[Congressional Record Volume 166, Number 112 (Wednesday, June 17, 2020)]
[Senate]
[Pages S3050-S3052]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]



                               Telehealth

  Mr. ALEXANDER. Madam President, it is hard to think of much good that 
has come out of the 3-month experience with COVID-19, but here is one 
thing: the number of patients who have seen their doctors remotely 
through the internet, FaceTime, and all of the other remote 
technologies we have, including the telephone. We call that telehealth.
  Our Health Committee this morning had a fascinating hearing on 
telehealth. There was a lot of bipartisan interest from the Senators--
Democrat and Republican Senators. The Senator from Minnesota was the 
ranking member of the committee today at the request of Senator Murray. 
My sense at the end of the hearing was that there were a number of 
things we agreed on.
  I ask unanimous consent that my opening statement at the hearing 
today be included in the Record following my remarks.
  My colleague, the Senator from Tennessee who is presiding today, and 
I both know Tim Adams, who is the CEO of the Saint Thomas hospital 
system in Middle Tennessee.
  He told me on the phone last week that Saint Thomas employs about 800 
physicians in its several hospitals. During the month of February, 
there were 60,000 visits between physicians and patients in the Saint 
Thomas system. Only 50 of those 60,000 were by telehealth, were remote. 
But during the 2 months of March and April, Ascension Saint Thomas 
conducted more than 30,000 telehealth visits. That is 50 to 30,000--
more than 45 percent of all of the visits between patients and doctors 
during that time.
  Tim Adams expects that to level off, but there will still be probably 
15 to 20 percent of all of Saint Thomas 60,000 visits a month by 
telehealth.
  I talked to the CEO of the largest hospital in San Francisco a few 
weeks ago, and he said that during February, about 5 percent of their 
visits between doctors and patients were telehealth. He said that was a 
very high percentage for a hospital. But in March, it was more than 
half, more than 50 percent.
  Think about that for just a moment. There were 884 million visits in 
2016 between doctors and patients, according to the Centers for Disease 
Control. If 15 to 20 to 25 percent of those were suddenly by telehealth 
instead of in-office visits, that would mean hundreds of millions of 
visits a year would be by telehealth. It is hard for me to imagine that 
there has been a bigger change in the delivery of healthcare services 
in recent history or maybe in our country's history than the sudden 
shift to telehealth in visits between patients and doctors.
  Telehealth has been around for a long time. Our witnesses testified 
to that. We had some excellent witnesses. Dr. Rheuban from the 
University of Virginia; Dr. Kvedar from Harvard, who is

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the new president of the American Telemedicine Association; Dr. Arora, 
who is the founder of Project ECHO, which is well known across the 
country; and Dr. Andrea Willis, who is the chief medical officer of 
Blue Cross Blue Shield of Tennessee, which apparently is the first 
major insurance company to say that it will insure telehealth visits in 
the same way that it insures other visits.
  What I recommended following the hearing was that two of the policy 
changes--which I judge to be the two most important changes in policy 
that the Federal Government made--be made permanent.
  The first is that physicians can be reimbursed for a telehealth 
appointment wherever the patient is, including the patient's home. That 
would change the originating site rule, as it is called.
  The second is that Medicare, during COVID-19, has begun to reimburse 
providers for nearly twice as many types of telehealth services. That 
rule, those changes, I believe, also should be made permanent.
  What has happened is that we have had an incredible pilot program on 
telehealth. We have crammed 10 years of experience into 3 months, and 
we have a rare opportunity to look at the 3 months of experience and 
make a decision about what works, what doesn't work, and right the 
rules of the road for the future.
  It is not just the Federal Government changing, I think, a total of 
31 different policies, all of which we should examine, but States have 
made some changes too. Those changes involve allowing individuals to 
cross State lines more easily to get appointments with doctors with 
whom they need to talk.
  Then the private sector is beginning to change too. I don't know of 
other insurance companies that have done what Tennessee Blue Cross Blue 
Shield did, but I know there will be some who decide on their own to 
begin to move to cover those services.
  Senator Braun and Senator Cassidy on our committee brought up the 
point that we want to watch carefully to see that we are not just 
adding to the cost of healthcare by telehealth; in fact, we ought to 
have an opportunity to reduce it. Our goal is always, when delivering 
healthcare services, to have as an objective a better outcome, a lower 
cost, and a better patient experience. It may very well be possible 
that telehealth not only improves the patient experience--we have had 
very few complaints about the experience of that--and improves the 
outcomes, but it may also lower costs, which is a major objective of 
our committee.
  Last week, 10 days ago, I issued a white paper about the changes I 
thought we needed to make--Congress needs to make--so that we could be 
well prepared for the next pandemic after COVID-19, the one we know 
will surely come. We don't know when, we don't know what the name of 
the virus will be, but we know it will come, and we need to take a 
number of steps to be as well prepared for that virus as we can.
  Whether its accelerating treatments and testing and finding a vaccine 
or collecting data in a different way or better coordination of Federal 
officials, all of those things are part of what we need to examine, and 
we need to do that this year--this year--because our attention spans 
are short in this country. We move on quickly to the next crisis. While 
COVID-19 is fresh on our minds, we should do whatever we need to do to 
get ready for the next crisis. We should do those things this year.
  Among those things we need to do this year is to make permanent the 
changes in Federal policy on telehealth that allowed this explosion of 
doctor and patient meetings by remote visits. People have been trying 
to think of ways to do this for a long time. Unfortunately, it took a 
pandemic to cause it to happen. Now, while we can see the result, make 
sure we don't have unintended consequences that are unfortunate. While 
we are doing that, we need to make those changes.
  So I recommend to my colleagues, the testimony from our excellent 
witnesses this morning. There were 884 million doctor-patient visits in 
2016 in the United States, and very few of them were by telehealth. In 
the future, the estimates are there could be as many as 20, 25, 30 
percent of all of them, hundreds of millions of doctor-patient visits, 
by telehealth. That most likely is the largest change in the delivery 
of medical services that our country has ever seen
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                           Opening Statement


     Telehealth: Lessons from the COVID-19 Pandemic--June 17, 2020

       I spoke recently with Tim Adams, the CEO of Ascension Saint 
     Thomas Health, which has 9 hospitals in Middle Tennessee and 
     employs over 800 physicians, who told me that in February 
     before COVID-19, there were about 60,000 visits between 
     patients and physicians each month.
       Almost all of those visits were done in person. Only about 
     50 were done remotely through telehealth using the internet.
       But during the last two months, Ascension Saint Thomas 
     conducted more than 30,000 telehealth visits--or around 45 
     percent of all its visits--because of changes in government 
     policy and the inability of many patients to see doctors in 
     person during the COVID-19 pandemic.
       Tim Adams expects that to level off at 15-20 percent of all 
     its visits going forward.
       The largest hospital in San Francisco told me that 5 
     percent of its visits in February were conducted through 
     telehealth--and the hospital considered that to be a very 
     high number. Then in March, telehealth visits made up more 
     than half of all its visits.
       Because of COVID-19, our health care sector and government 
     have been forced to cram 10 years' worth of telehealth 
     experience into just the past three months.
       As dark as this pandemic event has been, it creates an 
     opportunity to learn from and act upon these three months of 
     intensive telehealth experiences, specifically what permanent 
     changes need to be made in federal and state policies.
       In 2016, there were almost 884 million visits nationwide 
     between patients and physicians, according to the Centers for 
     Disease Control and Prevention. If, as Tim Adams expects, 15-
     20 percent of those were to become remote due to telehealth 
     expansion during COVID-19--that would produce a massive 
     change in our health care system.
       Our job should be to ensure that change is done with the 
     goals of better outcomes and better experiences at a lower 
     cost.
       Part of this explosion in remote meetings between patients 
     and physicians has been made possible by temporary changes in 
     federal and state policies. The private sector, too, has made 
     important changes. One purpose of this hearing is to find out 
     which of these temporary changes in federal policy should be 
     maintained, modified, or reversed--and also to find out if 
     there are any additional federal policies that would help 
     patients and health care providers take advantage of 
     delivering medical services using telehealth.
       Of the 31 federal policy changes, the three most important 
     are:
       1. Physicians can be reimbursed for a telehealth 
     appointment wherever the patient is, including in the 
     patient's home. That change was to the so-called 
     ``originating site'' rule, which previously required that the 
     patient live in a rural area and use telehealth at a doctor's 
     office or clinic.
       2. Medicare began to reimburse providers for nearly twice 
     as many types of telehealth services, including: emergency 
     department visits, initial nursing facility visits and 
     discharges, and therapy services.
       3. Doctors are allowed to conduct appointments using common 
     video apps on your phone, like Apple FaceTime, or phone 
     texting apps, or even on a landline call, which required 
     relaxing federal privacy and security rules from the Health 
     Insurance Portability and Accountability Act, or HIPAA.
       Many states made changes as well, most importantly making 
     it easier for doctors to continue to see their patients who 
     may have traveled out of state during the pandemic.
       For example, a college student from Memphis, who attends 
     college in North Carolina and has a doctor she sees in Chapel 
     Hill, was able to go home to Tennessee during the pandemic 
     and continue seeing her Chapel Hill doctor by FaceTime. Or, a 
     patient in Iowa has been able to start seeing a new 
     psychiatrist in Nashville.
       The private sector adapted to these changes, too. One of 
     our witnesses today is from Blue Cross Blue Shield of 
     Tennessee, which has already begun to make permanent 
     adjustments to its telehealth coverage policies based on some 
     of the temporary federal changes in Medicare.
       Looking forward, of the three major federal changes, my 
     instinct is that the originating site rule change and the 
     expansion of covered telehealth services should be made 
     permanent.
       One purpose of this hearing is to hear from the experts and 
     discuss whether there may be unintended consequences, 
     positive or negative, if Congress were to do that.
       It's also important to examine the other 28 temporary 
     changes in federal policy.
       The question of whether to extend the HIPAA privacy waivers 
     should be considered carefully. There are privacy and 
     security concerns about the use of personal medical 
     information by technology platform companies, as well as 
     concerns about criminals hacking into these platforms. When 
     HIPAA notification requirements are waived, a person might 
     not even know that their personal information has been 
     accessed by hackers.

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     Additionally, several of these technology platforms have said 
     they want to adjust their platforms to conform with the HIPAA 
     rules.
       Another lesson from these three months is that telehealth 
     or teleworking or tele-learning is not always the answer, 
     especially for people in rural areas or low-income urban 
     areas who do not have access to broadband.
       And still another lesson is that personal relationships 
     involved in health care, education, and the workplace cannot 
     always be replaced by remote technology. Children have 
     learned about all they want to learn over the internet, 
     patients like to see their doctors, and workplaces benefit 
     from employees actually talking and working with one another 
     in person. There are some limits on remote learning, health 
     care, and working.
       There are obvious benefits to allowing health care 
     providers to serve patients across state lines during a 
     public health crisis. As a former governor, I am reluctant to 
     override state decisions, but it may be possible to encourage 
     further participation in interstate compacts or reciprocity 
     agreements.
       Last week I released a white paper on steps that Congress 
     should take before the end of the year in order to get ready 
     for the next pandemic. One of those recommendations was to 
     make sure that patients do not lose the benefits that they 
     have gained from using telehealth during the COVID-19 
     pandemic.
       Even with an event as significant as COVID-19, memories 
     fade and attention moves quickly to the next crisis, so it is 
     important for Congress to act on legislation this year.
       Because of this 10 years of telehealth experience crammed 
     into 3 months--patients, doctors, nurses, therapists, and 
     caregivers can write some new rules of the road, and should 
     do so while the experiences still are fresh on everyone's 
     minds.

  Mr. ALEXANDER. I yield the floor.
  I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The senior assistant legislative clerk proceeded to call the roll.
  Mr. SCOTT of Florida. Madam President, I ask unanimous consent that 
the order for the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The PRESIDING OFFICER. The Senator from Florida.