feed real-time patient
data, such as vital signs, to clinicians and allow them to adjust
medications and treatment regimens as needed without bringing the
patient back into the office; however, these devices work only with a
strong, reliable Internet connection. I have a patient with congestive
heart failure issues who drives more than an hour each way to see me,
and who would benefit tremendously from this technology, but we can't
use it because of poor bandwidth.
The COVID-19 pandemic has reinforced how lack of access to
broadband and end-user devices perpetuates digital health inequity, and
limited access to virtual health information worsens the digital
divide. It is not enough to simply expand access to broadband. Congress
must ensure that patients in need can access end-user devices, such as
tablets, to connect to digital health tools and invest in training and
assistance so these patients can confidently use those tools to ensure
we don't further marginalize and disenfranchise them.
Question 3. Can you speak to the value of audio-only services in
ultra-rural communities without access to broadband? Is there a better
way that we can target these services to communities that need them?
Answer. Our nation has a long way to go before all Americans have
high-speed broadband and the tools and knowledge to leverage it for
virtual video health care visits. Further, there may be times that an
old-fashioned phone call is the best way for a clinician to treat a
patient. Therefore, it is critical to preserve access to audio-only
telehealth services provided by a patient's usual source of care.
From my own experience, and talking with other family physicians, I
can tell you that the reasons for this are lack of reliable, high-speed
Internet connection; patients' inability to navigate complex technology
required for video visits; and the challenge for physicians of adopting
or perfecting a video-visit platform.
Face-to-face interactions between a physician and a patient are
important components of a patient's care that allow a physician to
gather a comprehensive understanding of the patient and their needs and
build trust and communication. Unlike video visits, telephone visits do
not allow physicians the benefit of being able to visually examine a
patient or read body language and facial expressions. To protect
patient safety and reduce potential for fraud, it may be prudent to
limit coverage of telephone visits to established patients within their
medical home.
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. Preserving access to audio-only telehealth services is
important for ensuring equitable access to care.
Coverage and payment policies should support both 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 the 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 or tactile examination. As a family physician, I am highly
trained and adhere to standards of care. I also know my patients and
have formed trusted relationships with them over years. No two patients
or cases are alike, and I should be able to choose how to care for them
based on my clinical judgement, not based on arbitrary insurance rules.
______
Response to Written Questions Submitted by Hon. Ben Ray Lujan to
Hon. Brendan Carr
Question 1. During questioning, you stated that Universal Service
Fund reform was necessary to ensure sufficient and predictable support.
You also stated that the current contribution rate could spike to
seventy-five percent under the current system based on a recent study.
What are the benefits for including contributions from online
advertising and other sources of revenue generation that rely on high-
speed broadband in the Universal Service Fund? What are potential
consequences for failing to reform the contribution mechanism?
Answer. There are two key sources of funding today for the FCC's
Connected Care and COVID-19 telehealth programs--the FCC's Universal
Service Fund (USF) and congressional appropriations. At the outset, we
need to rethink the mechanism by which USF is currently funded. A study
prepared earlier this year showed that the 30 percent charge paid by
consumers today on the assessable portion of their telephone bills
could exceed 75 percent in the next few years. This is an unstable
contribution mechanism that needs to be revisited. Failing to do so
will result in higher costs for customers of traditional telephone
service.
I have put forth a proposal to assess contributions on large
technology companies, such as Google and Facebook. To your question,
this approach have several benefits. For one, it would sharply reduce
consumers' monthly costs by eliminating or largely eliminating the
existing 30 percent charge from their monthly bill. For another, this
approach would provide a stable, long-term funding solution for the
FCC's USF initiatives. For yet another, this approach would align
incentives given both the bandwidth consumed by these companies and the
benefits large technology companies realize from greater connectivity.
Finally, a fee based on digital advertising revenue, in particular,
would be difficult to pass on to consumers due to the nature of the
digital advertising business model.
Question 2. You stressed the important lesson of applications and
uptake regarding the COVID-19 Telehealth Program during the hearing.
Should the COVID-19 Telehealth Program or a similar initiative to
help health care providers provide telehealth and connected care
services to patients at their homes or mobile locations (including
remote patient monitoring) be made into a permanent program at the FCC?
Answer. Yes. The COVID-19 pandemic has helped demonstrate firsthand
the value of care at a distance. Long term, we should make sure these
types of programs are available to support telehealth services. In my
view, there are still questions about how to fund such programs and how
to maximize their effectiveness. I welcome the opportunity to work with
you and members of the committee on these important questions.
______
Response to Written Questions Submitted by Hon. Kyrsten Sinema to
Hon. Brendan Carr
Infrastructure Investment and Jobs Act. The bipartisan
Infrastructure Investment and Jobs Act includes $65 billion for
broadband deployment, rural and tribal broadband, digital equity, and
affordability in Arizona and throughout the country.
Question 1. How will this historic investment in broadband enable
more Arizonans to access telehealth services, including Arizonans in
rural and tribal areas?
Answer. Supporting telehealth technology is one of my top
priorities at the FCC. Since joining the Commission, I have had the
opportunity to visit 44 different health care facilities across 22
states to learn more about the work we can do at the Federal level to
support telehealth. Through these visits I have seen firsthand the
transformational impact of this technology on patients' lives and the
importance of investment in broadband and the devices that power these
services.
And while the FCC has made significant progress over the last few
years in closing the digital divide, too many Americans, particularly
in rural and tribal areas, remain unconnected. The goal of the $65
billion is to ensure that every American has access to affordable,
high-speed service. That will be key to ensure that the benefits of
broadband-powered telehealth are available to everyone in every
community.
The good news is that we now have more Federal dollars available
for bridging the digital divide than ever before. Indeed, by some
estimates we have more dollars available than necessary for
accomplishing that goal. So the challenge going forward will be to
ensure that these dollars serve the important purposes identified by
Congress and do not get sidetracked by significant amounts of waste,
fraud, and abuse. Ensuring that those dollars connect communities has
to be the goal, and it is one that will require significant oversight
in the months and years to come.
Over the past year, for instance, Congress has provided a range of
Federal agencies--including the FCC, Department of the Treasury,
Department of Education, Department of Agriculture, and NTIA--and
states with over $800 billion of additional funding that could be used
to bring broadband to all Americans. Distributing these significant
resources (as well as the additional $65 billion) on behalf of the
American people is an incredible responsibility, and if Federal
agencies and states work in a coordinated manner, we have the
opportunity to ensure that every American gets connected.
While the importance of coordination cannot be overstated, I have
significant concerns. Indeed, based on my own inquires and analysis of
the various funding programs and interagency agreements, I do not
believe that the appropriate coordination framework is in place.
Ultimately, congressional intervention may be necessary to ensure that
taxpayer money is not wasted and that broadband is finally deployed
throughout Arizona.
Funding for Telehealth Services. Congress created the COVID-19
Telehealth Program as part of the Coronavirus Aid, Relief, and Economic
Security (CARES) Act, to enable health care providers to provide
services to their patients at their homes or other mobile locations in
response to the COVID-19 pandemic. The program dispersed $200 million
in appropriated funds as grants to health care providers, including to
seven providers across Arizona in Colorado City, Flagstaff, Page,
Sahuarita, Tucson, and Window Rock. Congress later appropriated nearly
$250 million in the Consolidated Appropriations Act, 2021 to continue
the COVID-19 Telehealth Program in December 2020. In August, the FCC
awarded Tuba City Regional Health Care in Tuba City, Arizona, on the
Navajo Nation, a grant worth $266,946 to develop its telehealth
capabilities with funds from the Consolidated Appropriations Act under
phase 2 of the COVID-19 Telehealth Program.
Question 2. How can Congress build on funding to support telehealth
authorized during the pandemic to improve telehealth services in rural
areas, including tribal lands?
Answer. The funding that has been made available to-date has
created significant benefits--both in terms of health outcomes and a
reduction in costs. However, legal and regulatory barriers remain. I
believe that Congress can best support telehealth in rural areas,
including tribal lands, by looking for ways to eliminate these
barriers. As noted in my testimony, there are licensing and
reimbursement issues that have held back telehealth. While HHS has
helped facilitate greater access to telehealth services during the
COVID-19 pandemic through the issuance of waivers of some of their
regulations and requirements, these waivers are set to expire at the
end of the public health emergency declaration. We must not return to
the status quo and should move to make some of these waivers permanent.
Question 3. Does the FCC require additional resources to facilitate
telehealth capabilities in Arizona and throughout the country?
Answer. There are two key sources of funding today for the FCC's
Connected Care and COVID-19 telehealth programs--the FCC's Universal
Service Fund (USF) and congressional appropriations. At the outset, we
need to rethink the mechanism by which USF is currently funded. A study
prepared earlier this year showed that the 30 percent charge paid by
consumers today on the assessable portion of their telephone bills
could exceed 75 percent in the next few years. This is an unstable
contribution mechanism that needs to be revisited. I have put forth a
proposal to assess contributions on large technology companies, such as
Google and Facebook. Doing so would sharply reduce consumers' monthly
costs, provide a stable long-term funding solution for the FCC's USF
initiatives, and align incentives given both the bandwidth consumed by
these companies and the benefits large technology companies realize
from greater connectivity.
Further, I think we need to begin discussing a long-term solution
to funding these types of telehealth initiatives. The Connected Care
Pilot Program for instance is a three-year initiative. One goal for the
program is to provide additional evidence regarding the value that
flows from connected care technologies. In my view, the portions of the
health care industry that benefit from these technologies and their
associated reductions in health care costs should be the ones that
support them in the long run.
Mental Health for Veterans. Nearly half a million veterans live in
Arizona. The COVID-19 pandemic and recent events in Afghanistan have
led to an increase in the number of veterans seeking mental health
treatment.
Question 4. How is the FCC coordinating with the Department of
Veterans' Affairs to enable more veterans to receive telehealth
services, especially veterans living in rural areas or on tribal lands?
Answer. In terms of current coordination between the FCC and the
VA, I would have to defer to Chairwoman Jessica Rosenworcel. However,
in my view the VA has been an important leader in implementing
telehealth services aggressively for our veterans. And I highly value
the relationship and previous collaboration between the VA and the FCC.
The VA's remote patient monitoring program has resulted in a 25
percent reduction in days of inpatient care and a 19 percent reduction
in hospital admission for more than 43,000 veterans. It also cost
$1,600 per patient compared to more than $13,000 per patient for VA's
home-based primary services. While at the FCC, I have visited several
VA facilities and seen these benefits firsthand. During a trip to Ohio,
I met a veteran receiving care in West Virginia from specialists
located in Cincinnati that monitor his vitals, use video calls, and
employ AI to improve his care. In Texas, I had the opportunity to talk
to a veteran who credits her great progress from wheelchair to walking
again to the VA care she received virtually on her smartphone,
including video visits. Back in Washington, D.C., I also had the
opportunity to participate in a video discussion with a service-
disabled veteran of the U.S. Navy that has been using telehealth and
remote patient monitoring to improve his care.
These visits have informed my work on the FCC's Connected Care
Pilot Program, which is focused on low-income Americans and veterans
and was developed following engagement with other agencies, including
the VA. In the adoption of the Connected Care Pilot Program rules, the
FCC recognized that veteran patients are more likely to have complex,
high-cost health care needs, reside in areas with physician shortages,
and may not have Internet access. In the FCC's most recent announcement
selecting its third set of Connected Care projects, several of the
selected entities will focus almost exclusively on veterans, including
across Alaska, Hawaii, Indiana, New Jersey, New York, Mississippi,
Ohio, and Pennsylvania.
______
Response to Written Questions Submitted by Hon. Ron Johnson to
Hon. Brendan Carr
Question 1. The CARES Act provided $200 million to the FCC to
support health care providers' use of telehealth services. The funding
was depleted by July 2020. The Consolidated Appropriations Act of 2021
provided $249.95 million, but only $123.6 million has been approved to
date, including $40 million awarded on October 21, 2021.
What is the status of the remaining $126.35 million funds?
Can you explain why it has taken longer to distribute funds in the
second round? Has the need for the funds changed?
Do you believe that any remaining funds should be repurposed?
Answer. As part of the FCC majority last year, I was pleased that
the agency acted expeditiously in awarding the $200 million in CARES
Act telehealth funding appropriated by Congress. I have seen firsthand
the benefits that these funds brought to communities by allowing health
care providers to expand their telehealth services during the pandemic.
Available studies also indicate that the type of telehealth services
supported by this initiative result in significant savings in terms of
health care costs.
While the agency committed all $200 million of those CARES Act
dollars within four months of the law passing, the FCC has not moved as
quickly with awarding the $249 million that Congress appropriated in
December 2020. Just this week, the FCC concluded the initial phase of
the awards--totaling approximately $166 million--and facilities that
did not receive funding will have until November 19, 2021, to
supplement their applications before the remaining funds are committed.
So while Congress added some additional procedural requirements with
that December 2020 appropriation, I believe the FCC can and should move
with great dispatch to distribute the remaining funding. Despite the
longer timeline this year, it is my understanding that there is still
far more demand for these funds than dollars available. For instance,
in this second round of the COVID-19 program, we received 1,953
applications requesting almost $895 million.
Question 2. As you know, the new Connected Care Pilot Program will
utilize up to $100 million from the Universal Service Fund programs to
help defray health care providers' costs of providing connected care
services.
How does this program differ from the COVID-19 Telehealth Program?
Is there any duplication in services and funding?
To date, the FCC has awarded $57.8 million to 50 providers. Does
the FCC plan to award any additional funding?
Answer. While I am disappointed that the FCC has not moved more
expeditiously this year in committing the full $100 million from the
Connected Care Pilot Program, the agency is planning on awarding the
full amount of that funding. The studies I have seen show that the type
of telehealth programs supported here not only greatly improve patient
outcomes but save significant costs when compared to more traditional
methods of care.
The two different programs--Connected Care Pilot Program and the
COVID-19 Telehealth Program--are separate initiatives with several
distinguishing features. The Pilot Program--which the FCC began work on
in 2018--is a three-year program that receives funding from the USF and
is therefore subject to the funding restrictions in section 254 of the
Communications Act. Accordingly, the Pilot Program only provides
partial reimbursement for certain types of services and equipment. The
COVID-19 Telehealth Program, in contrast, received funding through the
CARES Act and congressional appropriations, so it provides full funding
for a broader range of technology and services. For example, tablets,
smartphones and other connected devices are funded by the COVID-19
Telehealth Program but not by the Pilot Program.
Under FCC rules for each program, participants are prohibited from
receiving duplicative funding for equipment or services that are
already funded by other FCC initiatives. Our rules also prohibit
awardees from receiving duplicative funding from other Federal and
state programs.
As of last month, the FCC has awarded over $69.3 million of the
$100 million total in funding through the Pilot Program. I have called
for the FCC to move quickly to issue the remaining funding to expand
more access to telehealth services across the country.
Question 3. The Biden Administration has signaled it will restore
heavy-handed net neutrality rules.
How would restoring net neutrality harm the buildout of broadband
in rural areas and negatively impact telehealth services?
How does a light touch regulation and spectrum allocation help
expand broadband networks and advance next-generation technologies?
Answer. Since the adoption of the FCC's Restoring Internet Freedom
order and the repeal of the Obama-era utility-style regulation of the
Internet in 2017, there has been an unprecedented acceleration in the
pace of Internet builds, including in rural America. In 2016, for
instance, U.S. providers built just 708 new cell sites. In 2019, with
the utility-style regulations gone and new streamlined infrastructure
rules in place, providers built over 46,000 new cells sites--a 65-fold
increase. Telecom crews also set records for new high-speed fiber
builds--adding over 450,000 route miles in 2019 alone, which represents
a nearly 70 percent increase over 2016.
As a direct result of these Internet builds, Internet speeds have
more than tripled over the last four years. Competition has increased
too, with the percentage of Americans with more than two options for
high-speed service jumping by 52 percent between 2016 and 2018 alone.
Prices continue to decrease for fixed and wireless services. The
digital divide has been cut nearly in half since 2016.
Indeed, COVID-19 was the ultimate stress test of global telecom
policy. As stay-at-home recommendations spread across the world, many
people recreated their daily routines online. Virtually overnight,
network usage spiked here and abroad. Our networks showed speed and
resiliency despite this surge in usage because of the common-sense
regulatory framework that governs America's broadband networks. In
contrast, in Europe--where regulators have long imposed heavy-handed
and utility-style regulations to their Internet providers--officials
worried that the continent's networks would collapse under the strain
in demand. So regulators there asked streamers like Netflix and others
to degrade the quality of their signals to take up less bandwidth. We
did not face those issues in the U.S. because our regulatory framework
has encouraged providers to invest substantially more in their networks
that than their counterparts in Europe.
As we've seen before, a return to the heavy-handed, utility-style
regulations would likely lead to a decline in network investment and a
decline in innovative service offerings. New broadband deployments
could be delayed or abandoned, ultimately precluding some parts of
rural America from receiving the services they want and need.
By contrast, the FCC and Congress should maintain a forward-looking
approach that builds on the successes of recent years. We must continue
make spectrum commercially available as quickly as possible. We must
also ensure that the FCC's infrastructure reforms are not rolled back
so that industry can continue its record-breaking investment in
America's broadband networks.
Question 4. In April 2021, members of the Congressional Hispanic
Caucus called on the FCC to stop the sale of WSUA-AM to America CV,
owner of the conservative America TeVe network.
You issued a tweet stating, ``This crosses a clear line drawn by
the First Amendment and would turn the FCC into an arm of the DNC.''
Have there been any further attempts from Democrats or private
businesses to call on the FCC to censor conservative media or
viewpoints? If so, what has been the response from the FCC?
What factors does the FCC consider when it reviews acquisitions?
Answer. The repeated calls by elected officials for the FCC to deny
a transaction based on the political viewpoints that those politicians
ascribe to the purchaser crosses a line. The FCC has no business
acceding to such demands or using our regulatory process to censor
political opinions. As you note, the elected officials appear to be
pressuring the agency to take action that they believe will increase
their electoral odds in Florida in 2022. This is a deeply troubling
assault on free speech and the FCC's status as an independent agency.
Indeed, the perceived political views of an entity purchasing a
broadcast radio station have no bearing in the FCC's transaction review
process. Station acquisitions, such as the proposed sale of WSUA-AM,
are governed by our broadcast ownership limits and related regulations.
And while each transaction must be measured on its own merits,
political viewpoints are not part of this consideration.
Unfortunately, the WSUA-AM letter is not an isolated incident, and
I have long and frequently spoken out against such efforts to stifle
political speech.
In February of this year, two senior Democrats on the House Energy
and Commerce Committee selectively targeted a handful of news media
outlets for their coverage of political events. Their decision to write
letters to the cable providers and other regulated entities that carry
these news media outlets sent a message that is as clear as it is
troubling--these regulated entities will pay a price if the targeted
newsrooms do not conform to the Members' preferred political
narratives. This is a chilling transgression of the free speech rights
that every media outlet in this country enjoys.
And less than a month after the WSUA-AM letter, the Office of the
State's Attorney for Baltimore City, led by Democrat Marilyn Mosby,
filed a formal complaint with the FCC asking the Commission ``to enlist
the full investigative and enforcement powers granted to you by the
Federal government to take action against the
[local broadcaster] WBFF as soon as possible'' for ``the tone'' and
``the frequency of'' stories by WBFF journalists about State's Attorney
Marilyn Mosby. This complaint was a direct attack on free speech and
journalistic freedom. Indeed, invoking the power of the state to
silence journalists for unfavorable coverage strikes at the very heart
of the First Amendment.
I have repeatedly called on my FCC colleagues to join me in
denouncing each of these efforts to inject partisan politics into the
FCC's processes. Moreover, I called for the FCC to immediately dismiss
the Mosby complaint with prejudice, though to my knowledge the
complaint is still pending. I find this inaction unconscionable, as no
journalists should have a complaint like this from their city's top
prosecutor hanging over their newsroom.
______
Response to Written Question Submitted by Hon. Roger Wicker to
Hon. Brendan Carr
Question. When Congress provided additional telehealth funding for
the COVID-19 Telehealth program, we required the Commission to be more
transparent in its selection criteria and process.
How can the Commission improve the transparency of the selection
process for both the COVID-19 Telehealth and Connected Care Pilot
programs?
Are the application scoring criteria publicly available to
potential applicants?
Should individual applications be made available for public
comment?
Do commissioners have a role in the process, or is it driven solely
by the staff at the direction of the Acting Chairwoman's office?
Answer. Yes, the application scoring criteria for both Round 2 of
the COVID-19 Telehealth Program and the Connected Care Pilot Program
are publicly available. For Round 2 of the COVID-19 Telehealth Program,
for example, applications are evaluated by staff using objective
factors about the health care provider and the area they serve, such as
whether it is an area hit hard by COVID-19, is a rural county or low-
income area, or whether it is an area where there is a health care
provider shortage.
Individual applications are made available publicly on the FCC's
website. Currently, however, they are not made available for public
comment as part of the review process. When we stood up these programs,
our goal was to be transparent by adopting the scoring criteria
publicly at the Commission level in order to help ensure an even
playing field and to provide FCC staff and USAC with appropriate
guidance for the funding process. I believe my colleagues and I struck
the right balance between ensuring a wide and equitable distribution of
funding and promoting the widest possible participation of health care
providers. But of course there is always room for improvement, and I am
open to taking a different or modified approach. I agree that we should
strive for transparency, and I am open to working with you on ideas
that would further advance this interest.
As you know, supporting telehealth technology is one of my top
priorities at the FCC. From our visits to the North Sunflower Medical
Clinic in Ruleville to the state-of-the-art Center for Telehealth at
the University of Mississippi Medical Center, we have seen firsthand
the transformational impact of this technology on patients' lives. That
is why I am pleased that FCC staff under both former Chairman Pai and
Chairwoman Rosenworcel have been open to working collaboratively with
me and my staff on these important bipartisan initiatives.
______
Response to Written Questions Submitted by Hon. Shelley Moore Capito to
Hon. Brendan Carr
Question 1. Commissioner Carr -many communities in my state have
had to forego other Federal funding opportunities that would allow for
more rapid broadband deployment to unserved areas because certain
census blocks were included in an RDOF bid.
What potential Federal remediation efforts are there for rural
areas in my state that were included in an RDOF census block but are
also eligible for other types of Federal support?
Answer. I am deeply disappointed in the pace of funding for
successful bidders in the first phase of the RDOF, including those
looking to rapidly deploy broadband to unserved areas in West Virginia.
Indeed, RDOF is the FCC's most significant step towards connecting the
hardest-to-serve parts of the country. It will allow providers to bring
millions of Americans across the digital divide. But none of that can
happen if the money is not allocated quickly and comprehensively.
The Phase I auction closed nearly a year ago, but the agency has
been slow to release funds and has fallen behind the pace set by the
previous administration in the Connect America Fund II auction. The
time I spent with you in West Virginia highlighted the urgency required
when it comes to deploying broadband in unserved communities. Broadband
connectivity is a key economic driver for small communities and is
vitally important for the adoption and proliferation of telehealth
initiatives, such as those we saw at Boone Memorial Hospital and the
Charleston Area Medical Center.
The most important thing the FCC can do to help promote broadband
builds in rural West Virginia is to get the RDOF money into the hands
of the broadband providers that have been forced to sit idly by as the
FCC's process grinds along. That said, if the FCC does not accelerate
the disbursement of funds to West Virginia providers that are now
foregoing other Federal funding opportunities, I am open to working
with stakeholders to identify ways for these providers to access
Federal funding from other sources.
Question 2. Commissioner Carr--in late June--the FCC, NTIA, and
USDA all entered into an interagency agreement to coordinate broadband
funding deployment.
In your experience--can you speak to the effectiveness of these
interagency agreements--and do you have thoughts on how to beef up
coordination between agencies to ensure the efficient use of taxpayer
money to deploy broadband in West Virginia?
Answer. Over the past year, Congress has provided a range of
Federal agencies--including the FCC, Department of the Treasury,
Department of Education, Department of Agriculture, and NTIA--and
states with over $800 billion of additional funding that could be used
to bring broadband to all Americans. This is more than enough money to
close the digital divide, and it is imperative that we not waste this
opportunity. Distributing these significant resources on behalf of the
American people is an incredible responsibility, and if Federal
agencies and states work in a coordinated manner, we have the
opportunity to ensure that every American gets connected.
While the importance of coordination cannot be overstated, I have
significant concerns. As you note, the FCC executed an interagency
agreement with USDA and NTIA for the sharing of limited information,
but that agreement does not apply to all of the ongoing and planned
broadband spending programs nor does it cover all of the agencies that
Congress recently provided funding for broadband projects. It also does
not require the use of a common set of data or standards. We are
already seeing divergent funding standards that will likely reduce
investment in unserved areas in West Virginia and there are even
reports that one agency wants to exclude certain funding programs from
established administrative procedures and public disclosure
requirements.
It was apparent to me early in the process that coordination was
lacking. That is why, in July of this year, I sent letters to the other
agencies that have been entrusted with Federal broadband funding asking
various questions to help ensure greater collaboration and
coordination. The responses I received--from those agencies that
provided a response--confirmed my concerns that we are not on the right
track. Indeed, the picture that emerges is of opaque and disparate
funding processes, incomplete information sharing, lack of performance
metrics and measuring, and a high likelihood of waste, overbuilding,
and missed opportunities to connect those most in need. And hanging
over all of this is the FCC's failure to produce accurate broadband
maps to help guide funding decisions and the necessary collaboration
between agencies.
This collaboration is key to avoiding the problems that plagued the
government's last major broadband stimulus initiative. Following the
2008 recession, Congress appropriated a then-unprecedented $7.2 billion
for broadband in the American Recovery and Reinvestment Act of 2009. As
GAO found in multiple reports examining that initiative, failures in
program design, reporting, and coordination resulted in significant
waste and an inability to verify the impact of Federal funds on
broadband availability and subscribership. Given the magnitude of
current funding and the pressing need to connect more Americans, it is
even more important that we ensure that these funds are spent wisely
and that their impact is carefully measured.
At present, however, I do not believe that the appropriate
coordination framework is in place. Ultimately, congressional
intervention--either through legislation or a hearing--may be necessary
to ensure that taxpayer money is not wasted and that broadband is
finally deployed throughout West Virginia.
______
Response to Written Question Submitted by Hon. Mike Lee to
Hon. Brendan Carr
Question. Telehealth is vital for patients to be able to have easy,
remote access to their doctor. The COVID-19 pandemic has only
reinforced the importance of telehealth offerings. In the early months
of the COVID-19 pandemic, the Commission along with HHS acted swiftly
and issued a number of waivers to more easily facilitate telehealth
offerings.
Have these waivers been effective? And if so, should they be
codified?
In addition to codifying the waivers, are there any other statutory
changes that Congress should consider to help lower the regulatory
barriers associated with the provision of telehealth services in the
United States?
Answer. COVID-19 accelerated the use and adoption of telehealth.
And the HHS waivers played a key role in driving this trend.
Moreover, the data I have seen shows that expanding the reach of
telehealth services delivers significant benefits--both in terms of
health outcomes and a reduction in health care costs. For instance, a
pre-pandemic study of the Veterans Health Administration's remote
patient monitoring program showed a 25 percent reduction in days of
inpatient care and a 19 percent reduction in hospital admissions for
more than 43,000 veterans. It also cost $1,600 per patient compared to
more than $13,000 per patient for VHA's home-based primary services.
Another remote patient monitoring initiative showed a 46 percent
reduction in ER visits, a 53 percent reduction in hospital admissions,
and a 25 percent shorter length of stay. Analysts estimate that the
widespread use of remote patient technology and virtual doctor visits
could save the American health care system $305 billion annually.
I have been able to hear of these significant benefits firsthand in
recent years. Since 2018, I have had the opportunity to visit 44
different health care facilities across 22 states. One thing I heard
from many of these visits is the critical importance of these HHS and
FCC waivers to the expansion of telehealth services. And while these
waivers are set to expire at the end of the COVID-19 public health
emergency declaration, we cannot afford a return to the status quo once
the pandemic ends. We have made too much progress to move backwards.
For this reason, I fully support making these waivers permanent.
In terms of other statutory changes, I believe we need to begin
discussing a long-term solution to funding these types of initiatives.
The Connected Care Pilot Program for instance is a three-year
initiative. One goal for the program is to provide additional evidence
regarding the value that flows from connected care technologies. In my
view, the portions of the health care industry that benefit from these
technologies and their associated reductions in health care costs
should be the ones that support them in the long run.
______
Response to Written Questions Submitted by Hon. Dan Sullivan to
Hon. Brendan Carr
Question 1. Thank you for helping us with the waiver of the Rural
Health Care rules at the beginning of this year. As you mention in your
testimony--the new rules would have resulted in irrational and insane
results in Alaska. Obviously, there is more work to be done--As we work
toward a permanent fix to the Rural Health Care Program rules, will you
commit to work with me and Alaskan stakeholders to ensure that new
rules avoid irrational and anomalous results BEFORE the rules are put
into place--unlike last time?
I also appreciate you mentioning in your testimony the need to
impose firmer deadlines on RHC funding decisions--I hope you mean that
and I look forward to seeing the results.
Answer. In 2018, I traveled to Alaska to see firsthand some of the
unique challenges that the residents in Alaskan communities face. I
also witnessed the transformative impact that broadband connectivity
and telehealth services can have when available to these communities.
And I carry these experiences with me as my colleagues and I continue
to improve the administration of the FCC's initiatives, including the
RHC Program and the Alaska Plan. I agree with you that there are
additional steps the FCC can take to make the FCC's initiatives more
effective, and I commit to working with you and Alaskan stakeholders to
ensure that any new rules applicable to Alaskan providers avoid the
irrational and anomalous results hit Alaska recently.
In particular, there are additional steps the FCC can take to
ensure the RHC Program provides the sufficient and predictable level of
support necessary to meet the needs of rural health care providers.
While the issuance of the January 2021 waiver and the addition of
additional rates into the RHC database were positive steps that I
pushed for, there is certainly more we can do to improve the
administration of the FCC's initiatives, including by imposing firmer
deadlines on funding decisions. I believe that imposing firmer
deadlines on funding decisions would provide greater certainty for
Alaskan providers.
I have also been working to make certain adjustments to
administration of the 10-year Alaska Plan to aid providers by reducing
burdens and ensuring the Alaska Plan meets its objectives. I am pleased
that just this week, the FCC granted a 7-month extension of the
deadline for the submission of drive test data. While the existing
deadline was set for March 1, 2022, Alaskan providers asked for a 7-
month extension until September 30, 2022, in order to have adequate
time to complete the testing after winter has ended in Alaska. The FCC
has not yet adopted a final order on the drive test parameters or a
drive test model, despite the deadline for submission by providers, and
I believe the newly-granted extension is highly warranted in light of
the adverse weather conditions in Alaska during the winter months. I
also believe the FCC should make certain changes to the drive test data
parameters as they were initially proposed by the FCC's Wireline
Competition Bureau in July in order to alleviate providers' concerns
about unnecessary burdens in data collection. Further, I believe it
would be inappropriate for the FCC to make any decision regarding
duplication of 4G LTE service in certain areas of Alaska, and therefore
eliminating funding for those areas, using our potentially faulty Form
477 data. Those decisions should be postponed until the FCC has more
accurate data from its ongoing data collection.
I look forward to continuing to work with my FCC colleagues and
stakeholders on these efforts and a broader set of reforms that will
ensure the FCC meets its statutory obligations to Alaska.
Question 2. During the pandemic it became very clear that
telehealth was going to be a big part of the solution. Therefore,
Congress invested $200 million in the FCC COVID-19 Telehealth Program
in the CARES Act. This program was unprecedented for the FCC because it
allowed them to fund devices for patients and software, not just
connectivity and broadband. This was important for Alaska, more than 80
percent of Alaskan communities are off the road system. This means you
need to use planes or boats to reach many of these communities. That
makes traveling for health expensive and inconvenient, therefore we
relay our telehealth infrastructure more than most states.
The first round of the program received more than 5,000
applications, but only 539 requests were funded. Congress then
allocated an addition $249 million under the Consolidated
Appropriations Act of 2021. Three programs received awards in Alaska:
the North Slope funded kiosks and wireless networking equipment to
high-risk, low-income, and geographically isolated residents.
In Kotzebue, they used the award to replace Health IT
infrastructure to meet the demands of COVID-19 testing, treatment, and
vaccination in rural communities off the road system, and ANTHC used
their award to supplement the existing telehealth program in residents
living in remote communities.
My question is this, the COVID-19 Telehealth Program expanded
eligible technologies and services to include devices, tablets, smart
phones and related technologies, have you seen a benefit to this shift?
As we work to expand access to broadband, can you help explain how we
should be thinking about ways to expand access to telehealth and
digital health technologies through programs like the COVID-19
Telehealth Program?
Answer. In my view, Congress made the right decision by funding the
COVID-19 Telehealth Program through its own appropriation rather than
through USF dollars. By doing so, the Commission was able to design a
program without the restrictions that are in place with our other USF
programs, such as not funding devices. This is a good thing. The trend
we are seeing in health care towards connected care is one that I have
seen the benefits of firsthand at the Alaska Native Tribal Healthcare
Consortium at the Alaska Native Medical Center. Indeed, you and I
joined the Alaska Native Health Board for a discussion about the role
that broadband can play in addressing health care challenges in remote
areas. But for all its promise, patients and care providers can't take
full advantage of these innovative services without broadband-powered
devices. We should continue to build on efforts that promote a more
holistic solution like the one you describe.
Question 3. Obviously broadband is challenging for my state. This
has resulted in a reliance on audio-only services in some Alaskan
communities. I understand the national concern that the government
needs to be funding quality services and that audio-only is not as
beneficial as visual telehealth. However, Alaska has communities with
no access to broadband. We cannot discuss advancing telehealth without
discussing the value of audio-only for communities without access to
broadband.
Last year I cosponsored a letter to HHS defending the use of audio-
only services and asking for equity in reimbursements. HHS, thankfully,
responded to this letter and did increase the reimbursement for audio-
only services.
Can you speak to the value of audio-only services in ultra-rural
communities without access to broadband? Is there a better way that we
can target these services to communities that need them?
Answer. Despite the great strides that have been made to close the
digital divide and expand connectivity, there remain communities that
lack access to broadband services. It is imperative that those
communities have access to audio-only services, particularly where
other forms of telehealth are not available. This is especially
important in geographic areas like Alaska where there may be great
distance between an individual and their health care providers or
specialists.
There are other times where audio-only services may also be
helpful. As we heard from Mr. Ransone from the American Academy of
Family Physicians during his testimony, there may be times where a
phone call may be the better way for a clinician to treat a patient,
particularly where there are technical challenges with using a platform
or language barriers that require the use of telephone translation
services.
And while there are unique benefits to video visits, where patients
can be visually examined, for example, Mr. Ransone also pointed to
literature showing that patient outcomes were generally comparable
between video conference and audio-only. In my view, this refutes any
argument that these services should not be reimbursed where they are
appropriate for use.
______
Response to Written Questions Submitted by Hon. Maria Cantwell to
Deanna Larson
Question 1. In 2019, I visited Harborview Medical Center in Seattle
and heard how doctors in rural areas can consult in real time with
experts who are based elsewhere. We met a patient who lived on the
smallest island in the San Juan chain and was able to receive a stroke
diagnosis and transportation to Seattle for surgery within six hours
thanks to his ``tele-stroke'' care. And, we heard from the panel during
the hearing regarding how telehealth can improve patient care through
increasing availability of both primary care and specialist care.
In your experience, what areas of healthcare have seen the greatest
increase of delivery through telehealth? How did the pandemic increase
utilization of telehealth visits?
Answer. From Avel's perspective, one area of healthcare that has
seen the greatest increase of delivery through telehealth has been in
behavioral health. The Public Health Emergency waiver allowed for the
delivery of behavioral health care and services at the patient's home,
reducing no-show rates and improving outcomes. For example, Avel
partnered with the Indian Health Service to offer behavioral health to
patients in the great plains, Billings, MT, and Albuquerque, NM areas.
This flexibility and continued access to care was critical to those who
needed to maintain their medication schedule and helped avoid any
disruption of care for those struggling with mental health disorders.
In addition, another area we saw increased demand was acute health
care for rural and underserved communities. These small critical access
hospitals and clinics needed help with the increased number of cases
requiring acute care, and our hospitalist, ICU, and emergency
clinicians stepped in to help meet this demand.
Overall, telehealth visits increased during the pandemic because
regulatory bodies understood the need to allow for more flexibility in
care delivery. The PHE waivers opened telemedicine care to previously
unqualified individuals which resulted a dramatic increase in
utilization. For example, before the pandemic, telehealth visits
accounted for less than 1 percent of all total visits. At its peak in
April of 2020, nearly 52 percent of all health care visits nation-wide
in April of 2020 were telehealth in nature.
When considering these national trends in telehealth utilization
during the pandemic, the CDC notes ``telehealth could have multiple
benefits during the pandemic by expanding access to care, reducing
disease exposure for staff and patients, preserving [PPE], and reducing
patient demand on facilities. Telehealth policy changes might continue
to support increased care access during and after the pandemic.''
Ultimately, Avel appreciates the work that was done to improve
patient's access to telemedicine care through the Public Health
Emergency waivers, and strongly encourages to make the temporary
changes permanent. Healthcare--like every sector--was fundamentally
altered by COVID-19. We must utilize every resource and avenue to
ensure patients, regardless of what they earn or where they live, have
access to high quality care.
Question 2. One persistent challenge with telemedicine, even with
the payment flexibilities afforded by the public health emergency, is
the ability for physicians to care for patients across state lines.
This can be challenging when large metropolitan areas straddle state
lines, such as the City of Vancouver, Washington that borders Oregon.
In these instances, state licensing laws can act as a barrier for
patients to receive telehealth services.
In your experience, how would telehealth patients benefit from a
healthcare system that cuts across state licensing barriers? What are
the categories of care that would most benefit from a telehealth
delivery system that cuts across state licensing barriers?
Answer. The U.S. healthcare system would be greatly improved by
enabling healthcare delivery across state lines. The true value of
digital care cannot be harnessed, especially to reach hard-to-reach
patients, if providers only have the ability to practice in their
immediate geographic location. Avel recognizes and acknowledges the
importance of maintaining a viable and thorough registration and
licensing process to protects patients. Unfortunately, the current
regulatory process has the effect of hindering access to telemedicine
care, particularly when the multi-state licensing process is overly
burdensome for the provider. It is for this reason Avel strongly
supports the adoption of a universal approach that cuts down on time
and eliminates redundancy.
When considering the patient benefits of a telehealth delivery
system that cuts across state licensing barriers, one must first
consider the obstacles and challenges the existing system poses. The
first obstacle being access. People who live in remote areas or
underserved communities struggle with access to healthcare, and this
can translate to lack of care options available to treat more acute or
severe conditions. This makes telemedicine care an attractive option
because it helps save patients drive time and the costs associated with
making long trips to receive health care.
Although telemedicine expands access to care, the next obstacle is
whether physicians can meet the licensing and credentialing
requirements of each state in which they practice. For example, when
Avel partners with a new provider to deliver telemedicine care for
particular service line (i.e., Emergency or Hospitalist), this
individual must be licensed and credentialed in every state that Avel
currently offers that service before they can start responding to
calls. On average, this process can take months and varies based on
each individual state.
Reducing burdens on the multi-state licensing process would
drastically cut down on the time it would take for new providers to
start delivering telemedicine care to patients. Those who would benefit
most include specialists practice across state borders and rural
hospitals and critical access hospitals who require acute care. If
clinicians are able to practice across state lines, telehealth can be
used to address workforce shortages in primary care, specialty care,
behavioral health and substance use disorder, and other types of
clinical care in both rural and urban areas. Additionally, telehealth
fills gaps in care coverage by connecting patients to the specialists
they need, regardless of where the specialist is based.
As for critical access and community hospitals in underserved
communities, the quicker these facilities can implement telemedicine
care, the more equipped they are to deliver the next level of care and
keep patients in the local community, reducing costly transfers and
boosting capacity.
______
Response to Written Questions Submitted by Hon. Kyrsten Sinema to
Deanna Larson
Infrastructure Investment and Jobs Act. The bipartisan
Infrastructure Investment and Jobs Act includes $65 billion for
broadband deployment, rural and tribal broadband, digital equity, and
affordability in Arizona and throughout the country.
Question 1. How will this historic investment in broadband enable
more Arizonans to access telehealth services, including Arizonans in
rural and tribal areas?
Answer. For millions of Arizonans, telehealth and digital health
care tools are out of reach because they lack broadband access, the
budget to purchase service, the tools to connect and the training to
use digital devices--all critical to realizing the full potential of
virtual medicine.
Enhanced broadband connectivity and access remains a critical
component of providing high quality telemedicine care for underserved
and rural communities. These infrastructure investments will allow for
high-speed Internet to reach remote and underserved areas that
currently lack access. What does this mean for patients? It means that
high-tech, two-way audio/visual telemedicine care will be delivered--
improving delivery options (including in acute and emergent care),
reducing interruptions caused by low-bandwidth or high-latency, and
ensuring all patients, regardless of where they live, receive high
quality care when and where they need it.
Medicare Coverage of Telehealth Services. Congress expanded the
ability of Medicare of cover telehealth services in the midst of the
COVID-19 pandemic. I have joined my colleagues from both parties to
support legislation, the Creating Opportunities Now for Necessary and
Effective Care Technologies (CONNECT) for Health Act of 2021, that
would make Medicare coverage of many telehealth services permanent.
Question 2. How would the CONNECT for Health Act enable more
Arizonans to access health care services?
Answer. Prior to the pandemic, Medicare coverage of telehealth was
limited to only patients in specific rural geographic areas at specific
facilities (``originating sites'') for a limited set of practitioners
to provide a limited set of services. During the pandemic, Congress
gave HHS the authority to waive these geographic and originating site
restrictions so that Medicare beneficiaries could see providers
remotely. This has largely been successful in its goal to continue
access to necessary care without creating fraud or overutilization
problems.
If passed, this bill would expand care options and allow patients,
including the some 350,000 Arizonans who live in rural areas, to access
more care options. As we saw with our Behavioral health services when
patients can schedule appointments in the privacy of their own home,
there is a significant drop in no-show rates and a noticeable uptick in
utilization.
Question 3. What would happen if telehealth services currently
eligible for Medicare coverage were no longer covered by Medicare?
Answer. The telehealth cliff is approaching and, if Congress allows
the waivers to lapse, we will return to the state of disparate care.
Senior citizens who have come to rely on the flexibility and
independence associated with telemedicine care will experience reduced
access and limited care services. Ultimately, beneficiaries would lose
access to clinically appropriate and necessary virtual care services if
telehealth services currently eligible for Medicare coverage were no
longer covered.
Mental Health. The pandemic illustrated the importance for people
of all ages to have access to mental health services, especially during
periods of limited social interaction. Arizona's Teen Lifeline saw the
volume of text messages received by its suicide prevention hotline
increase over 450 percent during the pandemic.
Question 4. How does telehealth provide more opportunities for
patients to receive mental health services? Does the virtual nature of
a telehealth appointment encourage some patients to reach out for help
who may not otherwise?
Answer. It is no longer difficult or uncomfortable to receive
health care--particularly behavioral health--through a screen. As
technology has become ubiquitous in our society, so too has our ability
to deliver high quality healthcare through advanced, two-way audio and
video technology. Telehealth has created opportunities for patients to
receive mental health services in communities where behavioral health
professionals are not always readily available in person. Also, since
most individuals, including children, are comfortable with the
technology, it removes barriers to care these patients to adapt to
telehealth and reap its associated benefits--less drive time, reduced
costs, and improved access to care when and where it is needed.
Additionally, now that behavioral health services can be delivered
right to a patient's location, we see more patients attending their
appointments and feeling comfortable since they are usually in the
privacy of their own home. For example, Avel data demonstrates the
positive impact of Avel's in-home behavioral health services when
delivered to Indian Health Services patients in the Billings, Great
Plains, and Albuquerque areas, including a sharp reduction in no-show
rates.
Mental Health for Veterans. Nearly half a million veterans live in
Arizona. The COVID-19 pandemic and recent events in Afghanistan have
led to an increase in the number of veterans seeking mental health
treatment.
Question 5. How can telehealth services help veterans receive the
mental health care they need before a veteran faces a mental health
crisis?
Answer. Telehealth can ensure timely access to critical behavioral
health services. When veterans are close to experiencing a mental
health crisis, every second counts, and telemedicine can help these
individuals connect with high quality expert care. And, for some
veterans, telemental health care allows them the flexibility to choose
to receive mental health care where and when they need it without fear
of stigma.
______
Response to Written Question Submitted by Hon. Ben Ray Lujan to
Dr. Sanjeev Arora
Question. In expanding telehealth access, telementoring services
like Project ECHO must remain a core focus. Having a presence in every
state, Project ECHO has shown that telementoring has a role to play in
expanding access to critical health services nationwide.
What are the most effective ways for Congress to provide sustained
support for telementoring services?
Answer. Telementoring models, such as Project ECHO, enhance
workforce capacity in underserved areas by empowering community-based
primary care providers with the knowledge to manage patients with
complex conditions. There are now ECHO projects at more than 250
organizations in all 50 states across the U.S., many of these at major
academic health centers like the University of New Mexico, University
of Washington, the University of Hawaii, MD Anderson, the University of
Minnesota, and many more.
Despite receiving some financial support from federal, state, and
local government grants and national foundations, telementoring has not
yet been integrated into reimbursement models or other financing models
for federally-supported health care in the U.S. Efforts by Congress to
provide sustained support for telementoring services will be critical
for establishing a cohesive and responsive telehealth system that
ensures access to high quality care for rural and underserved
communities across the country while optimizing the effective use of
health care workforce resources.
I want to highlight three pathways in particular to encourage
Congress to explore, but a more comprehensive slate of ideas is
included in the Center for Health Care Strategies report Project ECHO:
Policy Pathways to Sustainability at: https://www.chcs.org/media/
Project-ECHO-Policy-Paper_011819.pdf.
1. Direct the Center for Medicare and Medicaid Services (CMS) to
issue guidance to state Medicaid offices on financing
strategies currently available through Medicaid to support
telementoring--and request they explore existing authorities
through Medicare as well. In the previous Congress, more than
twenty Senators--including multiple members of this Committee--
signed a letter to the then-HHS Secretary requesting that CMS
issue this guidance to states, but it was never acted on.
2. Fully fund the telementoring grant program established in the
Consolidated Appropriations Act of 2021 (P.L. 116-159) at the
$10 million level annually over five years as authorized in the
Act. This program, which is being administered by the Health
Resources and Services Administration (HRSA) awarded grants
this fall to evaluate, develop and expand the use of
technology-enabled collaborative learning and capacity building
models (telementoring) like Project ECHO.
3. Commit to exploring longer-term changes to healthcare financing
to embed sustainable and ongoing funding for effective
telementoring approaches. This effort by Congress could explore
multiple different options such as: adding an enhanced Medicaid
match rate; adding telementoring to the physician fee schedule;
building it into a CMMI demonstration; embedding funding in
HRSA health center grants; including it in the Merit-Based
Incentive Payment Incentive System (MIPS); and even exploring
new or tying existing GME slots to participation in
telementoring.
We would be grateful to work directly with you and any other
interested Senators or Representatives to discuss these ideas further.
______
Response to Written Questions Submitted by Hon. Kyrsten Sinema to
Dr. Sanjeev Arora
Infrastructure Investment and Jobs Act. The bipartisan
Infrastructure Investment and Jobs Act includes $65 billion for
broadband deployment, rural and tribal broadband, digital equity, and
affordability in Arizona and throughout the country.
Question 1. How will this historic investment in broadband enable
more Arizonans to access telehealth services, including Arizonans in
rural and tribal areas?
Answer. Improving broadband will support all domains of
telehealth--remote monitoring; telemedicine; and telementoring. All
three can advance health equity in rural and underserved communities.
People across the country face a lack of specialists. There are simply
not enough experts anywhere to serve all that need their help and
patients everywhere have to wait weeks and months to see a specialist.
And that's where telementoring to build workforce capacity comes in.
Telementoring models like Project ECHO actively work with the
Indian Health Service and other rural healthcare providers in Arizona,
and across the country, to improve access to best-practice and
specialized healthcare. By investing in the infrastructure of
broadband, telementoring programs like the ECHO model help support
recruitment and retention of providers, especially in rural areas, and
increase access to best practice specialty care to patients in remote
areas and within traditionally marginalized groups. More than 400
publications demonstrate the effectiveness of ECHO programs to support
expanded access to best practice care (https://hsc.unm.edu/echo/
partner-portal/data-marketplace/publications-reach/).
Medicare Coverage of Telehealth Services. Congress expanded the
ability of Medicare of cover telehealth services in the midst of the
COVID-19 pandemic. I have joined my colleagues from both parties to
support legislation, the Creating Opportunities Now for Necessary and
Effective Care Technologies (CONNECT) for Health Act of 2021, that
would make Medicare coverage of many telehealth services permanent.
Question 2. How would the CONNECT for Health Act enable more
Arizonans to access health care services?
Answer. Creating systemic changes to our healthcare system which
financially support telehealth services will help put telehealth
solutions on a path to sustainability. I hope Congress will commit to
exploring and supporting longer-term changes to healthcare financing
for approaches like telementoring that can support our healthcare
workforce.
Question 3. What would happen if telehealth services currently
eligible for Medicare coverage were no longer covered by Medicare?
Answer. As we have seen the pandemic exposed what we all knew
instinctively--we need to fundamentally reorient our healthcare system
to enable patients to get the care they need, when they need it, where
they live. We learned that ensuring financial sustainability for
telehealth services is vital for the future of healthcare in the United
States.
Mental Health. The pandemic illustrated the importance for people
of all ages to have access to mental health services, especially during
periods of limited social interaction. Arizona's Teen Lifeline saw the
volume of text messages received by its suicide prevention hotline
increase over 450 percent during the pandemic.
Question 4. How does telehealth provide more opportunities for
patients to receive mental health services? Does the virtual nature of
a telehealth appointment encourage some patients to reach out for help
who may not otherwise?
Answer. Ensuring access to mental health services to all Americans
is vital. Across the country we are facing a shortage of experts in
mental health modalities. Capacity building models, like Project ECHO,
can help close that gap by creating more experts in both rural and
urban settings.
As an example of the role the ECHO model can play in expanding
access to behavioral health, Arizona State University has developed a
range of ECHO programs to expand access to behavioral health and
addiction treatment services in the state. Every Wednesday a team hosts
a behavioral health integration ECHO program. More than half of
patients with behavioral health problems seek treatment by their
primary care providers. By training care teams how to identify key
issues and work with complex patients, this program is helping expand
access to quality care throughout the state (Project ECHO | College of
Health Solutions (asu.edu).
Mental Health for Veterans. Nearly half a million veterans live in
Arizona. The COVID-19 pandemic and recent events in Afghanistan have
led to an increase in the number of veterans seeking mental health
treatment.
Question 5. How can telehealth services help veterans receive the
mental health care they need before a veteran faces a mental health
crisis?
Answer. Ensuring access to mental health services for Veterans is
critical, especially in light of the mental health crises many face as
a result of their service. Building capacity by embedding telementoring
models into the VA and into rural health practices, to ensure that
veterans have access to the expertise they need, is a critical step in
ensuring better care for our Nation's heroes. Historically, Project
ECHO has worked collaboratively with the Department of Veterans
Affairs. The ECHO model has been adopted in many parts of the VA system
to support priority issues such as expanding Hepatitis C treatment. We
would welcome recommendations of how we can help support the
Department's priority of providing broad access for veterans for mental
health services.
______
Response to Written Question Submitted by Hon. Dan Sullivan to
Dr. Sanjeev Arora
Question. Obviously broadband is challenging for my state. This has
resulted in a reliance on audio-only services in some Alaskan
communities. I understand the national concern that the government
needs to be funding quality services and that audio-only is not as
beneficial as visual telehealth. However, Alaska has communities with
no access to broadband. We cannot discuss advancing telehealth without
discussing the value of audio-only for communities without access to
broadband.
Last year I cosponsored a letter to HHS defending the use of audio-
only services and asking for equity in reimbursements. HHS, thankfully,
responded to this letter and did increase the reimbursement for audio-
only services.
Can you speak to the value of audio-only services in ultra-rural
communities without access to broadband? Is there a better way that we
can target these services to communities that need them?
Answer. It is our belief that communities should use the best
available technology to support access to quality medical care. If for
very rural communities, where that is audio-only, our experience has
been that this access is better than no access at all in expanding
care.
With respect for the echo model ECHO for telementoring, in rural
Alaska and other very rural parts of the country, we know that some
participants in ECHO virtual communities of practice participate via
phone rather than video. Rural providers are often very isolated and
many times the only providers in their community. Access to virtual
communities of practice provides a much-needed trusted venue for
providers to learn from peers working in similar situations and from
leading specialists. As broadband becomes more accessible through
innovations in technology, we are hopeful that a growing number of
these communities will be connected to broadband over time and
encourage officials to work toward universal broadband coverage across
the entire country. This infrastructure provides the technology
railroad tracks for access to healthcare.
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