[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
TELEHEALTH TO DIGITAL MEDICINE: HOW 21ST CENTURY TECHNOLOGY CAN BENEFIT
PATIENTS
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
MAY 1, 2014
__________
Serial No. 113-142
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
__________________
U.S. GOVERNMENT PUBLISHING OFFICE
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COMMITTEE ON ENERGY AND COMMERCE
FRED UPTON, Michigan
Chairman
RALPH M. HALL, Texas HENRY A. WAXMAN, California
JOE BARTON, Texas Ranking Member
Chairman Emeritus JOHN D. DINGELL, Michigan
ED WHITFIELD, Kentucky Chairman Emeritus
JOHN SHIMKUS, Illinois FRANK PALLONE, Jr., New Jersey
JOSEPH R. PITTS, Pennsylvania BOBBY L. RUSH, Illinois
GREG WALDEN, Oregon ANNA G. ESHOO, California
LEE TERRY, Nebraska ELIOT L. ENGEL, New York
MIKE ROGERS, Michigan GENE GREEN, Texas
TIM MURPHY, Pennsylvania DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee MICHAEL F. DOYLE, Pennsylvania
Vice Chairman JANICE D. SCHAKOWSKY, Illinois
PHIL GINGREY, Georgia JIM MATHESON, Utah
STEVE SCALISE, Louisiana G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio JOHN BARROW, Georgia
CATHY McMORRIS RODGERS, Washington DORIS O. MATSUI, California
GREGG HARPER, Mississippi DONNA M. CHRISTENSEN, Virgin
LEONARD LANCE, New Jersey Islands
BILL CASSIDY, Louisiana KATHY CASTOR, Florida
BRETT GUTHRIE, Kentucky JOHN P. SARBANES, Maryland
PETE OLSON, Texas JERRY McNERNEY, California
DAVID B. McKINLEY, West Virginia BRUCE L. BRALEY, Iowa
CORY GARDNER, Colorado PETER WELCH, Vermont
MIKE POMPEO, Kansas BEN RAY LUJAN, New Mexico
ADAM KINZINGER, Illinois PAUL TONKO, New York
H. MORGAN GRIFFITH, Virginia JOHN A. YARMUTH, Kentucky
GUS M. BILIRAKIS, Florida
BILL JOHNSON, Missouri
BILLY LONG, Missouri
RENEE L. ELLMERS, North Carolina
(II)
Subcommittee on Health
JOSEPH R. PITTS, Pennsylvania
Chairman
MICHAEL C. BURGESS, Texas FRANK PALLONE, Jr., New Jersey
Vice Chairman Ranking Member
ED WHITFIELD, Kentucky JOHN D. DINGELL, Michigan
JOHN SHIMKUS, Illinois ELIOT L. ENGEL, New York
MIKE ROGERS, Michigan LOIS CAPPS, California
TIM MURPHY, Pennsylvania JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee JIM MATHESON, Utah
PHIL GINGREY, Georgia GENE GREEN, Texas
CATHY McMORRIS RODGERS, Washington G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey JOHN BARROW, Georgia
BILL CASSIDY, Louisiana DONNA M. CHRISTENSEN, Virgin
BRETT GUTHRIE, Kentucky Islands
H. MORGAN GRIFFITH, Virginia KATHY CASTOR, Florida
GUS M. BILIRAKIS, Florida JOHN P. SARBANES, Maryland
RENEE L. ELLMERS, North Carolina HENRY A. WAXMAN, California (ex
JOE BARTON, Texas officio)
FRED UPTON, Michigan (ex officio)
(III)
C O N T E N T S
----------
Page
Hon. Joseph R. Pitts, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement........................................... 2
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 3
Hon. Fred Upton, a Representative in Congress from the State of
Michigan, opening statement.................................... 5
Prepared statement........................................... 6
Witnesses
Rashid Bashshur, Executive Director for Ehealth, University of
Michigan Health System, Professor Emeritus, University of
Michigan School of Public Health............................... 8
Prepared statement........................................... 10
Answers to submitted questions............................... 91
Ateev Mehrotra, Policy Analyst, Rand Corporation, Associate
Professor of Health Care Policy And Medicine, Harvard Medical
School......................................................... 24
Prepared statement........................................... 26
Answers to submitted questions............................... 113
Tom Beeman, President and Chief Executive Officer, Lancaster
General Health................................................. 35
Prepared statement........................................... 37
Answers to submitted questions............................... 121
Gary Chard, Delaware State Director, Parkinson's Action Network.. 47
Prepared statement........................................... 49
Answers to submitted questions............................... 133
Kofi Jones, Vice President of Public Affairs, American Well...... 56
Prepared statement........................................... 58
Answers to submitted questions............................... 144
Submitted Material
Documents submitted by Mr. Pitts................................. 76
Statement of Dr. Topol........................................... 90
TELEHEALTH TO DIGITAL MEDICINE: HOW 21ST CENTURY TECHNOLOGY CAN BENEFIT
PATIENTS
----------
THURSDAY, MAY 1, 2014
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:02 a.m., in
room 2123, Longworth House Office Building, Hon. Joseph R.
Pitts (chairman of the subcommittee) presiding.
Present: Representatives Pitts, Burgess, Shimkus, Lance,
Guthrie, Griffith, Bilirakis, Ellmers, Barton, Upton (ex
officio), Pallone, Dingell, Engel, Green, Barrow, Christensen,
and Waxman (ex officio).
Also present: Representative Harper.
Staff Present: Clay Alspach, Chief Counsel, Health; Sean
Bonyun, Communications Director; Noelle Clemente, Press
Secretary; Sydne Harwick, Legislative Clerk; Robert Horne,
Professional Staff Member, Health; Chris Pope, Fellow, Health;
Macey Sevcik, Press Assistant; Heidi Stirrup, Health Policy
Coordinator; Tom Wilbur, Digital Media Advisor; Ziky Ababiya,
Minority Staff Assistant; Kaycee Glavich, Minority GAO
Detailee; Karen Lightfoot, Minority Communications Director and
Senior Policy Advisor; and Matt Siegler, Minority Counsel.
OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Mr. Pitts. The subcommittee will come to order. The chair
will recognize himself for an opening statement.
Telemedicine and digital medicine in all their forms
present a host of potential benefits to both patients and
providers. Virtual doctor visits are one way to help address
provider shortages, particularly in rural areas where patients
may have to travel a great distance at their own cost to see a
doctor in person. Telemedicine can allow in-home monitoring of
chronically ill patients and facilitate patient education.
Provider-to-provider virtual consultations may also lead to
greater efficiencies in the system by providing continuity of
care and reducing duplicative testing and services. The ability
to Skype or use a video call can also reduce the inappropriate
use of resources by patients. For example, a parent with a
small child who is sick in the middle of a night could access a
provider via web cam and potentially avoid an unnecessary trip
to the emergency room.
For all of its potential benefits, concerns about the
appropriate way to support such technologies abound. If not
done carefully, some fear the potential for good that many
envision in this space can instead lead to waste, fraud, and
abuse. Therefore, the purpose of today's hearing is to explore
the types of technologies that hold great promise and hear
ideas that allow the Federal Government to realize this
potential to reduce cost, improve efficiencies, and ensure
quality in our healthcare programs.
To that end, Ranking Member Pallone and I will be releasing
a call for ideas following the hearing. We will be looking for
specific policy and legislative ideas on how the Federal
Government can support technology adoption in our healthcare
programs for the express and explicit purpose of reducing cost
and increasing the overall quality and efficiency of the
programs.
We are also looking for ways in which the Federal
Government currently inhibits the use or adoption of such
technologies by all players in the healthcare system, be they
insurer, provider, or patient. The more specific and targeted
policy, the greater chance it will hold for congressional
support down the line.
I would like to welcome all of our witnesses to the
subcommittee hearing today, especially Dr. Tom Beeman,
president and CEO of Lancaster General Hospital, the largest
hospital and one of the largest employers in my congressional
district.
I would like to yield the remainder of my time to the
gentleman from Mississippi, Mr. Harper.
[The prepared statement of Mr. Pitts follows:]
Prepared statement of Hon. Joseph R. Pitts
The Subcommittee will come to order.
The Chair will recognize himself for an opening statement.
Telemedicine and digital medicine, in all of their forms,
present a host of potential benefits to both patients and
providers.
Virtual doctor visits are one way to help address provider
shortages, particularly in rural areas, where patients may have
to travel a great distance, at their own cost, to see a doctor
in-person.
Telemedicine can allow in-home monitoring of chronically
ill patients and facilitate patient education.
Provider-to-provider virtual consultations may also lead to
greater efficiencies in the system by providing continuity of
care and reducing duplicative testing and services.
The ability to Skype or use a video call can also reduce
the inappropriate use of resources by patients. For example, a
parent with a small child who is sick in the middle of the
night could access a provider via web cam and potentially avoid
an unnecessary trip to the emergency room.
For all its potential benefits, concerns about the
appropriate way to support such technologies abound. If not
done carefully, some fear the potential for good that many
envision in this space can instead lead to waste, fraud, and
abuse.
Therefore, the purpose of today's hearing is to explore the
types of technologies that hold great promise, and hear ideas
that allow the federal government to realize this potential to
reduce costs, improve efficiencies, and ensure quality in our
health care programs.
To that end, Ranking Member Pallone and I will be releasing
a call for ideas following the hearing. We will be looking for
specific policy and legislative ideas on how the federal
government can support technology adoption in our health care
programs for the express and explicit purpose of reducing costs
and increasing the overall quality and efficiency of the
programs.
We are also looking for ways in which the federal
government currently inhibits the use or adoption of such
technologies by all players in the health care system--be they
insurer, provider, or patient. The more specific and targeted
the policy, the greater chance it will hold for Congressional
support down the line.
I would like to welcome all of our witnesses to the
Subcommittee today, especially Dr. Tom Beeman, President and
CEO of Lancaster General Hospital, the largest hospital and one
of the largest employers, in my congressional district.
Thank you, and I yield the remainder of my time to --------
------------------------------------.
Mr. Harper. Thank you, Mr. Chairman. I appreciate your
attention to this important subject.
And, Ranking Member Pallone, I value your shared interest
in telehealth.
Over the last couple of years, I have had the privilege of
being a part of this exciting conversation on telemedicine. My
staff and I have engaged in a years-long discussion and
dialogue with patients, providers, and many other industry
stakeholders to determine the most appropriate way for Congress
to advance telehealth.
The bottom line is that until we can attract more
physicians to underserved communities and tighten the access
gap, the best and most cost-efficient alternative is to improve
telehealth networks. That is why I have introduced the
Telehealth Enhancement Act, a bill to strengthen Medicare and
enhance Medicaid through expanded telemedicine coverage.
But most importantly, it is really about fairness. Access
to care should not be limited based on where Americans choose
to live. My goal is to build on existing telemedicine reforms
that States like Mississippi have advanced and pioneered. The
University of Mississippi Medical Center, for example, has been
a leader in advancing telemedicine. Along the way, I hope also
that we can help States, as well as the Federal Government, to
lower healthcare costs by encouraging people to adopt healthier
lifestyles and reducing avoidable hospital visits.
Just this past Monday, the State of Mississippi was
devastated in many communities from a series of tornados.
Yesterday, I was able to fly down with our two United States
Senators and another Congressman to view the damage, and
particularly hard hit were areas in Tupelo, in my home county
of Rankin County, and the cities of Richland, Pearl, and
Brandon, but most extensively was in the city of Louisville,
which experienced about a 0.75 of a mile to a mile-wide tornado
that was on the ground for some distance, with many deaths. And
so the University of Mississippi Medical Center was able to
utilize telemedicine to help on the ground there and continuing
to do so. And these are things that, I think, have a great
future.
So thank you, Mr. Chairman. And I yield back.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the ranking member, Mr. Pallone, 5 minutes
for an opening statement.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Chairman Pitts, for agreeing to
hold today's important hearing on telehealth. As ranking member
of this subcommittee and a member of the Communications and
Internet Subcommittee, telehealth has been an interest of mine
for some time. And I also know there are many members of the
committee and across Congress who share this interest. So I am
glad we are having this opportunity.
An aging population and an expansion in healthcare coverage
means that more Americans will be using healthcare services in
the coming years. And as new demands are placed on our national
healthcare system, I strongly believe as policymakers we need
to be actively working to leverage technology to lower costs,
increase access, and improve quality of care.
The convergence of medical advances, health information
technology, and a nationwide broadband network is transforming
the delivery of care by bringing the healthcare provider and
patient together virtually. Telemedicine has the potential to
serve a large portion of the U.S. by expanding the reach of
medical resources while reducing cost and increasing quality.
And while we continue to advocate transforming our system from
one of treating the sick to preventing people from getting
sick, telemedicine can play a pivotal role.
For example, persons who have difficulty leaving the home,
the elderly and the physically disabled, could easily and
regularly access health care from the comfort of their home.
Telemedicine also has the ability to assist people with
diabetes, obesity, heart failure, and mental illness, as well
as other diseases by reducing the number of readmissions to
hospitals.
When Congress passed the Affordable Care Act we strongly
felt that the status quo was not sustainable. Not only did we
have to expand coverage in this country for the uninsured, but
we also needed to change our system to reflect and incentivize
both quality and efficient care. And as a part of that broader
goal, the law includes a variety of provisions aimed at
expanding the use of telehealth, recognizing that doing so can
help to increase the quality of care through monitoring and
specialization.
For example, the Independence at Home Demonstration is
testing whether providing chronically ill patients with a range
of services in the home setting can reduce hospitalization and
improve health outcomes. It also includes an option for states
to provide health homes for Medicaid enrollees with chronic
conditions. And of course the greater use of ACOs can play an
important role in the expansion of telehealth services.
Telehealth also allows patients' health to be constantly
monitored between doctors visits and makes it easier for
patients to connect with more specialists. Evidence shows the
specialists utilizing telemedicine are still able to accurately
evaluate and diagnosis patients without person-to-person
contact. Telephone, video conferencing, computers, and Internet
applications or apps are all employed. Hospitals and medical
centers use telehealth to reach patients in underserved rural
areas. The military makes use of telehealth in its health
program, and States within their bounds are working with
universities to practice telemedicine.
Telemedicine can also reduce healthcare costs. It would
enable doctors and other specialized professionals to come
together and effectively reach more patients, which is
important as the ACA is being implemented and more Americans
are becoming insured. It also allows for diseases to be tracked
so they can be treated before they become more costly. And
telehealth proponents suggest that these technologies can
relieve medical workforce shortages and the unequal
distribution of clinicians in the United States.
For patients, telehealth can mean connecting with medical
expertise not locally available, saving time, money, and
travel, reducing unnecessary hospital visits, and improving the
management of chronic conditions.
And that is why I joined with my Republican colleague,
Representative Devin Nunes, a member of the Ways and Means
Committee, to introduce the Telemedicine for Medicare or TELE-
MED Act, which aims to increase access to telemedicine in the
Medicare program. Specifically, it would permit Medicare
providers who are licensed to practice medicine physically in
one State to treat patients electronically across State lines.
Under that bill, the State in which the license is issued
would have enforcement authority regardless of the patient's
location. And by connecting the Medicare patient and provider
virtually at the point and time of care, the TELE-MED Act gives
Medicare patients access to the best health care anywhere at
any time. It also directs the Secretary to report to Congress
on how we can ensure increased use of telemedicine in the
Medicare program.
Now, I know there are stakeholders who remain concerned
about the approach we have taken in this bill. I also know that
telehealth raises operational questions and faces serious
challenges. For example, most clinicians have not been trained
in telehealth, and there are also security and privacy
concerns. As a strong advocate of preserving and strengthening
Medicare, we must ensure program integrity is preserved and
utilization costs do not rise.
So we have a lot of work to do, Mr. Chairman, but I hope
that we can still find common ground. We have a great
opportunity to come together to expand the use of telehealth in
this country. That is why I am proud to join with you in
calling for an exchange of ideas. And as you said, we intend to
set up a process in which all stakeholders can share with our
subcommittee their views on this topic. Our goal is to use this
process to further inform the subcommittee on what public
policies that, if adopted by Congress, might allow for improved
delivery and access to health care.
Thank you, Mr. Chairman.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the chairman of the full committee, Mr.
Upton, for 5 minutes for an opening statement.
OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MICHIGAN
Mr. Upton. Well, thank you, Mr. Chairman.
We are here today to explore the opportunities 21st century
technology presents to improve the lives of patients and
advance our healthcare system. The introduction of digital
forms of communication and applications, such as wireless
technologies and smart phones, hold tremendous and great
promise for the future of our healthcare system.
Twenty-first century technologies can allow providers to
monitor patients released from an inpatient hospital, help
reduce the chances of relapse or even readmittance. They also
can support new delivery reforms and models that were part of
the focus of the doc fix SGR reform legislation that was
authored by Dr. Burgess, which we passed out of this committee
51 to nothing; help improve access for those in rural areas
like South Haven, Michigan; reduce the overall invasiveness and
risk related to healthcare procedures and illnesses.
I want to commend particularly you, Chairman Pitts and
Ranking Member Pallone, for your collaboration on today's
hearing. As you have discussed, we will be soliciting ideas for
how technology can be incorporated into our healthcare system
to improve the cost, quality, and delivery of health care
across the country.
And in support of that effort there are a number of
questions that need to be answered. Which technologies hold
promise for improving the quality and delivery of health care
in this country? What role, if any, exists for the Federal
Government in supporting such technologies? How can Congress
help foster and realize the promise of 21st century
technologies to improve the lives of all Americans?
This will be a priority of the Committee on Energy and
Commerce over the next couple of years as we work together
towards fostering innovation that will lead to more treatments
and cures for issues related to personal illnesses and the
overall delivery of health care. The topics discussed today
will certainly be a vital part of the 21st Century Cures
initiative that was unveiled yesterday and will continue in the
weeks and months ahead.
I also want to recognize the efforts of committee members
Gregg Harper, Bill Johnson, Doris Matsui, and Peter Welch, who
have helped author legislation that in part made today's
hearing possible. I yield back the balance of my time to
gentleman from Texas, Dr. Burgess.
[The prepared statement of Mr. Upton follows:]
Prepared statement of Hon. Fred Upton
We are here today to explore the opportunities 21st century
technology presents to improve the lives of patients and
advance our health care system.
The introduction of digital forms of communication and
applications, such as wireless technologies and smart phones,
hold great promise for the future of our health care system.
Twenty-first century technologies can allow providers to
monitor patients released from an inpatient hospital and help
reduce the chances of relapse and re-admittance. They also can
support new delivery reforms and models that were part of the
focus of SGR reform legislation authored by Dr. Burgess, help
improve access for those in rural areas, and reduce the overall
invasiveness and risks related to health care procedures and
illnesses.
I want to commend Chairman Pitts and Ranking Member Pallone
for their collaboration on today's hearing. As they just
discussed, they will be soliciting ideas for how technology can
be incorporated into our health care system to improve the
cost, quality, and delivery of health care in this country.
In support of that effort, there are a number of questions
that need to be answered: Which technologies hold promise for
improving the quality and delivery of health care in this
country? What role, if any, exists for the federal government
in supporting such technologies? How can Congress help foster
and realize the promise of 21st century technologies to improve
the lives of Americans?
This will be a priority of the Committee on Energy and
Commerce over the next few years as we work towards fostering
innovation that will lead to more treatments and cures for
issues related to personal illness and the overall delivery of
health care. The topics discussed today will certainly be a
vital part of the 21st Century Cures initiative that was
unveiled yesterday.
I also would like to recognize the efforts of committee
members Gregg Harper, Bill Johnson, Doris Matsui, and Peter
Welch who have helped author legislation that in part made
today's hearing possible.
I yield the balance of my time to ------------------------
----------------------.
Mr. Burgess. I thank the chairman for yielding and I thank
the chairman for the recognition about the SGR bill. It is a
landmark achievement.
I will never forget the time in practice when I learned
about the CPT Code 99371. It was a code that paid for a
telephone consultation. I thought my life would be forever
changed because now all of these hours at night I spent on the
telephone could be reimbursed. But little did I know it fell
into the broad category of codes with no reimbursement. All
right.
Medicine has changed a lot in the 21st century, and a lot
of it has been for the good. Some of the policy has been the
opposite of good, but many of the things that are happening on
the technological front are certainly dramatically changing the
practice of medicine, and telemedicine is helping to improve
access to care and make practices more efficient. The
convergence of medical and technological advances; everyone is
now carrying a smart phone. The nationwide broadband network is
transforming the delivery of care by bringing providers and
patients together, together in a virtual world that previously
did not exist.
In Texas, providers from across the State can now treat
patients in remote locations. A Texas law passed in 2013
enables physicians to more easily collaborate with rural nurse
practitioners via teleconference, helping to expand vitally
needed primary care services to patients. Thus the role of the
physician extender is finally being fulfilled.
It is important that these services be provided in a manner
that is safe and effective for patients. The technological
advances before us and those just over the horizon have great
potential to connect patients to cutting-edge care, but it must
be practiced by those appropriately trained for the maximum
potential benefit. For that reason, I am grateful that we have
the panel before us today, certainly, an all-star panel of
people who live in this world every day. I am looking forward
to their testimony. And I will yield back, Mr. Chairman.
Mr. Pitts. The chair thanks the gentleman.
I now would like to ask unanimous consent to include the
following statements for today's hearing record from the
American Osteopathic Association, the American Academy of
Dermatology Association, American Medical Association, and the
American Academy of Family Physicians. Without objection, so
ordered.
[The information appears at the conclusion of the hearing.]
Mr. Pitts. We have on our panel today five witnesses. I
will introduce them in the order in which they should speak.
First, Dr. Rashid Bashshur, executive director for eHealth,
University of Michigan Health System. Secondly, Dr. Ateev
Mehrotra, policy analyst, RAND Corporation; then Dr. Tom
Beeman, president and CEO of Lancaster General Health; Mr. Gary
Chard, Delaware State director, Parkinson's Action Network; and
Ms. Kofi Jones, the vice president of public affairs of
American Well.
Thank you very much for coming. Your written testimony will
be made a part of the record. We will give you each 5 minutes
to summarize your testimony. There is a little system of lights
on your table, so when you see red, that means you should wind
up, if you please.
And Dr. Bashshur, we will start with you. You are
recognized for 5 minutes for your opening statement. Poke the
button on there, please. Yes. The light should come on and then
you are on.
STATEMENTS OF DR. RASHID BASHSHUR, EXECUTIVE DIRECTOR FOR
EHEALTH, UNIVERSITY OF MICHIGAN HEALTH SYSTEM, PROFESSOR
EMERITUS, UNIVERSITY OF MICHIGAN SCHOOL OF PUBLIC HEALTH; DR.
ATEEV MEHROTRA, POLICY ANALYST, RAND CORPORATION, ASSOCIATE
PROFESSOR OF HEALTH CARE POLICY AND MEDICINE, HARVARD MEDICAL
SCHOOL; DR. TOM BEEMAN, PRESIDENT AND CHIEF EXECUTIVE OFFICER,
LANCASTER GENERAL HEALTH; GARY CHARD, DELAWARE STATE DIRECTOR,
PARKINSON'S ACTION NETWORK; AND KOFI JONES, VICE PRESIDENT OF
PUBLIC AFFAIRS, AMERICAN WELL
STATEMENT OF RASHID BASHSHUR
Mr. Bashshur. Thank you very much. I am delighted to be
here to discuss telemedicine with you. Thank you for the
opportunity. For convenience, I will use the term
``telemedicine'' throughout my discussion, also referred to as
telehealth, e-health, m-health, and connected health.
If I may, Mr. Chairman, I would like to thank the
distinguished Members of Congress who just spoke for making my
job easy. They have already said it: No one has to prove that
ready access to expert medical consultations at reasonable cost
can save lives; that obviating travel and reducing waiting
times for patients and their families by providing appropriate
quality care in their local community and referrals only when
necessary is a step in the right direction; that ready access
to evidence-based medicine by providers is in the best interest
of patients; that giving providers immediate access to
electronic health records, which include patients' medical
history, allergies, medications, would enable them to make
better clinical decisions and to avoid errors and adverse
events from medication contraindications; that enabling
patients to adopt healthy lifestyles and take an active part in
their own care is inherently good and saves money; that
avoiding unnecessary medical visits for pre- and post-surgery
appointments; the list goes on.
On a more personal level, no one needs to prove that saving
the life of a young boy presenting with cardiac arrest in a
remote community hospital is worth the limited cost of a
multipurpose telemedicine network. I know of one tragic event
where such a boy died en route to a tertiary care hospital when
a remote consultation with a pediatric intensivist could have
saved his life.
Telemedicine can save money by early intervention, rapid
response, and empowered patients. It can avoid costly
complications of chronic diseases. Its tools can be used to
reduce human resource cost, travel cost, and wasted waiting
times as a substitute and not an add-on service.
The expansion of this modality of care with proper goals,
ongoing assessment, together with attendant adjustments and
quality controls, would save money and improve health outcomes.
It is most effective when limited assets across State lines can
be brought into play. Consumer feedback is necessary to avoid
potential abuse and incompetence. National reciprocity with
minimal paperwork and national databases are necessary.
The technologies that can be used to promote adoption of
healthy lifestyles with enormous implications for cost savings
are wearable sensors, smart phones, and mobile devices, likely
to become the dominant telemedicine technology. These
technologies have produced efficiencies in the delivery of
service to the point of need in entertainment, banking,
commerce, and education. The same applies to health care.
With continued public support for research and development
for further deployment and refinement of these systems, there
will be winners: patients, providers, and the public purse.
Thank you.
Mr. Pitts. Chair thanks the gentleman.
[The prepared statement of Mr. Bashshur follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Pitts. And I now recognize Dr. Mehrotra 5 minutes for
an opening statement.
STATEMENT OF ATEEV MEHROTRA
Dr. Mehrotra. Thank you, Chairman Pitts, Ranking Member
Pallone, and the distinguished members of the committee, for
inviting me to testify. My name is Ateev Mehrotra. I am a
physician and researcher at the Beth Israel Deaconess Medical
Center, the RAND Corporation, and Harvard Medical School.
One of my core research interests is understanding the
impact of delivery innovations, and I have termed the
burgeoning number of new delivery options as the convenience
revolution in health care. My hope is that these new care
options can address the common complaint I hear from my own
patients: that they often have difficulty getting care in a
timely manner.
My testimony today is organized around four points for the
members of the committee to consider. First, frame telehealth
broadly. One form of telehealth is simply replacing a face-to-
face visit with a video conference. And while this form of
telehealth technology is important, I believe telehealth should
be framed much more broadly. Telehealth essentially means using
technology to deliver care in a mode other than a traditional
face-to-face visit.
The great diversity of telehealth technologies makes
Congress' job very difficult. While it might be tempting to
begin to define, regulate, or pay for telehealth on how it is
delivered, technology changes very rapidly, and any definition
that specifies the type of technology runs the risk of being
outdated quickly. One reason I advocate for global payment
methods is the payment is not specific to how the care is
provided, and this is a point I will return to later in my
testimony.
My second point is do not always assume that telehealth
improves care. As with all new technologies and delivery
models, it is important not to assume that telehealth always
improves care. While many studies have shown that telehealth
can have a positive impact, others have found telehealth is
ineffective and sometimes even harmful. For example, one recent
study of home monitoring for older adults found that the home
monitoring led to an increased risk of death.
To ensure that telehealth is beneficial, we need more
population-based quality measures instead of our current
quality measures, which are often specific to how the care is
delivered; for example, care in a nursing home. Also, it is
hard to make blanket statements about whether a given
telehealth technology is effective or ineffective. Rather, the
impact of the telehealth technology depends on what are the
patient and the clinical situation. And so the complexity
emphasizes the need for more ongoing evaluation of telehealth
and what works and what doesn't work.
My third point is that telehealth may improve access but
not always for the populations we expect. I believe telehealth
can improve access for people who live in rural areas. However,
it is important to recognize that people who live in urban
areas and wealthier communities may be the most likely to use
telehealth. They may preferentially turn to telehealth because
they are equally attracted to the convenience and may have more
access and familiarity with technology. Recognizing
telehealth's broad appeal is essential because policies should
not be crafted just for rural communities.
My fourth and final point is that telehealth can be cheaper
per clinical encounter, but could also increase utilization and
spending. Telehealth can reduce healthcare spending. Many
studies, including my own, have documented that telehealth can
lead to be cheaper on a per-visit basis. However, lower costs
per visit does not ensure that telehealth reduces spending. To
reduce spending, the telehealth visit must replace an in-person
visit.
The concern is that telehealth could drive greater
utilization and increase spending. In other words, people who
otherwise would have not sought care use telehealth to get
care. Now, if this increased use of care leads to better
treatment, better health, then this new utilization is good for
society. However, the concern is this new use could be
overutilization, that is care that does not lead to
improvements in health, and therefore this increased
utilization does not have any benefit.
The very advantage of telehealth, its ability to make care
convenient, is also potentially its Achilles' heel. In some
cases telehealth can be too convenient. This possibility of
overutilization can be tempered through bundled payment. Under
a bundled payment system, providers have more flexibility on
deciding upon the most appropriate and cost-effective means of
delivering care for a given patient in a clinical situation.
To sum up, I am a firm believer in the potential for
telehealth and other delivery innovations to improve quality,
decrease costs, and increase access, but there are many
complexities that require consideration to ensure that
telehealth reaches that potential.
Again, let me thank you for allowing me to appear before
you today, and I would be happy to take any questions.
Mr. Pitts. The chair thanks the gentleman.
[The prepared statement of Dr. Mehrotra follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Pitts. Now a special welcome to my constituent. I call
him Mr. Tom Beeman, but he is listed as Dr. Beeman. He is also
Admiral Beeman.
But whichever title you would like, Tom, you are welcome.
You are recognized for 5 minutes.
STATEMENT OF TOM BEEMAN
Mr. Beeman. Good morning, Mr. Chairman, Ranking Member, and
distinguished members of the House Commerce Subcommittee on
Health. My name is Thomas Beeman, president and CEO of
Lancaster General Health. Thank you for allowing me to
represent our perspective and share how 21st century
technologies can benefit patients.
An integrated not-for-profit health system, Lancaster
General Health, includes 690 beds, 40 outpatient sites, home
care and infusion therapy services, a family practice residency
program, the Pennsylvania College of Health Sciences, through
which we educate over 1,600 future medical professionals
annually. We employ over 7,100 employees and are aligned with a
medical staff of over 1,000 physicians and advanced practice
providers.
Our leadership defines telehealth as the use of technology
to connect the right people at the right time and place in
order to improve the patient experience and health outcomes.
Today, through the use of Web-based solutions, the
affordability of mobile devices, and an increasingly tech-savvy
population, the innovative solutions are seemingly without
limit. These innovative solutions help us to reach our patients
outside the walls of our system and outside the confines of a
traditional workday.
Our current state of technologies includes a HIMSS Level 7
integrated platform that spans all care settings and
incorporates our $100 million investment in Epic as our
electronic health record. Our investment in Epic connects
providers with clinical evidence decision support tools and
patients via our patient portal called MyLGHealth, which gives
patients access to their medical record anywhere Internet is
available. Additionally, our health system participates in
Healtheway, connecting us with the national health information
exchange.
With our limited time today, I would like to elaborate one
example from the written testimony which highlights how we
leverage our technological resources. This program is a pilot
we call Care Connections. We know that a small percentage of
the population accounts for most of the healthcare costs, most
of which are generated through avoidable emergency department
visits and inpatient stays.
Leveraging the information gleaned from our electronic
health records and billing department, we learned that at
Lancaster General Health 480 patients accounted for $36 million
in charges between 2008 and 2009. With this in mind, in 2011 we
launched the Superutilizer Project, which incorporates a
multidisciplinary team of a case manager, lawyer, medical care
providers, pharmacists, psychologist, and social worker to
manage a group of 30 patients.
Since 2011, we have formalized the program and dubbed it
Care Connections and expanded enrollment to 100 patients. Our
latest results show that inpatient days in the hospital
decreased by 84 percent and emergency department visits by 26
percent. Limited available cost data reveals after enrollment
per-member per-month spend decreased $670 or for 100 patients
savings of more than $800,000 in one year.
While this level of success requires superior clinical
management and great effort on the part of a multidisciplinary
team, the foundation upon which the program is built is
telehealth. The entire Care Connections team is mobile, with
secure iPads, iPhones, and laptops, upon which they connect in
patient's homes using Microsoft Lync to have a visual
connection with a provider in the office to allow for virtual
communications, video conferencing, and patient education.
Care Connections helps decrease our operational needs for
physical space while achieving our optimal goal of treating the
patient in the appropriate setting and engaging them in their
own care. This is further supported with alerts the team
receives whenever any of their patients enter an emergency
department in the area so we can continue to monitor and
intervene in their care.
Finally, we also leverage commercial products such as Find
My Friends mobile app to identify exact locations of our
caregivers in the field to ensure the safety of our workforce.
Our written testimony includes other examples of programs
that we have instituted at Lancaster General Health that
similarly blend technology and medicine in exciting and
collaborative ways. As care providers, we ultimately believe
that better informed and better engaged patients lead to better
health, and better health is the ultimate reform, the best and
most definitive solution to controlling the ever-spiraling
percent of GDP that the Nation spends on healthcare.
Mr. Chairman, it has been my honor to appear before you
today. I would be pleased to respond to any questions that you
or members of the subcommittee may have.
Mr. Pitts. Chair thanks the gentleman.
[The prepared statement of Mr. Beeman follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Pitts. Mr. Chard, you are recognized for 5 minutes for
an opening statement.
STATEMENT OF GARY CHARD
Mr. Chard. Good morning, Mr. Chairman and Ranking Member
Pallone and members of the subcommittee. My name is Gary Chard,
and I am the Delaware State Director for the Parkinson's Action
Network. Thank you for the opportunity to speak before you
regarding the role telehealth technology can play in the lives
of Parkinson's disease patients in the 21st century. As a
person with Parkinson's, please hear me with the voice of my
fellow persons with Parkinson's moving and shaking right along
with me.
I am a 62-year-old vibrant and healthy resident of the
State of Delaware. I was diagnosed with this insidious disease
in the spring of 2008 when I was anticipating another 10 to 15
years of productive work life. I am a financial representative
by practice, as well as a husband, father, grandfather, church
and community member of whom much was expected. To say that
many of the hopes and dreams of my family, community members,
and clients were dashed with the progression of my PD is an
understatement.
I come to you today to tell you how technology can
revolutionize the treatment and care of people living with PD
and how it has personally helped me. Please hear me that the
employment of telehealth technology is not limited to benefit
only persons with Parkinson's or people in deep rural
communities, but it is an asset that can provide safe, secure
and in-depth diagnostic and evaluative care to the immobile and
infirm, bringing them to experts who may otherwise be
unaccessible.
Parkinson's Disease is a neurological disorder that stems
from reduced dopamine production in the substantia nigra
portion of the brain leading to tremors in the limbs, slowness
of movement, rigidity, and impaired balance and coordination.
It also exhibits itself through cognitive changes such as
confusion, forgetfulness, loss of thought pattern, and sleep
disruptions. If my voice begins to fade this morning, please
recognize it is a typical example of my PD.
Parkinson's is a disease that impacts between 500,000 and
1.5 million Americans and has an economic burden of at least
$14.4 billion a year in the United States, and prevalence is
estimated to more than double by the year 2040.
With the advent of telehealth, my access to Dr. Ray Dorsey,
my diagnosing specialist in Rochester, New York, or Dr. David
Perlmutter, my neurological health coach in Naples, Florida,
can be achieved with the use of existing and improving
technology, thereby providing me with the counsel and tracking
I rely on in a safe and comfortable environment, saving me and
my family costs for care, travel, and productive time.
With use of a telehealth link established between Dr.
Dorsey and the University of Delaware's Nurse Managed Health
Care facility, I can now safely visit with Dr. Dorsey on a
frequent basis consistent with my diagnosis in a medically
staffed local facility and receive his evaluation of my disease
progression and recommendation for treatment.
Part of the invaluable experience of telehealth is a real-
time visit with my specialists. As long as I am in a private
environment, I feel that I can speak as candidly with my doctor
as I can when face to face. The improvements of this technology
serve to enhance and expedite the one-on-one interaction with a
specialist, not detract from it. I can say that I don't feel as
comfortable as I do with an office visit, but in lieu of
traveling long distances, waiting to be seen in an office, and
experiencing the other logistics of planning for an office
visit, telehealth technology serves to provide me with a
doctor-patient consult that surpasses searching for and
traveling to a specialist who may be hundreds of miles away or
more.
In establishing the telehealth link at the University of
Delaware, issues of patient privacy, across-state licensure,
reimbursement, and the always looming liability immediately
came into play. It took the interaction of several legal and
government channels months of negotiating before allowing Dr.
Dorsey from New York to speak with me in a doctor-patient
relationship in Delaware, leaving me without interaction with a
medical specialist for more than 18 months. Why? Because the
legal, financial, and licensure channels are so convoluted that
it took that long to sort through the terms and conditions in
order to allow this exercise to proceed.
For the Parkinson's community, telehealth has the potential
to be an extremely useful tool in providing greater access to
specialists, such as neurologists or movement disorder
specialists. In order to provide the data needed to inform the
needed policy changes, Dr. Dorsey, in partnership with the
National Parkinson Foundation, is currently executing a Patient
Centered Outcomes Research Institute-funded study on the
quality and effectiveness of treating people with Parkinson's
via video conferencing. Dr. Dorsey and NPF hope to build on
previous smaller studies to prove that expert care is important
for Parkinson's patients and that it can be delivered via
virtual house calls.
In conclusion, for people with Parkinson's or other complex
diseases, I believe telehealth is a present day solution to
address the serious issue of access to proper medical care.
Through advocacy organizations such as the Parkinson's Action
Network, I look forward to working with members of the
committee to find commonsense solutions to the hurdles that
face the utilization of telehealth in order to improve the
quality of care for patients across the country.
Thank you again for allowing me to testify today, and I
would be happy to answer any questions.
Mr. Pitts. The chair thanks the gentleman.
[The prepared statement of Mr. Chard follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Pitts. And now recognize Ms. Jones 5 minutes for an
opening statement. If you will just pull the mike a little bit
closer, that helps members hear. Thank you.
STATEMENT OF KOFI JONES
Ms. Jones. Mr. Chairman, Mr. Ranking Member, and members of
this committee, I thank you for this tremendous opportunity of
testifying before you today. I am here today on behalf of my
company American Well. Based in Boston, Massachusetts, American
Well was founded in 2006 by two brothers who also happen to be
physicians. Their goal was simple: transform healthcare
delivery through technology and improve access to quality care
by removing traditional barriers to healthcare delivery, such
as distance, mobility, and time constraints.
American Well's telehealth platform is used by health
plans, individual providers, pharmacies, delivery networks,
hospitals, and employers all over the country offering real-
time, synchronous, audiovisual, HIPAA-compliant, and secure on-
demand health care from any location to any location, on the
Web or even in the palm of your hand through mobile apps. And
health plans like WellPoint, through its LiveHealth Online
national telehealth initiative, have made telehealth encounters
an integrated benefit for all of their customers.
These technologies offer the opportunity to move
appropriate care to lower-cost settings, into the home or
workplace, or bring care to where it is currently not
available, like schools, prisons, or rural areas, lacking
facilities or healthcare providers. Telehealth has been shown
to reduce unnecessary ER utilizations, hospitalizations, or
even general overhead, as well as support preventative care
efforts for chronic care patients.
I am acutely aware that I sit this morning before a panel
of distinguished policy leaders who have already heard from a
knowledgeable panel and know all too well that we as a Nation
are at a critical juncture in our healthcare journey. However,
despite the accelerating momentum for telehealth we have many
questions left to answer as a Nation before telehealth can
reach its full potential. That is why I applaud this committee
for having this hearing.
First, I would like to raise an issue that should be the
backbone of this entire discussion: patient safety. Medical
boards and similar boards across the Nation not only deal with
licensure, but what is considered appropriate practice or
clinically appropriate care to provide to patients.
Now, currently there exists an inconsistent patchwork of
State laws that have inhibited the deployment of telehealth in
both the private and public sectors. There have been several
proposed solutions to this, including the Telehealth
Modernization Act, a bipartisan measure introduced this past
December by Representatives Doris Matsui and Bill Johnson,
which provides States with clear definitions and principles
they can look to for guidance when developing new policies that
govern telehealth. And just this past weekend the Federation of
State Medical Boards ratified a new model national telehealth
policy. The FSMB's new model policy marks the first time the
medical community has unilaterally acknowledged the extremely
beneficial impact that telehealth has had in the practice of
medicine.
Whatever the solution to the 50 state regulatory
environment, we need to strike a balance between innovation and
patient safety.
Second, we face issues with licensure. Currently, there
exists a home field rule: Providers must be licensed in the
state where they provide care. These days, doctors and other
healthcare professionals can be physically located in one state
while their expertise is required in another.
Licensure is a lengthy and costly process for providers and
each state has its own set of rules. Now, there are many ways
to address this, one of which is the bipartisan TELE-MED Act
introduced by Representatives Frank Pallone, ranking member of
this subcommittee, and Devin Nunes, and that would allow
Medicare patients to be cared for by a licensed provider in any
state.
Ultimately, the issue of licensure will need to be
addressed if we are to allow telehealth to reach its full
potential, and that solution will need to both allow providers
to provide care when and where it is needed while ensuring the
oversight necessary to ensure patient safety.
And finally, we should address the issue of payment:
reimbursement. The Social Security Act defines telehealth and
how Medicare will reimburse for telehealth services. That
language was crafted in the year 2000, 7 years before the first
iPhone, the iPhone you now can get real-time live health care
on. Imagine what this language would look like if we crafted it
today.
This outdated language says that patients can only receive
care if they are in a rural area presenting from a clinical
site. That means patients still need to get into the car to
receive care, and cities don't count. This is widely viewed as
one of the major barriers to the full and complete deployment
of telehealth.
In summary, by the end of the decade, the terms online
care, virtual care, telemedicine, and telehealth will all be
antiquated. Telehealth will simply just become health care and
replace a significant portion of in-person care. As these
technologies are proven to improve outcomes, they will become
the status quo.
Thank you again for the opportunity for presenting before
you today, and I am happy to answer any questions.
Mr. Pitts. The Chair thanks the gentlelady and thanks all
the witnesses for their opening statements.
[The prepared statement of Ms. Jones follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Pitts. We will now begin questioning, and I will
recognize myself 5 minutes for that purpose.
And let me start with you, Tom. How has the advancement of
telehealth in recent years benefitted your health system? Be
specific, if you can.
Mr. Beeman. Let me address what the electronic health
record has allowed us to do in our ability to leverage the new
data that we have to deploy our resources more efficiently.
Before we deployed the electronic health record, we could not
tell you how many diabetics we had in our health system. We
care for about 300,000 patients in our community. We could tell
you we have a billion bits of data, but we could not marshal
that data to have good information for our patients.
Today, I can tell you that we have 280 diabetics in our
Lincoln Family Medicine practice. We know that 270 of them are
consistent with their regimen for insulin, 10 of them are
noncompliant. We can deploy a nurse navigator on those 10 and
really assist them in getting the resources that they require.
As an example, we found one of our patients was a gambler, had
gambled all his money, could not buy the insulin. We can help
through resources to get him that insulin to really help
improve his life, and that really is what, you know, health
care is really about.
Just the other thing I would mention on the Care
Connections. We are talking about medical assistance patients
that are the most difficult, most troubled patients that we
have in our community, the most vulnerable. They use multiple
sites for health care. By coordinating their care, leveraging
technology, we can bring them the dignity that they need and
want and deserve, and we can also dramatically reduce the cost
of medical assistance care, which many of my colleagues say
can't be done. And we actually believe that you can actually
manage those patients' care more effectively if you really
concentrate on marshaling those costs rather than spending more
money on their care.
Mr. Pitts. Just a quick follow-up. The administrative
burden that Congress and the Federal Government has placed on
providers also takes time away from patients. It is something
this committee sought to partially address in Dr. Burgess' SGR
reform bill, H.R. 4015, but much more needs to be done. In the
meantime, are there ways in which you could imagine
telemedicine easing the administrative burden on providers,
thereby freeing up more time for the care patients?
Mr. Beeman. I think it already has. We routinely use e-
visits for which we don't get paid for, but most of my
physicians would say they would rather not have inappropriate
visits to their office and respond through e-visits. Of course,
they would prefer to get paid for it, which creates all sorts
of headaches for us as far as how do you incent your physicians
to focus on quality when they can't get paid for those. But
most of them respond at night, early in the morning to a lot of
their patients. So I think there are opportunities to really
break through some of the barriers.
I think the best thing that Congress can do is to really
focus on things like bundled payment, the MSSP program, and
helping us be more at risk, and then we can leverage those
technologies. And we want to be held accountable for quality
and cost. Let us do that and help break down those barriers,
sir.
Mr. Pitts. Dr. Mehrotra, in health care we have frequently
seen new technologies promise to save money but in reality
creating a new way for providers to bill the Medicare program.
If Congress were to act to encourage further adoption in
Medicare or other healthcare programs, how can we ensure that
telemedicine actually does deliver the savings that it
promises?
Dr. Mehrotra. I think you raise a critical issue, and I
would maybe echo what Dr. Beeman said, which is that it is a
combination of having accountability through quality metrics
that actually say this provider, what is the quality of care
that they are providing for this patient, irregardless of how
they are providing that care; as well as the financial
responsibility through bundled payment and other programs that
actually make sure that they have the flexibility with the
single payment to decide what is best for that patient in that
clinical encounter. And I do fear that encouraging telehealth
through fee-for-service might be a mechanism to actually
increase healthcare spending.
Mr. Pitts. Dr. Bashshur, in your opinion, can the
recognition and expanded use of telemedicine in Medicare help
lower costs for patients and the government?
Mr. Bashshur. The expansion of reimbursement for Medicare
patients is not likely to increase the cost to the government,
but it all depends how it is administered. I think there are
good ways and bad ways of doing things. The telemedicine
intervention itself, the modality in telemedicine does not
inherently encourage increased use of service. We have plenty
of evidence and programs that have been pondered where the
patients don't pay out of pocket where the use of telemedicine
has been extremely low.
The point that my colleague, Dr. Mehrotra, raised regarding
overuse of service has not been borne by any facts in the
situation. Among all programs delivering care in the country
none has experienced a flood of people using this modality of
care. It has been extremely low.
Mr. Pitts. Thank you. I have other questions, but my time
has expired, so I recognize the ranking member, Mr. Pallone, 5
minutes for questions.
Mr. Pallone. Thank you, Mr. Chairman.
I wanted to start with Mr. Chard. Thank you for being here
today to share your experience in using telehealth to help you
manage your Parkinson's and maintain the quality of your life.
It is important for people like you to speak out about when the
healthcare system works for them and when it doesn't, and
stories like yours are why I care a lot about this issue.
So I wondered if you could tell us a little more about your
telehealth experience. What was it like before you had the
ability to receive care using telehealth? Are there times when
you had to travel to see a specialist because they weren't
licensed in Delaware? And what you have liked about your
telehealth experience. In what ways, if any, do you think it
could be improved? It is a lot.
Mr. Chard. Thank you, Mr. Pallone. To start with, when I
moved from upstate New York to Delaware, I had already been
diagnosed with Parkinson's disease, and I began researching
looking for a neurologist that could help with my symptoms and
give me continuing diagnosis and treatment. And I was unable to
find a movement disorder specialist in the State of Delaware.
To my pleasure, Dr. Dorsey, my diagnosing physician, moved
down to Johns Hopkins University, which brought him into range
at least at Baltimore, a little over an hour drive for me. But
it was, you know, a half day, three-quarters of a day out of
production. I would take my wife with me to make sure we got
there safely in and out.
So the experience in moving to Delaware was that we were
unable to find the resources that we needed in the state. We
had the opportunity of driving up to Pennsylvania, but it was
one way or the other we had to travel in order to find the
resources.
In the interim Dr. Dorsey moved back to Rochester, New
York, and the aspect of telehealth has been introduced through
Dr. Dorsey and the University of Delaware, and as I mentioned
earlier in my testimony, the licensing issues were constricting
the ability to access Dr. Dorsey, who was my primary
neurologist, movement disorder neurologist. So since the
telehealth link has been established, I have been able to meet
with Dr. Dorsey via the telehealth link in a secure setting
with secure information privately and be able to share with him
and he would share with me his opinion and recommendations for
my care.
Mr. Pallone. And just going back to the last part, in what
ways, if any, do you think we could improve telehealth
experience?
Mr. Chard. Technologically, I think the improvements are
all pretty strong right now. Legislatively, I would think that
easing the process and making sure that there is a
reimbursement program. It is out-of-pocket costs right now.
Making sure there is a healthcare reimbursement program of some
sort to ease the cost of establishing that telehealth link
would be beneficial.
Mr. Pallone. Well, thank you very much.
Let me ask Dr. Mehrotra, again, thank you for sharing your
perspective. But you noted the use of telehealth has a lot of
potential to improve the healthcare delivery system and the
Medicare and Medicaid programs are tremendously important. So
as we think about expanding uses to telehealth in Medicare and
Medicaid, we have got to make sure we are thoughtful, we go
about it in the right way, particularly with regard to patient
safety and cost effectiveness. So could you just speak a little
more about the risks that my colleagues and I should consider
as we look at expanded use of telehealth?
Dr. Mehrotra. I think maybe an analogy would be helpful in
this circumstance as we think about many patients who will
benefit and many patients who may not benefit. And I might use
the example of cardiac catheterization. Cardiac catheterization
for many patients, either as a diagnostic or treatment for
heart disease, is life saving.
On the other hand, as you are well aware from some of the
press as well as research that has been done, is in many cases
cardiac catheterization is used inappropriately and does not
benefit care and has been overutilized and potentially could be
driving healthcare spending up. That is the theme of many of
the technologies that have been introduced in health care, this
two-edged sword, that it helps in some cases and it doesn't.
And I think that is the real issue as we try to figure out how
telehealth can be beneficial.
In many cases, including Mr. Chard, telehealth is probably
a very beneficial kind of therapy, but how do we make sure that
it is not overused?
Mr. Pallone. All right.
And then, Dr. Bashshur, just briefly, if you think
telehealth can be used effectively to treat more patients at
lower cost, you suggested that. Can you just give us an
example, perhaps?
Mr. Bashshur. The example has several parts to it, if I may
explain it. There are different elements of cost here, and our
cost to the consumer is rarely considered by the payers because
they are not responsible for it. That element of cost is always
reduced because if they don't have to travel, they don't have
to encumber the cost. There is also the convenience and the
waiting times and sometimes time lost from work. So there are
several aspects of cost that must be considered in their
totality as a way to deal with the problem.
Mr. Pallone. All right. Thanks a lot.
Thank you, Mr. Chairman.
Mr. Pitts. Chair thanks the gentleman.
I now recognize chair emeritus of the full committee, Mr.
Barton, 5 minutes for questions.
Mr. Barton. Thank you, Mr. Chairman. And I am sincere in
saying I appreciate this hearing. I think this is really
important, what this subcommittee is discussing today.
I have two general framed questions, and I will put them
out on the table and anybody who wants to answer them. First
question is concerning the privacy of the records that are
generated by the telehealth or telemedicine. How secure are the
medical records if you use this technology?
And the second is a Medicare, Medicaid billing issue. I am
told there are some concerns that if the doctor is in one place
and the patient is in another and the health insurance is in
another place, that Medicare and Medicaid sometimes are
unwilling to or don't know quite how to cost the charges that
result from a telehealth or telemedicine visit.
So if anybody wants to take a crack at either of those two,
the privacy issue or the billing issue, I am all ears.
Mr. Bashshur. If I may, I would deal with the privacy issue
and leave my colleague to answer the other question.
Mr. Barton. I will come to you after him.
No go ahead, sir, and then we will go to the young lady
down there. Either one of you. You are both going to get to
talk.
Mr. Bashshur. I yield to her.
Ms. Jones. Thank you.
It is an excellent question. I think privacy is of the
utmost concern. Most certainly, our technology is HIPAA
compliant and secure. All information contained within the
encounter is secure and kept on a server. I won't pretend to be
able to describe the server from a technology standpoint, but
everything is HIPAA compliant and secure.
For the most part, you will find from a policy perspective
that that is kind of the emerging understanding of what is
required for a telehealth encounter to be considered secure.
The emerging policy, including from the Federation of State
Medical Boards that was just passed this past weekend, is that
that should be in place within the context of any given
telehealth encounter.
So it most certainly is within our platform. Many of the
telehealth programs that are out there now support HIPAA
compliance and security to protect any PHI information. So that
is occurring. It is the emerging standard within policy. It is
most certainly contained within the Telehealth Modernization
Act that just came out this past December. So it is the
emerging standard within any telehealth technologies that you
see out there and critically important in ensuring patient
safety and security.
Mr. Barton. Doctor.
Mr. Bashshur. Yes, I agree. We have to be HIPAA compliant,
and that really answered the question about security for the
patient. If we violate, we will be in deep trouble, so we avoid
trouble.
With regards to Medicare and Medicaid billing, there are
some differences. Typically, as you know, there is the CPT code
that we have to submit for billing purposes and these are
issued by CMS. Their use in the country is still extremely
limited. For example, during the entire year of 2013 the total
expenditures for telemedicine services for Medicare patients
has been only $12 million for the entire country.
Mr. Barton. So it is basically not being used for Medicare?
Mr. Bashshur. Because of the restrictions that are placed
on it, yes, absolutely.
Mr. Barton. Well, if each of you will give some thought to
that and put in writing some suggestions on how to correct that
to the subcommittee, we would appreciate it.
I believe we would have a bipartisan agreement that we
shouldn't let a billing problem prevent doctors and patients
from using this technology. We ought to be able to come up. And
I don't think it will take legislative action so much as it
might just take a letter from members on both sides of the
aisle of this committee and subcommittee to Medicare and
Medicaid and CMS to give them some guidance on what they should
do in terms of billing.
So with that, I yield back, Mr. Chairman. But again, thank
you for the hearing.
Mr. Pitts. The chair thanks the gentleman.
We have just been called to vote. We are going to continue.
The chair recognizes the ranking member emeritus, Mr. Dingell.
Five minutes for questions.
Mr. Dingell. Mr. Chairman, thank you for your courtesy and
thank you for having this hearing.
I would like to welcome our distinguished panel,
particularly Dr. Bashshur, who is a constituent of mine from
the University of Michigan and is the Executive Director of the
health--for eHealth at the University of Michigan Health
System.
It is a pleasure to have the whole panel with us today, but
especially you, Dr. Bashshur.
Now, I have a number of questions which I hope that you
will answer ``yes'' or ``no'' in order to save time.
Doctor, is it correct that spending on chronic illness
accounts for 75 percent of health expenditures in the U.S.? Yes
or no.
Mr. Bashshur. Yes. In approximate----
Mr. Dingell. Now, Doctor, given your expertise in the area,
do you believe that investing telehealth--in telehealth
technologies to improve chronic disease management will save
money over the long run? Yes or no.
Mr. Bashshur. Yes.
Mr. Dingell. Doctor, I want you to know that we would like
to have you submit additional information as you might feel
necessary later so that we have the benefit of your full
judgments here.
Now, while the Affordable Care Act has done a great job in
making health care more accessible to the American people, I
think most people continue to believe that much more must be
done to improve access to care for the people in this country
with unmet medical needs.
Now, Dr. Bashshur, I know that you have done several
studies about increasing access to health care.
Do you believe that the use of telemedicine can help
improve access to care in medically underserved communities
like the Upper Peninsula in Michigan? Yes or no.
Mr. Bashshur. Yes.
Mr. Dingell. Now, Doctor, rural areas are not the only part
of our country with citizens who have unmet medical needs, yet
telemedicine in this country today is mostly faced--mostly
focused on rural areas.
Doctor, is it correct that, generally speaking, CMS has
limited physician reimbursement for telehealth to services
provided in rural areas? Yes----
Mr. Bashshur. Yes.
Mr. Dingell [continuing]. Or no?
Mr. Bashshur. Yes.
Mr. Dingell. Do you believe that is a good limit?
Mr. Bashshur. No. I don't think so.
Mr. Dingell. Now, how else has CMS restricted reimbursement
for telemedicine in the United States today?
This does not require a yes or no. It requires a quick
answer to be followed by a followup in additional remarks.
What do you have to say on this, Doctor?
Mr. Bashshur. CMS requires synchronous live video
conferencing with a presenting provider on one end at the
originating site and connected to a specialist at the remote
site.
This happens to be the least efficient mode of telemedicine
service. The so-called asynchronous mode is more efficient.
Mr. Dingell. Now, Doctor, Alaska and Hawaii are exempt from
CMS reimbursement restrictions.
Is the use of telehealth more prevalent in those States in
comparison to the continental 48 States? Yes or no.
Mr. Bashshur. Yes.
Mr. Dingell. Do you believe that telehealth technology used
in Alaska and Hawaii are a model for the rest of the country?
Yes or no.
Mr. Bashshur. Yes.
Mr. Dingell. Doctor, I want to thank you. I want to express
my respect and high regard for you and, also, to the other
members of the panel.
I look forward to any additional remarks that you or any of
the panel members might submit to any of the questions in order
that we could have the fullest expression of your thoughts and
views.
Thank you, gentleman and ladies, for being here this
morning.
Thank you, Mr. Chairman.
Mr. Pitts. The chair thanks the gentleman.
I now recognize the vice chairman of the subcommittee, Dr.
Burgess. Five minutes for questions.
Mr. Burgess. I thank the chairman for the recognition.
Mr. Chairman, I just wanted to point out there is an online
medical community called medscape.com, and Dr. Eric Topol, who
is their editor-in-chief, actually had an article addressing
this issue.
His conclusion to the article: ``If you fast-forward over
the next 5 years, we will be doing a lot of office visits in a
completely different way, and whether they are telephone
consults or video links with transmission of the data in real
time or in advance, it is a different look, and we should be
getting ready for the virtual physician visit with patients in
the years ahead.''
I would like to ask unanimous consent that we submit Dr.
Topol's remarks for the record.
Mr. Pitts. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Burgess. And I think we have heard that same theme
expressed several times this morning.
You heard my anxiety, Dr. Beeman, along the old CPT code
that I found one day. I thought my life was changed, my income
will double, and, yet, that was a code that was available, but
not reimbursed, back in the HMO days.
What are you doing with your super-utilizer network--what
are you doing to get around those issues?
Mr. Beeman. Doctor, I think one of the big challenges we
have in this is we are doing tremendous demand destruction with
the anticipation that providing better care and services is the
ultimate benefit.
When Lancaster General Health decided to embark on
population health management, we actually went through a 3-year
process of restructuring our health care delivery system to
take out $100 million worth of cost, and we continue to focus
on that through Lean Six Sigma so we can afford to do the
demand destruction.
The problem that we have been talking about in telehealth
is: It is a tool. It is not the end. And so, when we talk about
paying for telehealth, what I think we need to be talking about
is putting us health care providers at risk to care for a
population and let us deploy the tools that we need in order to
manage that.
Mr. Burgess. Let me interrupt you just in the interest of
time.
And I don't disagree with you, but you recognize the real
world is--there are going to be a lot of practices that will
live in a fee-for-service world for the rest of my natural
lifetime.
And the SGR reform that has been mentioned several times
this morning, it tried to acknowledge that. Sure, there are
going to be different models of practice, bundled payment ACOs
where just the situation you talk about may make sense.
But I got to tell you. I practiced OB/GYN. I practiced for
years. My greatest fear was that next-to-the-last patient on
Friday afternoon was going to have a blood pressure--a
diastolic blood pressure of 88 where she had always been normal
before.
And you know the drill. This is someone who simply could
have an elevated blood pressure because their husband wasn't on
time for the appointment, they couldn't find a parking place,
or it could be the beginning of a very serious illness that
within a very short period of time was going--she was going to
be critically ill.
So I am sitting in the clinic at 4:15 on a Friday
afternoon. I got no way of knowing--some other parameters you
can check to be sure. But even if they are all normal, you
still have no way of knowing.
How great would it be to have her with a blood pressure
cuff at home and a smartphone and to be able realtime, ``Send
me your next 10 blood pressures and, if it is over X, let's get
together right away.''
The old days, what was at your disposal? Put her in the
hospital for the weekend so that someone could monitor the
blood pressure.
And if you didn't do that and she really was severely pre-
eclamptic, the next visit was at 3 o'clock in the morning in
the emergency room with a seizure, with organ damage. I mean,
it was a big deal if you guessed wrong.
This will eliminate a lot of the guesswork out of that type
of practice. And, you know, I would argue, too--someone brought
up the issue of overuse.
I mean, if we reform our liability laws in this country,
maybe we can get around some of those problems as well. But I
would be interested in your thoughts on that.
Mr. Beeman. Doctor, I agree. I think right now we are
deploying a lot of this technology in aspirational hope that it
will pay for itself by better health care.
And some of it is deployed because we would rather keep the
patient out of the hospital and healthy than we would seeing
them one more time in the emergency department.
And, in some respects, with a medical assistant's patient
who uses that as a primary care office rather than an office,
it allows us to take the office to them rather than have them
use the emergency department.
Mr. Burgess. Let me just ask you this. And we are going to
run out of time. But, in your opinion, are there conditions
where the potential for misdiagnosis, the potential for harm,
is of particular concern and it will be inappropriate to use
telemedicine?
Mr. Beeman. Yes. I think the----
Mr. Burgess. Right answer. Thank you.
Ms. Jones, I just wanted to follow up on Mr. Barton's
questions on the issue of privacy. And I am glad you brought
that up. I hope you will provide some thoughts to the committee
in writing that he requested.
Clearly this needs to be a balanced conversation. I
remember having this discussion in 2007 with a CEO of a big
insurance company.
They were doing a lot of stuff with the--just financial
data where they could perhaps predict outcomes in future
medical issues.
And one of things he said to me was, ``You have got to
define privacy and stop changing your minds every 3 months.''
And I hope you will help us with that conversation because it
is a critically important conversation to have.
Ms. Jones. Certainly. We are more than eager to be partners
in this conversation.
I think one of the things that we have always uphold--
upheld as an organization is that there are some principles
that uphold the highest common denominator of care, some things
that should be in place so that providers who are providing
care via telehealth have the ability to use the very same
discretion that they use in person while they are providing
care electronically.
And the infrastructure that is required there are things
like HIPAA compliance, documentation of care, continuity of
care. There is some discussion around formulary and what kind
of prescribing isn't appropriate, identity of the provider
being affirmed, identity of the patient being affirmed.
So I think some of these kind of principles that create the
infrastructure for safe and secure telehealth need to be
discussed because, when you have those in place, then, again,
you are in a position where you are creating a safe and secure
environment and these physicians can decide--use the very same
discretion that they use in a face-to-face encounter to say,
``Yes. This is appropriate for care,'' ``No. This is not
appropriate for telehealth care,'' ``Yes. I have this
expertise,'' ``No. I need to refer for in-person or refer to
another expert.''
And those are very important discussions to have and ones
that we have on an ongoing basis.
Mr. Burgess. Mr. Chairman, thank you very much for the
time. I know a vote is close. So I will yield back.
Mr. Pitts. The chair thanks the gentleman.
Unfortunately, we have been called to the floor on the
vote. I think we only have a couple of minutes to go to get
there. And so we have lost our Members.
Members will have a lot of other questions we would like to
submit to you. We will ask that you please respond promptly in
writing.
This is not the end of the discussion. It is just the
beginning. I look forward to working with my colleagues, with
all of you, as we pursue this issue.
I remind Members that they have 10 business days to submit
questions for the record, and they should submit those
questions by the close of business on Thursday, May the 15th.
This is a very important issue. Thank you very much for
your time, for coming, for your expertise. And we will continue
to work with you.
Without objection, the subcommittee is adjourned.
[Whereupon, at 11:11 a.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
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