COVID-19 Health Care Flexibilities: Perspectives, Experiences, and Lessons Learned (hearing transcript, May 19, 2021), finance.senate.gov
Summary
The Senate Committee on Finance, chaired by Ron Wyden, met for this hearing on COVID–19 health care flexibilities on May 19, 2021; the printed transcript is S. Hrg. 117–546. Witnesses were Jessica Farb of the Government Accountability Office, Kisha Davis of the American Academy of Family Physicians, Linda V. DeCherrie of Mount Sinai at Home, Narayana Murali of America’s Physician Groups and Robert A. Berenson of the Urban Institute. Ms. Farb testified that CMS approved more than 600 different Medicaid waivers and other flexibilities, including care at non-hospital buildings and waiving certain criminal background checks for new provider enrollment. Senator Crapo said telemedicine visits in Idaho went from an average of about 200 appointments per month to 28,000 telehealth visits in April 2020 alone.
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Full text
S. HRG. 117–546
COVID–19 HEALTH CARE FLEXIBILITIES:
PERSPECTIVES, EXPERIENCES,
AND LESSONS LEARNED
HEARING
BEFORE THE
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
MAY 19, 2021
(
Printed for the use of the Committee on Finance
U.S. GOVERNMENT PUBLISHING OFFICE
50–344—PDF WASHINGTON : 2023
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COMMITTEE ON FINANCE
RON WYDEN, Oregon, Chairman
DEBBIE STABENOW, Michigan MIKE CRAPO, Idaho
MARIA CANTWELL, Washington CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland RICHARD BURR, North Carolina
SHERROD BROWN, Ohio ROB PORTMAN, Ohio
MICHAEL F. BENNET, Colorado PATRICK J. TOOMEY, Pennsylvania
ROBERT P. CASEY, JR., Pennsylvania TIM SCOTT, South Carolina
MARK R. WARNER, Virginia BILL CASSIDY, Louisiana
SHELDON WHITEHOUSE, Rhode Island JAMES LANKFORD, Oklahoma
MAGGIE HASSAN, New Hampshire STEVE DAINES, Montana
CATHERINE CORTEZ MASTO, Nevada TODD YOUNG, Indiana
ELIZABETH WARREN, Massachusetts BEN SASSE, Nebraska
JOHN BARRASSO, Wyoming
JOSHUA SHEINKMAN, Staff Director
GREGG RICHARD, Republican Staff Director
(II)
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CONTENTS
OPENING STATEMENTS
Page
Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee on
Finance .................................................................................................................. 1
Crapo, Hon. Mike, a U.S. Senator from Idaho ...................................................... 3
WITNESSES
Farb, Jessica, Director, Health Care, Government Accountability Office,
Washington, DC ................................................................................................... 6
Davis, Kisha, M.D., MPH, FAAFP, member, Commission on Federal and
State Policy, American Academy of Family Physicians, Leawood, KS ............ 7
DeCherrie, Linda V., M.D., clinical director, Mount Sinai at Home; and pro-
fessor of geriatrics and palliative medicine, Icahn School of Medicine at
Mount Sinai, Mount Sinai Health System, New York, NY .............................. 9
Murali, Narayana, M.D., board member, America’s Physician Groups; and
executive director, Marshfield Clinic, Marshfield, WI ...................................... 11
Berenson, Robert A., M.D., institute fellow, Urban Institute, Washington,
DC .......................................................................................................................... 12
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Berenson, Robert A., M.D.:
Testimony .......................................................................................................... 12
Prepared statement .......................................................................................... 51
Responses to questions from committee members ......................................... 56
Crapo, Hon. Mike:
Opening statement ........................................................................................... 3
Prepared statement .......................................................................................... 60
Davis, Kisha, M.D., MPH, FAAFP:
Testimony .......................................................................................................... 7
Prepared statement .......................................................................................... 61
Responses to questions from committee members ......................................... 65
DeCherrie, Linda V., M.D.:
Testimony .......................................................................................................... 9
Prepared statement .......................................................................................... 71
Responses to questions from committee members ......................................... 73
Farb, Jessica:
Testimony .......................................................................................................... 6
Prepared statement .......................................................................................... 81
Responses to questions from committee members ......................................... 94
Murali, Narayana, M.D.:
Testimony .......................................................................................................... 11
Prepared statement .......................................................................................... 101
Responses to questions from committee members ......................................... 107
Wyden, Hon. Ron:
Opening statement ........................................................................................... 1
Prepared statement with attachment ............................................................. 115
COMMUNICATIONS
Adventist Health ...................................................................................................... 127
Advocate Aurora Health .......................................................................................... 129
Alliance for Connected Care ................................................................................... 133
America’s Health Insurance Plans ......................................................................... 138
(III)
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IV
Page
American Association of Nurse Practitioners ........................................................ 144
American Hospital Association ............................................................................... 147
American Medical Association ................................................................................ 151
American Medical Rehabilitation Providers Association ...................................... 157
American Occupational Therapy Association ........................................................ 161
American Pharmacists Association ........................................................................ 165
American Physical Therapy Association ................................................................ 168
American Telemedicine Association ....................................................................... 172
Association for Clinical Oncology ........................................................................... 174
Association of American Medical Colleges ............................................................. 181
Better Medicare Alliance ......................................................................................... 186
Center for Fiscal Equity .......................................................................................... 190
ERISA Industry Committee .................................................................................... 193
Healthcare Leadership Council .............................................................................. 199
HealthEquity ............................................................................................................ 201
Kaiser Permanente .................................................................................................. 202
Medically Home Group, Inc. ................................................................................... 205
Moving Health Home Coalition .............................................................................. 207
National Association of Chain Drug Stores ........................................................... 209
National Indian Health Board ................................................................................ 212
98point6 .................................................................................................................... 216
Ochsner Health ........................................................................................................ 218
Partnership for Employer-Sponsored Coverage .................................................... 226
Premier Inc. .............................................................................................................. 229
Psychiatric Medical Care, LLC ............................................................................... 231
TechNet .................................................................................................................... 233
Teladoc Health, Inc. ................................................................................................. 234
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COVID–19 HEALTH CARE FLEXIBILITIES:
PERSPECTIVES, EXPERIENCES,
AND LESSONS LEARNED
WEDNESDAY, MAY 19, 2021
U.S. SENATE,
COMMITTEE ON FINANCE,
Washington, DC.
The hearing was convened, pursuant to notice, at 10:06 a.m., via
Webex, in the Dirksen Senate Office Building, Hon. Ron Wyden
(chairman of the committee) presiding.
Present: Senators Stabenow, Cantwell, Menendez, Carper, Car-
din, Brown, Bennet, Casey, Warner, Whitehouse, Hassan, Cortez
Masto, Warren, Crapo, Grassley, Cornyn, Thune, Portman, Cas-
sidy, Lankford, Daines, Young, Sasse, and Barrasso.
Also present: Democratic staff: Joshua Sheinkman, Staff Direc-
tor; and Beth Vrable, Deputy Chief Counsel and Senior Health
Counsel. Republican staff: Brett Baker, Deputy Health Policy Di-
rector; and Gregg Richard, Staff Director.
OPENING STATEMENT OF HON. RON WYDEN, A U.S. SENATOR
FROM OREGON, CHAIRMAN, COMMITTEE ON FINANCE
The CHAIRMAN. The Finance Committee will come to order. And
before we begin today’s hearing, I particularly want to thank my
colleagues on both sides of the aisle for the exceptional participa-
tion yesterday on the infrastructure hearing, because I thought we
got a lot of good ideas out, hearing from Senators on both sides,
and I want to thank my colleagues.
Today we are going to turn to another important area. And I par-
ticularly want to thank our Ranking Member Senator Crapo, be-
cause he and I have been talking about telehealth, talking about
a variety of ideas that the committee could work on in a bipartisan
way. And we thought in particular it made some sense as part of
our duties, from time to time to step back and take a look at what
happened during the pandemic, areas where we can do better,
ideas where this committee can lead with bold changes, and par-
ticularly in the health-care area prevent dramatic disruptions of
health care in our country.
We all understand that when COVID hit, it was no longer safe
to meet face to face, take a bus to the doctor’s office, even in many
instances walk into a hospital for care. So when we talk about
changes and what ought to stick around and what we ought to
build on post-pandemic, Senator Crapo and I both thought tele-
health was an ideal place to start.
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2
Now the telehealth challenge has always been about balancing
the speed and efficiency of new technologies with the need for
health-care quality and accountability. During the pandemic, some
patients have felt that they had to jump through too many hoops,
too many bureaucratic challenges, in order to get access to tele-
health.
My view, as a general proposition, is that patients ought to be
able to have more accessible opportunities for telehealth. And par-
ticularly after they have seen a provider for the first time, we
ought to be able to work together to clear out the bureaucratic
hoops so that they can get access to telemedicine.
In some cases, the right approach may in fact be to give the
green light to telehealth from the get-go, at the very beginning. So
we are looking forward today to discussing how to go about striking
that balance, after a year of experience during the pandemic.
Just so we get back to the question of the history here, the com-
mittee led the effort to shoehorn coverage for telehealth in Medi-
care as part of the CARES package. That was a particularly impor-
tant part of CARES because it allows health-care providers in
Medicare to offer telehealth services to all older people, regardless
of whether they live in big cities or small rural towns.
And that particularly badly needed health-care measure provided
care safely into the homes of tens of millions of seniors nationwide.
The CARES Act also allowed Federally Qualified Health Centers,
including community health centers and Rural Health Clinics, to
receive Medicare payment for telehealth services, which meant that
still more health-care providers could be involved in stepping up,
as they did, to provide assistance, particularly for health-care serv-
ices that would otherwise be very remote, and possibly beyond the
reach of millions.
Now again, for just a short bit of history, the Finance Committee
actually paved the way for a lot of those changes in Medicare. Be-
cause for years we pressed the case on a bipartisan basis to update
the Medicare guarantee, and to in effect say Medicare was not like
it was in the days when I was director of the Gray Panthers. It is
not primarily an acute care program any longer; it is a chronic care
program. And so we led the effort to update the Medicare guar-
antee.
And for too many years, the Congress simply fell behind in terms
of recognizing the transformation of the flagship health-care pro-
gram at the Federal level. And telemedicine exists now largely be-
cause it was kicked off by work done by the Senate Finance Com-
mittee. Telehealth is going to be a big part of the transformation
going forward, moving beyond acute care to dealing with chronic
disease.
The CHRONIC Care Act, which was passed by the committee
when Orrin Hatch was the chair, marked the very first time sen-
iors, for example, could get telehealth in-home for kidney disease.
The law also made it easier to use telehealth to diagnose and treat
strokes. It allowed more flexibility for Medicare Advantage plans
and Accountable Care Organizations.
So when the pandemic hit, because of the work of the Senate Fi-
nance Committee, the Centers for Medicare and Medicaid Services
already had a head start for telehealth.
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3
I would also like to mention, as Senator Crapo knows, we have
had a number of colleagues in the Senate who have been interested
in the telehealth issue, and I want to particularly commend Sen-
ator Schatz and Senator Wicker, who also have spent considerable
time on this.
So Federal agencies have taken advantage of existing law to
allow providers to care for their patients in fresh ways. For exam-
ple, certain hospital doctors and nurses were able to travel out into
their communities and provide services at home that would typi-
cally be reserved for inpatient care. Others could set up temporary
spaces, like tents, near hospitals themselves. They were not al-
lowed to do this prepandemic—in ordinary times. So these steps to
increase capacity kept patients safe and helped maintain care.
Today we are going to hear from physicians and hospitals who
have been on the front lines, and health-care experts who have
seen how the fresh approaches I have just mentioned transformed
care. And as we have indicated, there is bipartisan interest in
building on these changes that work for seniors and providers, and
that can allow us to use Medicare, and particularly the telehealth
breakthroughs, as a model for other parts of the health-care sys-
tem.
In the last year we also made progress on legislation that lets
seniors on Medicare receive mental health services via telehealth,
including at home. My view is, mental health services ought to be
available via telehealth for all Americans. That provision was part
of a bill that I authored that would also permit telehealth for rou-
tine health-care visits in Medicare, known as evaluation and man-
agement.
I believe the committee can work together on a bipartisan basis
to make that and other changes a reality.
Let me recognize Senator Crapo, and I am again going to express
my thanks for his partnership in making sure that we got this
issue front and center, and we are starting to look at how to build
on the lessons of the pandemic.
Senator Crapo?
[The prepared statement of Chairman Wyden appears in the ap-
pendix.]
OPENING STATEMENT OF HON. MIKE CRAPO,
A U.S. SENATOR FROM IDAHO
Senator CRAPO. Thank you, Mr. Chairman. Thanks for holding
this important hearing.
Congress and the administration provided certain health-care
flexibilities during the pandemic so that patients could continue to
receive high-quality care. Making permanent changes based on
these lessons learned is a top priority.
I shared my interest with President Biden’s nominees for the key
health-care positions that have come before this committee, and I
appreciate their commitment to work with us on this committee.
Republicans and Democrats often disagree on the best way to
achieve our shared health-care goals. This hearing, however, high-
lights an area of common ground. In fact, Senator Wyden and I
asked the majority and minority staff to jointly plan this hearing,
demonstrating strong bipartisanship.
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4
Acting on legislative changes and using administrative authority,
the Centers for Medicare and Medicaid Services waived over 200
payment rules during the pandemic in Medicare alone. Needless to
say, there is a lot we can learn. Today’s witnesses will provide in-
sight into our efforts that we need to take to evaluate these flexi-
bilities.
Hearing firsthand about the patient experience during the pan-
demic from providers who overcame challenges to provide care will
be invaluable. Understanding how the flexibilities are used in fee-
for-service, Medicare Advantage, and alternative payment models
will be insightful.
Much of the hearing will focus on care provided during the pan-
demic through telehealth. Telehealth has been a lifeline for pa-
tients and providers, especially in the early months of the pan-
demic. The reliance on telehealth increased in rural and urban
areas alike, allowing patients to receive remote care from the safe-
ty of their own home.
Telehealth services have been especially useful for Idahoans. Ac-
cording to the Idaho Department of Insurance, telemedicine visits
went from an average of about 200 appointments per month to
28,000 telehealth visits in April 2020 alone.
To ensure financial stability, providers have been paid at the
same rate as if the service was furnished in person. This has facili-
tated care that otherwise would be risky or unavailable, and pa-
tients have appreciated the convenience. It has reduced the fre-
quency of missed appointments and assisted provider investment in
the infrastructure needed for remote care.
This long period of expanded telehealth will help us understand
the impact on quality of care and program costs. This serves as a
robust test project on a scale few could have imagined. The promise
of telehealth is clear, but it is important that we gather evidence
on its impact on access, quality, and cost.
There are approaches to providing care in the most efficient set-
ting that go beyond telehealth. Some hospitals are using a waiver
that provides flexibility to triage patients who present to the hos-
pital to see if they can be best cared for in their home. Whether
through telehealth, Hospital at Home, or other innovative care ar-
rangements, it is important to find ways to get patients care that
best meets their needs, and at the lowest cost possible.
Congress has taken permanent steps to do just that in recent
years. Nephrologists can conduct remote evaluations of patients re-
ceiving home dialysis. Providers can administer certain drugs to
vulnerable patients in their own homes. Hearing from our provider
witnesses helps us to continue down this path.
The Government Accountability Office will supplement what we
hear from our provider experts, offering a perspective on how to
track and evaluate flexibilities in Medicare and Medicaid as we
chart the right course forward.
I fully expect that we will take what we learn from this hearing
to continue our bipartisan efforts to help providers give patients
the best care possible. Permanent changes based on lessons learned
from the pandemic can modernize our Medicare payments and sys-
tems and lend to the pressing need to address Medicare’s financial
struggles.
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5
Identifying smart reforms that make Medicare more efficient will
be better for patients and better for taxpayers. Such changes alone
will not put Medicare on a sustainable path, but they should be a
part of that broader conversation. Addressing Medicare solvency
should be a bipartisan issue, with time best spent determining how
to shore up the current system instead of expanding it to a broader
population.
Finding the right path on these priority issues is important to
patients and the health programs in the committee’s jurisdiction.
This hearing will help us to capitalize on that bipartisan oppor-
tunity.
Thank you again, Mr. Chairman. I yield back.
[The prepared statement of Senator Crapo appears in the appen-
dix.]
The CHAIRMAN. Thank you, Senator Crapo. And I especially ap-
preciate the focus on smart reform. And if we tie smart reforms to
the whole notion of updating the Medicare guarantee, then I think
we have really done a service in terms of the health-care debate,
and I thank you for it.
We have virtually every member of the committee signed up to
ask questions after we hear from the witnesses, so we are going to
have a particularly busy morning. And we are just going to move
ahead, our first witness being Ms. Jessica Farb, Director of Health
Care at the Government Accountability Office. She has an exten-
sive portfolio there.
Then we will hear from Dr. Kisha Davis, a family physician and
a member of the American Academy of Family Physicians’ Commis-
sion on Federal and State Policy. She is also a vice president of
health equity for Aledade and cares for patients at a primary care
clinic in Baltimore, MD. We thank her.
We then have Linda DeCherrie, M.D., a geriatrician and pallia-
tive medicine physician who serves as clinical director of Mount
Sinai, part of the Mount Sinai Health System in New York.
After that, we will have Dr. Narayana Murali, a nephrologist and
the executive director of the Marshfield Clinic in Wisconsin.
And finally, we will hear from Dr. Robert Berenson, whom we
have had a chance to work with often over the years, an internal
medicine physician and institute scholar at the Urban Institute,
who is an expert on health policy, particularly Medicare.
So I would also like at this point—and I think we will not have
any objection to this—to enter into the record, by unanimous con-
sent, the statement of the Medicare Payment Advisory Commis-
sion, or MedPAC, on pandemic flexibilities in Medicare. Hearing no
objection, we will make that part of the record.
[The statement appears in the appendix on p. 117.]
The CHAIRMAN. We will go right to our witnesses, and then
today, colleagues, because we have so many Senators who are going
to be asking questions, we are going to have to stick to the 5-
minute rule pretty scrupulously or you will be eating your corn
flakes tomorrow morning when everybody is still waiting to ask
questions.
Ms. Farb?
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6
STATEMENT OF JESSICA FARB, DIRECTOR, HEALTH CARE,
GOVERNMENT ACCOUNTABILITY OFFICE, WASHINGTON, DC
Ms. FARB. Chairman Wyden, Ranking Member Crapo, and mem-
bers of the committee, thank you for the opportunity to discuss
GAO’s ongoing work examining Medicare and Medicaid waivers
and flexibilities implemented by CMS in response to COVID–19.
We undertook this work as part of GAO’s broader responsibility
to conduct monitoring and oversight under the CARES Act. To in-
crease access to medical services during a public health emergency,
the Secretary of HHS can use several different authorities to tem-
porarily waive or modify certain Federal health-care program re-
quirements.
Since the beginning of the pandemic, CMS has issued over 230
waivers related to the Medicare program and approved more than
600 different Medicaid waivers and other flexibilities. Many of the
Medicare waivers offer flexibilities for providers, hospitals, nursing
facilities, and hospices. They generally were intended to increase
capacity at facilities, expand the available workforce and bene-
ficiary access to care, and reduce administrative burdens.
As examples, CMS, one, allowed hospitals to provide patient care
at non-hospital buildings or spaces, also known as ‘‘a hospital with-
out walls;’’ two, created an expedited process for new provider en-
rollment, including waiving certain criminal background checks;
and three, increased flexibility for providers to treat beneficiaries
through telehealth.
Similarly, CMS approved Medicaid waivers and flexibilities
aimed at addressing obstacles that affect beneficiary care, provider
availability, and program enrollment. For example, CMS allowed
out-of-State licensed providers to care for Medicaid patients across
State lines, and permitted virtual patient assessments needed to
qualify for long-term care services in Medicaid.
The full effects of most of these waivers and flexibilities are not
yet known, but CMS has reported some data on the use of tele-
health in both programs. For example, over the first 8 months of
the pandemic, utilization of telehealth services by Medicare fee-for-
service beneficiaries sharply increased from about 325,000 services
per week at the start of the pandemic, to a peak of about 1.9 mil-
lion about a month later. Since then, utilization has slowly de-
clined, and as of mid-October was slightly over 700,000 services per
week, still much higher than pre-pandemic levels.
This utilization varies in a number of ways, including by service
type, provider specialty, and beneficiary demographics. For exam-
ple, telehealth was used more frequently for mental health services
and by beneficiaries under the age of 65, as well as those located
in urban areas. CMS has also reported variation in the use of tele-
health in the Medicaid program across the States and across age
groups within the States.
The waivers and flexibilities implemented in Medicare and Med-
icaid during COVID–19 likely benefited providers and beneficiaries,
yet determining whether and, if so, how to continue them post-
pandemic warrants consideration.
Factors to consider include program spending, program integrity,
beneficiary health and safety, and health equity. Both the Medicare
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7
and Medicaid programs are on GAO’s high-risk list in part due to
concerns about fraud, waste, and abuse.
Telehealth and other waivers pose some risks of unnecessary pro-
gram spending. The lower but stable telehealth utilization trend we
saw last fall in Medicare suggests that demand for telehealth may
continue after the pandemic.
Medicare currently pays the same for telehealth and in-person
services, and one provider group we interviewed cautioned that this
could create incentives for specialties that can provide and be paid
for both in-person and additional telehealth services to generate
telehealth visits without obvious clinical benefit.
In addition, the lack of complete data for oversight and suspen-
sion of some program safeguards may have increased program
risks. For example, CMS lacks complete data to determine the tele-
health modality being used, audio-only or audio-video, or where the
services are originated—important information to consider, given
payment incentives and the lack of evidence so far about the qual-
ity of telehealth services in Medicare.
Extending or ending waivers and flexibilities may affect bene-
ficiary health and safety in unknown ways. For example, expedited
processes for provider enrollment in both programs, including waiv-
ers of normal screening and criminal background checks, could af-
fect the quality and safety of care provided to beneficiaries.
And finally, the health disparities we have observed during the
pandemic also extend to beneficiaries’ access to services and may
be exacerbated by differences in access to things such as technology
used to support telehealth in rural areas. Thus, health equity may
be an important factor in decisions about the continuation of these
flexibilities.
Careful contemplation of the benefits and risks of continuing
these waivers and flexibilities will be key to determining the path
forward. We look forward to working with Congress and this com-
mittee as we continue our oversight of the Federal response to the
COVID–19 pandemic.
Chairman Wyden, Ranking Member Crapo, and members of the
committee, this completes my prepared statement. I would be
pleased to respond to any questions that you may have.
[The prepared statement of Ms. Farb appears in the appendix.]
The CHAIRMAN. Thanks very much, Ms. Farb.
We go now to Dr. Davis.
STATEMENT OF KISHA DAVIS, M.D., MPH, FAAFP, MEMBER,
COMMISSION ON FEDERAL AND STATE POLICY, AMERICAN
ACADEMY OF FAMILY PHYSICIANS, LEAWOOD, KS
Dr. DAVIS. Good morning, Chairman Wyden, Ranking Member
Crapo, and members of the committee. I am Dr. Kisha Davis, a
member of the American Academy of Family Physicians’ Commis-
sion on Federal and State Policy, and I am honored to be here
today representing over 133,000 physician and student members of
the AAFP.
I am a practicing family physician providing primary care to pa-
tients in Baltimore, MD, and I also serve as vice president of
health equity at Aledade, working to reduce health disparities in
physician-led ACOs across multiple States.
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8
I have experienced the impact of COVID–19 and resulting Fed-
eral policy changes first-hand, as well as through the shared expe-
riences of the physicians that I support. I am appreciative of the
flexibilities granted due to the public health emergency. These have
allowed all patients, especially some of the most vulnerable, iso-
lated, elderly, and disadvantaged patients, to maintain their rela-
tionship with their trusted primary care physician, while many of-
fices had to close or severely limit in-person visits due to social
distancing restrictions.
They have also allowed these practices to remain financially sol-
vent, whereas their mass closure would have been devastating at
a time when medical care was needed most.
Lastly, the ability to connect with one’s trusted primary care
physician via telehealth helped to alleviate the burden on emer-
gency rooms and hospitals.
As a physician myself, I want telehealth to be a tool in my tool-
box that I can deploy based on a clinical judgment, not based on
whether I get paid. As Congress considers whether to extend these
flexibilities beyond the public health emergency and how to build
upon recent advances, it is vital that Medicare and Medicaid policy
changes are designed to advance health equity, protect patient
safety, and enable clinicians to provide the right care at the right
time.
To this end, I suggest the following four recommendations re-
garding telehealth flexibilities.
First, Congress should permanently remove the section 1834(m)
geographic and originating site restrictions, to ensure that all
Medicare beneficiaries can access care at home. Expanded access to
telehealth visits has allowed me to observe my patient’s home or
work environment, identify factors that may be affecting their
health, and develop more personalized treatment plans. While
some worry that telehealth will cause patients to become discon-
nected from their doctor, I have seen just the opposite. For pa-
tients, telehealth enables timely first contact access to care, while
building and maintaining long-term trusting relationships. I have
numerous examples of physicians ensuring patients were still get-
ting the preventive care they needed by conducting annual wellness
visits via telehealth, the monitoring and treatment of chronic dis-
eases such as diabetes and hypertension, addressing acute con-
cerns, and most notably conducting transitional care management
visits—visits done post-hospital discharge aimed at preventing re-
admission.
Prior to COVID, coming into the doctor’s office after being hos-
pitalized was often a barrier. Providing these services for patients
in their home increases accessibility for patients who may be home-
bound or lack transportation, and creates opportunities to engage
distant family and caregivers. Eliminating geographic and origi-
nating site requirements is essential and improves utilization of
high-value care and patient outcomes.
Second, Congress should require Medicare to cover audio-only
E&M services beyond the public health emergency. It is vital to en-
sure equitable access to telehealth services for patients who may
lack broadband access or be uncomfortable with video visits. For
many of our patients, especially rural, low-income, elderly, and
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non-English speakers, voice calls are simply the most accessible op-
tion. Payments should support patients’ and physicians’ ability to
choose the most appropriate modality of care, whether it be tele-
phone, audio-video, or in-person, and ensure appropriate payment
for care provided.
Third, Congress should ensure the permanent equitable coverage
and payment of telehealth services provided by community health
centers, and modify existing payment methodologies to provide
timely, appropriate payment for telehealth. Community health cen-
ters have been stalwarts during the COVID–19 pandemic, pro-
viding testing services, remaining open during staffing shortages,
and now leading in vaccine distribution, while ensuring quality of
care for millions of low-income persons.
Fourth, policymakers should monitor the impact of telehealth on
access and equity, and invest in infrastructure to promote digital
health equity. While the rapid expansion of telehealth has yielded
many benefits for patients and clinicians, not everyone has bene-
fited equally. To achieve the full promise of telehealth, Congress
must proactively address structural barriers to virtual care. Addi-
tional studies to inform the direction of permanent telehealth poli-
cies should include the collection and reporting of data stratified by
race, ethnicity, gender, language, and other key factors.
Thank you for the opportunity to discuss with this committee the
impact of these flexibilities on family physicians and the AAFP’s
recommendations for permanent policies to advance accessible, eq-
uitable, high-quality health care beyond the pandemic.
[The prepared statement of Dr. Davis appears in the appendix.]
The CHAIRMAN. Dr. Davis, thank you. You said so many sensible
things, but I especially appreciate your bringing up and advocating
for the voice calls, because I heard that repeatedly again and again.
Thank you.
Our next witness will be Dr. Linda DeCherrie, a geriatrician.
STATEMENT OF LINDA V. DeCHERRIE, M.D., CLINICAL DIREC-
TOR, MOUNT SINAI AT HOME; AND PROFESSOR OF GERI-
ATRICS AND PALLIATIVE MEDICINE, ICAHN SCHOOL OF
MEDICINE AT MOUNT SINAI, MOUNT SINAI HEALTH SYSTEM,
NEW YORK, NY
Dr. DECHERRIE. Thank you.
The CHAIRMAN. There she is. Good.
Dr. DECHERRIE. Chairman Wyden, Ranking Member Crapo, and
the members of the Senate Finance Committee, it is my distinct
pleasure on behalf of the Icahn School of Medicine at Mount Sinai,
and the Hospital at Home Users Group, to be part of this panel to
discuss Hospital at Home, specifically extending the current acute
hospital care at home flexibilities being offered under the public
health emergency.
Hospital at Home is patient-centered model of care which pro-
vides hospital-level care at home for patients with select acute ill-
nesses who would otherwise be hospitalized. Multiple Hospital at
Home studies have demonstrated improved patient safety, reduced
mortality, enhanced quality, and reduced costs.
It was a model that many Medicare Advantage commercial and
Medicaid Managed Care plans already covered before the pan-
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demic. Adding the rest of the Medicare beneficiaries allows equi-
table care and has been extremely helpful since November 2020
when the Acute Hospital Care at Home waiver was approved.
I believe the coverage of Acute Hospital Care at Home should be
covered beyond the pandemic, preferably as a 30-day bundle of
care. In 2014, Mount Sinai applied and received a Center for Medi-
care and Medicaid Innovation award to develop and test Hospital
at Home for the fee-for-service Medicare population. From this
work, we submitted a proposal to the Physician-Focused Payment
Model Technical Advisory Committee.
The PTAC recommended our proposal in 2018 to the Secretary
of the Department of Health and Human Services for implementa-
tion. The Secretary expressed interest in testing home-based
hospital-level care models, but no payment model was advanced for
beneficiaries in fee-for-service Medicare.
In 2017, when our CMMI award was finished, our Hospital at
Home program was no longer able to provide care for fee-for-service
Medicare patients, as there was no reimbursement, and the pro-
gram shifted to focus on Medicare Advantage commercial and Med-
icaid Managed Care plans.
We believe congressional action to extend the current waivers
and flexibilities is necessary and particularly valuable for patient
care. During the initial surge of COVID–19 in March of 2020, we
were an important part of helping the Mount Sinai health system
open up more capacity for patients needing higher levels of care,
such as ICU, by completing Acute Hospital Care at Home for pa-
tients already hospitalized.
However, we were still unable to admit fee-for-service Medicare
patients from the emergency departments. We were very excited to
be part of the original group of hospitals approved for the Acute
Hospital Care at Home waiver in November 2020. In addition, we
formed a Hospital at Home Users Group with support from the
John A. Hartford Foundation, which provides technical assistance
and office hours to other hospitals seeking to respond to the waiv-
er.
To date there have been 129 hospitals approved for the Acute
Hospital Care at Home waiver, with 56 health systems in 30
States, all since November. This shows that there is great interest.
However, it does take significant start-up resources and time, and
many hospitals are not planning to launch until this summer.
I believe even more hospitals would implement Hospital at Home
if they knew this program would be extended or made permanent.
Therefore, we request Congress and HHS to consider a perma-
nent extension of Acute Hospital Care at Home waivers beyond the
PHE to mitigate the residual impacts of COVID–19 on the public
health, and to encourage broader adoption of providing patient-
centered health-care services in the home.
Thank you for the opportunity to present today.
[The prepared statement of Dr. DeCherrie appears in the appen-
dix.]
The CHAIRMAN. Thank you very much, Dr. DeCherrie.
Next will be Dr. Murali.
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STATEMENT OF NARAYANA MURALI, M.D., BOARD MEMBER,
AMERICA’S PHYSICIAN GROUPS; AND EXECUTIVE DIREC-
TOR, MARSHFIELD CLINIC, MARSHFIELD, WI
Dr. MURALI. Thank you, Chairman Wyden, Ranking Member
Crapo, and members of the committee. I serve as the executive vice
president of care delivery and chief strategy officer of the Marsh-
field Clinic Health System. I also serve as the executive director.
What I am advocating for, and strongly believe, is that perma-
nently supporting the flexibilities created in response to the
COVID–19 pandemic, and broadband, particularly in middle Amer-
ica, will combat the rising cost of health care in America and its
economic impact on both patients as well as their employers.
The potential that telehealth infrastructure has advanced in the
American health-care system in enhanced equity, access to health
care, as well as prosperity for all Americans, cannot be overstated.
It is my honor and privilege to testify on behalf of America’s Phy-
sician Groups. APG is a national professional association rep-
resenting 300 physician groups and their members with approxi-
mately 195,000 physicians who provide care to nearly 45 million
patients from coast to coast.
Our vision is to transition from legacy transaction fee-for-service
reimbursement to a capitated value-based system, where physician
groups are held accountable for the total cost of care, the quality
of care that they provide for their patients, and are incentivized to
innovate to provide the best possible care.
Marshfield Clinic Health System is one of the Nation’s largest
fully integrated systems, serving a predominantly rural population
in the State of Wisconsin. Our 1,400 primary care and specialty
providers provide approximately 3.5 million encounters annually.
Our primary service area encompasses over 80 percent of Wis-
consin’s rural population. In fact, over half of our 60-plus facilities
serve populations of less than 2,000 people. We have more cars
than people. Our mission to provide health care for the large area
greater than the State of Maine led to the genesis of our telehealth
program in 1997, where we performed heart and lung exams over
the Internet.
Today we use telehealth for Hospital at Home care, acute care,
arterial care, dental screenings in schools, and much more. We
were one of the first hospitals in the country granted a Hospitals
Without Walls waiver by CMS; this, because we were already pro-
viding hospital-level care in the comfort of our patients’ homes
since 2016, using telehealth even when there was no formal incen-
tive to do so. We knew that for a subset of our population, there
is no place like home for inpatient recovery.
Compared to matched hospital cohorts, we saw our patient satis-
faction increased by 22 percent, hospital readmission decreased by
44 percent, length of stay decreased by 37 percent, and ER visits
halved.
Together, this created a 15-percent cost savings per episode per
patient for the health plan. Since the onset of the pandemic, APG
physicians have adopted a lifeline of telehealth, ensuring access to
care for all patients who were terrified to leave their homes.
In 2020, MCH provided a quarter of a million telehealth and
telephone encounters. Presently, they average about 15 percent of
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all encounters. Telehealth is here to stay. It is convenient and eco-
nomically beneficial for patients, as well as employers. Our pa-
tients are older, sicker, and poorer than average in the State of
Wisconsin, as well as in the Nation.
Almost half our children are eligible for reduced or free lunches.
Public transportation is virtually nonexistent. Our patients are geo-
graphically isolated, and travel 2 hours in treacherous winter
weather to come and get essential care. Such obstacles deny care.
Telehealth addresses these disparities, ensuring proactive care that
reduces ER visits, as well as enhancing equity and access to health
care and stabilizing the economy.
My heart tugs at the story of a 67-year-old diabetic woman whom
I had managed for heart failure as well as kidney disease back in
2007. Since then, we managed her care virtually, except for one
visit in a year. For the last 13 years, every year she has sent me
a Christmas card.
Telehealth has the power to become the norm of this country. We
are at a critical juncture at this point. Here are some obstacles.
First, given our experience with the current waivers, the site
visit restrictions are no longer justifiable. The location for a physi-
cian or a patient should not deny care for a patient.
Second, the greatest obstacle for patient satisfaction is access to
broadband or Internet that is stable. Our patient appointments are
taken by patients at schools, as well as library parking lots. It
would be important for us to focus, at least as a stopgap, on using
phone care for increasing access for Medicare Advantage people.
Our members agree with that, that restricting care denies care.
Finally, and most importantly, permanently reviewing and re-
newing the waivers, including acute care without walls, will trigger
commercial investments to go faster. I thank you for your service,
as well as your support.
I would like to share this in the historical context. The U.S. Con-
gress has acted decisively in the past, creating great infrastructure
like the Hoover Dam, the Tennessee Valley Authority, and the
highway system. We look forward to working with you in advanc-
ing America’s health care Thank you.
[The prepared statement of Dr. Murali appears in the appendix.]
The CHAIRMAN. Thank you, Dr. Murali. I can tell you, millions
of Americans would be clapping for your proposition that, with re-
spect to health care, there is no place like home. So thank you very
much for your valuable testimony.
Dr. Berenson?
STATEMENT OF ROBERT A. BERENSON, M.D.,
INSTITUTE FELLOW, URBAN INSTITUTE, WASHINGTON, DC
Dr. BERENSON. Thank you very much, Chairman Wyden, Rank-
ing Member Crapo, and members of the committee.
Telehealth offers the promise of an important disruptive innova-
tion in health-care delivery, improving access and quality, while re-
ducing spending. However, decisions on how to pay for expanded
use of telehealth will determine whether that promise is achieved.
As a practicing internist, the government official in charge of
Medicare payment policy at CMS, and now as a policy researcher
at the Urban Institute, I have spent much of my professional life
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exploring better ways of paying health professionals. I have also
worked on Medicare payment issues as the Vice Chair of MedPAC,
and as an initial member of the PTAC, which was established
under the MACRA legislation.
On PTAC, I often argued for a straightforward fee schedule
change, rather than the proposed alternative payment model, to
achieve the purpose sought. My objections to some alternative mod-
els are that they are not operationally feasible. The converse is the
case for telehealth. Fee-for-service for telehealth is not operation-
ally feasible as long-term payment policy. I will briefly outline
three major reasons.
First, fee schedules function reasonably well when the code de-
scriptions are concise and clinically relevant, producing reliable
and accurate coding. Codes for telehealth services are anything but
concise. Telehealth code descriptions specify the specific modality
employed, the patient’s location during the communication, which
party initiated the service, the duration of the virtual encounter,
and a range of other specifications for each code that was described
as part of the telehealth expansion.
These coding parameters were established for payment purposes
alone. They are not useful clinically. Using the standard fee sched-
ule to pay for telehealth services would likely produce a quagmire
of confusion, inadvertent or intentional miscoding, and lots of clini-
cian and patient complaints about burden and counterproductive
rules.
Second, for many telehealth services, fee-for-service payments
generate high billing costs relative to the payment actually re-
ceived. A recent study found that the cost for billing and related
documentation for an office visit was more than $20. And that is
just the billing cost for the first submitted claim from the practice.
A typical claim bounces between the practice, the Medicare con-
tractor, the supplemental insurer, back to the practice, and then to
the patient for applicable cost-sharing. Proper and fair payment
levels will often be lower than the billing cost. So they either will
not be billed or, even worse, they will not be provided post-COVID.
Yet, raising the fee to make it financially worthwhile, as under
pay parity, would ignore the 30-year process for setting relative
values in Medicare. Paul Ginsburg, who is the current Vice Chair
of MedPAC, and I wrote that that process needs to be changed, but
it should not be changed on an ad hoc, one-off basis just for tele-
health.
Third, patients face substantial time costs and inconvenience in
traditional travel, waiting rooms, and actual time with the clini-
cian. I recently waited 20 minutes after my annual wellness visit
just to check out. My time commitment for the visit was 3 hours.
Patients will often prefer virtual visits, but there should be brakes
on demand and spending, especially if paying for fee-for-service at
parity.
RAND researchers found in the pre-COVID period that 90 per-
cent of telehealth services were additional services, rather than
substitutes for in-person services. Used properly, telehealth serv-
ices often should be add-ons, such as for chronic care managers but
also for lots of other sound clinical reasons, and those communica-
tions can certainly be done by telephone calls in many cases. But
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those add-on services need to be managed by the practice, within
a spending constraint, to help assure that virtual visits are used
appropriately.
CMMI has developed a primary care alternative payment model
called ‘‘Primary Care First.’’ The approach needs to be tested in an
expedited fashion on a regional, mandatory basis, in my opinion. It
has the potential to be the permanent payment model for primary
care practices generally, while also addressing payment for tele-
health services. My written testimony also provides initial thoughts
on using lump sum payments to practices for specialists’ use of
telehealth, rather than fee-for-service.
So in conclusion, I would just suggest that this is an important
time and a real opportunity to fundamentally examine how Medi-
care pays physicians and other health professionals, and it should
not be just sort of a default ‘‘let’s just continue the current payment
flexibilities and high payment levels’’ without full consideration.
Thank you very much.
[The prepared statement of Dr. Berenson appears in the appen-
dix.]
The CHAIRMAN. Doctor, thank you. And we have virtually every
member participating, so we are going to have to stay pretty close
to the 5-minute rule today, colleagues.
My first question really speaks to the question of balance. We
love the speed and efficiency of new technologies like telehealth,
and at the same time, as Dr. Berenson just mentioned, we have to
ensure quality care and accountability. And he described this hor-
ror story of bills just bouncing from place to place to place. So we
are going to have to move around.
In terms of questions, I think I will start with our GAO person,
and Dr. Berenson, on this. What are the lessons learned from how
we did telehealth during the pandemic in striking this balance that
I described as speed and efficiency and quality and accountability?
Why don’t we start with the GAO person, and then we will go to
you, Dr. Berenson.
Ms. FARB. Sure. Thank you, Chairman Wyden. I think what we
have learned so far is that we do not have the complete informa-
tion that we need to study what we need to study in order to make
some determinations about some of the issues that Dr. Berenson
was raising.
I believe that is why MedPAC actually recommended that some
of these flexibilities continue with some guard rails in place so that
we can study the effects of these issues on the quality of care,
which is still not quite known in Medicare at this point, and on
sort of program spending and provider and beneficiary behavior.
The CHAIRMAN. Dr. Berenson?
[Pause.]
The CHAIRMAN. You are muted, Doctor.
Dr. BERENSON. Okay, I am on. I will make two points. One is
that we learned that if you simply pay what the sort of process is
for generating relative values and fees that has been used in Medi-
care, you will not get the services you are desiring.
In 2019, Medicare, CMS, put into effect something called a
check-in visit, which was a payment to physicians to call their pa-
tients to discuss whether they needed to come in for an in-person
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visit. The payment by the traditional method was about $14 and
change. And guess what? Nobody did the visits. It was less. The
practices are not stupid, so they may have made the call but they
sure did not bill for it, and I would suspect that many practices did
not even do it because of the inadequate payment.
And within 2 weeks of announcing that there would be a whole
new list of telehealth services, CMS raised that payment level from
$14 and change to $56. And guess what? Doctors did it. And I
think it was a very smart move by CMS to get money out the door
to beleaguered practices that suddenly saw their revenues decrease
dramatically and patients who could not get care. So the payment
level matters a lot. And so that is one point.
The second point I want to make is that—actually I am blanking
on what my second point is, and so I will move on.
The CHAIRMAN. Thank you.
Let’s go to the equity question. And by the way, all of you can
give us additional information for the record. I just felt that this
question of striking a balance is what practitioners and patients
are always asking me. They want the speed. They like the effi-
ciency. But they want the quality, and they want answers to these
kinds of questions. So apropos of what we heard from GAO, we will
be interested in more information, for example, on your work ap-
parently in the guard rail kind of area.
A question for you, Dr. Davis. We have said in our work on this
committee, every single time out, we are going to focus on equity
issues, because we know in America much of health care is really
a desert for vulnerable people. If you are affluent, and you are
white, and you are in the suburbs, you have the world in front of
you. If you are in the BIPOC community, very often these options
just pass you completely.
So our first work was on maternal mortality, but we want to
make sure that the principles of fairness extend to new technology
as well. Wave your wand and tell us a couple of things you think
you would be doing if you were on the Finance Committee to pro-
mote racial equity in telehealth.
Dr. DAVIS. Thank you, Senator Wyden. That is a great question,
and it is a concern that we have as well. What we have seen from
the pandemic is that there has been unequal access, and the com-
munities that have been most likely to access telehealth have been
whiter, richer, more urban, and with more access.
And so I think the first thing is—really as we are exploring and
expanding telehealth—really being sure to make sure that the data
that we collect is stratified by race, ethnicity, gender, language,
and other key factors, making sure that we are taking customer
and patient reviews into account as we are expanding outward.
And then also, continuing to invest in infrastructure, in broadband
for our rural communities, for our underserved communities, mak-
ing sure that they continue to have access so that we are not inad-
vertently creating a two-tiered system where all have access to in-
person and only some have access to telehealth.
The CHAIRMAN. Good. I am over my time.
Senator Crapo?
Senator CRAPO. Thank you very much, Mr. Chairman.
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I will start with you, Ms. Farb. The waivers have clearly been
successful in increasing patient access. The impact of telehealth on
the quality and cost of care is more complicated to measure, as you
have indicated.
Focusing on the quality part of the equation, what metrics do you
use to measure the quality of telehealth services, including in com-
parison to in-person care?
Ms. FARB. Well, Chairman Crapo—Senator Crapo, sorry—thank
you for that question. Organizations like the NCQA and AQF have
been working during the past year to retool their quality measure-
ment sets and the frameworks that they use to develop quality
metrics specifically for telehealth.
The key areas that AQF has noted include things like the timeli-
ness of care—and obviously, telehealth may have an advantage in
that regard—how well it encourages care coordination, and patient
empowerment and engagement.
So there are a number of different metrics and sort of categories
of metrics along which the quality organizations are suggesting
telehealth be measured. We at GAO have not yet looked into spe-
cific quality measures for telehealth yet. We have been asking
about those as part of our ongoing work to try to understand how
providers and others are viewing that.
Senator CRAPO. All right; thank you.
And, Dr. Murali, it seems the ideal way to deploy telehealth is
for a physician working with the patient to decide which care mo-
dality works best for each patient visit. But payer policies related
to billing, documentation, and payment play a large role in the ex-
tent to which providers offer telehealth.
Understanding that physicians provide the same level of patient
care regardless of the type of insurance, is telehealth more feasible
in a capitated payment arrangement?
[Pause.]
Senator CRAPO. You are muted. There you go.
Dr. MURALI. Senator Crapo, thank you very much. Absolutely.
Transactional fee-for-service does not help people to innovate be-
cause it is transactional. If you need transformation, you need pro-
spective payments. Capitated payments allow the physician groups
to focus on what is important as well as invest in the infrastruc-
ture required to provide optimal telehealth that is integrated in the
electronic medical records.
As I shared in my documentation, presently physicians have
worked as heroes. They do the video chats, the e-coms, as well as
all the transactions while they are doing telehealth, but the sys-
tems are not optimally designed to get at patient care. So if you
want to get the efficient care and adoption at a much higher rate,
that is absolutely necessary, and you are right on.
Senator CRAPO. Well, thank you.
And, Dr. Berenson, could you comment on the same question?
You are muted.
Dr. BERENSON. I don’t know who is muting me. In any case, I
agree very much with Dr. Murali. Capitation does not—the prob-
lems that I described in fee-for-service where you have all these
rules and requirements as to the circumstances that you have to
follow and on which you can bill, in my practice I have found often
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a 2- or 3-minute phone call follow-up the week after I either made
a tentative diagnosis or changed the medication, was the proper
way to follow up with a patient. Yet, that would not qualify for
payment under fee-for-service.
With capitation, you have essentially an account that can be de-
ployed to appropriately use capitation without artificial rules and
regulations, to use telehealth without artificial rules and regula-
tions. So I think that is the way to go.
CMMI has actually developed a model which is sort of half fee-
for-service and half capitation. It seems like with expedited testing
it could, within a couple of years, become a national model for mov-
ing primary care practices. It is a little trickier to figure out how
to pay specialists for their telehealth because, with capitation, it is
not easily done for specialty services.
Senator CRAPO. All right; thank you.
And back to you, Dr. Murali. We have talked about broadband
and some of the infrastructure aspects of getting this issue re-
solved. You stated that telehealth was a fundamental element of
caring for patients in rural Wisconsin, even before the pandemic.
And can you speak to how Marshfield Clinics made the necessary
investment in infrastructure and physician training to make that
possible?
Dr. MURALI. Yes; some before the pandemic, some during the
pandemic. Before the pandemic, we invested in optic fiber cables,
along with our community of three-quarters of a million in Marsh-
field, to expand the capacity to provide that service; invested in a
stand-alone data warehouse; as well as focused on trying to get the
intelligence required for providing good care with quality outcomes
that are measured.
In addition to what needs to be done—so if you want to provide
telestroke coverage or ER coverage, or you want to do Hospital at
Home, you need to invest in equipment and platforms that trans-
late to roughly about $41⁄2 million a year for us as a health system.
And so we have been doing that without any concern, because
there is no other way to optimize labor and recruit physicians to
provide the care in populations that are less than 2,000 in a 45,000
square mile geography.
Senator CRAPO. Thank you very much.
The CHAIRMAN. Doctor, thank you.
With 26 Senators waiting to ask questions, we are going to move
quickly.
Senator Stabenow?
Senator STABENOW. Well, thank you very much, Mr. Chairman.
And you know, I have been smiling this morning as I am thinking
back to when so many of us pulled together before the CARES Act
was put together. At the time, Senator Thune and I were charged
with getting together to make some recommendations, bipartisan
recommendations on Medicare. And we quickly came together
around telehealth. And of course the committee embraced those
recommendations.
And I am just so pleased that we were, all of us together, willing
to move forward on telehealth. And I support yours and the rank-
ing member’s desires to make these things permanent, certainly
dealing with the issues around accountability that we need to do.
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So when we look at the issues around telehealth, I wanted to
specifically ask about mental health and addiction services. We did
include these areas for behavioral health clinics to be able to use
telehealth, as well as community health centers and others.
And while we are seeing that there has been dramatically ex-
panded access to telehealth—CMS reported a 2,700-percent in-
crease in telehealth utilization for Medicaid and children’s health
insurance beneficiaries. That is amazing.
But in behavioral health treatment for Medicaid and for CHIP,
actually at the same time, it dropped dramatically overall during
the pandemic—22 percent for adults, and 34 percent for children.
So we definitely want to move ahead and do what we need to do
to strengthen all these policies. But I do want to ask, Dr. Davis,
if you could speak to the mental health addiction services piece of
this, and what we need to do to be able to make sure we are reach-
ing out to everyone who needs help, because obviously in this
space, we are not reaching people.
Dr. DAVIS. Thank you, Senator Stabenow. Yes, telehealth for
mental health and behavioral care is so important, and it really
can help remove barriers to access, to stigma in terms of patients
who may be hesitant to get out and meet somebody in person—and
being able to see them face to face makes a huge difference.
In the practice that I work in, we have a strong connection with
mental health. And so it has been absolutely beneficial to our pa-
tients to be able to provide them with behavioral health services
through telehealth.
We also provide addiction services. And so being able to provide
substance use disorder and MAT treatment through telehealth has
been essential for our patients. I cannot explain why we have not
seen the increase that we might have expected, but I can tell from
patient experience that it is an essential service.
Senator STABENOW. Thank you.
And let me take my last moments just to ask Dr. DeCherrie
about home health, more about home health, because we know that
as we were expanding eligibility for more people to get care at
home during COVID–19, how important that was. And many Medi-
care beneficiaries can now receive that care at home that they
would previously have had to travel, or risk exposure, to be able
to receive. And we know that home health care helps in many dif-
ferent ways.
But, Dr. DeCherrie, could you discuss the benefit to meeting pa-
tients’ needs in their communities, including at home, when medi-
cally appropriate? Just a little bit more about why you think it is
important that we focus on that.
Dr. DECHERRIE. Yes. Thank you for that great question. So yes,
I provide care both in Hospital at Home—home-based primary
care, home-based palliative care—so I believe in multiple models of
home-based care. They all have their place, and we have seen in-
creased need during this pandemic, where patients want to be
home and get that care at home.
So yes, I think all of those are things that we should think about
how to expand.
Senator STABENOW. Thank you. Thank you, Mr. Chairman. I am
going to yield back 30 seconds, for the good of order.
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The CHAIRMAN. Thank you for your good work.
Senator Grassley is next.
Senator GRASSLEY. Thank you, Mr. Chairman. I am glad to be
with you for a very important issue of lessons learned from the
pandemic, but we are still going to continue to learn a lot. Thank
you very much.
So I am going to ask questions of all the panelists, pretty much,
so if you can save some time by not repeating each other, I would
appreciate it.
So my first question to the panel is, while the pandemic has
shown many flexibilities in health care take place without compro-
mising patient safety and quality, there are still areas in health
care that are restricted by Federal laws and regulations. I spon-
sored the Pharmacy and Medically Underserved Areas Enhance-
ment Act with Senators Casey and Brown. This bill would let phar-
macists operate in a medically underserved area, offer health serv-
ices like wellness screening in diabetes management, and be paid
by Medicare.
For each of the panelists, which additional flexibilities should
Congress consider, to improve patient access and remove Federal
red tape?
Dr. MURALI. Senator Grassley, if I may, at this point in time in
the Marshfield Clinic Health System, we do about 53,000 to 55,000
telepharmacy visits using the pharmacist at one center to help with
respect to mixing in a sterile environment all the medications that
are required across the large geography. So promoting programs
that will help, like you have, is going to be very, very valuable in
this space.
Senator GRASSLEY. Is there anybody else who wants to add, al-
though you do not all have to speak if you do not have something
to add.
Dr. DAVIS. Sure. This is Dr. Davis. I will say, I appreciate the
extension of pharmacy, and as long as that is done as part of the
medical home, I think that is important.
Speaking of other flexibilities beyond telehealth that should be
considered, one is Medicare and Medicaid coverage for all AAFP-
and also ACIP-required recommendations, not just the COVID–19
vaccines, but access without cost sharing beyond the public health
emergency.
In addition, allowing physicians to provide direct supervision and
teaching services via real-time two-way audio/video communication,
which would expand access to primary care and increase training
opportunities. This is already being done in rural areas, but ex-
tending that to all communities.
And then permanently removing or reducing the volume of prior
authorizations, step therapy, and other administrative require-
ments, and allowing those to be done via telehealth or in person.
Senator GRASSLEY. Okay. Since you brought up telehealth, I am
going to go to my next question. It is really a positive thing, I
think, that has resulted from the pandemic, if you want to say any-
thing good can come out of a pandemic. The public health emer-
gency permitted more than 140 services to be administered through
telehealth. Last Congress, we made mental services by telehealth
a permanent Medicare benefit.
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For each of the panelists who are physicians, telehealth was
widely adopted throughout the pandemic, with its current utiliza-
tion greater than pre-pandemic but less than its peak last spring.
What type of medical services are most utilized today through tele-
health? And which ones are most effective for patients and pro-
viders? And maybe the last half of that question is the most impor-
tant part of it.
Dr. MURALI. Senator Grassley, so from the standpoint—I heard
Senator Stabenow’s comment. In the Marshfield Clinic Health Sys-
tem, the number of behavioral and psychological consults that go
through telehealth has more than doubled compared to the aver-
age.
So more than 30 to 40 percent of home visits are actually for be-
havioral visits, for substance abuse, as well as with other elements.
So that is an important factor from the standpoint of telehealth. I
leave it to the others to comment.
Dr. BERENSON. I will just make a brief comment on that as well.
I am going to agree again with Dr. Murali about the role of behav-
ioral health by telehealth. I was involved with interviewing pri-
mary care physicians, nearly 20, and they all said, even though
they are not specifically behavioral health physicians, that that has
been the biggest uptake and the most valuable thing that has oc-
curred.
The only issue that I can raise there is that, in some families
there may be a confidentiality issue, where we are doing the tele-
health when the patient is at their home. But that can usually be
worked around.
I do not think there is a comprehensive analysis yet of which
services—we heard anecdotally, for example, that hypertension was
good to manage by telehealth because patients had their own blood
pressure machines and could take their blood pressure, whereas for
diabetes the patient needed to come in for a blood test to check the
hemoglobin A1C. And this will evolve over time.
I think, however, that for the most part virtually all, sort of gen-
eral medical and—not surgical, which needs a procedure in many
cases—but general medical issues can be dealt with with telehealth
being a central part of the management strategy.
Senator GRASSLEY. Thank you, Mr. Chairman. I am going to sub-
mit other questions for answers in writing.
The CHAIRMAN. That will be fine.
Senator Cantwell, chair of the Commerce Committee, and an ex-
pert, is next.
Senator CANTWELL. Thank you, Mr. Chairman. Thanks for hav-
ing this hearing.
If I could just get a quick ‘‘yes’’ or ‘‘no’’ answer from all the wit-
nesses, do you think we need more affordable health-care options
for people in America?
Dr. DAVIS. Yes.
Dr. DECHERRIE. Yes.
Ms. FARB. Yes.
Dr. MURALI. Yes.
Dr. BERENSON. Yes.
Senator CANTWELL. Thank you.
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21
Ms. Farb, one plan that is out there that could help reduce the
cost is the Essential Plan in New York, or better known as the
Basic Health Program from the legislation. It has allowed people
under 200 percent of the Federal poverty line to see a huge savings
in their costs.
Should we be doing more to drive the value of expansion of this
program to other States?
Ms. FARB. Senator Cantwell, thank you for the question. We
have not done any work looking at that plan in New York at GAO,
so I cannot really comment on whether or not it should be ex-
panded. I defer to my colleagues.
Senator CANTWELL. Yes, Dr. DeCherrie, you are a New Yorker.
What do you think?
Dr. DECHERRIE. That is also not in my area of expertise, so I do
not have anything to add to that.
Senator CANTWELL. Okay. Anybody else?
[No response.]
Senator CANTWELL. Okay, so I guess we have a mystery here
that maybe I can try to illuminate for the future. But I can tell you
this. My constituents are tired of subsidizing expensive health in-
surance plans when we do not have to. If there are ways to buy
in bulk, which New York and Minnesota have done, and bundle up
a large percentage of the population, then, yes, they believe they
should get discounts. That is what is happening.
So, Mr. Chairman, mark me down as someone who is not going
to go along, even if it is a Democratic proposal, not going to go
along until we do something about lowering the investments we are
making in expensive subsidies to insurance companies for health
care.
This plan has worked in two States, and we should be using it
as a way to save dollars and expand coverage to more people.
Americans cannot, even with our tax subsidies, continue to have
expensive health insurance costs.
Okay, great discussion on telehealth. I really appreciate all of
that. The University of Washington has gone from doing about
20,000 people a year to 20,000 a month. And I am curious, Dr.
DeCherrie or Dr. Berenson, what do you think that—what else do
we need to do to change the actual reimbursement rate? Does it
have to be on exact parity? Can it be a little off of parity? What
do we need to do to make sure the reimbursement rate is fair? Or
is there something else we need to do to differentiate?
Dr. DECHERRIE. I think that is probably Dr. Berenson’s field to
answer.
Dr. BERENSON. Again, my compulsion would be that we continue
fee-for-service as an interim strategy. I do not have the magic num-
ber for you. If we pay based on the traditional resource-based rel-
ative value scale approach, the payments for the low end of tele-
health would be too low to actually have them perform.
Pay parity, where we are now paying three times what that sort
of proper amount should be, is too high. So I think some smart peo-
ple could get into a room and come up with some middle ground
so that it was high enough that physicians and practices would ac-
tually bill it. But RAND has pretty well demonstrated in a prior
study, and I have not seen it challenged, that the costs for tele-
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22
health are less than the costs for in-person. It just makes sense.
And telehealth becomes sort of standard in most practices. They
will—practices will reduce some of their infrastructure, and maybe
work with less space, and their costs may come down. But in the
interim, I think we can find some middle ground. But it should be
in the context that we are moving to something different at some
date, if not certain——
Senator CANTWELL. Thank you for that honest answer. Do you
think that is rocket science? Or do you think that is just coming
to terms on numbers—and yes, people will obviously have strong
opinions. But do you think that is something we could achieve in
the next several weeks?
Dr. BERENSON. The next several months. I think we have seen
surveys of practices to get some answers.
Senator CANTWELL. Thank you so much. I do not know if I have
any time left, Mr. Chairman. I cannot see the clock here, so——
The CHAIRMAN. You are pretty much on the line, but do you have
one other one you want to ask?
Senator CANTWELL. I just want to say that I hope that Dr.
DeCherrie could answer some questions in writing about—
MultiCare got a CMS waiver on helping integrate doctor care and
home care. So it is basically better ways for the home health-care
programs to work with health-care providers, and I hope that we
could look at that also as a cost savings in keeping patients in their
homes longer.
So thank you very much, and we will write something for the
record on that.
The CHAIRMAN. Great. And, Senator Cantwell, I want everybody
to know I am with you all the way on this proposition that States
ought to be given the opportunity to be able to do more to hold
down health-care costs. And I think you said it very well.
Senator CANTWELL. Thank you.
The CHAIRMAN. Senator Cornyn is next.
Senator CORNYN. Well, thank you, Mr. Chairman. We all know
that in an effort to maintain adequate capacity in our hospitals and
doctors’ offices, we limited the amount of elective procedures that
were performed to deal with the potential surge of COVID–19 pa-
tients. And as a result, a lot of health-care screenings, colonos-
copies, other life-saving diagnostics, dropped dramatically.
We know that about a third of adults have not received rec-
ommended screenings for age-associated risks during the pan-
demic, and 43 percent of patients have missed routine preventative
health appointments as a consequence of these precautions.
Fortunately, now that more people are being vaccinated, hope-
fully those numbers will improve. But I want to add my voice to
the chorus, I guess, here today of advocating the enhanced use of
telehealth. I tell my friends and constituents back in Texas there
are only two good things that came out of COVID–19. One is tele-
health, and the second is margueritas to go. Those are the only two
good things I can think of.
So let me ask. We are all very familiar with the digital divide.
And this is very true, particularly of big States like mine, and we
are working on that diligently. Senator Manchin and I have a Dig-
ital Divide Act which would provide grants to Governors to help
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23
them work with Internet service providers to connect underserved
areas.
But I want to ask the panel about audio telehealth. It seems to
me that this could be an interim solution to make sure that low-
income earners could get access to a doctor or health-care advice
over the telephone. So maybe starting with Ms. Farb and Dr.
Davis, could you explain how telehealth services furnished by
audio-only communications could increase access to care, particu-
larly in rural and underserved areas?
Ms. FARB. Sure. I’ll start, and then I think Dr. Davis can speak
more fully to this. But what we have observed—and even talking
to some of the provider groups you have spoken with—is not only
the beneficiaries not having access, but providers not having access
is also an issue. And so a lot of providers initially started off using
audio-only telehealth services, especially for the office visits, the
evaluation and management codes. And that has probably contin-
ued throughout the pandemic.
But in the early days, that was definitely a source of modality
that really was working for a number of groups that we have spo-
ken to.
Senator CORNYN. Dr. Davis?
Dr. DAVIS. Thanks for that question. I would also echo that the
need for audio-only is essential, both for our under-represented
communities and under-serviced. We realize that sometimes broad-
band is just not there, and we will try and try to connect with pa-
tients via video, and the resource is just not there. The patient is
not comfortable with it. They cannot get their smartphone or device
to work, or they just do not have one. And as we build infrastruc-
ture, we should build it in a way that is mindful of that.
I also want to call out specifically around translation services for
our non-English-speaking patients. And being able to get that lan-
guage translation is often easier through an audio-only visit than
it is through an audio-video visit.
Senator CORNYN. So, Dr. Murali, I saw you nodding when I
asked about audio-only telehealth. What is your view?
Dr. MURALI. Well, out of the quarter-million or so encounters
that we have in Wisconsin, more than 50 percent of the visits are
by audio only. Unfortunately, even Medicare Advantage does not
consider it for risk evaluation or adjudication, and that is a bad
deal for patients because it increases disparities. And I think when
you think about the digital divide, as well as racial disparities, we
also need to think about the fact that even white people in rural
America are poor. They basically do not have access to care. And
there is also the question of literacy that needs to increase.
So all of those are disparities that we have to keep in mind. So,
right on.
Senator CORNYN. I have time for one more question. You know,
one of the concerns we have is about security of, specifically, per-
sonal health information. Obviously HIPAA provides that generally
speaking, but as we continue to provide more telehealth, I am wor-
ried about the protection of the privacy of the doctor/patient rela-
tionship.
In closing here, do any of you have any particular observations
or experience about how we can make sure that that is preserved?
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Dr. MURALI. Yes. So I think it is important to invest in the infra-
structure for security breaches. What is happening in Ireland right
now with Conti is a good example of a security breach. And that
can be addressed by infrastructure.
And then from the psychiatric care side, patients actually prefer
to do that from home because it gives them the psychological safety
of having that discussion in the comfort of the home, as opposed
to sitting in a public health waiting room.
So those are all factors that should be factored in, and that is
why payment parity is necessary to get us moving forward on this.
Senator CORNYN. Thank you very much, Mr. Chairman.
The CHAIRMAN. Thank you, Senator Cornyn. And we are with
you on the audio question, particularly if the take-up rate is as low
as Dr. Murali said; it is probably even worse when you are talking
about traditional Medicare. If the take-up rate is low on MA, think
about what it is like on traditional Medicare. So we are going to
follow that up. Thank you.
Our next questioner is Senator Menendez.
Senator MENENDEZ. Thank you, Mr. Chairman.
Dr. Davis and Dr. Murali, in your testimony you both highlight
the importance of audio-only telehealth. Can you tell the committee
a little bit more about why coverage of audio-only telehealth serv-
ices is so critical to ensure that we do not further fall behind on
health-care equity?
Dr. MURALI. Senator Menendez, I would like to invite you to visit
us in Marshfield. You can go from one location to any of our 60 lo-
cations for 2 hours without having access to the Internet. And the
only thing that works is the old-fashioned telephone network.
So if we are really trying to address geographic isolation, that
phone call is the most critical piece. In the Hospital at Home pro-
gram that we started, we were trying to work those pieces back in
2016, and we were looking for one bar out of five to make sure that
we could provide some kind of virtual help.
So it is not just the access to broadband, it is also the degree to
which broadband is available in these rural areas that causes the
disparity. So I hope that answers your question.
Senator MENENDEZ. Dr. Davis?
Dr. DAVIS. And I would second everything that Dr. Murali just
said. The extension to rural areas is so important, and really in-
vestment in primary care is helpful in bridging that digital divide
so that patients have timely access to in-person care and audio-
video telehealth.
But the audio-only is really just essential for getting past some
of those barriers. And we do not want to create a two-tiered sys-
tem, so we need to make sure that payment is adequate to support
the flexibility and modalities of care.
Senator MENENDEZ. Thank you.
Dr. DeCherrie, building on the previous question, the COVID–19
pandemic did not create inequity in our health-care system. In-
equity is in fact a hallmark of American health care.
What role can telehealth play in addressing longstanding health
disparities in our health-care system?
Dr. DECHERRIE. Yes. I mean, I witnessed this firsthand in my
home-based primary care program where, again, most patients did
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25
not own a cellphone and had no ability to do any video visits. And
we, like Dr. Murali mentioned, did everything by telephone those
first couple of months.
In my Hospital at Home program, we actually provide every pa-
tient with a telehealth kit. And even here in New York City, one
kit that is set up with Verizon does not always work when they
switch to the AT&T one. You know, even here in New York City
we have these issues.
So, to be able to provide care for patients in their homes, we
need to think through these things and make sure we have all op-
tions available.
Senator MENENDEZ. Ms. Farb, data collection has been an ongo-
ing issue throughout this pandemic. I sent letters to the adminis-
tration, as well as the last one, about the need for better data col-
lection during the pandemic.
I am disappointed that HHS has still not consolidated data col-
lection into one site with standardized reporting requirements.
What data is needed about the flexibilities extended during this
public health emergency to show the committee the impact of these
flexibilities? And what, if any, flexibilities should be made perma-
nent?
Ms. FARB. We do not have any recommendations yet on any flexi-
bilities that should be made permanent. One thing I did want to
point out that might be worth considering as the committee under-
takes some of this work is ensuring that some of the program re-
quirements between both Medicare and Medicaid—you know, look-
ing at how well they align and what are some of the differences.
Because I think the providers on the panel probably agree that
having two very different sets of rules around how telehealth works
can make it difficult for them to operate in that environment where
they are dealing with that.
As far as data collection goes, yes, we have made a number of
recommendations during the pandemic around providing better
data, as well as ensuring that the data are contained in a site that
is publicly accessible on cases, hospitalizations, et cetera.
For flexibilities, I think what we do not have is some of the infor-
mation we need about differences between different telehealth mo-
dalities and some of the patient information demographics that we
need and the sites of care so that we can look at quality and other
things that would be important to measure.
Senator MENENDEZ. Thank you.
Finally, Mr. Chairman, I know we are all committed to building
back a stronger health system, ensuring our Nation is ready for the
next pandemic, and dealing with the inequities in our system, but
if we are going to do that, I think one of the most effective and in-
formed ways that we can come together on a nonpartisan basis is
to conduct a thorough examination of the United States’ COVID–
19 response. What went right? What went wrong? How can we do
it better? That is why we have a bipartisan, bicameral National
Coronavirus Commission Act that my friend and colleague, Susan
Collins, has joined me on. I appreciate your support as well, Mr.
Chairman, as well as Senator Brown and Senator Kaine. And the
House has Representatives Malinowski and Diaz-Balart on a bipar-
tisan basis leading an effort. And I hope we can get that, because
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26
I think that would provide us an unvarnished and fair process of
understanding what went right and what went wrong. Thank you.
The CHAIRMAN. We will be supporting you. Thank you.
Senator Cardin is next.
Senator CARDIN. Well, thank you, Mr. Chairman, and I want to
thank all of our witnesses. And I want to just join the over-
whelming number of our members on lessons learned from
COVID–19 about telehealth. But I just really want to follow up
with Senator Menendez.
It also shows the inequities in our health-care system. And those
communities that do not have the same degree of infrastructure,
health infrastructure, or access to infrastructure, health care, were
the ones who suffered the most during COVID–19. There is no
question about that.
So it means we have to strengthen that. So as we look at tele-
health—which was critically important for mental health—I hope
we go forward with permanent changes in our reimbursement
structures and in the reciprocal regulatory issues among States so
that we can expand telehealth, because I think it gives timely ac-
cess to care for so many individuals.
I just really want to underscore the point that Senator Menendez
made about not developing a two-tiered system. It is very clear to
me that, as a practical matter, having audio-only is better than not
having any care. But if we set up a structure that has a two-tier
system, those who have access to high-speed Internet or have the
ability to access providers that can provide a much more com-
prehensive telehealth service, and other communities that do not
have that same degree given only audio, we run the risk of a two-
tier system. And if the reimbursement structure incorporates that,
it then becomes also a two-tier system.
So I guess my question to all of you is, as we look at the recip-
rocal regulations, as we look at the reimbursement structures, as
we look at access to broadband, and not just access to high-speed
but the capacity to be able as an individual person to properly ac-
cess that—some of our elderly have difficulty with this—what steps
should be our top priority to make sure that, as we expand tele-
health, which we all agree needs to be done, we do it in a way that
does not set up a two-tier system?
Dr. BERENSON. I would be glad to start with——
Senator CARDIN. Jessica Farb, do you want to start? Or whoever
wants to start?
Ms. FARB. I think one option that has been suggested, although
it does not sort of completely align with what the panel has been
talking about, is to make sure to cover audio-only where there is
a documented barrier to audio-visual visits, and look at that for a
brief period of time so that data could be collected to study the
quality of care and determine the comparability to in-person visits.
And as I said earlier, we have heard from providers—and we
have already heard from this panel—that they have had to resort
to audio-only when the patient did not have access. And as you
pointed out, Senator Cardin, just having something is better than
nothing.
So trying to do some kind of targeted study of differences would
be one way to try to make sure that we are giving comparable care.
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Senator CARDIN. Dr. Davis?
Dr. BERENSON. If I could go next?
Senator CARDIN. Sure.
Dr. BERENSON. I have not had a chance to say this yet, but I will
take this opportunity. I actually got interested in how to pay for
telehealth after our Professor Ed Wagner at the University of
Washington—who I am sure the chairman and Senator Cantwell
know—proposed his chronic care model. And the chronic care
model included—this was in 2003—it called for robust use of tele-
phones, before we had video. I see video as being hyped a little too
much here.
In many situations such as chronic care management, you only
need a few minutes with a patient. You have already seen them,
either in person or through a video conference, and you want to be
checking on how they are doing. We have created in Medicare a
chronic care management code, but that is for very sick people who
need really intensive care management.
Most patients with hypertension or diabetes or congestive heart
failure will benefit from a follow-up phone call. And so my view is
that the phone calls are the encounters that take place for minutes.
The video visit is for something longer, like an annual visit, or for
something that really requires 20 or 25 minutes, and where visual
contact is necessary.
And that would, I think, help a lot on the equity issue. I think
that phones, audio-only as it is being called, should be equal. And
that was one of my points, that the coding is sort of arbitrary. So
I will pose the question, is the Zoom call with the video off, is that
an audio-only? Or is that a defective video call?
Senator CARDIN. I think I will just underscore Ms. Farb’s point.
It would be good to have a study as to how audio works. Obviously
follow-up conversations with health-care providers are one thing.
But to do a diagnostic-type of interview is a lot of times easier and
more effective with video.
Anyway, I look forward to that study, and thank you, Mr. Chair-
man; an excellent hearing.
The CHAIRMAN. Thank you, Senator Cardin. And I will tell you,
Dr. Berenson, you are spot-on with respect to the history on chron-
ic care. Senator Hatch and I always conceded that there would be
a significant audio/phone component of it, and that is what we
really envisioned in the first part of the bill.
Okay. Senator Portman, I believe, is next, if he is there.
[Pause.]
The CHAIRMAN. Senator Portman, are you out in cyberspace
somewhere?
[No response.]
The CHAIRMAN. Senator Brown?
[No response.]
The CHAIRMAN. Senator Cassidy, a physician?
[No response.]
The CHAIRMAN. Senator Bennet?
[No response.]
The CHAIRMAN. Senator Lankford?
[No response.]
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The CHAIRMAN. I do see Senator Whitehouse on the screen, and
he is not even on our list, but we have no other Senators, so let’s
have Senator Whitehouse, who is a very knowledgeable person on
health care.
Senator Whitehouse?
Senator WHITEHOUSE. Thank you, Mr. Chairman. Every once in
a while, you get lucky and can jump the queue. I just wanted to
pass along to the panelists the success that Rhode Island has had
with these waivers during the COVID pandemic.
We have made very good use of the Hospitals Without Walls pro-
gram, and I would love to see that continued. We kind of broke the
back of opposition to telehealth generally, and I do not think there
is really any going back on that. It has been particularly welcome
in the behavioral health, mental health, addiction area, where
practitioners report to me not only better compliance with showing
up and participating, but also better substantive content.
It is hard for them to quantify that, but it is a repeated theme
that there is something about being able to talk from your own
home, from a comfortable place, rather than having to drive across
town and fill out the clipboard and sit in somebody else’s office. It
just seems better.
And the medication-assisted treatment element, and allowing ac-
cess to buprenorphine, for instance, with telehealth, has been a
godsend for that population.
And the last thing I will mention is that I have been working for
a long time to try to get CMMI to sign off on a bunch of waivers
to deal with people who are nearing the end of life, for whom a lot
of waivers make a lot of sense. It does not make any sense to fuss
too much on how home-bound somebody is at that stage of their
life. Home health services, waivers that we have seen through
COVID, are very helpful.
Respite care is not ‘‘respite’’ if you have to stuff granny in the
hospital and not get help to come to her in the house. And the
whole 3-day/2-night rule is ridiculous for those patients. And those
waivers, I hope we can extend.
I would ask Director Farb, with respect to the homebound and
home health service and 3-day/2-night waivers, has GAO seen any
evidence of heightened utilization as a result, heightened cost?
Ms. FARB. Senator Whitehouse, no, we have not examined that
directly. We also tried to look to see what CMS has been reporting,
and so far they have created an accomplishment report sort of de-
scribing effects of many of the waivers.
They have not included anything thus far in their reporting, but
it is something that we are going to be tracking going forward, as
we start to work on the additional waiver study that we are plan-
ning to do.
Senator WHITEHOUSE. Good. It is particularly important to me
for people nearing the end of their lives, because it just does not
make any sense. It is kind of cruel to the family to deny them those
supports because of some funding requirement that is not even de-
signed for that population but has terrible effects on families and
their access to care.
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Dr. DeCherrie, are you familiar with the Hospitals Without
Walls program? And would you like to comment on the wisdom of
extending that?
Dr. DECHERRIE. Yes, and it is specifically the Hospital at Home
portion of that that we made use of during this pandemic. I want
to also go back to one thing that you mentioned earlier about the
comfort of someone in their home. You mentioned it in the context
of behavioral health, but I would broaden that.
When we are in the home—and that could be either in person
for the Hospital at Home, the nurses in person in the home, or
through the video when a provider might be doing a video visit—
seeing someone in their own context, to see what they are actually
eating, might actually have long-term real impacts in their lives.
And so these little snippets of getting into someone’s home have
really improved health for people long-term.
So I just wanted to make sure that that was understood.
Senator WHITEHOUSE. Let me close out with a little brag on
Rhode Island ACOs. We have two—Rhode Island Primary Care
Physicians, which operates an Integra ACO, and Coastal Medical
in Rhode Island—and both of them are absolutely top-performing
ACOs nationally. I mean they are right up in the upper corner of
savings, and quality of outcome, and patient satisfaction.
And part of what they have done is to engage with patients in
their home in order to get better information, and that is part of
what has made it work so well. I will go as far as you want to go,
Dr. DeCherrie, on this. My problem is, I have been jammed up in
CMMI for 10 years trying to get it just for those patients. So that
is our beachhead. But I do think a lot more can be done, and the
ACOs have shown a lot of good results on that.
So I will yield back, because I think I am probably out of time,
but I really appreciate this conversation. There is a lot to be done,
and if people at CMMI are listening, I think we gave them these
powers for a reason. Let’s use them.
The CHAIRMAN. Well said.
Senator Brown?
Senator BROWN. Thank you, Mr. Chairman. I appreciated the
comments of my friend from Rhode Island, and I know that Sen-
ators Cornyn and Menendez asked about audio health, audio-only
telehealth. So I would like to follow up with a couple of questions,
particularly about folks who live in more urban and suburban set-
tings who may not have access to video conferencing or Internet ca-
pabilities to access video telehealth.
So my question is starting with Dr. Murali. Speak briefly, if you
would, about the increased reimbursement for audio-only telemedi-
cine, how it helped you stay connected with hard-to-reach popu-
lations throughout the pandemic, both in underserved urban areas
and underserved rural areas, if you would, Dr. Murali.
Dr. MURALI. Thank you, Senator Brown. So as I said previously,
out of the quarter-million visits that we did at the Marshfield Clin-
ic Health System, greater than 50 percent of those visits were done
by audio visits. So what it allowed us to do is manage patients with
heart failure. In fact, we had studies that demonstrated that we
were able to save close to $2.7 million while managing 600 pa-
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30
tients. Just imagine the power of that if you were to take that
across the entire country.
From the standpoint of behavioral health, I have already made
my point about audio, because it gives you pretty much all of what
you need to know from the standpoint of that care. So there are
several benefits, but that is just a snippet of what audio can do.
Senator BROWN. Thank you, Dr. Murali——
Dr. MURALI. The other piece is——
Senator BROWN. Sorry.
Dr. MURALI. The other piece is that it is extremely difficult to get
broadband access in rural Wisconsin. And so, if you do not provide
that support on the audio side, you are geographically isolating
these patients from seeking the care that they need, and therefore
you are not being proactive. And that will increase your emergency
care visits, as well as your urgent care visits, and overall costs
from the standpoint of care.
Senator BROWN. Thank you.
Dr. DeCherrie, I appreciated your comments about nutrition and
what the window into the home can provide.
Dr. Davis, my questions, my next couple of questions are for you.
You recommend Congress act to require Medicare to cover audio-
only evaluation and management services beyond the public health
emergency to ensure equitable access to care. Talk, if you would,
about two questions: how audio-only telemedicine services could
help reduce disparities in access to care, and how should CMS
monitor the impact of telehealth, including audio-only telehealth,
in access inequity?
Dr. DAVIS. Sure. Thanks, Senator Brown. You know, as a pri-
mary care provider and also working in an Accountable Care Orga-
nization, we have lots of experience with this. And audio-only care,
when used appropriately, is high-quality care. And so I want to
make sure that we note that distinction, that studies comparing
telephone-only visits to telehealth visits conducted prior to the pan-
demic found no significant difference in health outcomes or pa-
tients’ reported satisfaction.
And so it certainly is an additional tool in the toolbox in order
to be able to provide equitable care for patients, regardless of
whether patients are rural or suburban. I have provided care for
those patients; the docs I work with have provided care for those
patients; and across the board, we have had challenges when they
are restricted to only video services.
And so being able to interact with our elderly patients who may
have trouble connecting and not have a family member close by
who can help, or our non-English speakers who may have trouble
connecting and using translation services, and for those who do not
have access to broadband in a robust way, audio-only is essential
for providing good care for them.
Senator BROWN. And CMS can monitor the impact of that?
Dr. DAVIS. Yes. I mean, I think we have coding and an ability
to do that, paired with patient satisfaction, paired with care out-
comes, the ability to collect data. Now I feel like, as a physician,
my quality is monitored in many different ways and getting back
to health outcomes. And I think it is important to distinguish that
telehealth audio-only and with video should be differentiated be-
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31
tween what happens in the primary care patient-centered medical
home, versus a vendor that is providing just that service.
And so audio telehealth is provided best when it is part of the
care continuum that a primary care provider is providing. You have
the background and the history on the patient, the access to their
chart, and that long-term trusting relationship.
Senator BROWN. Thank you, Dr. Davis.
I am on my last 30 seconds, Mr. Chairman, and thank you for
your indulgence. I wanted to bring up another issue—no question,
just an issue. Senator Capito and I have proposed, related to Medi-
care’s hospice respite benefit, the COVID–19 Hospice Respite Care
Relief Act of 2020, giving the Secretary of HHS the authority to
allow hospice patients to receive respite care at home, and for
longer periods of time during any public health emergency, includ-
ing obviously the one we are in. It was not able to make a dif-
ference for family caregivers over the past year. So I hope the com-
mittee, Mr. Chairman, can consider ways to strengthen the hospice
respite benefit moving forward.
So thank you, and thanks to the witnesses today for their in-
sight.
The CHAIRMAN. We will follow up with you, Senator Brown, and
Senator Capito. Very important.
Senator Lankford is next.
Senator LANKFORD. Mr. Chairman, thank you, and thanks to all
of our witnesses and the insight that you are bringing, and for all
your work during the pandemic. There is a great deal of work that
was done and a lot of innovation that happened at your places to
be able to actually take care of people. So thanks for that level of
engagement that you have as we work our way through this.
There were over 200 flexibilities that were given by CMS during
this time period. Congress is obviously very engaged. My office was
engaged, as well as all the other offices here in this hearing today,
trying to be able to go back and forth on it. We have talked a lot
about telehealth, and I want to mention some of those things in a
moment.
But, Dr. Berenson, I do want to be able to bring up an issue
about the 3-day rule for skilled nursing facilities. When I called
back to touch base with a lot of our hospitals and facilities and
such and ask, of all the flexibilities that are there, which one really
stands out as one that needs to last, everyone brought up tele-
health, but then this 3-day rule for the skilled nursing facilities
came up.
Can you talk about that a little bit?
[Pause.]
Senator LANKFORD. You are on mute, still.
Dr. BERENSON. I apologize for forgetting that I am on mute. It
has been around since the beginning of the program, basically, be-
cause of the concern that Medicare would be turned into a long-
term care program if you did not have a requirement that skilled
nursing was associated with an inpatient hospitalization.
It is clear that an MA functions very well without the 3-day rule.
There are exceptions for ACOs, and there is sort of general agree-
ment that it has a perverse incentive, and it involves a lot of gam-
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32
ing, in fact. I have been involved with a family member who was
kept an extra day just to qualify for the 3-day rule.
So for me, if we can figure out a way to sort of eliminate it with-
out running into the concern that we have created a long-term care
benefit, I think we should do so. And the more we sort of move to-
wards risk-taking and capitated type of arrangements where the
organization itself has an incentive not to abuse the hospitaliza-
tion, I think we can make good progress.
But I agree with you completely that it is very frustrating. It
even affects the observation stay rule in Medicare where bene-
ficiaries do not qualify because they actually were not on an inpa-
tient stay, they were just in an observation stay, and therefore they
do not get the same access to skilled nursing. It really is a problem
that deserves real attention.
Senator LANKFORD. It is a serious issue. I would be interested in
any other practitioners who have had observations on this 3-day
rule.
Dr. DAVIS. Sure. This is Dr. Davis with AAFP. I would like to
second that AAFP would be in favor of reducing that. And just to
share an example from a patient that I had, a patient that I was
actually doing home visits on, which is rare, but we still do home
visits. And we could see in his home that he needed a higher level
of care. He did not need to go to the emergency room or hospital.
He just needed to be at a skilled nursing facility to receive some
rehab. But in order to get him there, he had to go to the hospital.
He developed an infection in the hospital, which lengthened his
length of stay and raised his Medicare costs. He eventually did end
up in the nursing home, but the relationship that I had with that
patient—I knew his history. I knew what the appropriate next level
of care was, and it just created barriers and increased costs that
were unnecessary.
Dr. MURALI. Senator Lankford, at Marshfield in 2014 we started
our process for creating comfort and recovery suites, got skilled
nursing facility bed licenses, and did all of our orthopedic surgery,
our gall bladder surgery, our gynecological surgery, thyroid sur-
geries, and kept them in the SNF a little longer than 24 hours, and
then we could send them home. Phenomenal cost savings that can
be achieved on the commercial side as well as in Medicare Advan-
tage, which we have shown in our data. And so I think it is an ar-
chaic rule that needs to be looked at, because its costs are waste-
fully spent.
The other piece is in the Hospital at Home. When somebody
comes into the ER, you wind up putting them in an observation
bed from the standpoint of 24 hours or whatever duration of time.
If you have the skilled nursing facility option available, if somebody
comes in the middle of the night and cannot go back home, you
prop them up in the skilled nursing facility bed for 12 hours and
then make arrangements for Hospital at Home care at home.
So that is what we do in the rural environment. Because, when
you have the little old lady who is 84 years old come into the ER
at midnight, you cannot possibly arrange for oxygen. It is easier to
deliver pizza in Manhattan at midnight than it is to get oxygen de-
livered to a home at midnight.
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So I think for all of those reasons, thinking about skilled nursing
facilities differently and creatively is important on a risk basis
model. So I will rest there.
Senator LANKFORD. All right; thank you.
Mr. Chairman, thank you very much.
The CHAIRMAN. Thank you very much.
And, Doctor, you really highlighted the importance of care over
some other things people are thinking about sometimes.
Senator Casey?
Senator CASEY. Mr. Chairman, thanks very much for having this
hearing. It is critically important, the number of issues that we are
learning so much about in the last more than a year now.
I will have a question for Dr. DeCherrie and Dr. Davis. The ques-
tion for Dr. Davis will be about mental health for children and
teens. But I wanted to ask you, Dr. DeCherrie, about the PACE
program and the expansion of it.
We are learning so much and exploring today innovative models
of care. I think if there is one thing we have learned over the
course of the pandemic, it is the importance of services that allow
seniors and people with disabilities to remain in their homes, in
their communities, as we have heard over and over again today.
And that is of course the setting that they would prefer. They
prefer to get care in the home, or in the community. And like the
Hospital at Home model, which provides hospital-level care for peo-
ple with acute illnesses, the PACE program, or the so-called Pro-
gram of All-Inclusive Care for the Elderly—we refer to it in Penn-
sylvania by a different acronym, the LIFE program—is similarly a
way that seniors and people with disabilities can receive wrap-
around care while remaining at home.
So I think we have to take the lessons we learned in the last
year to improve and expand upon services like PACE to ensure
that seniors and people with disabilities have access to the sup-
ports that they require.
I have introduced the PACE Plus Act just last month. This would
provide funding for existing PACE programs to service more peo-
ple. And it would allow these specialized programs to expand into
areas that do not currently offer PACE as a long-term care option.
So, Doctor, I would ask for your perspective on what is the value
of expanding programs like PACE that provide these wraparound
services for seniors and people with disabilities?
Dr. DECHERRIE. Thank you for that excellent question. I have
not worked at a PACE program since my residency. I was fortunate
enough to get that opportunity to work at a PACE program for an
entire year during my residency, and so I have familiarity with the
model. But it is very much like home-based primary care, which I
do every day. And so I do believe that expanding access for home-
based programs, Hospital at Home, Home Based Primary Care,
and PACE, is very important.
We have seen here in the pandemic that patients absolutely
want that type of care, and we should act to expand it.
Senator CASEY. Doctor, I appreciate that.
I want to ask a question for Dr. Davis, as I mentioned earlier,
about children. We know that if there was one problem that was
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terribly, terribly exacerbated by the pandemic, it was the crisis in
mental health, especially for children and teens.
Some of the most horrific stories and some of the numbers that
are so horrific, I think will stay with us a long time. We are told,
for example, of a 24-percent increase in emergency room visits for
mental health crises among children ages 5 to 11, increased wait
times to access inpatient mental health treatment, and so much
else. And as we recover from the pandemic and the restrictions are
lifted, children with mental and behavioral health needs, of course,
are not going to be going away.
We have to make sure that we have programs in place and strat-
egies to make sure we have the appropriate care for them. We need
to make sure that they have the appropriate treatment in the ap-
propriate setting at the appropriate time.
So, Dr. Davis, are there ways and existing tools or options in
both Medicaid and CHIP that can be used to address mental and
behavioral health needs of children and teens?
Dr. DAVIS. Thank you, Senator Casey. You know, as a mom of
three school-aged sons, this is acutely aware to me, in the chal-
lenges that they have had in virtual schooling and not being able
to connect with their friends. And I see it in my patients as well.
So, one, the expansion of telehealth for mental health is crucial
for children. One of the biggest barriers as a primary care physi-
cian is just being able to find a therapist, or a psychologist, or psy-
chiatrist in the area to be able to treat children. And so being able
to expand that treatment network is really huge.
I think the second is creating parity in payment with Medicaid,
continuing that. And we especially see low reimbursement for men-
tal health providers who are offering Medicaid services. And so, if
we really are trying to address that divide, we need to make sure
that Medicaid is having reimbursement for mental health services,
especially for children.
Senator CASEY. Doctor, thank you.
Mr. Chairman, thank you.
The CHAIRMAN. Thank you, Senator Casey.
Next is Senator Thune.
Senator THUNE. Thank you, Mr. Chairman and Ranking Member
Crapo. I think if we can find a bright spot from this pandemic, the
embrace of telehealth across the Nation is certainly one. For four
Congresses, the Senate Telehealth Working Group has advocated
for increased access to telehealth, and working with this com-
mittee, many provisions from past versions of our group’s CON-
NECT for Health Act have become law. In fact, CONNECT in-
formed a lot of our discussions on the CARES Act, which Senator
Stabenow already mentioned.
So that bring us to where we are today. And I think the question
is, what have we learned?
Dr. Murali, you represent a health system that utilized tele-
health long before the pandemic, like many of the systems in South
Dakota have. Do you support the CONNECT Act? And which provi-
sions, in your view, are most important to improve access for rural
and urban patients?
Dr. MURALI. First, I thank you for cosponsoring the CONNECT
Act. It is one of the most important acts, especially in the space of
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35
rural health care, particularly the provision to waive the require-
ments of geographic restrictions to allow FQHCs and RHCs to do
the work that they need to do. It is one of the craziest rules.
For instance, you have a physician who can see say 20 patients
a day. They are in a rural center as part of an FQHC or RHC, and
they only have four patients to see that day. If they need to provide
that service in some of the remote areas, they could not do it if not
for the Act. So that is a wonderful piece of what that act has
achieved, at least in remote and rural parts of Wisconsin.
So I hope I have answered your question as to the value of the
CONNECT Act. And I think Sanford, which is in your State, has
some of the same issues, and they are part of the Clinic Club, and
we spent a lot of time trying to see how we can provide service.
So that is my response.
Senator THUNE. In your testimony, you discussed what could be
the, quote, ‘‘new norm’’ with telehealth and phone. You predict that
15 or 16 percent of all appointments per month may be handled
this way moving forward. Could you talk to us a little bit more
about how you came to that conclusion, and if your data includes
both Medicare and commercially insured patients?
Dr. MURALI. As to the last question, our answer is ‘‘yes,’’ for both
commercial as well as Medicare patients at this point in time for
that calculation.
So let me just make a quick illustration. My wife is a pediatric
neurologist. She is one of three pediatric neurologists in the 45,000
square miles where we provide care. If a mother has to bring her
child for general epilepsy care, which is a 30-minute visit, she
needs to bundle those kids in winter gear, in the peak of winter,
and travel 2 hours, and then back 2 hours, for a 30-minute visit.
This can be done through telehealth.
Like that, there are lots of established visits that can be done
through telehealth, once you have had the first physical visit, and
can be done efficiently. Think about the impact of that to the em-
ployer; think of the impact to the mother; the cost of driving these
kids, paying for their lunches, paying for the gas, and losing 1 day’s
work. That is happening all across rural America. So that is the
number one point.
You can extend that to E&M visits for dermatology. You can do
that for pretty much all specialties in terms of how you can man-
age that care. And that number is about 15 to 16 percent in our
present numbers, and could go up to 20 percent if we are actually
allowed to adopt these services in a creative manner. And that is
confirmed by my colleagues in APG who also do some of that same
work, and further confirmed—when the pandemic happened, when
we shut down all services, 22 percent of all care, even by physi-
cians who were unwilling to do telephone or telehealth visits, was
the number that we had in our institution.
So it is a phenomenal step if we can go down that direction.
Senator THUNE. So as Congress continues to discuss which of
these pandemic flexibilities should be made permanent, there have
been discussions about whether increased program integrity meas-
ures are needed. And some have suggested a requirement for a
face-to-face encounter.
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Concerning this from a health disparity standpoint, I think we
have to be careful about a one-size-fits-all approach that could pre-
vent rural patients in particular from taking the first step to seek
care.
So as things stand today, is there any reason that a clinician
could not tell their patient that an in-person visit is needed, with-
out having a mandate to do that?
Dr. MURALI. Yes; so all clinicians will do the right thing for their
patients. If we believe a physical visit is required, we will do it, be-
cause we have signed the Hippocratic Oath and we want to provide
the best care for our patients. And we carry the burden of their
sickness or outcomes.
So I do not think that that is a concern at all. Like I said in my
testimony, I manage a 67-year-old lady for complex heart failure at
a distance of 200 miles, and she came to visit me once a year for
4 years, and she is well even now 13 years after the episode. She
still sends me a Christmas card. A lot can be done from the stand-
point of how care is provided.
Senator THUNE. Good. Thank you, Mr. Chairman.
The CHAIRMAN. Senator Carper? Senator Carper, I think you are
out there somewhere?
[No response.]
The CHAIRMAN. Okay, we are missing Senator Carper. Let’s see;
yes, Senator Daines would be next, and then Senator Warner and
Senator Hassan.
Senator Daines?
Senator DAINES. Yes.
The CHAIRMAN. All right.
Senator DAINES. Thank you, Mr. Chairman. I appreciate it.
Well, I appreciate this hearing today. We are a rural State in
Montana, and we have faced the access challenge to health care be-
fore the pandemic. And so when folks were told to stay home to
prevent the spread of COVID and avoid exposure to the virus, vir-
tual care became even more important. It was a lifeline in many
cases for Montana patients.
Montanans now are telling me that that test drive of COVID
health-care flexibilities was a success, especially when it comes to
expanded access to telehealth. I believe we need to do what we can
to make expanded access to telehealth permanent for Montanans
and all Americans, especially in rural areas, and not cut access
back once we are in the post-pandemic period.
Back in March of last year, I introduced the Telehealth Expan-
sion Act to allow American workers and families to access virtual
care without the burden of first meeting their deductible. My bill
was signed into law as part of the CARES Act, allowing these high-
deductible health plans with Health Savings Accounts to offer cost-
free telehealth services. This ensures patient access to critical care
during the pandemic.
Today I am teaming up with my colleague Senator Cortez Masto,
and we are introducing legislation to make this policy permanent.
One of the lessons certainly we learned from the pandemic is the
value of leveraging telehealth to meet rising demand for health-
care services.
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Access to virtual care should not solely be considered a COVID–
19 policy. Our legislation, entitled The Telehealth Expansion Act of
2021, will meaningfully expand access to care by permanently al-
lowing first-dollar coverage of virtual care under high-deductible
health plans.
My question for Dr. Murali is, practicing in Wisconsin, you are
all too familiar with rural health-care challenges. Could you speak
to the value of reducing barriers to telemedicine, and specifically
the advantage of making this particular policy permanent?
Dr. MURALI. We actually strongly support that policy. I think you
are talking about your first-dollar policy with respect to high-
deductible health plans, and we believe that that brings immense
value to our communities. And if that is expanded to behavioral
health and other pieces, I think it is a wonderful thing.
I have discussed this with our health plan CEO, as well as our
folks who are on the ground, and the information I received from
them is, it will be extremely well received from the standpoint of
care, and for providing access to care, which is critical in rural Wis-
consin.
Senator DAINES. Thank you, Doctor.
When it comes to accessing telehealth in Montana, our people in
rural communities who lack sufficient broadband Internet connec-
tivity do not have the option of that face-to-face virtual care. In
some cases, audio telehealth using a phone is the only option.
In fact, I just met with some of my primary care docs from Mon-
tana this morning. They talked about being forced to audio tele-
health when we sometimes do not have the visual option. And that
is why I worked with my colleagues last year to ensure payment
parity for audio-only telehealth, ensuring that rural Montanans can
access telehealth no matter where they live, and no matter what
access they might have.
Dr. Murali, how important is payment parity when it comes to
ensuring that folks in rural communities can access care?
Dr. MURALI. I think, as I have said before, there is a lot of in-
vestment that goes into infrastructure to maintain that ability to
provide telehealth and actually lower the cost of care. So payment
parity is absolutely important from that standpoint.
Senator DAINES. So expanded access to telehealth services, in-
cluding physical therapy, has helped our seniors in Montana and
around our country who have been the most vulnerable to the
virus. It also helped demonstrate that therapy needs to be, and can
be met with the use of technology, and that patients can have im-
proved access in rural areas particularly.
Ms. Farb, what has GAO found when it comes to the value of ex-
panded telehealth, including physical therapy, during this pan-
demic? And is there evidence that using telehealth has helped re-
move delays, or perhaps barriers to people accessing preventive
services that have helped to prevent the deterioration of a patient’s
condition?
Ms. FARB. So, Senator Daines, we are still working on our study
looking at the effects of telehealth on the beneficiaries who have re-
ceived it. I can say from some of the interviews we conducted with
beneficiary advocacy organizations that much of what you just said
in terms of serving as a lifeline, and serving as a way for bene-
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38
ficiaries to access services that they otherwise would not have been
able to do—we definitely have heard that.
We will be breaking out some of the utilization both pre-
pandemic and during the pandemic in terms of looking at some of
the data by various demographic characteristics, including urban
areas, as well as particular services, as you mentioned, such as
physical therapy and other services that were available.
So I do not have any preliminary data yet to share on that, but
that is what we are currently working on in our study that we are
doing right now.
Senator DAINES. Thank you, Ms. Farb.
Mr. Chairman, thank you.
The CHAIRMAN. Thank you, Senator Daines.
Senator Crapo is going to help us keep this going. So I believe
our next three will be Senator Carper, Senator Warner, and Sen-
ator Hassan. We can get all three in before the vote.
Senator Carper?
Senator CARPER. Thanks, Mr. Chairman. I was out during our
last recess, Mr. Chairman and colleagues, I was out in the Bay
Area and visited a number of technology companies. Some of them
were startups, some have been around for a while. One of the com-
panies I visited—I think her name was, I want to say Ginger—and
they are involved in behavioral science. And they work with help-
ing people who have behavioral science challenges in their lives,
mental health and so forth, and it is a company that uses telemedi-
cine to try to bring some help to more people early on in their ill-
nesses.
So for me it is something in real life, and I saw it for myself, and
it is, I think, another way to get results, and hopefully better re-
sults, for less money in helping people who are dealing with those
kinds of challenges in their lives.
But I very much welcome this hearing today. During the pan-
demic, telehealth has been an essential, and is becoming a more es-
sential, tool in our toolbox to try to make sure that not just adults,
but children receive the care that they need, while minimizing risk.
And although telehealth in Medicare has been a focus, close to
40 million children, I am told, are enrolled in Medicaid or the Chil-
dren’s Health Insurance Program—close to 40 million. And across
our Nation, families experience barriers that prevent them from ac-
cessing routine health services, like a limited availability of pro-
viders, or long lead times for an appointment.
And for many in Medicaid and the Children’s Health Insurance
Program, increased access to telehealth services can mitigate those
barriers to improve the timeliness and convenience of care delivery,
while also improving health-care outcomes, and do so at reduced
cost.
I have a question for Dr. Berenson, if I could. What are the main
policy changes, Dr. Berenson, that we need to ensure the broader
use of telehealth can be continued for children beyond the pan-
demic? Dr. Berenson?
Dr. BERENSON. Well, I—there is an echo—it tends to be a Medi-
care effort, and I am not a CHIP expert, but I think basically
States need to have generous telehealth policies. But I am not the
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39
person who really can tell you precisely what we should do for chil-
dren in this area.
Senator CARPER. Okay; thank you. Anybody else among the pan-
elists who would like to take a shot at that, please?
Dr. DAVIS. This is Dr. Davis. Again, Medicaid payments for chil-
dren are really important [much echoing] to ensure they have ac-
cess.
Senator CARPER. All right; thank you. Anyone else, please?
[No response.]
Senator CARPER. All right; let me move to the next question. This
is my follow-up question that deals with guidance for State Med-
icaid and CHIP programs. And during the COVID–19 public health
emergency—which we are still struggling to get out of, but making
progress—a wide variety of policy waivers have been put in place
across our country to expand access to telehealth services, unleash-
ing the power and potential of telehealth to safely and effectively
provide care to children and to their families.
However, there is a wide variation in telehealth policies among
State Medicaid programs. And as States consider how to expand
coverage of telehealth services, there is limited guidance or infor-
mation to aid in their planning.
Moreover, there are limited comprehensive studies specifically
looking at the impact of telehealth on the Medicaid population, in-
cluding during national public health problems.
And if I could, Dr. Davis and Ms. Farb, according to MACPAC’s
March 2018 report on telehealth in Medicaid, States looking to ex-
pand telehealth in their Medicaid and CHIP programs would ben-
efit from additional research and a more robust understanding of
the impact of telehealth.
My question of Dr. Davis and Ms. Farb: do you believe that fur-
ther study in this space is still needed? And do you think the real-
world evidence gathered during the pandemic could provide further
insights that support the expansion of telehealth for our children?
Dr. Davis, Ms. Farb, please.
Dr. DAVIS. Thank you, Senator Carper. There has been a lot of
study already, and I think from MACPAC’s work and work that we
have seen, we can start to move forward and recognize the impor-
tance of Medicaid, especially for the benefit of our children who are
participating in the CHIP program and in the Medicaid program.
Ms. FARB. And I will just add, we are actually studying tele-
health and the Medicaid program as we speak, as well. My state-
ment today has been based on the ongoing work that we are doing
both in Medicare and Medicaid. So we are looking at the effects of
the use of telehealth during the pandemic and trying to garner
some lessons learned.
As far as guidance from CMS, we understand that they are plan-
ning to issue some additional guidance to States, but some of that
guidance is still in review within the agency. So, in our ongoing
work, we have talked to CMS about what plans they have to pro-
vide that guidance, especially in looking at sort of program integ-
rity types of things that they need to be aware of.
But we are doing work. So it is hard for me to say we should
not study it more, I think, given where I sit at GAO, but I defi-
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40
nitely think there is a lot of evidence out there, as Dr. Davis point-
ed out.
The CHAIRMAN. There is an important vote, and let us get Sen-
ator Warner and Senator Hassan in before we have to run. And we
are going to keep this going.
Senator Warner?
Senator WARNER. Thank you, Mr. Chairman. I will try to make
sure I address the quick timelines.
First, I think we all know that obviously COVID exposed some
of the racial disparities we see in health-care coverage. I think this
committee and others have tried to do a better job of making sure
we get good data on some of those racial disparities.
One of the things that I have worked with the chairman and oth-
ers on is making sure that we encourage States to go ahead and
expand Medicaid, and that we increase our premium payments. I
actually hope on the ACA, I hope we can make some of those
things permanent.
But, Dr. Berenson, do you want to weigh in on this issue of
whether the expansion of Medicaid in States that were not covered,
whether the ACA additional premium payments support that we
put in place in some of the legislation recently will actually start
to help diminish some of the racial disparities that were exposed
by COVID–19?
[Pause.]
Senator WARNER. I think you are on mute, Dr. Berenson.
Dr. BERENSON. Sorry about that. Again, I am not a Medicaid ex-
pert, but my understanding of the results from Oregon, which had
that study where they sort of randomly selected people into Med-
icaid, demonstrated better access when people did get Medicaid.
And I think that the outcomes were a little mixed, but the study
was not conducted long enough to be able to demonstrate those.
So I basically agree with the premise of your question there.
There need to be incentives for all States without Medicaid as an
expansion.
Senator WARNER. Well, thank you. I think I am going to, obvi-
ously, continue working with the chairman and others on this.
Let me move to a slightly more probing question for Dr. Davis
and Ms. Farb. You know—and let me preface this question with,
obviously we all realize the opioid abuse and substance abuse
issues are a huge challenge, and this committee again, with folks
like my friend Senator Portman, has been grappling with that for
some time.
On the other hand, I have been trying to get the DEA, literally
for close to 10 years, to allow for physicians to—and frankly, for
the DEA to promulgate rulemakings, which they were supposed to
have done by law, to allow certain physicians to prescribe certain
controlled substances via telehealth. We have made sure to make
this happen in legislation called The SUPPORT Act last Congress.
But the DEA continues to refuse to take up this rulemaking.
I have reached out to them multiple times on this. I do believe
that the Biden administration is trying to work in good faith, but
with the importance of telehealth being accentuated by COVID, by
this panel, Dr. Davis, I would like to hear from you, given your ex-
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41
perience with patient care, and, Ms. Farb, maybe GAO may have
taken a look this issue as well.
I know we want to make sure there is not abuse, particularly
when it comes to controlled substances, but I do think we have
been waiting 10 years. It is in the law. And while we need to put
appropriate protections in place, we need to let physicians have
these tools.
So, Dr. Davis and Ms. Farb, will you comment on that subject?
Dr. DAVIS. Sure. Thank you, Senator Warner.
I do also want to go back to your previous question. As Vice
Chair of MACPAC, I do want to echo that we have already started
to see a reduction in health disparities in those States that have
expanded Medicaid. And we need to continue to study that and
look and see those drivers.
In terms of substance abuse treatment, as a buprenorphine pro-
vider myself, I have seen the benefit, especially throughout
COVID–19, of being able to conduct those services by telehealth.
Being able to prescribe remotely and electronically, being able to
keep patients from relapsing, has been essential, especially with all
of the stresses that have happened over the last year.
And so I encourage continuation of, as well as passing new legis-
lation getting us further along to be able to conduct that service
electronically, both in terms of prescription and in terms of the
visit by telehealth or audio.
Senator WARNER. Thank you, Doctor. I agree with you. And
again, DEA, on some of this rulemaking, has just been dragging its
feet.
Ms. Farb, do you want to make a comment?
Ms. FARB. Sure. So GAO does have prior work kind of looking at
some of the barriers to medication-assisted treatment for opioid use
disorder. And we have noted that some of what you are discussing
did occur, in terms of prior authorization requirements, and restric-
tions on distribution, and just the Federal waiver that providers
need to prescribe or administer some of the prescriptions that are
needed.
So we did not make any recommendations out of that study, but
we definitely did enumerate all the barriers that are being faced
by providers and various health-care programs.
Senator WARNER. Well, I hope we can keep working on this. I
think I will turn it back now to, I guess, Senator Crapo, you are
filling in. Thank you.
The CHAIRMAN. Thank you, Senator Warner. This is great.
We are—let’s see. It is Senator Hassan there, and Senator Crapo
is back, and I will run and vote and come right back. But Senator
Hassan is up now, Senator Crapo.
Senator HASSAN. Well, thank you so much, Chairman Wyden and
Ranking Member Crapo, for this hearing. I want to echo what Sen-
ator Warner was just talking about when it comes to facilitating
medication-assisted treatment, and I look forward to working with
colleagues on both sides of the aisle on that.
And before I get to my questions, I also want to reinforce my col-
leagues’ calls to continue to expand telehealth access, including in
rural communities. The dramatic expansion in telehealth services
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during the pandemic has benefited a large number of patients, in-
cluding in my home State of New Hampshire.
I want to turn now to Dr. Davis. The news that there could be
an authorized COVID–19 vaccine for all children by the end of this
year is truly an exciting development for many families. However,
I am very concerned that over the past year routine child wellness
visits and pediatric vaccinations have declined significantly, par-
ticularly for children enrolled in Medicaid and the Children’s
Health Insurance Program.
Telehealth expansions have improved access to many routine pri-
mary care services, but unfortunately you cannot get a vaccination
over Zoom.
So, Dr. Davis, as telehealth becomes more integrated into pri-
mary care services, how can we ensure that children will continue
to attend routine, in-person wellness visits that help ensure that
children are receiving lifesaving vaccinations, as well as critical de-
velopmental and physical screenings? And how do we get children
who missed their routine vaccinations over the past year back on
track?
Dr. DAVIS. Thank you, Senator Hassan. The answer is, you know
it is very important, and I do worry about the kids who are delayed
in their vaccines because of hesitancy in going into care. But I have
seen the resilience of our family physicians and pediatricians, espe-
cially at our community health centers, in getting creative and in-
novative and making sure that kids are getting their vaccines in
terms of drive-up clinics, parking lot operations, and being able to
make sure that they are getting them.
I am not worried that telehealth is going to replace what we do
as physicians. And in combination with the primary care relation-
ship, doctors are going to make sure that their kids are coming in
for their vaccines, and I have really seen them being stalwarts and
champions in continuing that.
I think that there are other things that we can do to encourage
vaccines, requirements that happen at schools, you know, to make
sure that kids are getting the vaccines. But I am not worried
that—there is a lot of catch-up to do, but I think that we can get
there.
Senator HASSAN. Thank you so much for that.
To Dr. DeCherrie, I want to talk with you a little bit about home
and community-based services. The American Rescue Plan in-
creases Federal funding for home and community-based Medicaid
services. However, while this initial investment is an important
step, we need to do more to ensure that older adults and individ-
uals with disabilities have access to this care.
Many of us on the committee are continuing to work towards
some long-term solutions here, but what changes do you believe are
needed to expand the home health workforce and improve the qual-
ity and accessibility of home and community-based services?
Dr. DECHERRIE. Thank you so much for this question. We can-
not—you know, in geriatrics we cannot do what we do without the
family support, without the aides who are there to care for our pa-
tients. Our work is like one-tenth of the daily work that these peo-
ple do to help support our patients. And it is so important that we
are able to support the caregivers.
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So I agree with you that we need to think about how to expand
that workforce, how to make sure that patients are able to get
quality care through that workforce. And it could be through family
caregivers or paid caregivers.
Senator HASSAN. Thank you. Is it fair to say that families who
can get some support and relief from home care health aides, for
instance, often are able to support their loved ones better at home
than when they try to do it all by themselves?
Dr. DECHERRIE. Yes. Definitely.
Senator HASSAN. Thank you.
Dr. Davis, one more question. The COVID–19 pandemic has dem-
onstrated the value of providing critical vaccines to vulnerable pop-
ulations at no cost. Women covered through Medicaid are less like-
ly to receive the tetanus and influenza vaccines during pregnancy
than those who have commercial insurance.
Earlier this year, Senator Cassidy and I reintroduced the Mater-
nal Immunization Coverage Act to help address this disparity. This
is a bipartisan bill that would ensure that State Medicaid programs
cover ACIP-recommended vaccines for pregnant beneficiaries at no
cost.
Dr. Davis, how should we parlay the lessons that we have
learned from this public health emergency about the benefits of
providing vaccines to vulnerable populations at no cost in order to
ensure that all Americans have access to life-saving vaccinations?
Dr. DAVIS. You know, we have really learned from the COVID–
19 vaccination that when you are able to offer it without cost, that
removes a significant barrier. And the AAFP agrees that we should
expand access to all ACIP-recommended vaccines at no cost
through Medicare and Medicaid, CHIP, and all other commercial
insurers.
Senator HASSAN. Thank you very much.
And thank you, Senator Crapo.
Senator CRAPO [presiding]. Thank you.
And Senator Young is next on the list, but I do not see him on
the screen. Is Senator Young with us?
[No response.]
Senator CRAPO. All right, Senator Warren, I see you. Go ahead,
please.
Senator WARREN. Thank you, Mr. Chairman.
So when coronavirus hit, patients still needed access to basic
health services like primary care and mental health visits, but
COVID made it harder for patients to get the care that they need-
ed. On top of the usual struggles like taking off time from work,
people now had to keep themselves safe from infection. Services
that were already difficult to manage even in the best of times be-
came much harder to get.
Take hearing loss, which affects 48 million Americans. On aver-
age, it takes 7 years for patients to seek treatment for hearing
issues, even when we are not in a global pandemic. And COVID–
19 only added additional burdens.
So that is a key reason why the Centers for Medicare and Med-
icaid Services made it easier for providers like audiologists to offer
hearing services remotely during the pandemic.
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Ms. Farb, what steps has CMS taken to make it easier for pa-
tients to access care from audiologists through telehealth during
this pandemic?
Ms. FARB. Well, Senator, as you pointed out, CMS initially ex-
panded the types of providers that could furnish telehealth services
to include all those eligible to bill, which included physical thera-
pists and speech language pathologists, as well as audiologists.
At the beginning, they were able to bill for certain codes starting
in March of 2020, and some of those codes are not typically the
codes that are billed by audiologists, but CMS added additional
codes to the list at the end of March of 2021. And that coverage
is effective retroactively back to January of 2021. The list included
services such as tone decay tests and assessments of tinnitis. And
so that expanded sort of the ability for audiologists to provide those
services.
We spoke with ASHA, the association that covers speech lan-
guage pathologists as well as audiologists, and they were very sup-
portive of those changes.
Senator WARREN. So, Ms. Farb, if I can just summarize, CMS
considered all the audiologists to be important enough to include
in the response to the pandemic, but audiologists usually are not
treated equally in the Medicare program. Despite their years of
schooling and training, audiologists are considered, quote, ‘‘sup-
pliers’’ not, quote, ‘‘practitioners’’ in the program. And outdated
Medicare rules require patients to get their doctor’s permission to
see an audiologist rather than letting patients make the decisions
they need to improve their hearing.
So let me ask, Dr. DeCherrie, why is it so important that seniors
with hearing loss can access the providers they need, including au-
diologists, without bureaucratic limitations that make it harder for
them to get care?
Dr. DECHERRIE. Thank you for that question. Yes, I mean being
able to hear is so important, especially for our elderly patients. I
mean, there have been numerous studies that have shown reduced
risk of falls, improved mood, improved memory, all by being able
to hear better. I mean, we see this every day on home visits now
when we are trying to do something by video. If they cannot hear,
just turning up the volume does not work.
So these patients really do need their hearing assessed, and then
potentially a hearing aid or whatever is needed.
Senator WARREN. In other words, audiologists provide critical
services to people with hearing loss. That is why I am joining Sen-
ator Paul and Senator Grassley in reintroducing the Medicare Au-
diologist Access and Services Act. This is a bill that would expand
seniors’ access to hearing services by reclassifying audiologists as
practitioners in the Medicare program. And that will allow them to
bill for services without a physician referral, and to provide pa-
tients with both the diagnostic and treatment services that are
within an audiologist’s scope of practice.
It seems to me that the COVID–19 pandemic has forced us all
to reconsider bureaucratic limitations to health care, including
hearing care. So I believe that the Senate should prioritize the pas-
sage of our bill to help seniors get the care that they need.
Thank you, Mr. Chairman.
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Senator CRAPO. Thank you, Senator Warren.
And I see Senator Cortez Masto, so, Senator, you may proceed.
Senator CORTEZ MASTO. Senator Crapo, thank you. And thank
you to the panelists. This has been a very, very informative con-
versation. And let me echo and agree with my colleagues. I think
making telehealth permanent is so important for the reasons that
we are discussing today. But I also recognize and really appreciate
the challenges that we still need to understand, the data. We need
to capture the accurate data, the diversity in the data. We need to
make sure we put up guard rails but still to study it. But for the
many reasons we have talked about, I think it is so important.
I have seen the benefits in Nevada alone, but here is one thing—
and we have talked about this already this morning—which is
audio-only diagnostic information. I absolutely have concerns that
we are not allowing the diagnostic information for audio-only to
occur. This is information that I have been talking to CMS about.
And so, because I think it is so important that we address this—
and clearly my colleagues feel the same way after listening to the
conversation this morning—Senator Tim Scott and I introduced a
bill, the Ensuring Parity in Medicare Advantage for Audio-Only
Telehealth Act.
It would really require CMS to include diagnosis obtained via an
audio-only telehealth visit in a Medicare Advantage risk adjust-
ment program. And it is so important for the very reasons that you
talked about.
So I want to get that out there. But let me also—Dr. Davis, let
me ask you this. In your experience, are patients with high-
deductible health plans more or less likely to seek regular treat-
ment?
Dr. DAVIS. Pre-public health emergency, I certainly saw patients
who were hesitant to come in because of the high-deductible health
plans, and just not being able to afford it.
The AAFP supported temporarily waiving the deductible for tele-
health visits, because the investment was necessary for providers
to really be able to make that investment in telehealth. We are
concerned, though, with the permanent waiver of that and the pos-
sibility of creating a two-tiered system where low-income enrollees
are only able to afford virtual care.
And so we recommend that the committee pass legislation to
allow high-deductible health-care plans to waive the deductible for
primary care and mental health services, both in person and tele-
health, to promote timely access to high-value care and preserve
patients’ freedom to choose the most appropriate modality of care.
Senator CORTEZ MASTO. Yes, I could not agree more. And I thank
you for that.
And so let me jump to Ms. Farb. There was conversation about
identifying the quality of telehealth health services. And I know
you were asked what were the metrics that GAO was looking at.
And you said that GAO had not defined yet the metrics for identi-
fying the quality of telehealth services.
Can you give me a timeline? Is this something that is a priority
now for GAO? And is this something you will be further looking
into, or GAO will, in identifying those metrics?
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Ms. FARB. Yes, Senator. So, as far as identifying and creating the
metrics, that is a role that GAO does not play. We rely on the insti-
tutions that are sort of responsible and contracted with HHS, such
as the National Quality Forum, to develop consensus-based quality
metrics.
And as I mentioned earlier, both the NCQA, another quality or-
ganization, and NQF have been working this past year to sort of
adapt some of the metrics and frameworks that they use to incor-
porate telehealth, the concept of telehealth, and focusing it on
things that are clinically meaningful for patients and providers to
measure quality.
So that is sort of what we are waiting on: to see what these other
institutions are going to do in terms of how they are going to define
quality. There are ways to compare particular end points and out-
comes where you could compare telehealth to in-person care. But
that is still a ways away for us in terms of our work that we are
doing right now.
Senator CORTEZ MASTO. Well, thank you. And so then, let me
jump to Dr. DeCherrie, because I think it is important. In your tes-
timony you really talked about the acute Hospital at Home waiv-
ers, and particularly the front-end costs of getting things started,
whether it is telehealth, acute Hospital at Home waivers, whatever
is needed—that the hospitals were not making some of these in-
vestments long-term because they were not sure if the waivers
would become permanent.
And I guess my question to you is, what is it that you need from
us on a Federal level, or you would think that the hospitals need,
to really be thinking long-term that we want to move in this direc-
tion, short of passing legislation?
Dr. DECHERRIE. Yes, well, the Hospital at Home waiver came
about last November. Obviously we do not know exactly when the
public health emergency is going to end, but it is tied to the public
health emergency. Right now, that date is July. And so, making an
investment now for a program that might end in July, that is a big
decision for a hospital.
So making the waiver permanent for another year, or another 2
years, or extending the waiver while things are being analyzed, I
think that that would be one way that would entice the hospitals
to apply for it.
Senator CORTEZ MASTO. Thank you. Thank you again.
Thank you to the panel members.
The CHAIRMAN. Thank you, Senator Crapo, for filling in. It has
gotten to be a tradition. We juggle all of this.
Senator Young, I believe, is next. We are moving into the home
stretch, colleagues, if members have not gotten a chance to ask
questions. We are putting out the word that we are almost done.
Senator Young?
Senator YOUNG. Thank you, Mr. Chairman.
Well, I welcome our panelists, and I will begin with the topic of
telehealth. Even prior to the pandemic, I heard from my constitu-
ents in Indiana, particularly those in rural areas, about the ways
in which telehealth can both increase access to underserved Ameri-
cans and reduce health-care costs.
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Since the start of the public health emergency, the telehealth
flexibilities provided by Congress and the Department of Health
and Human Services have been a lifeline for vulnerable seniors. I
have seen it up close and personal. It is amazing how we have been
able to leverage telehealth to provide vital services, to our seniors
in particular.
But others have taken advantage of this as well to access all
manner of care from the safety of their own homes. Currently, au-
thorizations are included in the CARES Act to create additional
flexibility for patients and providers using telehealth that only ex-
tend through the pandemic.
So I will ask some questions of Dr. Murali. The Federal Govern-
ment has relaxed, waived, or changed many regulations to extend
access to telehealth during COVID–19. What regulatory flexibilities
are key to providing telehealth today and should be made perma-
nent after COVID–19?
Dr. MURALI. So I personally think that all the telehealth waivers
that came in during the pandemic need to be extended. The par-
ticular focus on behavioral health is something that you have been
a strong proponent of, and looking at what is happening in the
rural geography. And I heard a story of a 63-year-old farmer who
had to sell all his cows and would not come in to our institution
for psychiatric care if telehealth was not available. So it is fun-
damentally important to extend that.
In terms of the acute care without walls, that is something that
we are all invested in, and we know it works very well. The out-
comes from the standpoint of fall prevention, the outcomes from
the standpoint of reducing infections, length of stay, cost of care,
safety, patient satisfaction, patient acceptance rates, are all phe-
nomenal and off the charts. And that is something that should be
extended beyond the pandemic. So those are two things.
And then in terms of the geographic site requirements, I think
that that also has to be remote because the geographic site require-
ments restrict care. So it does not make sense that a Medicare Ad-
vantage patient can go to an MSA and seek care, when the Medi-
care fee-for-service patient cannot go to the same location and seek
care. So it works for one, but it does not work for the other.
So there are several of these waiver programs that just need to
be disposed and done with. And if there are prospective payment
mechanisms for groups that are taking risk or capitation, they will
figure a way of how to manage the cost of health care within the
budget that they are allocated. But actually making sure that out-
comes and quality are tied to the provider who is providing care
is important. So you want to take the middle man out of the equa-
tion and say, physician groups, care delivery groups, you are re-
sponsible for delivering on this, and this is the expectation, and
they will telework. Because if you have front-end money to invest
on that, we can provide care creatively, just as we did during the
pandemic.
And so those are things we would support.
Senator YOUNG. So you just provided a very concise and compel-
ling tutorial on the extension, I think, of these waivers. I appre-
ciate that.
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48
Just from personal experience—I visited mental health providers,
and they have indicated to me that not only have they seen an in-
crease in the rate of maintaining appointments, which increases
their efficiencies, but there are certain individuals, for private rea-
sons, who would prefer to have their initial consultation, or in some
instances all their consultations, through telehealth, irrespective of
the public health condition at a particular period of time.
The providers are generally very happy with the ability to pro-
vide telehealth. It took a period of time for many of them to become
used to it, but one could envision hybrid services, here again even
for those who have access to or are able to physically go into the
office. But there are just so many efficiencies, conveniences to the
consumer as well as to the provider, that can be realized here.
And as we talk about bending the cost curve down—actually we
stopped talking about that, because we have utterly failed, for a
number of reasons. Number one, I do not think we have invested
enough in prevention across a number of different areas. But this
is another area where I see just sort of a fertile opportunity to re-
duce the actual cost of care, and therefore reduce the cost of insur-
ance for my constituents and others.
So it is very important. Thank you for your quick summary.
How much time do I have left, Mr. Chairman? It looks like 30
seconds. And so, for that reason, I will yield back the balance of
my time.
The CHAIRMAN. All right. If my colleague, because he is the last
one, has a last question, I do not want to see him stifled.
Senator YOUNG. I have a vote to cast, but thank you for your
time, Mr. Chairman.
The CHAIRMAN. Great. Thank you.
All right, I believe we have heard from all of our members. I
have a brief closing statement, and I always like Senator Crapo to
have a chance to do one as well.
Senator Crapo, would you like to go now?
Senator CRAPO. Well, certainly. I will be very brief, Mr. Chair-
man. I again thank you for holding this hearing, and I thank our
witnesses. I think we have had a very strong support for a number
of the provisions that you and I, Mr. Chairman, think we need to
address on a permanent basis, particularly telehealth. I appreciate
your helping us confirm what the issues are, and what the benefits
are of making that loop.
And, Mr. Chairman, I turn it back to you.
The CHAIRMAN. Okay. Let me say ‘‘thank you’’ to all our wit-
nesses.
Back in the days when I was director of the Gray Panthers, we
dreamed of being able to tap the technology treasure trove that ex-
ists today. It is extraordinary what can be accomplished. And you
all made so many important points. Certainly this question of eq-
uity is fundamental.
I would probably say telemedicine during the pandemic was a
godsend for people who could get access to it. And you all have
made a compelling case that a number of people could not. We
started, I guess, 3 hours ago.
Dr. Davis, you and I were talking about the importance of mak-
ing sure that audio-only telehealth is expanded. I also share your
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49
view about the fact that it ought to be accessible in other languages
as well. And you could hear the strong sentiment from my col-
leagues of both political parties on that. Because you know, audio-
only can be a lifeline in rural communities and communities of
color where access to telehealth is limited at best.
We also got a lot of good recommendations. Dr. DeCherrie made
the recommendation to allow permanent waivers for Hospital at
Home. It strikes me as a very good suggestion.
I think several of you made the point that it was time for Con-
gress to remove geographic site restrictions on telehealth. I think
you, Dr. Davis, and maybe the good souls at GAO recommended
that, but several of you said that there really was not a substantive
case for doing that.
And Dr. Murali, off on the corner of my screen, really brought
it home when he said there is no place like home for American
health care, and probably if Americans could have heard the news
you were giving, you would have gotten a digital standing ovation
for that one.
Now in terms of the challenges, I was really struck when Dr.
Berenson described, several hours ago, the process of billing and
approval bouncing from office to office to office, leaving both pa-
tients and providers in something resembling a bureaucratic
Never-Never Land.
And, Dr. Berenson, you and I have known each other for a lot
of years. We have appreciated your good work. But we would like
to conscript all of you good people into this question of sorting out
the bureaucracy. And Senator Crapo and I have made this kind of
a special priority, because if we are really going to get it right and
squeeze out every bit of value for both patients and providers, as
well as taxpayers, we have to sort this out. And I will tell you, Dr.
Berenson, you brought it home, because I have been hearing that
at home too about billing and approval and the like. Because this
was something that was put together so quickly—and that is an-
other story, because then-Chairman Hatch and I thought it would
have been done well before the pandemic, because the CHRONIC
Care Act was passed in 2017. It was stood up very quickly. And
when you painted that picture of billings and approvals, it was al-
most like the days when I ran the legal aid office for the elderly
and we just bounced bill after bill after bill, and program after pro-
gram from office to office, and eventually they said, ‘‘Well, Ron is
going to run it down.’’
Well now, Senator Crapo and I are going to do this together. We
are going to sort this bureaucracy challenge out, and we are going
to conscript all of you. But it has been a terrific panel. In my time
in public service, we have had a chance to talk to a lot of thought-
ful people, and we managed to get everybody together who was
thoughtful this morning. So a big thanks, and with that the Senate
Finance Committee is adjourned—excuse me. One bit of business.
For members, all questions in writing for our guests are due a
week from today.
And with that, the Finance Committee is adjourned, and we
thank you all.
[Whereupon, at 12:45 p.m., the hearing was concluded.]
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APPENDIX
ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD
PREPARED STATEMENT OF ROBERT A. BERENSON, M.D.,*
INSTITUTE FELLOW, URBAN INSTITUTE
Chairman Wyden, Ranking Member Crapo, and members of the committee, tele-
health offers the promise of an important disruptive innovation in health-care deliv-
ery. With broad adoption, the approach could simultaneously (1) increase access to
care for the American public, (2) raise the quality of that care, and (3) substantially
reduce spending growth. However, decisions on how to pay for expanded use of tele-
health—decisions that need to be made in the near future—will determine whether
that promise is achieved or, alternatively, whether telehealth adoption will raise
spending substantially without corresponding benefits to patients or society.
I have spent a good part of my professional career, first as a practicing, general
internist in a Washington, DC, group practice; then as a government official in
charge of Medicare payment policy at the Centers for Medicare and Medicaid Serv-
ices (CMS) in the Clinton administration; and for nearly 20 years as a policy re-
searcher at the Urban Institute, exploring better ways of compensating physicians
and other health professionals. (The views expressed here are my own and should
not be attributed to the Urban Institute, its trustees, or its funders.) I have focused
both on making improvements to the predominant fee schedule method of paying
practitioners and on seeking workable payment alternatives to fee-for-service. I have
also worked on these payment method issues as vice chair of the Medicare Payment
Advisory Commission, better known as MedPAC, and more recently as an initial
member of the Physician-Focused Payment Model Technical Advisory Committee, or
PTAC, which was established under the Medicare Access and CHIP Reauthorization
Act of 2015, or MACRA.
Payment reform has not been easy or particularly successful. Over the past 40
years, ‘‘alternative payment models’’ (APMs) have come and gone as clinicians and
hospital providers have continued to battle more for their share of the fee-for-service
pie rather than embrace alternatives that in the long run would enhance their own
practice environment and sense of professionalism, provide economic stability to
practices, and better serve their patients.
Although I am sure that with so many other issues to address following the
COVID–19 pandemic, there is temptation to simply ratify as permanent what were
intended to be temporary policies during this public health emergency. But Con-
gress needs to recognize that it has a unique (though maybe short-lived) opportunity
to act decisively to move away from nearly complete dependence on the Medicare
Physician Fee Schedule (MPFS) to more successful, alternative payment approaches
that will open the door to further APM development and adoption. In my view, mak-
ing permanent the temporary public health emergency work-arounds could be a
years-long setback to the compelling need for fundamental provider payment reform
for Medicare and, because Medicare typically establishes the model for other payers,
the entire health-care system.
The committee should understand that over the past decade as public policy has
encouraged the development of so-called ‘‘value-based payment,’’ I have been some-
thing of a contrarian, pointing out that all payment methods have strengths and
weaknesses, including fee-for-service. Accordingly, I argue that the legacy payment
* The views expressed are my own and should not be attributed to the Urban Institute, its
trustees, or its funders.
(51)
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52
models (for physicians, the MPFS) need attention to improve value and to better
complement proposed APMs. I have also argued that many proposed APMs, al-
though conceptually compelling, are operationally challenged if not impossible, yet
they consume a lot of what economists call ‘‘opportunity costs.’’ The result is that
I sometimes defend the MPFS and point to recent improvements that have clearly
added to the value produced by the MPFS (i.e., that improve access and quality at
an acceptable cost). But as I will try to make clear in this testimony, fee-for-service
is a particularly inappropriate payment method for most telehealth services.
My interest in finding a payment method appropriate for what we are calling vir-
tual care (i.e., not in person, using a growing range of communication technologies)
is not new. I co-authored a paper in 2003 commenting on the Chronic Care Model,
which had been recently developed by Edward Wagner and colleagues at the Uni-
versity of Washington.1 Besides advocating for other innovative approaches to car-
ing for the increasing number of individuals living with one or more chronic condi-
tion, the Wagner Model called for robust communications with patients outside of
the occasional in-office visit (largely by telephone at the time). In the paper, I ex-
plained why payment for what should be high-frequency communications should not
be through fee schedules; instead I called for telehealth payment primarily through
per person per month (PPPM) payments. In essence, these would be telehealth ac-
counts that would provide practices a lump sum that patients spend down to sup-
port virtual care. It is fair to say that that paper was thoroughly ignored. However,
the urgency and interest in finding an alternative to fee schedule payments for tele-
health has now increased substantially. In this testimony I will expand on that per-
spective, laying out the main barriers to fee schedule payment for telehealth serv-
ices and suggesting alternatives.
Last year, CMS acted with decisive speed to provide a safety net for practices and
ongoing access for patients during the public health emergency. CMS (1) introduced
flexibility in the requirements for a qualifying telehealth video visit by permitting
the patient’s home (rather than only a medical facility) to be an accepted telehealth
originating site; (2) reversed a long-standing policy, now designating phone calls as
short as 5 minutes as a reimbursable service; (3) softened security and privacy re-
quirements to permit usage of a broad range of communication devices and methods;
and as I will discuss in more detail below, (4) raised fees substantially, in the proc-
ess ignoring the resource-based relative value scale approach that the organization
has followed since 1992, however imperfectly. The public health emergency modi-
fications also expanded the range of clinicians, such as physical therapists, eligible
to bill telehealth services.
I will identify three major reasons why maintaining most of these rule flexibilities
and increased payments should not be maintained over the long term. Adele
Shartzer (an Urban Institute colleague) and I outlined these concerns in a recent
paper in JAMA Forum.2
1. ADMINISTRATIVE COMPLEXITY
Fee schedules can function reasonably well when code descriptions are concise
and specific, thereby producing reliable and accurate coding. For example, there are
about 20 different payment codes for colonoscopies, with each one detailing whether
there was a polyp removed, a biopsy taken, or some other distinctive feature of the
procedure. Colonoscopies represent a clearly defined procedure. Operationally, it is
easy to bill for and receive fee schedule payment for a colonoscopy. Most procedures,
tests, and imagings lend themselves operationally to payment by fee schedule. But
codes for telehealth services are not concise; indeed, CMS telehealth codes attempt
to delineate the specific communication technology employed, the patient’s location
during the communication, which party initiated the service, the duration of the vir-
tual encounter, the time interval from prior and subsequent office visits, the fre-
quency of allowed billing for the service, and other characteristics specific to the
particular telehealth services. Importantly, these coding parameters were estab-
lished for payment purposes alone: they do not provide useful clinical distinctions.
Given rapidly evolving technological capabilities, telehealth codes will quickly be-
come outdated. The tangle of telehealth codes (now numbering about 250 and count-
ing in the MPFS), combined with lots of code requirements, will lead to fraud in
some cases, but also more commonly to ‘‘gaming behavior’’ by provider practices. For
1 Berenson, RA and Horvath J. ‘‘Confronting the Barriers to Chronic Care Management in
Medicare,’’ Health Affairs, 22, Suppl 1 (2003): W3–1—W3–14.
2 Robert Berenson and Adele Shartzer, ‘‘The Mismatch of Telehealth and Fee-for-Service Pay-
ment,’’ JAMA Health Forum 1, no. 10 (2020): e201183.
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example, if a phone call needs to last at least 5 minutes to qualify for payment, how
will Medicare ferret out 4-minute calls that were billed (many of which will be as
clinically important as calls lasting a minute longer). Will the agency require use
of timing devices on phones?
Especially if overly generous payments are made through pay parity for telehealth
visits and phone calls, CMS will feel compelled to impose additional burdensome
(and ultimately ineffective) documentation requirements as these telehealth services
proliferate. In short, following the COVID–19 pandemic, using the standard MPFS
to pay for telehealth services would likely produce a quagmire of confusion, inad-
vertent or intentional miscoding, and lots of clinician and patient complaints about
burden and counterproductive rules.
2. BILLING COSTS IN RELATION TO PAYMENT LEVELS
For reasons that practices and hospitals know well but policymakers rarely ac-
knowledge, fee-for-service payments can generate high billing costs relative to the
payment sought and received. The result is that it is imprudent to pay for high-
frequency, low-payment services by fee schedule, at least when the low-priced serv-
ice is the only service billed rather than one line on a larger claim. A recent study
from an academic health center found that the cost for billing and related docu-
mentation activities for an office visit was $20.49, including 13 minutes of work for
various individuals, including clinicians.3 There is no obvious reason why billing and
documentation costs for submitting telehealth services would be much less than
that. Indeed, studies have documented that the costs of billing and related functions
make up 10 to 15 percent of operating revenue for practices.4 In short, because a
major portion of billing costs are fixed and apply to any service regardless of the
payment level, practices would bear transaction costs approaching or exceeding the
payment they would receive.
And that is just the billing cost for the first submitted claim from the practice.
A typical claim for a MPFS service is generated by the practice and sent to a Medi-
care administrative contractor, which adjudicates the claim and makes a payment
to the practice for Medicare’s portion. The contractor passes the claim to a supple-
mental insurer, such as a Medigap carrier, which determines its portion and informs
the practice what it can bill the patient for applicable beneficiary cost-sharing, at
which point the practice generates another bill for the patient. Even with electronic
transfer, this cycle of claiming and paying requires many manual steps, and the cu-
mulative costs clearly exceed the $20 for the initial claim.
Practices understand this billing reality. CMS adopted a ‘‘virtual check-in’’ code
in the 2019 MPFS for short (5- to 10-minute) phone calls with patients to sort out
whether patients needed to come in for an office visit. The ‘‘correct’’ national fee ac-
cording to usual relative cost determination was about $15. Although the check-in
call may make good clinical sense in some situations, it failed from a financial point
of view. Not surprisingly, practices rarely billed for the service, suggesting that
practices considered the relatively meager payment too little to justify the even
higher billing costs. The result was that Medicare allowed less than $200,000 for
this code in 2019 (compared with total spending under the MPFS of more than $90
billion.)
Perhaps CMS learned the lesson of payment levels below billing costs. Within a
few weeks of adopting payment for phone calls during the public health emergency,
CMS raised the payment for a 5- to 10-minute phone call from $15 to a more accept-
able $46—the rate for a level 2 office visit. It made perfect policy sense during the
public health emergency to get money out to financially strapped practices while
also facilitating needed access for beneficiaries to their practitioners. However, re-
taining this three-fold increase in the proper fee (indeed, adopting complete pay par-
ity) presents an unresolvable dilemma for policymakers. Using standard, relative
3 Phillip Tseng, Robert S. Kaplan, Barak D. Richman, Mahek A. Shah, and Kevin A.
Schulman, ‘‘Administrative Costs Associated with Physician Billing and Insurance-Related Ac-
tivities at an Academic Health Care System,’’ JAMA 319, no. 7 (2018): 691–97.
4 Bonnie B. Blanchfield, James L. Heffernan, Bradford Osgood, Rosemary R. Sheehan, and
Gregg S. Meyer, ‘‘Saving Billions of Dollars—and Physicians’ Time—by Streamlining Billing
Practices,’’ Health Affairs 29, no. 6 (2010): 1248–54; James G. Kahn, Richard Kronick, Mary
Kreger, and David N. Gans, ‘‘The Cost of Health Insurance Administration in California: Esti-
mates for Insurers, Physicians, and Hospitals,’’ Health Affairs 24, no. 6 (2005): 1629–39; Julie
Ann Sakowski, James G. Kahn, Richard G. Kronick, Jeffrey M. Newman, and Harold S. Luft,
‘‘Peering into the Black Box: Billing and Insurance Activities in a Medical Group,’’ Health Af-
fairs 28, no. 4 (2009): w544–54.
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54
cost calculations, the fees for many desirable ‘‘small-ticket’’ items would be too low
to justify practices performing them and /or billing for them. Yet raising the fees to
make it financially worthwhile for the practices would create a major precedent for
ignoring relative values based on relative resources, thereby opening up the fee
schedule to special pleadings from many stakeholders.
Paul Ginsburg (the Vice Chair of MedPAC) and I wrote a paper in 2019 arguing
that it is time for the MPFS to move off of strict adherence to relative costs to deter-
mine fees (Berenson and Ginsburg 2019).5 This could be accomplished by both (1)
altering fee levels for likely overpriced services by examining service volume
changes that occur in response to initial fee changes, usually fee reductions, and (2)
seeking to accomplish specific policy objectives that could be supported by fee
changes, usually providing increases in underpriced services, such as to increase the
attractiveness and supply of primary care health professionals. Pay parity for tele-
health services in the face of research that shows substantially lower production
costs 6 should not be adopted as a policy ‘‘one-off ’’ under the current pressure to gen-
erously expand telehealth. Rather, such parity should be considered only as part of
a more comprehensive approach to modifying how MPFS fees are determined. Doing
otherwise could lead to a policy free-for-all in which plausible (but self-interested)
pleadings are advanced outside of a disciplined process for weighing the merits of
fee changes. Dr. Ginsburg and I argued that CMS, under the guidance of a formal
Federal Advisory Committee Act—compliant committee, should have the authority
to change fees considering factors other than relative costs.
3. INCREASED VOLUME AND SPENDING
I anticipate that patients and their families will love the alternative of video-
based telehealth and much greater use of phone communications with their practi-
tioners and primary care team members. Patients face substantial time costs and
inconvenience in traditional travel, waiting rooms, and actual time with the practi-
tioner. I recently waited 20 minutes after my visit just to check out. The routine
annual wellness visit took about three hours altogether (admittedly with some
delays created by COVID–19 concerns).
I would reiterate that telehealth should be advanced substantially as a potential
game-changer in how care is delivered. My objection lies in using fee schedule pay-
ments as the way to compensate the practices when alternatives exist that can be
adopted and adapted over time. Without the constraints of consumer time and in-
convenience, the potential for a spending explosion is real, especially if policymakers
resolve the pricing dilemma posed above by paying far above production costs, as
pay parity would do. Furthermore, important work by researchers at RAND (per-
formed before the COVID–19 pandemic) found that 90 percent of telehealth services
were additional services rather than substitutes for in-person services.7
Clearly, that has not been the case during the public health emergency, during
which virtual visits became the only way for patients to receive timely care for a
period of time. Nevertheless, used properly, telehealth very often should be an add-
on to often insufficient in-person care, especially for chronic care management but
also, for example, to clarify whether a tentative diagnosis was correct, to monitor
the effect of adding a medication or changing a dosage, or for myriad other potential
clinical reasons. But those add-on, virtual services need to be managed by the prac-
tice within a spending constraint to help assure that virtual visits are used appro-
priately.
4. ALTERNATIVE PAYMENT METHODS FOR TELEHEALTH
Fee schedule payments should be limited to virtual visits equivalent to high-level
office visits and paid somewhat less than office visits, in line with relative cost cal-
culations as usual. There may be compelling reasons to pay fee-for-service for
unique provider types. A challenging issue is whether Medicare should routinely pay
for telehealth vendors that do not have established relationships with beneficiaries
as do many private insurers (but not Medicare). Younger patients often do not have
established relationships such that an occasional telehealth vendor encounter can
5 Robert A. Berenson and Paul B. Ginsburg, ‘‘Improving the Medicare Physician Fee Schedule:
Make It Part of Value-Based Payment,’’ Health Affairs 38, no. 2 (2019): 246–252.
6 J. Scott Ashwood, Ateev Mehrotra, David Cowling, and Lori Uscher-Pines, ‘‘Direct-to-
Consumer Telehealth May Increase Access to Care but Does Not Decrease Spending,’’ Health
Affairs 36, no. 3 (2017): 485–491.
7 Ashwood et al., ‘‘Direct-to-Consumer Telehealth May Increase Access to Care but Does Not
Decrease Spending.’’
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make good clinical sense as a reasonable convenience for patients. But for Medicare
beneficiaries, policy in general should encourage continuous, established relation-
ships, not occasional telehealth vendor visits supported through fee-for-service.
Assuming established relationships between clinicians and patients, telehealth is
best paid through PPPM payments to cover the costs of robust telehealth. Currently,
CMS is working to test various forms of hybrid payment models that would pay
partly by fee schedule and partly by a monthly PPPM, called capitation. The latter
approach pays the practice for patients who are expected to seek care initially from
their chosen or assigned practice (but remain free to seek care elsewhere). The pay-
ment is adjusted for the person’s underlying health risks and represents an average
amount for the population of beneficiaries with similar health risks.
Capitation incentives are fundamentally different from fee-for-service: the practice
receives the funds regardless of how many services they provide an individual for
whom payment is received. The incentives are reversed—the practice is rewarded
for keeping patients healthy and not in need of health services.And the approach
should reward broad use of telehealth when a virtual visit or phone call suffices
without need for an in-office visit. There would be no billing costs associated with
the telehealth provision, and, indeed, beneficiary cost-sharing for the capitation por-
tion of the hybrid payment could be waived altogether under a well-functioning hy-
brid model. Initially, maintaining fee schedule payments for some services (includ-
ing in-office visits) would help mitigate the expressed concern about stinting on care
(i.e., accepting the PPPM payments but stinting on actually providing care).
In my view, the compelling need to find an alternative to fee schedule payments
for telehealth calls for expediting the design and testing of the Center for Medicare
and Medicaid Innovation’s (CMMI) model called Primary Care First on a regional
and mandatory basis. It has the potential to be the alternative permanent payment
model for primary care practices while also addressing payment for telehealth serv-
ices.
Paying for telehealth for specialists presents a different challenge, because many
specialists do not and should not have continuous, established relationships. Based
on analyzing the use of telehealth by specialty during the public health emergency,
specialty practices that provide a large amount of telehealth services could receive
lump sum, monthly payments that they control and use for appropriate application
of virtual care. The practices would allocate the funds for telehealth services as they
deem appropriate and not have to submit claims for each instance. Some accounting
would be necessary to ensure that the telehealth services were actually provided.
5. CONCLUSION
Congress and CMS face an urgent need to adequately fund telehealth services as
an essential component of 21st-century health-care delivery. However, payment
should not simply continue public health emergency-based flexibilities and generous
payments that are important to allow during the COVID–19 pandemic. It would be
a policy mistake not to use this unique opportunity not only to provide a better pay-
ment method to support virtual health care and other evaluation and management
services, including in-office services, but also to reform how Medicare Physician Fee
Schedule fees are determined in the first place.
Telehealth should not be supported primarily through fee-for-service, but rather
through hybrid payment methods that should include capitation for primary care
practices and periodic lump sum payments for specialists. The latter approach has
not been tested and will need immediate development and pilot testing. Continued
fee schedule payments for telehealth should be limited to lengthy, virtual care en-
counters and for particular clinicians and other providers that do not have contin-
uous, established relationships with patients. Policy should encourage development
of established relationships, especially for the Medicare population, who often have
multiple, interacting chronic conditions.
Admittedly, pursuing these recommendations would be challenging; it would be
easier politically and operationally to simply ratify the PHE changes going forward,
as many stakeholders advocate. That would be a mistake both because it could
produce sustained increases in Medicare spending for years to come and because of
the missed opportunity presented by telehealth to adopt alternative payment models
that would produce greater value than even improved fee-for-service is able to
produce. True value-based payment, although aspirationally worthy, has been dif-
ficult to accomplish. Telehealth provides a ready opportunity to make a virtue of ne-
cessity. Congress should not allow the opportunity to pass by.
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QUESTIONS SUBMITTED FOR THE RECORD TO ROBERT A. BERENSON, M.D.
QUESTIONS SUBMITTED BY HON. CATHERINE CORTEZ MASTO
Question. More than a quarter of Medicare beneficiaries lacked digital access at
home in 2018, a figure that is higher among those with low socioeconomic status,
those 85 years or older, and in communities of color. States have just received un-
precedented funding from the American Rescue Plan to support COVID–19 response
and recovery efforts, including expanding digital infrastructure that communities
need to get up and running again.
What could be done at the State level to leverage the funding provided in the
American Rescue Plan to close the gap in access to telehealth services?
What more could be done at the Federal level to support communities?
Answer. The prospects for passage of the American Rescue Plan are uncertain at
this time. I suggest that a large portion of unspent funds from the Provider Relief
Fund of the CARES Act be reprogrammed for the purpose of building comprehen-
sive, national digital infrastructure. On June 21, 2021, The Washington Post again
documented that many large non-profit health systems actually improved their fi-
nancial margins in 2020. In addition, research work that I have helped lead and
is now in the process of journal peer review, when published, will demonstrate that
many health systems have many billions of dollars readily available as cash and
marketable securities and have no need for additional CARES Act bailout. They
have substantial surpluses as days cash on hand to meet their expenses, even if
they had no new revenues at all, in some cases exceeding 365 days. Building up
digital infrastructure to support telehealth and for a range of other purposes should
take priority over further funding of already flush health systems.
In the longer term, Federal and State action to increase antitrust scrutiny of
mergers and acquisitions and of anticompetitive behavior from extant health system
oligopolies would reduce health-care spending increases, again freeing up funds to
support access to basic health-care services in all communities.
QUESTIONS SUBMITTED BY HON. THOMAS R. CARPER
Question. During the pandemic, telehealth has been an essential tool to get chil-
dren the care that they need while minimizing risk. Although telehealth under
Medicare has been a focus, close to 40 million children are enrolled in Medicaid.
What are the main policy changes we need to ensure this broader use of tele-
health can continue beyond the pandemic for children?
Answer. I have limited expertise on Medicaid and CHIP issues and, so, will not
respond.
Question. During COVID–19, many States adopted temporary changes to their
telehealth policies, such as expanding the scope of services and providers able to fur-
nish telehealth, relaxing of licensure requirements and modifying reimbursement
policies. Many States legislatures have also begun the work to adopt more perma-
nent telehealth policy changes.
How can the Federal Government best support State Medicaid programs in their
efforts to expand telehealth?
Are there Medicaid supports, incentives, and learnings that Federal policymakers
could provide?
Answer. I have limited expertise on Medicaid and CHIP issues and, so, will not
respond.
Question. COVID–19 has introduced additional stress and trauma for children and
families. Telehealth, and particularly audio-only telehealth has been a crucial tool
to connect children and adolescents to needed mental health-care services.
How can telehealth be best utilized to meet kids’ mental health-care needs, and
can you speak to the use of audio-only telehealth specifically?
Answer. I will repeat two points I emphasized in my testimony and in response
to questions raised by Senators at the hearing. One, fee-for-service is a particularly
poor payment method for telehealth. Public and private payers need to promptly
move away from total dependence on fee schedule payments to health professionals
in include a substantial amount of lump sum payments that allow clinicians to de-
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ploy telehealth appropriately, rather than be dependent on incomplete and changing
code-level descriptions of fee schedule services. Two, audio-only services (which used
to be called phone calls) should be considered an essential, ‘‘must include,’’ compo-
nent of telehealth services. When patients are well known to their clinicians, video-
based calls in health-care delivery often is needed only for group conversations or
for visual display of clinically-relevant physical appearance and data transfer. In
many situations, the phone can be as effective and certainly more efficient than a
video visit, assuming appropriate attention to security and confidentiality. At the
same time, fee-for-service payment for audio-only services would be particularly
challenging in the long term and would likely generate intrusive and ultimately
counterproductive compliance requirements. The solution, again, is moving tele-
health payment to lump sum payments, such as primary care capitation (per person
month payments for patients empaneled with a primary care practice).
Question. As State Medicaid programs look at expanding their use of telehealth,
it is particularly important that vulnerable populations like children are not nega-
tively impacted. Policies must be looked at through a health equity lens, considering
access to reliable and affordable broadband services, access to devices that support
HIPAA-compliant telehealth platforms and coverage policies.
How can Medicaid programs work to ensure telehealth policies are equitable for
children and mitigate potential inequities that may arise?
Answer. Again, given my lack of expertise on Medicaid, I will not respond to this
question.
QUESTION SUBMITTED BY HON. PATRICK J. TOOMEY
Question. In your testimony, you cited pre-pandemic research undertaken by
RAND that found 90 percent of telehealth services were additional services rather
than substitutes for other in-person services and consultations. Moreover, other wit-
nesses’ testimony clearly demonstrates that telehealth utilization in Medicare and
Medicaid has increased over the past year in light of the COVID–19 pandemic.
Given the unsustainable fiscal trajectory of the Medicare program and the need
for payment reforms, what types of tools exist or may be needed in the Medicare
fee-for-service program or Medicare Advantage program that will ensure appropriate
utilization management of telehealth services?
Answer. In my writing and speaking on Medicare, I do not refer to the ‘‘Medicare
fee-for-service program,’’ for the simple reasons that most of the payment methods
in this program are no longer fee-for-service and calling it fee-for-service supports
an inaccurate, negative caricature of the program. For example, the inpatient pro-
spective payment system in 1984 abandoned fee-for-service by adopting case rate
payment, known as diagnosis-related groups (DRGs). Nearly two dozen other coun-
tries have now adopted various versions of DRGs, precisely because this payment
method is not fee-for-service. The Medicare Physician Fee Schedule stands out as
true fee-for-service and in need of reform.
It is true, however, that most Medicare payment methods, remain volume-based,
if not fee-for- service. That is total payment depend on the number of payment units
generated and billed for, whether at the individual service level or whether bundled
into larger payment units. Many payment policy experts are currently recom-
mending that the traditional Medicare program adopt a hybrid payment model for
primary care practices, consisting of a hybrid of equal parts fee schedule and capita-
tion relying on patient empanelment with their preferred primary care practice.
Such a payment system would substantially restrain the potential explosion of tele-
health services; telehealth services would be covered under the capitation portion
of the hybrid paymemt. Limited exceptions to permit fee schedule payments for tele-
health should be considered, e.g., for other categories of health professionals, such
as physical therapists, or for especially long and unusual telehealth visits. Neverthe-
less, I strongly recommend that Medicare generally should not pay mainstream phy-
sician practices for telehealth through the fee schedule payments.
Medicare Advantage plans are in a position to pioneer the use of innovative pay-
ment methods. They need not—and sometimes do not—adopt traditional Medicare’s
payment methods for various reasons. Unfortunately, MA plans have tended to be
followers rather than innovators, perhaps because of their limited market shares
compared to traditional Medicare’s. Ideally, payment reform would occur as a col-
laboration between traditional Medicare, Medicaid agencies and MCOs, and both
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MA plans and commercial insurers. That kind of collaboration has not been very
successful over the past decade, but needs to be reinvigorated, with CMS taking the
lead.
QUESTIONS SUBMITTED BY HON. CHUCK GRASSLEY
Question. Throughout the public health emergency, the Centers for Medicare and
Medicaid Services (CMS) issued over 200 waivers under Medicare and approved
more than 600 waivers and other flexibilities under Medicaid. While some of the
regulations waived are specifically for responding to a pandemic, ensuring patient
safety, controlling costs, and maintaining program integrity its clear innovation and
common sense ideas in our health-care system have been stifled too often by Federal
regulations. For example, CMS permanently added certain new services (including
mental health and care planning services) that it had temporarily added to the ap-
proved list of Medicare telehealth services during the pandemic. Some regulations
play an important role in protecting safety and maintaining program integrity but
others may stifle good ideas.
Is health care too regulated that it’s stifling good ideas?
Should executive agencies sunset regulations in the future to enable more innova-
tion in health care?
Answer. Unfortunately, a primary reason for relative lack of innovation in health-
care results from fee-for-service and other volume-based payment incentives. Pro-
viders with well-established, profitable revenue streams typically are not eager to
consider disruptive innovation that might undermine these streams. Both horizontal
and vertical integration based around hospitals has resulted to a significant extent
in non-responsive, health systems that dominate health delivery to the detriment
of independent practitioners and patients. The Nation has needed more and more
creative antitrust enforcement. Although some deride assertive antitrust enforce-
ment as ‘‘over-regulation,’’ antitrust serves to preserve competition and choice,
which is where innovation takes place.
Currently, in the face of increasingly non-competitive health provider markets,
policy is needed to actively regulate the ‘‘monopoly prices’’ that health systems de-
mand of commercial insurers. Indeed, regulated, rather than market- determined,
prices have allowed Medicare Advantage plans to thrive as a choice that 40 percent
of Medicare beneficiaries have exercised. In short, regulating prices now would allow
markets to work better to reward innovation rather than preserve what economists
call ‘‘monopoly rents.’’ Regulations can have negative effects on innovation, but in
my opinion are not a major source of the current high spending, poor quality health
system the U.S., regrettably now exhibits. And, as I emphasized in my testimony
and in other responses here, paying telehealth through fee-for-service would un-
doubtedly produce substantially increased, intrusive and counterproductive regula-
tion to try to protect against the inevitable fraud and abuse that telehealth would
spawn if paid for that way.
QUESTIONS SUBMITTED BY HON. JOHN BARRASSO
Question. Before coming to the Senate, I had the privilege of practicing medicine
in Wyoming. Rural health care faced challenges prior to the pandemic. In particular,
we know since 2010 more than 135 rural hospitals have closed.
In the Senate, I am proud to help lead the bipartisan Rural Health Caucus. This
group is committed to ensuring patients in rural America can get access to the care
they need.
Can you specifically discuss the changes in Federal health-care policy that you be-
lieve have helped rural providers the most during this pandemic?
Can you please discuss any specific changes that Congress should consider to bet-
ter support rural health-care providers?
Answer. The Affordable Care Act authorized creation of a Workforce Commission,
which was constituted with appointments of commissioners but never met because
of the absence of the requisite appropriation. Workforce policy is desperately needed
to address access to basic health services for rural populations, which now face a
drastic shortage of health professionals. Medicare Graduate Medical Education pol-
icy needs overhaul to redistribute funds to primary and preventive care education
and to require academic health centers to better educate and provide ongoing edu-
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cational support to rural practitioners. The workforce issues have mostly been ig-
nored over the past decade, partly because the Workforce Commission has not been
able to carry out its legislated mission.
Telehealth provides a new opportunity to reconfigure workforce needs for rural
communities, once the requisite electronic infrastructure is deployed, Again, there
is need for a dedicated commission to present a set of comprehensive recommenda-
tions for congressional consideration.
Question. Prior to the pandemic, I introduced bipartisan legislation with Senator
Tina Smith, which among other things, would allow Rural Health Clinics (RHCs)
to provide more telehealth services.
I was pleased that Congress through the CARES Act authorized both Rural
Health Clinics and Federally Qualified Health Centers to furnish telehealth services
to Medicare beneficiaries during the public health emergency.
Can you discuss the importance of Rural Health Clinics and Federally Qualified
Health Centers continuing to provide telehealth services after the public health
emergency has ended?
Answer. RHCs and FQHCs are crucial for access to basic health services in rural
areas and underserved urban areas. As I emphasized in my testimony, fee-for-
service is a poor way to compensate for telehealth services, even if based on costs,
as in these two programs. Both RHCs and FQHCs receive cost-based per visit pay-
ments subject to limits relying on rates from 2000 trended forward 20 years. That
method will not work to encourage telehealth services. There has been interest in
moving payment for RHCs and FQHCs away from per visit rates. Telehealth can
be a catalyst for moving to a population-based payment method for these important
centers.
Question. My wife Bobbi and I are passionate about improving access to mental
health services. This pandemic has clearly impacted the mental, as well as the phys-
ical health of our Nation.
For people living in rural America, getting help from a mental health provider
was challenging before the pandemic. This is why Senator Stabenow and I have long
supported professional counselors and marriage and family therapists participating
in Medicare. We believe that increasing the number of mental health providers able
to care for our Nation’s seniors is an important priority.
Please discuss how telehealth has impacted the ability of patients to receive men-
tal health services during the pandemic.
Can you please identify ways Congress can improve access to mental health serv-
ices, including expanding the number of providers that can participate in Medicare?
Answer. I have no expertise in provision of mental health and other behavioral
health services. However, in interviews with primary care physicians and other dis-
cussions I have participated in, I have heard a consensus viewpoint expressed that
mental health services are particularly amenable to telehealth interactions with
health professionals, who do not have to reside in the community. An operational
issue that needs ongoing attention is the need to assure confidentiality and security
of the telehealth services. But that is a soluble problem.
Question. I agree telehealth is transforming the way we are providing care. How-
ever, in Wyoming, most of our providers are part of smaller hospitals and practices.
We need to make sure government regulation is not making it more difficult for
these providers to serve their patients.
Can you discuss specific ways Congress can reduce the administrative burden in
providing care through telehealth?
Answer. One of the responses to the telehealth imperative for adoption use during
the public health emergency was the relief expressed by clinicians to the lessened
administrative burden that disappeared because of the regulatory waivers. That
said, maintaining the flexibility waivers and continuing to pay fee-for-service is a
dangerous mix and likely to encourage even more fraud and abuse. To avoid that
outcome I called for prompt adoption of new payment methods—capitation for pri-
mary care physicians, and telehealth-based, lump sum payments for specialists—as
substitutes for fee schedule payments for telehealth services. Doing so should sub-
stantially reduce administrative burden for providing care through telehealth while
also reducing the likelihood of fraud and abuse. There surely will need to be ac-
countability for the telehealth services provided when using these alternative pay-
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ment methods, but such accountability would likely require much less burden for
practices than what would be required under standard fee schedule payments.
Question. Wyoming has many passionate advocates supporting both hospice and
palliative care. These folks are committed to ensuring patients have the highest
quality of life and are able stay out of the hospital and with their families. This
is why I help lead the bipartisan Comprehensive Care Caucus. Our mission is to
improve both palliative and hospice care for patients.
Can you please discuss how telehealth flexibilities have impacted access to pallia-
tive care and how we can continue making progress in this area?
Answer. I have no knowledge about impact of telehealth flexibilities on the provi-
sion of palliative care.
PREPARED STATEMENT OF HON. MIKE CRAPO,
A U.S. SENATOR FROM IDAHO
Thank you, Mr. Chairman, for holding this important hearing.
Congress and the administration provided certain health-care flexibilities during
the pandemic so that patients could continue to receive high-quality care. Making
permanent changes based on lessons learned is a top priority.
I have shared my interest with President Biden’s nominees for the key health-
care positions who have come before this committee, and I appreciate their commit-
ment to work with me and this committee. Republicans and Democrats often dis-
agree on the best way to achieve shared health-care goals. This hearing, however,
highlights an area of common ground.
In fact, Senator Wyden and I asked the majority and minority staff to jointly plan
this hearing, demonstrating strong bipartisanship. Acting on legislative changes and
using administrative authority, the Centers for Medicare and Medicaid Services
waived over 200 payment rules during the pandemic in Medicare alone.
Needless to say, there is a lot we can learn.
Today’s witnesses will provide insight to guide our efforts in evaluating these
flexibilities. Hearing firsthand about the patient experience during the pandemic
from providers who overcame challenges to provide care will be invaluable. Under-
standing how the flexibilities are used in fee-for-service, Medicare Advantage, and
in alternative payment models will be insightful.
Much of the hearing will focus on care provided during the pandemic through tele-
health. Telehealth has been a lifeline for patients and providers, especially in the
early months of the pandemic. The reliance on telehealth increased in rural and
urban areas alike, allowing patients to receive remote care from the safety of their
home. Telehealth services have been especially useful for Idahoans.
According to the Idaho Department of Insurance, telemedicine visits went from an
average of about 200 appointments per month to 28,000 telehealth visits in April
2020 alone. To ensure financial stability, providers have been paid at the same rate
as if the service was furnished in-person. This has facilitated care that otherwise
would be risky or unavailable, and patients have appreciated the convenience. It has
reduced the frequency of missed appointments, and assisted provider investment in
the infrastructure needed for remote care.
This long period of expanded telehealth will help us understand the impact on
quality of care and program costs. It serves as a robust test project on a scale few
could have imagined. The promise of telehealth is clear, but it is important that we
gather evidence on its impact on access, quality, and cost.
There are approaches to providing care in the most efficient setting that go be-
yond telehealth. Some hospitals are using a waiver that provides flexibility to triage
patients who present to the hospital to see if they can be best cared for in their
home.
Whether through telehealth, Hospital at Home, or other innovative care arrange-
ments, it is important to find ways to get patients care that best meets their needs,
and at the lowest cost possible. Congress has taken permanent steps to do just that
in recent years.
Nephrologists can conduct remote evaluations of patients receiving home dialysis.
Providers can administer certain drugs to vulnerable patients in their own homes.
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Hearing from our provider witnesses helps us to continue down this path. The
Government Accountability Office will supplement what we hear from our provider
experts, offering a perspective on how to track and evaluate flexibilities in Medicare
and Medicaid as we chart the right course forward. I fully expect we will take what
we learn from this hearing to continue our bipartisan efforts to help providers give
patients the best care possible.
Permanent changes based on lessons learned from the pandemic to modernize
Medicare payment systems lend to the pressing need to address Medicare’s financial
struggles. Identifying smart reforms that make Medicare more efficient will be bet-
ter for patients and better for taxpayers. Such changes alone will not put Medicare
on a sustainable path, but they should be part of that broader conversation.
Addressing Medicare solvency should also be a bipartisan issue, with time best
spent determining how to shore up the current system instead of expanding it to
a broader population. Finding the right path on these priority issues is important
to patients and the health programs in the committee’s jurisdiction.
This hearing will help us to capitalize on the bipartisan opportunity.
Thank you, Mr. Chairman. I yield back.
PREPARED STATEMENT OF KISHA DAVIS, M.D., MPH, FAAFP, MEMBER, COMMISSION
ON FEDERAL AND STATE POLICY, AMERICAN ACADEMY OF FAMILY PHYSICIANS
Chairman Wyden, Ranking Member Crapo, and members of the committee, I am
Dr. Kisha Davis, a member of the American Academy of Family Physicians (AAFP)
Commission on Federal and State Policy, and I am honored to be here today rep-
resenting the 133,500 physician and student members of the AAFP.
I am a practicing family physician and the vice president of health equity at
Aledade. In addition to seeing patients in Baltimore, MD, through my role at
Aledade, I support physicians in private practices and community health centers
across the country. I have experienced the impact of the COVID–19 pandemic and
resulting Federal policy changes firsthand as a front-line physician, and I have had
the opportunity to observe them on a broader scale.
Many of the emergency flexibilities that the Centers for Medicare and
Medicaid Services (CMS) made available during the COVID–19 pandemic
have improved patients’ access to primary and preventive care, bolstered
the physician workforce in rural and underserved communities, and allevi-
ated administrative burdens on clinicians, enabling us to focus on patient
care. As Congress considers whether to extend these flexibilities beyond the public
health emergency and how to build upon recent advances, it is vital that Medi-
care and Medicaid policy changes are designed to advance health equity,
protect patient safety, and enable clinicians to provide the right care at the
right time.
The AAFP offers the following recommendations.
• Adopt telehealth policies that enhance the physician-patient relationship
rather than disrupt it, and incentivize coordinated, continuous care provided
by the medical home.
• Adopt payment models that support patients’ and clinicians’ ability to choose
the most appropriate modality of care and ensure appropriate payment for
care provided.
• Permanently remove geographic and originating site restrictions to ensure
that all Medicare beneficiaries can access telehealth care at home.
• Require Medicare to cover audio-only evaluation and management services
beyond the public health emergency to ensure equitable access to care.
• Permanently cover telehealth services provided by Federally Qualified Health
Centers (FQHCs) and rural health clinics and ensure adequate payment.
• Monitor the impact of telehealth on access and equity by ensuring that data
collection and evaluation include race, ethnicity, gender, language, and other
key factors.
• Invest in infrastructure to promote digital health equity.
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• Mandate Medicaid coverage of all Advisory Committee for Immunization
Practices (ACIP)—recommended vaccines for all adults.
• Permanently allow physicians to provide direct supervision and teaching serv-
ices via telehealth to expand access to primary care services and increase
training opportunities.
• Reduce the volume of prior authorization requirements to decrease unneces-
sary administrative burden on physicians.
• Grant HHS the authority to waive reporting and other administrative re-
quirements for the Quality Payment and Medicare Shared Savings programs
in future public health emergencies without rulemaking to enable physicians
to focus on patient care during emergencies.
• Restore Medicare and Medicaid physician supervision requirements to safe-
guard patient safety and maintain access to appropriate, high-quality care.
Over the last year, family physicians rapidly changed the way they practice to
meet the needs of their patients amid a global pandemic. Arguably, the most dra-
matic shift was the unprecedented uptake and increase of telehealth services. Last
spring, out of necessity, physicians quickly pivoted from providing a majority of care
in-person to caring for their patients virtually to promote social distancing and in-
fection control. This would not have been possible without the swift legislative and
regulatory action that expanded coverage, increased payment, and added flexibility
for telehealth services.
Prior to COVID–19—due in large part to Medicare restrictions and inadequate re-
imbursement—fewer than 15 percent of family physicians were providing virtual
visits to their patients, and during the public health emergency that number surged
to more than 90 percent. Despite technical challenges on the part of patients and
physicians, both quickly came to realize the value of virtual care. According to a re-
cent survey of AAFP members, seven in ten family physicians want to continue of-
fering more virtual visits in the future.
Telehealth benefit expansions must increase access to care and promote
high-quality, comprehensive, continuous care. Telehealth, when implemented
thoughtfully, can improve the quality and comprehensiveness of patient care and ex-
pand access to care for under-resourced communities and vulnerable populations. As
outlined in our Joint Principles for Telehealth Policy,1 in partnership with the
American Academy of Pediatrics and the American College of Physicians, the AAFP
strongly believes that the permanent expansion of telehealth services should be
done in a way that advances care continuity and the patient-physician relationship.
Expanding telehealth services in isolation, without regard for previous physician-
patient relationship, medical history, or the eventual need for a follow-up hands-on
physical examination, can undermine the basic principles of the medical home, in-
crease fragmentation of care, and lead to the patient receiving suboptimal care. In
fact, a recent nationwide survey found that most patients prefer to see their usual
physician through a telehealth visit, feel it is important to have an established rela-
tionship with the clinician providing telehealth services, and believe it is important
for the clinician to have access to their full medical record.
Telehealth can enable timely, first-contact access to care and supports physicians
in maintaining long-term, trusting relationships with their patients, both of which
are central to continuity of care. Allowing physicians to provide telehealth services
from their home enables them to extend their availability beyond traditional office
hours for patients who, due to work or childcare constraints, are unable to take time
off work for an appointment. This not only advances equitable access to care but
also can prevent unnecessary trips to urgent care or the emergency room. Tele-
health can also be a tool to help alleviate physician burnout by facilitating better
work-life balance. One example: Some employers allow physicians to be on ‘‘tele-
health duty’’ in the period leading up to and following their maternity leave.
Given these benefits, patients and physicians agree that some current telehealth
flexibilities should continue beyond the public health emergency.
Congress should permanently remove the section 1834(m) geographic
originating site restrictions to ensure that all Medicare beneficiaries can
access care at home. The COVID–19 pandemic has demonstrated that enabling
physicians to virtually care for their patients at home can not only reduce patients’
1 https://www.aafp.org/dam/AAFP/documents/advocacy/health_it/telehealth/LT-Congress-
TelehealthHELP-070120.pdf.
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and clinicians’ risk of exposure and infection but also increase accessibility for pa-
tients who may be homebound or lack transportation. It can also offer opportunities
to engage distant family members and caregivers. Telehealth visits allow physicians
to get to know their patients in their home and observe things they normally cannot
during an in-office visit. This helps us to identify environmental factors that may
be affecting their health, and to develop more personalized treatment plans.
Transitional care management (TCM) services are another example of how perma-
nently eliminating geographic and originating site requirements could improve utili-
zation of high-value care and ultimately improve care coordination and patient out-
comes. TCM services are provided after a patient is discharged from a hospital stay,
with the goal of ensuring care continuity once they return home. Prior to the public
health emergency, patients were hesitant to come into the office after just being dis-
charged from the hospital. Once TCM services were available to all Medicare pa-
tients via telehealth, many more received TCM services, allowing me as their pri-
mary care physician to check on them, update their medications, schedule follow-
up visits with specialists, and prevent hospital readmissions.
There are many more examples of how telehealth visits can be used to promote
prevention through conducting Medicare Annual Wellness visits as well as for moni-
toring and treatment of chronic diseases such as diabetes and hypertension for pa-
tients in their home thereby increasing accessibility for patients who may be home-
bound or lack transportation and create opportunities to engage distant family and
caregivers.
Require Medicare to cover audio-only Evaluation and Management (E/M)
services beyond the public health emergency. Coverage of audio-only E/M serv-
ices is vital for ensuring equitable access to telehealth services for patients who may
lack broadband access or be uncomfortable with video visits. In September, after
using telehealth for several months due to the pandemic, more than 80 percent of
family physicians responded to an AAFP survey indicating they were using phone
calls to provide telehealth services. Together with ongoing reports from physicians
that phone calls are vital to ensuring access for many patients, this survey data in-
dicate that phone calls are more accessible for many patients than video visits. This
may be particularly true for Medicare beneficiaries. According to the Pew Research
Center, only about 53 percent of patients over the age of 65 own smartphones, while
91 percent own any type of cell phone. Recent studies of telehealth utilization by
patients with limited English proficiency show that non-English speakers have used
telehealth far less than English-speakers. Many physicians routinely use telephone
translation services to provide linguistically appropriate care, and these services can
be more seamlessly integrated into telephone visits, whereas integrating translation
services into audio-video platforms can be costly and complex. Outside of the PHE,
Medicare allowed physicians to bill for brief phone calls as ‘‘virtual check-ins.’’ Dur-
ing the PHE we conducted telephone visits, realizing that we would not get reim-
bursed appropriately, but did so because it was the right thing for our patients. Un-
fortunately the payment rate for those services does not adequately reflect the level
of time and effort required, and often the cost to bill the services exceeds that
amount.
Payment should support patients’ and clinicians’ ability to choose the
most appropriate modality of care (i.e., audio-video, audio-only or in-
person) and ensure appropriate payment for care provided. Some patients
and some cases are better suited to virtual care, and others require in-person care;
some issues can be effectively treated through a phone call, whereas others require
a visual examination. As a physician, I want telehealth to be a tool in my toolbox,
and I want to choose when and how to deploy it based on my clinical judgment, not
based on whether I will get paid.
Permanently ensure that beneficiaries can access telehealth services pro-
vided by Federally Qualified Health Centers (FQHCs) and Rural Health
Clinics (RHCs). FQHCs and RHCs serve as the primary source of care for millions
of low-income and underserved patients across the country. In order to promote care
continuity and ensure that beneficiaries have access to affordable, comprehensive
care, Medicare should permanently cover telehealth services provided by these
health centers. Medicare and Medicaid payment methodologies should also be modi-
fied to provide appropriate and timely payment to community health centers for
telehealth services.
In order to make long-term investments in telehealth platforms and workflow
modifications, physician practices need advanced notice of changing Medicare and
Medicaid telehealth policies. While more data will be needed to make determina-
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tions on whether to permanently continue certain telehealth services, temporary
policies should be avoided for well-established, high-value telehealth services such
as E/M office visits and mental health services.
The AAFP is supportive of broadly expanding access to telehealth services. How-
ever, we recognize that Congress and CMS are concerned about preventing waste,
fraud, and abuse and considering policy options to reduce those risks. In addition
to promoting the use of telehealth within the medical home, we also recommend re-
lying on existing Medicare policies to minimize confusion and administrative burden
imposed on physician practices. For example, Medicare defines an established pa-
tient as one that has received professional services from a clinician in the same
practice and of the same medical specialty within the last 3 years. This definition
should be repurposed in any new telehealth policies, instead of creating a new defi-
nition for an established patient that could conflict with current coding guidelines.
While the rapid expansion of telehealth has yielded many benefits for patients
and clinicians, not everyone has benefited equally. Without sufficient investment
and thoughtful policies, telehealth could actually worsen health disparities. Prior to
the COVID–19 pandemic, evidence suggests that telehealth uptake was higher
among patients with higher levels of education and those with access to employer-
sponsored insurance. Another study found that patients with limited English pro-
ficiency utilized telehealth at one-third the rate of proficient English speakers. Anec-
dotes from family physicians suggest that the same trend may hold true for the past
year—that those benefitting most from telehealth are those who already had better
access to care. As the committee seeks additional studies to inform the direc-
tion of permanent telehealth policies, you should ensure the collection and
reporting of data stratified by race, ethnicity, gender, language, and other
key factors.
One in three households headed by someone over the age of 65 do not have a com-
puter, and more than half of people over age 65 do not have a smartphone. Children
in low-income households are less likely to have access to a computer, and 30 per-
cent of black or Hispanic children do not have a computer, compared to 14 percent
of whites. Digital literacy also varies with age, income, and ethnicity. In order to
achieve the full promise of telehealth, Congress must act to address these
structural barriers to virtual care. The AAFP supports the creation of a pilot
program to fund digital health navigators; development of digital health literacy
programs; and deployment of digital health tools that provide interpretive services
at the point of care, are available in non-English languages, easily and securely in-
tegrate with third-party applications and include assistive technology. Such a pilot
should include a robust evaluation to demonstrate how the interventions addressed
gaps in care or increased access for underserved populations.
Beyond telehealth, CMS implemented several other flexibilities to facilitate access
to care and prevent the spread of COVID–19. We recommend making several of
these flexibilities permanent, while others should remain in place only during this
and future public health emergencies.
Congress took several actions to secure access to the COVID–19 vaccine for free
for most Medicare, Medicaid, and CHIP beneficiaries. We recommend that Congress
explore further actions to facilitate affordable, equitable coverage of routine adult
immunizations. Currently, only 43 percent of State Medicaid agencies cover all rec-
ommended adult vaccines, and overall adult utilization remains low. The AAFP be-
lieves 2 that all public and private insurers should include as a covered
benefit immunizations recommended by the ACIP without co-payments or
deductibles.
CMS should allow physicians to provide direct supervision and teaching
services via synchronous audio/video communication nationwide. During
the public health emergency, CMS allowed this to improve access to care in areas
with physician shortages and prevent the transmission of COVID–19. The flexibility
to provide these services virtually had clear benefits, as evidenced by CMS’s recent
decision to permanently allow virtual teaching and supervision in rural areas. If
made permanent nationwide, it would increase training opportunities in rural and
other underserved communities and improve patients’ access to comprehensive, con-
tinuous care.
A similar permanent policy was finalized for all levels of E/M office visits provided
at a primary care center during the PHE: Teaching physicians can permanently use
2 https://www.aafp.org/about/policies/all/immunizations.html.
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video conferencing to supervise residents providing primary care in rural areas. The
AAFP is supportive of this policy being made permanent, and we believe that, ap-
plied nationwide, it would bolster primary care training opportunities and improve
access to primary care in other underserved areas. The rural designation may not
capture many areas of the country that are experiencing primary care shortages.
Medicare and Medicaid both waived prior authorization requirements for durable
medical equipment (DME) and other services early on during the public health
emergency. While these requirements have since been reinstated, Congress should
permanently reduce the volume of prior authorization requirements across
Medicare and Medicaid payers. Prior authorization requirements delay care for
patients and contribute to alarming rates of physician burnout. Commonsense solu-
tions are needed to preserve and strengthen our physician workforce. For example,
prior authorization should not be required for most DME ordered by a primary care
physician for an established patient, regardless of whether it is ordered during a
telehealth or in-person visit.
Family physicians were relieved when CMS took swift action to delay and /or
waive reporting requirements for the Quality Payment Program, Medicare Shared
Savings Program, and other programs. However, many practices were frustrated
that CMS delayed the implementation of the extreme and uncontrollable cir-
cumstances policy for the 2020 performance year. This policy, along with other
waivers, should be quickly applied in future PHEs so physicians can focus
on providing patient care with minimized administrative tasks without
fearing negative financial repercussions. The AAFP also has urged CMS to up-
date measure benchmarks used across various programs to account for changes in
utilization of health-care services during the pandemic.
CMS waived requirements for physician supervision, including requiring certain
services to be ordered by a physician, in Medicare, Medicaid, and the VA system.
To safeguard patient safety and maintain access to appropriate, high-quality care,
these waivers and flexibilities should not be made permanent, because patients are
best served by a physician-led care team. Family physicians are particularly quali-
fied to lead the health-care team because they possess distinctive skills, training,
expertise and knowledge that allow them to provide medical care, health mainte-
nance and preventive services for a range of medical and behavioral health issues.
While certain flexibilities during the PHE addressed the historic nature of the pan-
demic, flexibilities to loosen supervision requirements should be restricted
by Congress to ensure continuity of care and high-quality, accessible
health care for all patients.
Thank you for the opportunity to discuss with this committee the impact of health
care regulatory flexibilities made available during the current public health emer-
gency on family physicians and the AAFP’s recommendations for permanent policy
to advance accessible, equitable, high-quality health care beyond the pandemic.
QUESTIONS SUBMITTED FOR THE RECORD TO KISHA DAVIS, M.D., MPH, FAAFP
QUESTIONS SUBMITTED BY HON. THOMAS R. CARPER
Question. During the pandemic, telehealth has been an essential tool to get chil-
dren the care that they need while minimizing risk. Although telehealth under
Medicare has been a focus, close to 40 million children are enrolled in Medicaid.
What are the main policy changes we need to ensure this broader use of tele-
health can be continued beyond the pandemic for children?
Answer. Telehealth, when implemented thoughtfully, can improve the quality and
comprehensiveness of patient care and expand access to care for vulnerable popu-
lations, including children enrolled in Medicaid. Children have unique medical
needs and the appropriateness of virtual care can differ between children and adults
and based on the amount of information that the treating clinician has about the
patient. Family physicians and pediatricians form long-term, trusting relationships
with their patients and parents, which not only enables them to provide personal-
ized care but also to assess and recommend the optimal mode of care. Some care
such as treatment for mild illness, follow-up care and behavioral health services
may be well-suited for telehealth; whereas other health needs require hands-on ex-
amination or treatment, and essential preventative services such as immunizations
and health screenings must be done in-person. In most instances children can ben-
efit from a hybrid of in-person and virtual care, which is optimized when all care
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is coordinated through the patient’s medical home. The AAFP joined with the Amer-
ican Academy of Pediatrics to develop these joint principles 1 for permanent tele-
health policy that support the medical home. Congress should support coverage and
payment models that enable primary care clinicians to provide virtual care to their
patients and discourage the proliferation of direct-to-consumer, virtual-only tele-
health vendors as a substitute for primary care.
The AAFP also encourages Congress to invest in initiatives to bridge the digital
divide including expanding broadband coverage and subsidizing access, providing
lower-income individuals with end devices (i.e., tablets, laptops, remote monitoring
tools) and /or access points and ensuring that digital health platforms and tools are
culturally and linguistically appropriate and accessible for vision and hearing im-
paired.
Question. During COVID–19, many States adopted temporary changes to their
telehealth policies, such as expanding the scope of services and providers able to fur-
nish telehealth, relaxing of licensure requirements and modifying reimbursement
policies. Many States legislatures have also begun the work to adopt more perma-
nent telehealth policy changes.
How can the Federal Government best support State Medicaid programs in their
efforts to expand telehealth?
Are there Medicaid supports, incentives, and learnings that Federal policymakers
could provide?
Answer. States have adopted a broad range of telehealth flexibilities during the
pandemic, including waiving restrictions on distant and originating sites, adjusting
provider reimbursement rates, and issuing guidance on the use of telehealth in par-
ticular areas (behavioral health, reproductive health, physical therapy). Most flexi-
bilities expire with the end of the public health emergency and coverage of par-
ticular services provided via telehealth is inconsistent across the States. With infor-
mation and data on the most effective and beneficial State policies during the pan-
demic, incentives and guidance on best policies would be helpful to facilitate infor-
mation sharing among States who wish to make changes permanent.
Federal financial support to States is critical in increasing both provider and pa-
tient access to telehealth technologies, starting with the need for investment in
broadband Internet for rural areas across the country and additional funding for
telehealth technologies for underserved areas and populations. There is a significant
digital divide that is even more visible in the context of telehealth. Adults in rural
areas lack access to broadband Internet and are more likely to be covered by Med-
icaid than those in other areas. Expanded broadband can lead to increased access
to telehealth, giving adults in rural areas the access to care they need, especially
those living in health professional shortage areas.
The AAFP encourages Federal policymakers to provide clear guidance to States
on ways to adopt alternative payment models that provide sustainable funding for
clinicians to incorporate telehealth into the medical home. The AAFP also encour-
ages CMS and States to provide guidance and oversight to Medicaid managed care
plans to ensure coverage and payment policies are not inappropriately steering pa-
tients toward one modality of care or limiting their choice of provider.
Question. COVID–19 has introduced additional stress and trauma for children and
families. Telehealth, and particularly audio-only telehealth has been a crucial tool
to connect children and adolescents to needed mental health-care services.
How can telehealth be best utilized to meet kids’ mental health-care needs, and
can you speak to the use of audio-only telehealth specifically?
Answer. Telehealth has been shown as highly effective mode of delivering mental
health care and can reduce access barriers and stigma. One model for expanding
access to mental health services that the AAFP supports is the Collaborative Care
Model (CCoM) for integrating behavioral health into primary care, and services pro-
vided virtually could extend the benefits of CCoM.
The AAFP strongly supports extending coverage of audio-only telehealth services
beyond the PHE to ensure that patients in rural areas and who lack access to
broadband or technology devices can access services.
1 https://www.aafp.org/dam/AAFP/documents/advocacy/health_it/telehealth/LT-Congress-
TelehealthHELP-070120.pdf.
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Question. As State Medicaid programs look at expanding their use of telehealth,
it is particularly important that vulnerable populations like children are not nega-
tively impacted. Policies must be looked at through a health equity lens, considering
access to reliable and affordable broadband services, access to devices that support
HIPAA-compliant telehealth platforms and coverage policies.
How can Medicaid programs work to ensure telehealth policies are equitable for
children and mitigate potential inequities that may arise?
Answer. Prior to the COVID–19 pandemic, evidence suggests that telehealth up-
take was higher among patients with higher levels of education and those with ac-
cess to employer-sponsored insurance. Another study found that patients with lim-
ited English proficiency utilized telehealth at one-third the rate of proficient English
speakers. Anecdotes from family physicians suggest that the same trend may hold
true for the past year—that those benefitting most from telehealth are those who
already had better access to virtual care. At a minimum, Congress, CMS, and State
Medicaid programs should ensure the collection and reporting of data on telehealth
utilization by Medicaid beneficiaries is stratified by race, ethnicity, gender, lan-
guage, and other key factors. Such data will be critical for identifying access dispari-
ties and informing equitable policy decisions.
The AAFP also encourages Congress to invest in initiatives to bridge the digital
divide including expanding broadband coverage and subsidizing access, providing
lower-income individuals with end devices (i.e., tablets, laptops, remote monitoring
tools) and /or access points and ensuring that digital health platforms and tools are
culturally and linguistically appropriate and accessible for vision and hearing im-
paired. In the interim, the AAFP also supports Medicaid coverage for audio-only
services to ensure all patients can access virtual care.
Medicaid coverage and payment for telehealth should promote virtual care that
is connected to patients’ medical home and should support physicians and patients’
freedom to choose the most appropriate modality of care—video, telephone, asyn-
chronous, in-person, etc.
QUESTIONS SUBMITTED BY HON. BENJAMIN L. CARDIN
Question. We have seen licensure limits substantially restrict access to cross-State
medical care during this unprecedented COVID–19 emergency period. To maximize
the utility of telehealth options and ensure provider accountability, some experts
have suggested that States should do more to ensure mutual licensing reciprocity
in the post-pandemic environment.
I am a cosponsor of Senator Murphy’s Temporary Reciprocity to Ensure Access
to Treatment Act (TREAT Act, S. 168/H.R. 708)—a narrowly tailored bill to enable
providers licensed in good standing in one State to treat patients in any State for
the duration of the COVID–19 Public Health Emergency.
In 2018, Congress allowed clinicians working within the U.S. Veterans Affairs
health system to practice both in-person and telehealth across State lines, as long
as they were licensed in good standing in their home States. Congress did the same
thing for Homeland Security providers in the CARES Act last year.
Would the American Academy of Family Physicians support a temporary, time-
limited reciprocity proposal like that in the TREAT Act given the extraordinary pub-
lic health crisis?
How should Congress help remove licensure barriers caused by the current patch-
work of State laws in the post-pandemic environment?
Answer. State-based licensure is part of the larger State-based infrastructure to
ensure patient safety. Monitoring medical practice and performing disciplinary ac-
tions is performed by State medical boards. Removing State licensure would bypass
that consumer protection performed by State medical boards. As well, the standard
of care and the practice of medicine does vary across States to support the varied
needs of individuals in the different States. We recommend that Congress should
look at options that strengthen and ease participation in the Interstate Medical Li-
censure Compact 2 by both physicians and States.
2 https://www.imlcc.org/.
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To prepare for the next public health crisis, Congress should look to support re-
search of the varied approaches that were performed by States during the COVID–
19 public health emergency with the goal of providing States with analysis of poten-
tial best practices. This would inform State Governers and Legislators on how best
to prepare their State for the next public health emergency. Such research could
also inform the Federal Government on best practices for their action in the next
public health emergency.
QUESTIONS SUBMITTED BY HON. CHUCK GRASSLEY
Question. Throughout the public health emergency, the Centers for Medicare and
Medicaid Services (CMS) issued over 200 waivers under Medicare and approved
more than 600 waivers and other flexibilities under Medicaid. While some of the
regulations waived are specifically for responding to a pandemic, ensuring patient
safety, controlling costs, and maintaining program integrity its clear innovation and
common-sense ideas in our health-care system have been stifled too often by Federal
regulations. For example, CMS permanently added certain new services (including
mental health and care planning services) that it had temporarily added to the ap-
proved list of Medicare telehealth services during the pandemic. Some regulations
play an important role in protecting safety and maintaining program integrity but
others may stifle good ideas.
Is health care too regulated that it’s stifling good ideas?
Answer. Family physician practices continue to be deeply overburdened by admin-
istrative functions at the point of care and after patient care hours, which hinders
their ability to provide high-quality care and contributes to physician burnout. The
AAFP and other frontline physician organizations developed joint principles 3 on re-
ducing administrative burden in health care.
• The AAFP urges CMS to adopt our recommendations 4 on prior authorization
(PA) and step therapy to promote efficiency, reduce administrative complexity
and improve patient access to treatment including exempting physicians par-
ticipating in financial risk-sharing agreements from PA, exempting generic
medications from PA, and not requiring step therapy for patients already on
a course of treatment.
• The AAFP has called on CMS to simplify Medicare rules surrounding pre-
scription of diabetic supplies and other DME ordered by a primary care physi-
cian for an established patient for the treatment of ongoing health conditions.
• The AAFP remains concerned that Medicare Incentive Payment System
(MIPS) reporting requirements necessitate expanded human and techno-
logical infrastructure that many smaller physician practices cannot afford. To
reduce reporting burden for all MIPS clinicians, CMS should provide scoring
flexibility through multi-category credit. There should be a single set of per-
formance measures across all payers that are universal, meet the highest
standards of validity, reliability, feasibility, importance, and risk-adjustment.
The measures should focus on outcomes that matter most to patients and that
have the greatest overall impact on better health of the population, better
health care, and lower costs.
• The AAFP calls on Congress and CMS to work together to repeal Meaningful
Use requirements for physicians’ utilization of health IT and reform the MIPS
promoting interoperability measure category. Health IT vendors should be
held accountable for interoperability before physicians are measured on EHR
use. Health IT should be a means to achieving desirable outcomes such as
improved quality of care and reduction of health disparities. Health IT utiliza-
tion is not an end goal in and of itself.
• The AAFP urges 5 Congress to delay implementation of the Medicare Appro-
priate Use Criteria (AUC) program. Physicians led the way in development
of AUC for diagnostic imaging and use it, but the AUC program as authored
by Congress is outdated and, if implemented, would add regulatory and finan-
cial burden to practices.
3 https://www.aafp.org/dam/AAFP/documents/advocacy/legal/administrative/ST-Group6-
AdministrativeBurden-061118.pdf.
4 https://www.aafp.org/dam/AAFP/documents/advocacy/legal/administrative/BKG-
PriorAuthorization.pdf.
5 https://www.aafp.org/dam/AAFP/documents/advocacy/coverage/medicare/LT-Congress-
AUCProgram-110720.pdf.
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The AAFP calls on Federal agencies to provide financial, time and quality-of-care
impact statements for new regulations and administrative tasks and to revise regu-
lations or administrative tasks that negatively affect the ability to provide timely,
appropriate, high-value patient care.
Question. Should executive agencies sunset regulations in the future to enable
more innovation in health care?
Answer. While the AAFP supports efforts to reduce the regulatory burdens on
physicians, we believe that automatically sunsetting regulations would increase reg-
ulatory complexity and lead to disruptions for a myriad of health-care stakeholders.
States, insurance issuers, physicians, and other health-care professionals all rely on
existing regulations and the regulatory process in order to serve patients. Patients
themselves also rely on clear regulatory guidance on the safety of food and medica-
tions, as well as health care coverage programs. Sunsetting these regulations would
undermine safety standards and could result in barriers to accessing essential
health services. Further, we are concerned that sunsetting regulations would inter-
fere with agencies’ ability to perform their essential functions and promulgate im-
portant new regulations to implement legislation passed by Congress. To ensure
agencies can focus on administering vital health care and public health programs
that advance the health of our Nation, we recommend against sunsetting regula-
tions. However, we look forward to working with Congress to find other legislative
solutions for reducing physicians’ administrative burdens.
QUESTIONS SUBMITTED BY HON. JOHN BARRASSO
Question. Before coming to the Senate, I had the privilege of practicing medicine
in Wyoming. Rural health care faced challenges prior to the pandemic. In particular,
we know since 2010 more than 135 rural hospitals have closed.
In the Senate, I am proud to help lead the bipartisan Rural Health Caucus. This
group is committed to ensuring patients in rural America can get access to the care
they need.
Can you specifically discuss the changes in Federal health-care policy that you be-
lieve have helped rural providers the most during this pandemic?
Can you please discuss any specific changes that Congress should consider to bet-
ter support rural health-care providers?
Answer. Rural physicians have benefited from nearly all telehealth changes dur-
ing the pandemic including removal of geographic and originating site restrictions
and coverage of audio-only E/M services. The AAFP has advocated for CMS to per-
manently cover audio-only E/M services to ensure access to virtual care for patients
in rural areas who lack access to reliable broadband.
The Teaching Health Center Graduate Medical Education (THCGME) is one of
the most successful, efficiently run programs in the country. Since its inception, this
program has trained 1,148 primary care physicians and dentists, and evidence sug-
gests that physicians who train in community-based underserved settings are more
likely to practice in those settings. Data from the American Medical Association
Physician Masterfile show that the majority of family medicine residents will stay
within 100 miles of where they train, which often includes rural areas. Congress
reauthorized the THCGME program in 2020 for 3 years and should perma-
nently reauthorize and expand the program by passing the Doctors of Com-
munity (DOC) Act (S. 1958).
In the FY 2022 Inpatient Prospective Payment System (IPPS) proposed rule, CMS
laid out a proposed methodology for distributing one thousand new Medicare GME
residency positions that were enacted by Congress in December. This is the first in-
crease to the number of available positions under the Medicare GME program in
nearly 25 years. The same legislation also allowed for the creation of new rural
training track sites. While the AAFP was largely supportive of CMS’s proposals to
allow for the creation of new rural training track sites, we strongly recommend that
CMS allow existing rural track sites to increase the number of physicians they are
able to train. These existing sites are successfully training rural physicians and ad-
dressing physician maldistribution and CMS should invest in their expansion.
Specifically for rural areas, Congress should consider the impact of low patient
volumes on physician payment. As payment transitions from volume to value, physi-
cians are being increasingly held accountable for quality and utilization perform-
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ance. A physician’s performance is more easily skewed by outliers when they have
a lower patient volume. Congress should ensure value-based payment models
make appropriate adjustments on quality and utilization assessment for
rural practices. Practices should not be assessed on measures unless the measure
is both valid and reliable for low patient volumes, and payers should consider the
high resource burden associated with quality reporting.
Increased funding for the National Health Service Corps (NHSC) primary
care physicians would allow more rural Health Professions Shortage Areas
(HPSAs) to qualify for family physician placements. Primary Care HPSA scor-
ing prioritizes population-to-provider ratio over travel time to the nearest source of
care. This leaves rural communities at a disadvantage when there is not adequate
funding of the National Health Service Corps (NHSC) to provide a family physician
for areas with lower HPSA scores. Those areas need physicians, but the funding
does not extend far enough to provide a NHSC clinician.
The rising cost of liability insurance premiums contributes to the grow-
ing loss of obstetrical services in rural communities. Higher premiums threat-
en the viability of some rural hospitals and make it difficult for rural areas to re-
cruit or retain an adequate number and mix of physicians. Through the Federal
Tort Claims Act (FTCA), the Federal Government offers a way for certain rural
health centers to lower their malpractice insurance costs. FTCA expansion could
help rural communities struggling to provide high-risk services due to the
increasing cost of private medical malpractice insurance.
Physicians utilizing J–1 visa waivers play an important role in addressing the
current physician shortage in rural areas. Conrad 30 has been a highly successful
program, enabling underserved communities to recruit both primary care and spe-
cialty physicians after they complete their medical residency training. The AAFP
recommends streamlining the green card program for the J–1 visa pro-
gram.
Question. Prior to the pandemic, I introduced bipartisan legislation with Senator
Tina Smith, which among other things, would allow Rural Health Clinics (RHCs)
to provide more telehealth services.
I was pleased that Congress through the CARES Act authorized both Rural
Health Clinics and Federally Qualified Health Centers to furnish telehealth services
to Medicare beneficiaries during the public health emergency.
Can you discuss the importance of Rural Health Clinics and Federally Qualified
Health Centers continuing to provide telehealth services after the public health
emergency has ended?
Answer. FQHCs and RHCs must continue to be allowed to be the distant site in
telehealth encounters beyond the PHE. This has improved health-care access for
historically marginalized populations and will be beneficial as we continue to strive
for health equity.
Question. My wife Bobbi and I are passionate about improving access to mental
health services. This pandemic has clearly impacted the mental, as well as the phys-
ical health of our Nation.
For people living in rural America, getting help from a mental health provider
was challenging before the pandemic. This is why Senator Stabenow and I have long
supported professional counselors and marriage and family therapists participating
in Medicare. We believe that increasing the number of mental health providers able
to care for our Nation’s seniors is an important priority.
Please discuss how telehealth has impacted the ability of patients to receive men-
tal health services during the pandemic.
Answer. Often, the only access rural patients have to mental health providers is
through telehealth. It is not unusual for a family physician to be the only health-
care provider in the county or in several counties driving distance. The pandemic
has opened access to mental health providers that were previously not accessible
due to Medicare’s arbitrary geographic and originating site restrictions, which pre-
viously only exempted certain substance use disorder treatment.
Question. Can you please identify ways Congress can improve access to mental
health services, including expanding the number of providers that can participate
in Medicare?
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I agree telehealth is transforming the way we are providing care. However, in Wy-
oming, most of our providers are part of smaller hospitals and practices. We need
to make sure government regulation is not making it more difficult for these pro-
viders to serve their patients.
Can you discuss specific ways Congress can reduce the administrative burden in
providing care through telehealth?
Answer. We encourage Congress to adopt and support policies that streamline
coverage and payment for telehealth services across public and private payers. Vari-
ations in coverage and coding requirements add undue complexity that is especially
burdensome for small and solo physician practices. Telehealth services provided by
a primary care physician to an established patient should not be subject to different
oversight than comparable in-person services.
PREPARED STATEMENT OF LINDA V. DECHERRIE, M.D., CLINICAL DIRECTOR, MOUNT
SINAI AT HOME; AND PROFESSOR OF GERIATRICS AND PALLIATIVE MEDICINE, ICAHN
SCHOOL OF MEDICINE AT MOUNT SINAI, MOUNT SINAI HEALTH SYSTEM
Chairman Wyden, Ranking Member Crapo, and members of the Senate Finance
Committee, it is my distinct pleasure on behalf of the Icahn School of Medicine at
Mount Sinai and Hospital at Home Users Group to submit this testimony in support
of Hospital at Home, specifically extending the current Hospital Without Walls and
Acute Hospital Care at Home flexibilities currently being offered under the public
health emergency (PHE).
The Mount Sinai Health System is New York City’s largest academic medical sys-
tem, encompassing eight hospitals, a leading medical school, and a vast network of
ambulatory practices throughout the greater New York region. Mount Sinai is a na-
tional and international source of unrivaled education, translational research and
discovery, and collaborative clinical leadership ensuring that we deliver the highest
quality care—from prevention to treatment of the most serious and complex human
diseases. The Health System includes more than 7,200 physicians and features a
robust and continually expanding network of multispecialty services, including more
than 400 ambulatory practice locations throughout the five boroughs of New York
City, Westchester, and Long Island. The Mount Sinai Hospital is ranked No. 14 on
U.S. News and World Report’s ‘‘Honor Roll’’ of the Top 20 Best Hospitals in the
country and the Icahn School of Medicine as one of the Top 20 Best Medical Schools
in the country. Mount Sinai Health System hospitals are consistently ranked region-
ally by specialty and our physicians in the top 1 percent of all physicians nationally
by U.S. News and World Report.
The Hospital at Home Users Group is a dynamic collaborative of Hospital at
Home programs around the United States and Canada. We are sharing resources
and best practices, working together to expand the reach of our programs, and de-
veloping the program and policy standards to inform regulatory and reimbursement
policies necessary to spread this hopeful model broadly throughout North America.
Hospital at Home (HaH) is a patient-centric model of care which provides
hospital-level care at home for patients with select acute illnesses and acuity level
who would otherwise be hospitalized. The traditional hospital can be dangerous for
older adults with resultant functional decline, iatrogenic illnesses, and other adverse
events. Multiple HaH studies have demonstrated improved patient safety, reduced
mortality, enhanced quality, and reduced cost. This was a model that many Medi-
care Advantage, commercial, and Medicaid managed care plans already covered be-
fore the pandemic. Adding the rest of Medicare beneficiaries allows equitable care
and has been extremely helpful since November 2020, when the Acute Hospital
Care at Home waiver was approved. I believe the coverage of Hospital at Home or
Acute Hospital Care at Home should be covered beyond the pandemic as a 30-day
bundle of care.
Typically, HaH starts in the emergency departments where a patient is evaluated
by the emergency physicians and staff and if they are determined to need inpatient
care they are screened for HaH. This screening first starts with a clinical screen
to see if the conditions and treatment plan can be effectively delivered in the home,
then the patients home environment is screened through a bedside survey. Common
diagnoses are Pneumonia, Congestive Heart Failure (CHF), Chronic Obstructive
Pulmonary Disease (COPD), and Cellulitis. The patient then is offered the oppor-
tunity to participate in the program and consents. Other physicians see the patient
and write admission orders. Patients go home with an IV in place, in an ambulance,
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with a telehealth kit and potentially with oxygen. The ambulance staff sets them
up in the home and within a couple of hours, a nurse arrives at the home and fur-
ther assesses the home for safety and starts the treatment plan. Multiple deliveries
typically occur such as IV and oral medications, equipment, and supplies. In the
subsequent days, nurses come twice a day (some programs use mobile integrated
health paramedics), and a physician or nurse practitioner sees the patient daily (in
person or via video visit). They have access to other services such as physical ther-
apy, occupational therapy, speech therapy, social work, and nutrition—all as needed
based on the patient’s individualized care plan. Patients usually require frequent
blood draws, IV fluids, antibiotics, x-rays, or oxygen, all of which can be done in
the home. Teams will round a couple times a day to review the care plan. There
is 24/7 immediate availability of the team, including in person within 30 minutes
if needed. This care is inclusive, patient centric, and equitable, as 41 percent of our
patients have some form of Medicaid. Once a clinician is in the home many addi-
tional barriers to improved health care, including health literacy, food insecurity,
nutritional misinformation, and medical equipment needs are all readily identifi-
able, allowing our social worker to get involved, and referrals to be made to help
improve the patient’s health longer-term.
There are other pathways into Hospital at Home, such as from a patient’s out-
patient doctors’ offices, urgent care, or from the inpatient floors as long as the pa-
tient requires inpatient level care and would otherwise have been admitted to the
hospital.
The model of Hospital at Home has existed for several decades internationally
with Australia, France, Spain, and Israel being some of the early adopters. In the
mid-1990s the first trials of Hospital at Home were performed in the U.S. at Johns
Hopkins. It was shown to be safe, efficacious and the patients desired this type of
care. Never the less, no payment was available and existing payment structures did
not adequately cover the costs of the program. Between the mid-1990s and 2014,
a number of veterans’ hospitals developed similar programs as they had payment
flexibilities. One integrated health system in New Mexico with their own Medicare
Advantage plan has offered a HaH program since 2008. In 2014, we at Icahn School
of Medicine at Mount Sinai in New York City applied and received a Center for
Medicare and Medicaid Innovation (CMMI) award to develop and test Hospital at
Home for a fee-for-service Medicare population. We did one thing differently than
previous iterations of Hospital at Home, we cared for the patients for 30 days. It
was split into two phases—the acute phase where the patient would have been in
the hospital and a transitional phase for monitoring and ensuring the patient was
stable and back under the care of their primary care provider and outpatient spe-
cialists.
From our CMMI period, we examined more than 500 fee-for-service Medicare
beneficiaries who received HaH care. We received additional funding from The John
A. Hartford Foundation, and were able to compare care to a group of patients who
received traditional inpatient care. For both groups of patients, the full 30 days of
care were examined, and more than 65 Diagnosis-Related Groups (DRGs) were in-
cluded in this analysis. Length of stay was reduced from 5.5 days to 3.2 days, 30-
day readmissions were reduced from 15.6 percent to 8.6 percent, and Skilled Nurs-
ing Facility transfers on discharge were reduced from 10.4 percent to 1.7 percent
with a resultant higher use of Certified Home Health for this HaH cohort. With re-
gards to patient satisfaction, 45.3 percent of traditionally hospitalized patients were
highly satisfied with care, while with HaH it increased to 68.8 percent.
While some programs may start with a limited number of DRGs for which they
can provide HaH care, we currently believe there are more than 150 DRGs that
HaH can serve, and believe this is probably a conservative estimate. As many pro-
grams expand into oncology and surgical cases, the number will increase.
From this work, we submitted a proposal to the Physician-Focused Payment
Model Technical Advisory Committee (PTAC)—‘‘HaH Plus’’ (Hospital at Home
Plus)—Provider-Focused Payment Model. Moreover, after evaluation, PTAC rec-
ommended two separate HaH proposals in 2018: (1) our proposal, the Hospital at
Home Plus Model (HaH-Plus); and (2) the Home Hospitalization: An Alternative
Payment Model for Delivering Care in the Home (HH–APM), to the Secretary of the
Department of Health and Human Services for implementation. The Secretary ex-
pressed interest in testing home-based, hospital-level of care models and agreed
with the PTAC that these models hold promise for testing. The agency has the au-
thority to further refine the recommended PTAC models; however, to-date, they
have not utilized this authority. While we recognize the broader need for a refined
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HaH model, and we look forward to working with the agency to advance such a
model to ensure greater availability of hospital care in the home to all patients, we
believe congressional action to extend the current waivers and flexibilities is nec-
essary and particularly valuable for patient care in the immediate and near term.
We believe these regulatory flexibilities should be made permanent beyond the
PHE and will be an effective foundation for establishing Medicare reimbursement
that is specific to Hospital at Home services. We applaud The United States Depart-
ment of Health and Human Services (HHS) for providing these flexibilities to ensure
hospital services in the home during the PHE, and we encourage Congress and HHS
to consider extending these flexibilities as a new model of care that prioritizes the
patient’s safety and care needs.
In 2017 when the CMMI award was finished, our Hospital at Home program no
longer provided care for fee-for-service patients as there was no fee-for-service reim-
bursement and the program shifted to focus on Medicare Advantage, commercial,
and Medicaid managed care plans. We created a joint venture with Contessa Health
and together have negotiated contracts with most of the major insurance providers
in our area.
During the initial surge of COVID–19 in March 2020 we were an important part
of helping the Mount Sinai Health system admit both COVID negative and positive
patients to open up more capacity for patients needing higher levels of care like
ICUs, but were still unable to admit a fee-for-service Medicare patient from the
emergency room. The PHE has demonstrated the need to have Hospital at Home
accessible to fee-for-service Medicare patients.
We were very excited to be part of the original group of hospitals approved for
the Acute Hospital Care at Home waiver in November 2020. Despite having oper-
ated since 2014, we still needed some time to set up and meet the new require-
ments. We are appreciative that CMS made this available to fee-for-service Medi-
care patients. My colleagues and I have been happy to engage with CMS as stake-
holders in this process. In addition, we formed the Hospital at Home Users group
with funding from The John A. Hartford Foundation, which provides technical as-
sistance, office hours and a member community which has engaged in multiple work
groups. To date, there have been 129 hospitals approved for the Acute Hospital Care
at Home waiver, with 56 health systems in 30 States since November. This shows
that there is great interest. It does take significant start up resources and time and
many are not planning to launch until this summer. I believe even more hospitals
would apply if they knew this program would be made permanent. This waiver al-
lowed many hospitals to jump start a program in the pandemic, which has been
helpful in many communities for the provision of high quality and safe patient hos-
pital inpatient care.
Having a payment model for Hospital at Home/Acute Hospital Care at Home is
needed to serve Medicare beneficiaries beyond the pandemic and especially if an
emergency of this type ever happens again. These programs are complex to start,
and many places could not start instantaneously; therefore, if the flexibilities con-
tinue beyond the PHE, I believe many additional hospitals will join. There is a
strong interest in the community of Hospital at Home programs to continue this.
Due to the regulatory barriers outlined above, hospitals have been wary about and
disincentivized from implementing the innovations of providing acute level care in
the home. Therefore, we request Congress and HHS to consider a permanent exten-
sion of the Hospital Without Walls and Acute Hospital Care at Home waivers be-
yond the PHE to mitigate the residual impacts of COVID–19 on public health and
encourage broader adoption of providing patient centered health-care services in the
home. Thank you for the opportunity to provide this testimony to the committee.
My colleagues and I look forward to continuing to work with Congress and HHS on
this important issue.
QUESTIONS SUBMITTED FOR THE RECORD TO LINDA V. DECHERRIE, M.D.
QUESTIONS SUBMITTED BY HON. MIKE CRAPO
Question. Mount Sinai health system was one of the first group of hospitals that
CMS approved for the Acute Hospital Care at Home waiver last year. Medicare pays
hospitals participating in the program at the same reimbursement rate that the fa-
cility otherwise would have received if the beneficiary had been admitted to the hos-
pital. In your testimony, as well as during interviews with my staff, you indicated
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that the Mount Sinai Hospital at Home program has demonstrated improved pa-
tient outcomes, increased quality of care, enhanced patient safety, reduced mor-
tality, and lowered costs. This committee wants to identify smart Medicare payment
reforms that show the greatest potential to ensure beneficiaries get the right care,
in the right setting, at the right time, and in a cost-efficient manner. Not only do
Medicare beneficiaries deserve high-quality care, but any innovative payment ar-
rangements that we consider implementing beyond the PHE, must also help put
Medicare on a more sustainable fiscal path.
If it was less expensive for Medicare to furnish certain acute inpatient services
in the home during the pandemic, and beneficiaries saw better health outcomes,
then how do you think these efficiencies should be factored into the Medicare hos-
pital inpatient payment rates?
Answer. In my opinion, the services provided by Hospital at Home (HaH) pro-
grams should be billed as a DRG based 30-day bundled value-based payment to bet-
ter manage the care of HaH patients, which was studied through our CMMI Innova-
tion Grant from 2014–2017. It is our belief that this is the most cost effective and
appropriate manner to bill these services going forward. While this value-based pay-
ment model is built, the current Acute Hospital Care at Home waiver should extend
to enable programs, like Mount Sinai, to continue providing and being paid for hos-
pital inpatient care in the home. I do not believe the two offerings and approaches
to hospital care in the home are mutually exclusive, and do believe they collectively
benefit patients, providers, and the Medicare program.
Question. Should CMS calculate separate Medicare claims codes in order to reim-
burse for these specific services?
Answer. No, it is not necessary to create separate Medicare claims codes to reim-
burse for Hospital at Home specific services. The services provided through HaH are
indeed the same level of services provided in an acute care setting for patients. Cre-
ation of a new set of Medicare claims code would add unnecessary burden to pro-
viders needing to learn a new set of codes for the same set of services. Importantly,
the patients seen under HaH receive higher quality, lower cost care, and have a
higher patient satisfaction scores than patients receiving the same level of care in
an acute care setting.
Question. The Congressional Budget Office (CBO) would analyze and provide a
cost-estimate for any legislative proposal seeking to make the Acute Hospital Care
at Home program permanent once the PHE expires. CBO has previously indicated
that Medicare fee-for-service programs are generally subject to unnecessary utiliza-
tion as well as potential fraud, waste, and abuse.
What specific policies do you recommend in order to minimize these risks?
Answer. HaH allows for treatment of patients that meet Milliman Care Guide-
lines or other equivalent guidelines for medical necessity for hospital admission by
a qualified team of care providers. In order to qualify for HaH, we advise that pa-
tients and their homes meet a strict set of screening criteria, as per our study at
Mount Sinai, before being deemed eligible for HaH. Additionally, we believe based
on our experience with the HaH plus model that home-based acute care services re-
sulted in less waste than traditional hospital inpatient care. Further studies could
be conducted to confirm these findings and expand upon the work previously done.
QUESTIONS SUBMITTED BY HON. THOMAS R. CARPER
Question. During the pandemic, telehealth has been an essential tool to get chil-
dren the care that they need while minimizing risk. Although telehealth under
Medicare has been a focus, close to 40 million children are enrolled in Medicaid.
What are the main policy changes we need to ensure this broader use of tele-
health can be continued beyond the pandemic for children?
Answer. Telehealth and audio-only telehealth need to continue to be reimbursed
as they were during the Public Health Emergency. Allowing the continuation of
these services for Medicaid beneficiaries is an important step to improving access
to care and health equity for children. During the PHE, Mount Sinai used grant
funding from the Federal Communications Commission (FCC) to provide 700 devices
to children and their families requiring telehealth monitoring and care, on a rotat-
ing basis, in addition to another 150 tablets for homebound adults in the Mount
Sinai Visiting Doctors Program. Through innovative partnerships, telehealth was
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provided to thousands of patients by removing obstacles to receiving health-care
services. This model could be expanded upon to the larger population in order to
provide convenient, cost-efficient, high-quality home-based health-care services to
children and adults.
Question. During COVID–19, many States adopted temporary changes to their
telehealth policies, such as expanding the scope of services and providers able to fur-
nish telehealth, relaxing of licensure requirements and modifying reimbursement
policies. Many States legislatures have also begun the work to adopt more perma-
nent telehealth policy changes.
How can the Federal Government best support State Medicaid programs in their
efforts to expand telehealth?
Answer. The Federal Government can help support State Medicaid programs by
ensuring telehealth and audio only telehealth continue to be reimbursed for the care
provided to beneficiaries. In addition, the Federal Government can help support
State Medicaid to cover Hospital at Home (Acute Hospital Care at Home) services.
HaH can provides acute levels of care to all adults, and during the pandemic that
has included patients within the Medicare and Medicaid population, who often
struggle with access to convenient health-care services. Additionally, the lifting of
geographic restrictions for providers of health-care services is another important
step that will allow telehealth to be provided across State lines and fill gaps of care
where access is limited. Lastly, enhancing the rollout of broadband Internet to rural
communities will ensure everyone has access to telehealth services.
Question. Are there Medicaid supports, incentives, and learnings that Federal pol-
icymakers could provide?
Answer. Federal policymakers could help State Medicaid programs by continuing
to rollout access to broadband Internet services across the country and subsidizing
affordable technology provided to Medicaid patients to allow telehealth and audio-
only telehealth visits. Extending the Acute Hospital Care at Home waiver beyond
the PHE is an additional step that should be taken to support the Medicaid popu-
lation. These supports and incentives would greatly improve access to care and
allow for continued innovation in how cost-efficient care is delivered to Medicaid
(and all) patients.
Question. COVID–19 has introduced additional stress and trauma for children and
families. Telehealth, and particularly audio-only telehealth has been a crucial tool
to connect children and adolescents to needed mental health-care services.
How can telehealth be best utilized to meet kids’ mental health-care needs, and
can you speak to the use of audio-only telehealth specifically?
Answer. Telehealth effectively increases access to mental health services for kids.
It is a cost-efficient, barrier removing (i.e., travel, parent/guardian time, access) so-
lution to provide much needed mental health services to children in need. As we
have seen during the public health emergency, mental health in our country is at
an inflection point and desperately needs to be addressed. The CDC found that sui-
cide rates among teenagers increased by more than 50 percent during the PHE,
worsening mental health issues long ignored. As such, audio only telehealth reim-
bursement needs to continue, as it provides additional coverage to children without
the financial and technological capabilities to engage in video enabled telehealth vis-
its and provides further options of convenient, cost-effective care.
Question. As State Medicaid programs look at expanding their use of telehealth,
it is particularly important that vulnerable populations like children are not nega-
tively impacted. Policies must be looked at through a health equity lens, considering
access to reliable and affordable broadband services, access to devices that support
HIPAA-compliant telehealth platforms and coverage policies.
How can Medicaid programs work to ensure telehealth policies are equitable for
children and mitigate potential inequities that may arise?
Answer. Subsidizing access to affordable technological resources to engage in
video enabled telehealth, like the grant funding Mount Sinai received from FCC to
provide children and their families devices, will help to improve equity of telehealth
policies. Reimbursement should also be allowed to continue for audio-only telehealth
services and HaH post-PHE. Additionally, Medicaid programs should enable pro-
viders to treat patients across State lines in order to improve access to care for
States that do not have enough health services providers. Lastly, it is crucial to fill
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the gap in rural broadband service to ensure rural populations have the same access
to telehealth services as other populations.
QUESTIONS SUBMITTED BY HON. BENJAMIN L. CARDIN
Question. We have seen licensure limits substantially restrict access to cross-State
medical care during this unprecedented COVID–19 emergency period. To maximize
the utility of telehealth options and ensure provider accountability, some experts
have suggested that States should do more to ensure mutual licensing reciprocity
in the post-pandemic environment.
I am a cosponsor of Senator Murphy’s Temporary Reciprocity to Ensure Access
to Treatment Act (TREAT Act, S. 168/H.R. 708)—a narrowly tailored bill to enable
providers licensed in good standing in one State to treat patients in any State for
the duration of the COVID–19 Public Health Emergency.
How have health systems and patients benefited from State licensing reciprocity
during the COVID19 public health emergency?
Answer. This allows providers to treat their patients regardless of what State
they are currently in. Patients have benefited from being able to access the pro-
viders of their choice. If a patient is traveling and needs their care managed by their
PCP who is in another State, they should be able to receive that care telephonically
and by video and be managed by the physician that knows them and their specific
health status best.
Question. I recently reintroduced the Home Health Emergency Access to Tele-
health Act (HEAT) Act with Senators Collins and Shaheen. This bill would allow
Medicare home health providers to be reimbursed for the telehealth services during
a public health emergency. I also have heard from other home-based care providers,
like hospice and palliative care as well as home-based primary care about the im-
portance of telehealth during the emergency and into the future as services in the
home and community continue to grow.
Could you talk about your experiences using telehealth to supplement care for the
populations you take care of ?
Answer. We have learned to be creative in this pandemic. In March 2020 a small
portion of our home-based primary care patients were able to access telehealth,
mostly those who lived with their adult children. However, with a grant from the
FCC where we provided tablets to some patients and working with other patients
who had consistent home health aides who had smart phones we were able to ex-
pand those we could use video visit. However, it still did not reach all patients, and
regular telephone was utilized instead.
When a patient is able to use video technology it is tremendously helpful to us,
when the call with an urgent complaint such as leg swelling, a new rash or ulcer,
our nurses can immediately get a visual on the issue and provide that to the pro-
vider who can decide how urgently and in what way a patient needs to be seen. In
the past we would do that telephonically only and then next day send a provider
out to the home.
In our Hospital at Home program (Acute Hospital Care at Home) we also heavily
utilize video technology, which allows the provider and care coordinator to partici-
pate in all visits to the home.
Question. What lessons from the pandemic would you like to see brought forward
into the future of care for home health, hospice, palliative, and other home-based
care providers?
Answer. The need for patient-centered, acute level care that can be furnished in
a patient’s home is the biggest lesson from the PHE that needs to be brought for-
ward into the future of care. We learned that a decades old model of care, Hospital
at Home, which provided value pre-pandemic despite lack of a Medicare payment
structure could bring value during the PHE by providing payment for and access
to hospital inpatient services. Moreover, this model can and should carry beyond the
PHE. While we recognize the broader need for a refined HaH model as part of the
shift to a value-based payment system, we believe congressional action to extend the
current Acute Hospital Care at Home waiver and associated telehealth flexibilities
is necessary and particularly valuable for patient care in the immediate and near
term. We believe these regulatory flexibilities should be made permanent beyond
the PHE and will be an effective foundation for establishing Medicare reimburse-
ment that is specific to HaH services. We look forward to working with Congress
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and the agency to advance such a model to ensure greater availability of hospital
care in the home to all patients.
QUESTIONS SUBMITTED BY HON. CHUCK GRASSLEY
Question. Throughout the public health emergency, the Centers for Medicare and
Medicaid Services (CMS) issued over 200 waivers under Medicare and approved
more than 600 waivers and other flexibilities under Medicaid. While some of the
regulations waived are specifically for responding to a pandemic, ensuring patient
safety, controlling costs, and maintaining program integrity its clear innovation and
common-sense ideas in our health-care system have been stifled too often by Federal
regulations. For example, CMS permanently added certain new services (including
mental health and care planning services) that it had temporarily added to the ap-
proved list of Medicare telehealth services during the pandemic. Some regulations
play an important role in protecting safety and maintaining program integrity but
others may stifle good ideas.
Is health care too regulated that it’s stifling good ideas?
Answer. In the case of the Hospital Without Walls and Acute Hospital Care at
Home waivers, policymakers have lifted critical regulatory barriers that have pre-
vented or at minimum dissuaded hospitals and health systems from investing in
Hospital at Home. Specifically, these waivers have allowed the home to be a permis-
sible site for acute level care and allowed section 482.23 of the Medicare Conditions
of Participation for 24-hour nursing services to be fulfilled virtually. These waivers
have allowed for necessary innovations to maintain patient safety, and we need to
continue to foster this innovation after the end of the PHE. This should be extended
as a distinct hospital program of hospital inpatient care as an integrated model of
hospital services, separate and distinct from home care services.
Due to the pre-pandemic aforementioned regulatory barriers, hospitals and health
systems have been unable to receive Medicare fee-for-service reimbursement. Hos-
pitals and health systems need time, funding, and predictability beyond 90-day in-
tervals to build the necessary infrastructure to administer Hospital at Home. With-
out the continuation of these waivers, these regulatory barriers will resume and in-
novations like the Hospital at Home program (Acute Hospital Care at Home) will
not be adopted across health systems and hospitals.
Question. Should executive agencies sunset regulations in the future to enable
more innovation in health care?
Answer. Prior to the public health emergency, Hospital at Home was only reim-
bursed in certain circumstances under commercial arrangements. With traditional
Medicare covering 15 percent of the population, it is vital that executive agencies
consider a formal payment model for fee-for-service patients. Having a payment
model for Hospital at Home is needed to serve Medicare beneficiaries beyond the
pandemic and especially in the event of a future public health emergency.
Moreover, executive agencies should allow a reinterpretation of section 482.23 of
the Medicare Conditions of Participation to allow nursing services to be fulfilled vir-
tually for Hospital at Home programs. Agencies should also sunset regulations that
limit the home as an originating site for acute level services and telehealth.
Question. In March 2020, CMS announced an effort known as Hospitals Without
Walls designed to rapidly increase hospital capacity at the start of the pandemic.
In November 2020, CMS established the Acute Hospital Care at Home demonstra-
tion model. This model allows approved hospitals to deliver home-based care and
meet patients’ needs with quality, convenience, and comfort. The model has proven
to be effective in better quality outcomes, shorter lengths of stay, and higher patient
satisfaction all while lowering overall cost of care. The UnityPoint at Home, an Iowa
health-care provider, was one of the first providers to be approved by CMS and the
first in the Nation in February 2021 to admit and bill for patients. Hospitals under
Medicare FFS were not previously allowed to offer this type of care that is more
intensive than home health. This model was already utilized by Medicare Advan-
tage, commercial, and Medicaid managed care plans. I have supported similar inno-
vations for hospitals in rural areas. Last Congress, we passed the Rural Emergency
Hospital Designation (REH) that will let rural hospitals right-size their infrastruc-
ture while maintaining essential medical services in their communities like 24/7
emergency care and outpatient care.
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Should CMMI extend the current waiver for the Medicare FFS program to exist
into the future?
Answer. Yes, the coverage of Hospitals Without Walls and Acute Hospital Care
at Home should be covered permanently beyond the PHE. Multiple studies on the
Hospital at Home program have demonstrated improved patient safety, reduced
mortality, enhanced quality, and reduced cost. We applaud the Department of
Health and Human Services for providing these flexibilities to ensure hospital serv-
ices in the home during the PHE, and we encourage Congress and HHS to also con-
sider a CMMI model that allows a reimbursement pathway for a new Hospital at
Home 30-day bundle value-based model of care that reduces costs of care and
prioritizes the patient’s safety and care needs.
Question. What efforts can be made to improve the model?
Answer. The shift of care in the community will require further training of pro-
viders, alignment with community partners, and shifting the current framework
that usually results in hospitalization. Successful treatment in the home of individ-
uals with acute illness requires a skill set that includes hospital care, home-based
care, and a strong focus on coordination of care and transitions. Hospital at Home
programs require home inspections and patient safety protocols that can respond to
abrupt changes in clinical status and needs when certain clinical resources are not
readily available. Leveraging the experience of a home-based primary or palliative
care program can help create that infrastructure. While we recognize the broader
need for a refined Hospital at Home value-based model of care, and we look forward
to working with the agency to advance such a model to ensure greater availability
of hospital care in the home to all patients, we believe congressional action to ex-
tend the current waivers and flexibilities is necessary and particularly valuable for
patient care in the immediate and near term.
Question. What similar cost-effective innovations are being stifled by Federal law
and regulations?
Answer. Value-based arrangements have historically been stifled by regulatory
barriers. Cost-saving innovations such as care coordination services have been dif-
ficult to implement with Federal laws restricting information sharing and access to
data between providers. Recently, CMS published the Modernizing and Clarifying
the Physician Self-Referral Final Rule, which mitigated some of these barriers by
giving greater flexibility to providers to participate in value-based care delivery
models and provide coordinated care or patients. While this rule offers exciting new
opportunities for providers, payers, and others to innovate, there are still limita-
tions. The safe harbors and exceptions in the Final Rule are highly prescriptive so
existing value-based arrangements will likely not satisfy all AKS or Stark Law
value-based requirements without review and amendment.
QUESTIONS SUBMITTED BY HON. JOHN BARRASSO
Question. Before coming to the Senate, I had the privilege of practicing medicine
in Wyoming. Rural health care faced challenges prior to the pandemic. In particular,
we know since 2010 more than 135 rural hospitals have closed.
In the Senate, I am proud to help lead the bipartisan Rural Health Caucus. This
group is committed to ensuring patients in rural America can get access to the care
they need.
Can you specifically discuss the changes in Federal health-care policy that you be-
lieve have helped rural providers the most during this pandemic?
Answer. During COVID–19, CMS allowed many evaluation and management
codes to be furnished via telehealth. Telehealth has become an essential service for
patients and primary care providers have led the charge in its use. Telehealth has
allowed providers to maintain, and in certain cases expand, the reach of their med-
ical services to populations in need. Many provider practices and the patients they
serve will remain reliant on telehealth services as a care tool for the immediate fu-
ture, if not longer.
Waiving originating and distant site requirements, allowing Medicare reimburse-
ment for audio-only, and increased funding for broadband infrastructure have all
helped rural health-care providers and contributed to increased access for patients.
Question. Can you please discuss any specific changes that Congress should con-
sider to better support rural health-care providers?
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Answer. There are a few avenues Congress can consider to better support rural
health-care providers:
• Support extending the Acute Hospital Care at Home waiver: There are
already many rural hospitals participating, and this will allow rural providers
options of site of care for their patients. Simultaneously or subsequently en-
courage and work with the Secretary to finalize a 30-day bundle value-based
payment model for HaH as proposed to the PTAC in 2017.
• Increase funding for telecommunications services and connected de-
vices for provider practices and patients: Small practices in rural areas
often do not have the upgraded technological platforms needed to provide tele-
health services for their patients. Additionally, funding opportunities for these
services and devices have been limited for independent provider practices. Ap-
plications for additional funding should be streamlined as much as possible
to preclude any unnecessary administrative burden for independent practices
that may lack some of the support services and administrative staff that larg-
er entities can take advantage of.
• Increase support for broadband infrastructure: The expanded use of
telehealth, including video visits and remote patient monitoring, require the
use of broadband which many patients in rural and underserved areas do not
have. Congress should consider the needs of this population and commit to
providing universal broadband to all who need it.
• Permanent removal of originating and distant site requirements: This
ensures that providers can provide needed care for patients without regu-
latory barriers and patients themselves have continued access to telehealth
services beyond the PHE when they need it.
• Permanently implement a separate payment for telephone-only serv-
ices: Post COVID–19, many physician practices and the patients they serve
will continue to rely on telehealth services for the foreseeable future. Not cov-
ering these codes post-PHE will disproportionally put patients without the
means or access to technology and the Internet at risk of not having access
to care.
Question. Prior to the pandemic, I introduced bipartisan legislation with Senator
Tina Smith, which among other things, would allow rural health clinics (RHCs) to
provide more telehealth services.
I was pleased that Congress through the CARES Act authorized both Rural
Health Clinics and Federally Qualified Health Centers to furnish telehealth services
to Medicare beneficiaries during the public health emergency.
Can you discuss the importance of Rural Health Clinics and Federally Qualified
Health Centers continuing to provide telehealth services after the public health
emergency has ended?
Answer. As you know, Rural Health Clinics and health centers are required to
offer comprehensive services in areas of high need, and many are using telehealth
to address geographic, economic, transportation, and linguistic barriers to health-
care access. During the PHE, Medicare and Medicaid adopted policies that have al-
lowed health centers to provide primary and preventive care virtually. These poli-
cies allow health centers to ensure their patients continue to receive the care they
rely on, often from the comfort and safety of their own homes. Disparities will not
disappear after the PHE, rather they will be exacerbated as a result. It is vital now
more than ever that Rural Health Clinics and FQHCs continue to provide telehealth
services after the PHE has concluded.
Question. My wife Bobbi and I are passionate about improving access to mental
health services. This pandemic has clearly impacted the mental, as well as the phys-
ical health of our Nation.
For people living in rural America, getting help from a mental health provider
was challenging before the pandemic. This is why Senator Stabenow and I have long
supported professional counselors and marriage and family therapists participating
in Medicare. We believe that increasing the number of mental health providers able
to care for our Nation’s seniors is an important priority.
Please discuss how telehealth has impacted the ability of patients to receive men-
tal health services during the pandemic.
Answer. Telehealth has greatly increased access to mental health services during
the pandemic. COVID–19 has far reaching mental health implications for a large
proportion of the US population. Prior to the pandemic, nearly one in five U.S.
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adults reported living with a mental illness, but only half received treatment. Many
obstacles remain in place for those living with a mental illness, including stigma
and lack of mental health services in urban and rural areas. With digital tools and
access to broadband Internet, patients can now consult with a mental health profes-
sional remotely using live video. Patients living in ‘‘mental health professional
shortage’’ areas can use these tools to speak with a licensed professional without
driving long distances. They can also receive care discretely if their loved ones or
colleagues perpetuate stigmas about receiving care. A large body of evidence has
demonstrated that telemental health programs help increase access to care in areas
with limited mental health resources, provide effective treatment for mental health
conditions, and improve medication adherence.
Question. Can you please identify ways Congress can improve access to mental
health services, including expanding the number of providers that can participate
in Medicare?
Answer. There are multiple ways in which Congress can improve access to mental
health services, including:
• Implementing a Federal statute permanently requiring payers to reimburse
telehealth encounters at the same rate as in-person or to generally cover tele-
health as parity remains an issue for widespread implementation of tele-
mental health.
• Revision to section 123 of the Consolidated Appropriations Act passed in De-
cember 2020, which expanded telehealth mental services but imposed a re-
quirement that the patient must be seen in person within 6 months of the
telehealth visit and periodically in person thereafter. This has imposed unnec-
essary obstacles to a service that is well suited for telehealth.
• Improving care reimbursement rates by enforcing parity laws and developing
new payment models for services such as telehealth group therapy.
• Increasing funding to train and develop more behavioral health professionals.
• Removing regulatory impediments to care coordination and information shar-
ing.
• Partnering with community organizations, patients, and caregivers to identify
and expand programs that reduce stigma and combat barriers to care.
• Ensuring sufficient coverage for behavioral health services.
• Increasing funding to schools to ensure administrators and teachers have the
tools and funding to help students deal with mental health issues and pro-
mote wellness.
Question. I agree telehealth is transforming the way we are providing care. How-
ever, in Wyoming, most of our providers are part of smaller hospitals and practices.
We need to make sure government regulation is not making it more difficult for
these providers to serve their patients.
Can you discuss specific ways Congress can reduce the administrative burden in
providing care through telehealth?
Answer. It is critical that Congress remove originating and distant site require-
ments to increase access for patients and reduce administrative burden for pro-
viders. CMS added a few evaluation and management codes to Category 1 of the
Medicare telehealth list for the CY 2021 Medicare Physician Fee Schedule and omit-
ted many others. Category 1 codes are considered permanently payable under the
Medicare Physician Fee Schedule. CMS notes that while the home is generally not
a permissible telehealth originating site, certain services could be billed as tele-
health only for treatment of a substance use disorder or co-occurring mental health
disorder under the flexibility afforded by the SUPPORT for Patients and Commu-
nities Act. This rule is limiting as many other patients with serious conditions also
highly benefit from telehealth visits. The home needs to be a permissible telehealth
originating site to ensure that patients have continued access to telehealth services
beyond the PHE.
Question. Wyoming has many passionate advocates supporting both hospice and
palliative care. These folks are committed to ensuring patients have the highest
quality of life and are able stay out of the hospital and with their families. This
is why I help lead the bipartisan Comprehensive Care Caucus. Our mission is to
improve both palliative and hospice care for patients.
I was particularly impressed with your background in palliative care.
Can you please discuss how telehealth flexibilities have impacted access to pallia-
tive care and how we can continue making progress in this area?
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Answer. Telehealth flexibilities have created greater access to palliative care for
many patients, particularly with the reimbursement of audio-only codes. In response
to COVID–19, CMS permitted certain services to be furnished using audio only tele-
health. In the CY 2021 Medicare Physician Fee Schedule Final Rule, CMS noted
that audio-only evaluation and management codes will not be reimbursed after the
end of the PHE and proposed an interim final rule on coding and payment for vir-
tual check-in services to support reimbursement for lengthier audio-only services
outside of the PHE. However, these audio-only services can only be used to deter-
mine whether the beneficiary requires an in-person services and are not services
that can be provided in lieu of in-person services.
Many physician practices, and the patients they serve will continue to remain re-
liant on telehealth services for the foreseeable future. Discontinuing the use of these
codes will disproportionally put patients without a means to technology or access to
the Internet at risk of not having access to care. Many complex palliative care pa-
tients are without Wi-Fi, computers, or smart devices and may be cognitively or
physically impaired in using video technology. Therefore, they require medical inter-
vention and guidance via audio-only telephone calls when they are not receiving in-
person care. Congress needs to permanently implement a separate payment for tele-
phone-only services that specifies what is included in the visit.
In our Home-based Primary Care and our Home-based Palliative Care practices
we utilized the telehealth flexibilities heavily during the pandemic. We were able
to quickly take patients from the emergency room home under palliative care where
we provided both video and audio only telehealth to work with patients and their
families.
PREPARED STATEMENT OF JESSICA FARB, DIRECTOR, HEALTH CARE,
GOVERNMENT ACCOUNTABILITY OFFICE
WHY GAO DID THIS STUDY
Medicare and Medicaid—two federally financed health insurance programs—spent
over $1.5 trillion on health-care services provided to about 140 million beneficiaries
in 2020. Recognizing the critical role of these programs in providing health-care
services to millions of Americans, the Federal Government has provided for in-
creased funding and program flexibilities, including waivers of certain Federal re-
quirements, in response to the COVID–19 pandemic.
The CARES Act includes a provision for GAO to conduct monitoring and oversight
of the Federal Government’s response to the COVID–19 pandemic. In response,
GAO has issued a series of government-wide reports from June 2020 through March
2021. GAO is continuing to monitor and report on these services.
This testimony summarizes GAO’s findings from these reports related to Medicare
and Medicaid flexibilities during the COVID–19 pandemic, as well as preliminary
observations from ongoing work related to telehealth waivers in both programs. Spe-
cifically, the statement focuses on what is known about the effects of these waivers
and flexibilities on Medicare and Medicaid, and considerations regarding their ongo-
ing use.
To conduct this work, GAO reviewed Federal laws, CMS documents and guidance,
and interviewed Federal and State officials. GAO also interviewed six provider and
beneficiary groups, selected based on their experience with telehealth services.
GAO obtained technical comments from CMS and incorporated them as appro-
priate.
WHAT GAO FOUND
In response to the COVID–19 pandemic, the Centers for Medicare and Medicaid
Services (CMS), the Federal agency responsible for overseeing Medicare and Med-
icaid, made widespread use of program waivers and other flexibilities to expand
beneficiary access to care. Some preliminary information is available on the effects
of these waivers. Specifically:
Medicare. CMS issued over 200 waivers and cited some of their benefits in a
January 2021 report. For example, CMS reported that:
• Expansion of hospital capacity. More than 100 new facilities were added
through the waivers that permitted hospitals to provide care in non-hospital
settings, including beneficiaries’ homes.
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• Workforce expansion. Waivers and other flexibilities that relaxed certain
provider enrollment requirements and allowed certain nonphysicians, such as
nurse practitioners, to provide additional services expanded the provider
workforce.
• Telehealth waivers. Utilization of telehealth services—certain services that
are normally provided in-person but can also be provided using audio and
audio-video technology—increased sharply. For example, utilization increased
from a weekly average of about 325,000 services in mid-March to peak at
about 1.9 million in mid-April 2020.
Medicaid. CMS approved more than 600 waivers or other flexibilities aimed at
addressing obstacles to beneficiary care, provider availability, and program enroll-
ment. GAO has reported certain flexibilities such as telehealth as critical in reduc-
ing obstacles to care. Examples of other flexibilities included:
• Forty-three States suspended fee-for-service prior authorizations, which help
ensure compliance with coverage and payment rules before beneficiaries can
obtain certain services.
• Fifty States and the District of Columbia waived certain provider screening
and enrollment requirements, such as criminal background checks.
While likely benefiting beneficiaries and providers, these program flexibilities also
increase certain risks to the Medicare and Medicaid programs and raise consider-
ations for their continuation beyond the pandemic. For example:
• Increased spending. Telehealth waivers can increase spending in both pro-
grams, if telehealth services are furnished in addition to in-person services.
• Program integrity. The suspension of some program safeguards has in-
creased the risks of fraud, waste, and abuse that GAO previously noted in its
High-Risk report series.
• Beneficiary health and safety. Although telehealth has enabled the safe
provision of services, the quality of telehealth services has not been fully ana-
lyzed.
Chairman Wyden, Ranking Member Crapo, and members of the committee, thank
you for the opportunity to discuss flexibilities related to Medicare and Medicaid that
were made available during the current public health emergency. More than a year
after the Secretary of the Department of Health and Human Services (HHS) first
declared a public health emergency for the U.S. and the World Health Organization
characterized the Coronavirus Disease 2019 (COVID–19) as a pandemic, COVID–19
continues to result in catastrophic loss of life and substantial damage to the global
economy, stability, and security.1
In response to COVID–19, the Centers for Medicare and Medicaid Services (CMS),
the Federal agency responsible for overseeing Medicare and Medicaid, provided in-
creased Federal funding and made widespread use of program waivers and other
flexibilities to expand the availability of services, maintain access for beneficiaries,
and give providers more flexibility in treating beneficiaries. For example, CMS
issued waivers to expand telehealth services in Medicare fee-for-service (FFS).2
Many of these waivers and flexibilities CMS granted were to States, which admin-
ister their Medicaid programs within broad Federal rules and according to State
plans that CMS approves.
The CARES Act includes a provision for us to conduct monitoring and oversight
of the Federal Government’s efforts to prepare for, respond to, and recover from the
COVID–19 pandemic.3 In response, we issued government-wide reports on the Fed-
1 On January 31, 2020, the Secretary of HHS declared a public health emergency for the U.S.,
retroactive to January 27th. Subsequently, on March 13, 2020, the President declared COVID–
19 a national emergency under the National Emergencies Act and a nationwide emergency
under section 501(b) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act
(Stafford Act). See 50 U.S.C. § 1601 et seq. and 42 U.S.C. § 5121 et seq. The President has also
approved major disaster declarations under the Stafford Act for all 50 States, the District of Co-
lumbia, and five territories.
2 Medicare FFS consists of two separate parts: Medicare Part A, which primarily covers hos-
pital services, and Medicare Part B, which primarily covers outpatient services. Medicare FFS
beneficiaries may also enroll in Medicare Part D, which offers prescription drug coverage. Tele-
health services include certain clinical services that are typically furnished in person but are
instead provided remotely via telecommunications technologies. By law, Medicare FFS generally
only pays for these services under limited circumstances; such as when the patient is located
in certain health-care settings and certain (mostly rural) geographic locations.
3 Pub. L. No. 116–136, § 19010(b), 134 Stat. 281, 580 (2020).
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eral efforts, have examined and reported on Medicare and Medicaid flexibilities dur-
ing the pandemic, and we have ongoing work examining related topics such as
Medicare and Medicaid telehealth waivers.4
My testimony today will summarize key findings from issued reports as well as
preliminary observations from our ongoing work related to expanded telehealth
services in the Medicare and Medicaid programs and flexibilities related to the pro-
vision of Medicaid home- and community-based services during the COVID–19 pan-
demic.5 In particular, my statement will address: (1) what is known about the ef-
fects of Medicare waivers on the Medicare fee-for-service program; (2) what is
known about the effects of Medicaid waivers and flexibilities on the Medicaid pro-
gram; and (3) considerations for the ongoing use of these waivers and flexibilities
for Medicare and Medicaid.
In developing this statement, we relied primarily on reports we issued from June
2020 to March 2021. For our previously issued reports on which my comments are
based, we reviewed applicable Federal laws; CMS documents, including guidance on
program waivers and guidance to States on resuming normal operations after the
end of the public health emergency; CMS written responses to questions regarding
Medicare waivers; and our prior work related to Medicare and Medicaid. We also
interviewed Medicaid officials from selected States regarding flexibilities they re-
quested during the COVID–19 pandemic.6 More detailed information on the scope
and methodology for our past work can be found in these published reports.
My comments also include preliminary observations from ongoing work, including
interviews with CMS officials and representatives from six beneficiary advocacy and
provider groups, selected based on their experience with telehealth services and
Medicare telehealth waivers, as well as Medicaid waivers and flexibilities.7 We re-
viewed CMS documents and other published research on the effects of Medicare
telehealth waivers on these types of services during the pandemic. In particular, we
reviewed a January 2021 report from CMS on the preliminary effects of some Medi-
care and Medicaid waivers on both programs—including the effect of telehealth
waivers on Medicare utilization of services.8 We also reviewed data from the Kaiser
Family Foundation on Medicaid waivers and flexibilities.9 We reviewed the utiliza-
tion data and Medicaid waivers and flexibilities data for any obvious errors and de-
termined these data were sufficiently reliable for the purpose of our objectives.
We shared our preliminary observations from this ongoing work with CMS offi-
cials to obtain their views. CMS officials provided us with technical comments,
which we incorporated as appropriate.
We conducted the work upon which this statement is based in accordance with
generally accepted government auditing standards. Those standards require that we
plan and perform the audit to obtain sufficient, appropriate evidence to provide a
reasonable basis for our findings and conclusions based on our audit objectives. We
believe that the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
4 GAO, COVID–19: Opportunities to Improve Federal Response and Recovery Efforts, GAO–20–
625 (Washington, DC: June 25, 2020); GAO, COVID–19: Urgent Actions Needed to Better Ensure
an Effective Federal Response, GAO–21–191 (Washington, DC: November 30, 2020); GAO,
COVID–19: Sustained Federal Action Is Crucial as Pandemic Enters Its Second Year, GAO–21–
387 (Washington, DC: March 31, 2021).
5 Medicaid home- and community-based services cover a wide range of services and supports
to help individuals remain in their homes or live in a community setting, such as personal as-
sistance with daily activities, assistive devices, and case management services to coordinate
services and supports that may be provided from multiple sources.
6 For more information about the scope and methods for our past work, please see our enclo-
sures on Medicaid Enrollment, Spending, and Flexibilities; Medicaid Spending; Medicaid Financ-
ing, Waivers, and Flexibilities; Medicare Telehealth Waivers; and Medicare Waivers.
7 The provider groups included umbrella organizations representing four broad specialty
types—primary care, medical, surgical, and mental and behavioral health specialties. We also
interviewed two beneficiary advocacy groups with knowledge of Medicare beneficiaries’ experi-
ence with Medicare telehealth.
8 See Centers for Medicare and Medicaid Services, Putting Patients First: The Centers for
Medicare and Medicaid Services’ Record of Accomplishments from 2017–2020 (January 13,
2021). We refer to this report as the CMS ‘‘Accomplishment Report’’ throughout this report.
9 See Kaiser Family Foundation, Medicaid Emergency Authority Tracker: Approved State Ac-
tions to Address COVID–19, accessed May 10, 2021, https://www.kff.org/coronavirus-covid-19/
issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/.
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BACKGROUND
Medicare Waivers and Flexibilities
In 2020, Medicare—the federally financed health insurance program for persons
aged 65 or over, certain individuals with disabilities, and individuals with end-stage
renal disease—spent about $910 billion on health-care services provided to about
62.8 million Medicare beneficiaries.10 Providers and suppliers furnishing services to
beneficiaries must comply with Medicare requirements and conditions of participa-
tion that are set in statute and regulations. In response to COVID–19, CMS ex-
panded the availability of Medicare services through widespread use of program
waivers. Specifically, section 1135 of the Social Security Act authorizes the Sec-
retary of HHS to temporarily waive or modify certain Federal health-care require-
ments, including in the Medicare program, to increase access to medical services
when both a public health emergency and a disaster or emergency have been de-
clared.11 The Administrator of CMS typically implements section 1135 waivers for
Medicare.
The president authorized HHS to issue waivers under section 1135 beginning
March 1, 2020. This authority will end no later than the termination of one of the
underlying emergencies or 60 days from the date the waiver is published, unless the
Secretary extends it for additional periods of up to 60 days.
There are two types of Medicare 1135 waivers:
• Blanket waivers apply automatically to all applicable providers and sup-
pliers in the emergency area, which encompasses the entire United States in
the case of the COVID–19 pandemic. Providers and suppliers do not need to
apply individually or notify CMS that they are acting upon the waiver. They
are required to comply with normal rules and regulations as soon as it is fea-
sible to do so.
• Provider/supplier individual waivers may be issued upon application for
States, providers, or suppliers only if an existing blanket waiver is not suffi-
cient.
Congress also enacted legislation to expand the Secretary’s authority to tempo-
rarily waive or modify application of certain Medicare requirements, such as the ge-
ographic restrictions on where telehealth services can be provided. The Coronavirus
Preparedness and Response Supplemental Appropriations Act, 2020, amends section
1135 of the Social Security Act to allow the Secretary to waive certain Medicare
telehealth payment requirements during the emergency period.12 The CARES Act
further expands the Secretary’s authority to waive telehealth requirements during
the emergency period.13
Medicaid Waivers and Flexibilities
Medicaid is one of the Nation’s largest sources of funding for health-care services
for low-income and medically needy individuals, covering an estimated 77 million
people and spending an estimated $673 billion (total Federal and State) in fiscal
year 2020. Medicaid allows significant flexibility for States to design and implement
their programs. For example, States can request waivers of certain Federal require-
ments to target certain populations or to test new or innovative approaches for man-
aging the health-care needs of beneficiaries. In addition to its normal authority to
approve these State waiver applications, CMS has additional authorities to waive
Medicaid requirements to help ensure the availability of care in certain emergency
circumstances.
Since the beginning of the COVID–19 pandemic, CMS has issued guidance to
States on implementing various flexibilities and on resuming normal activities once
the public health emergency has ended. (See fig. 1.)
10 Total Medicare spending is for fiscal year 2020 and from the Centers for Medicare and Med-
icaid Services’ Office of Financial Management. Count of Medicare beneficiaries is for calendar
year 2020 and from the Centers for Medicare and Medicaid Services’ Medicare Enrollment Dash-
board. See https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/CMSProgramStatistics/Dashboard; accessed May 12, 2021.
11 See 42 U.S.C. § 1320b–5 (authority to waive requirements during national emergencies).
12 Pub. L. No. 116–123, Div. B, § 102, 134 Stat. 146, 155–157 (adding 42 U.S.C. § 1320b–
5(b)(8)).
13 Pub. L. No. 116–136, § 3703, 134 Stat. 281, 416 (2020) (amending 42 U.S.C. § 1320b–5(b)(8)).
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For example, CMS created and released four templates to help States receive Fed-
eral waivers and assist them in identifying other authorities to implement program
flexibilities more efficiently. Specifically, CMS issued templates for four authorities
for the following purposes:
• Medicaid disaster State plan amendments: To revise or implement new
policies in Medicaid State plans related to eligibility, enrollment, benefits,
premiums and cost sharing, or payments in response to a public health emer-
gency or disaster.
• Section 1115(a) demonstrations: To furnish medical assistance in a man-
ner intended to protect, to the greatest extent possible, the health, safety, and
welfare of individuals and providers who may be affected by COVID–19.14
• Section 1135 waivers: To temporarily waive or modify certain Medicaid re-
quirements to ensure that sufficient health-care items and services are avail-
able to meet the needs of individuals enrolled in the respective programs and
that health-care providers that furnish such items and services in good faith,
but are unable to comply with one or more of such requirements as a result
of the COVID–19 pandemic, may be reimbursed for such items and services
and exempted from sanctions for such noncompliance, absent any determina-
tion of fraud or abuse.
• Section 1915(c), Appendix K waivers: To request amendment to an ap-
proved section 1915(c) home and community-based waiver authority to re-
14 Under section 1115 of the Social Security Act, the Secretary of HHS may waive certain Fed-
eral Medicaid requirements and approve expenditures that would not otherwise be eligible for
Federal Medicaid funds for certain experimental, pilot, or demonstration projects that, in the
Secretary’s judgment, are likely to promote Medicaid objectives.
51921.001.eps
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spond to an emergency, for example, expanding the pool of providers author-
ized to provide waiver services such as personal care.15
FULL EFFECTS OF MEDICARE WAIVERS NOT YET KNOWN; PRELIMINARY ANALYSIS INDI-
CATES MEDICARE FEE-FOR-SERVICE TELEHEALTH WAIVERS INCREASED UTILIZATION
AND ACCESS
CMS Has Issued Hundreds of Medicare Waivers During the COVID–19 Pandemic
According to the CMS Accomplishment Report, as of January 2021, CMS had
issued over 130 blanket Medicare waivers nationwide since the start of the pan-
demic. The blanket waivers cover flexibilities for hospitals, skilled nursing facilities,
home health agencies, and hospices, among others. They also cover flexibilities for
providers, including licensing and enrollment, to the extent these flexibilities are
consistent with applicable State laws, State emergency preparedness plans, and
State scope of practice rules. For example, CMS waived or modified certain tele-
health provisions to increase access to services and give providers more flexibility
in treating beneficiaries.
In addition to blanket waivers of statutory requirements, CMS also reported that
as of January 2021, it had issued over 100 Medicare waivers under its authority
to waive or modify its policies or regulations in response to the pandemic. CMS has
since made some of these waivers permanent.16 Table 1 provides examples of
changes that CMS approved, including under blanket waivers.17
Table 1: Examples of Medicare Waivers CMS Approved,
Since March 13, 2020
Waiver Changes
Increased capacity • Expand hospital capacity—for example, hospitals may provide pa-
tient care at nonhospital buildings or spaces provided that the lo-
cation is approved by the State, and hospitals may treat patients
in their own homes.a
• Allow hospitals to set up alternative screening sites on campus to
perform medical screening examinations as a triage function.b
• Waive sanctions for certain referrals that would otherwise violate
the Physician Self-Referral law that generally prohibits a physi-
cian from making referrals for certain health-care services to an
entity with which the physician (or an immediate family member)
has a financial relationship, unless an exception applies.c
Workforce expansion • Expedite process for provider enrollment in Medicare, including ex-
pediting pending or new applications and waiving certain criminal
background checks.
• Allow physicians whose privileges to practice at a hospital will ex-
pire to continue practicing at the hospital and allowing new physi-
cians to begin practicing before full approval.
Reducing administrative • Temporarily eliminate certain reporting and other paperwork re-
burdens quirements that providers must complete to be paid by Medicare,
such as program audits that may require additional information
from providers.
15 Under section 1915(c) of the Social Security Act, the Secretary of HHS may waive require-
ments that States offering home- and community-based services offer comparable benefits state-
wide and to all eligible beneficiaries, and that they use a single standard for eligibility.
16 For example, in December 2020, CMS announced it was permanently adding certain new
services (including mental health and care planning services) that it had temporarily added to
the approved list of Medicare telehealth services during the pandemic.
17 For more information on all COVID–19 related waivers approved by CMS, see Centers for
Medicare and Medicaid Services, Coronavirus Waivers and Flexibilities, accessed May 11, 2021,
https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emer-
gencies/coronavirus-waivers.
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Table 1: Examples of Medicare Waivers CMS Approved,
Since March 13, 2020—Continued
Waiver Changes
Expansion of telehealth • Allow telehealth services to be provided nationwide, rather than
services only in certain locations.
• Allow beneficiaries to receive, and providers to furnish, telehealth
services from any setting, including beneficiaries’ and providers’
homes.
• Allow additional types of providers, such as physical and occupa-
tional therapists, to furnish telehealth services.
• Temporarily add over 146 new telehealth services.
• Allow certain services to be furnished using audio-only technology
such as telephones, instead of interactive systems involving video
technology.
Source: GAO analysis of Centers for Medicare and Medicaid Services (CMS) information. | GAO–21–575T
a Hospitals typically must meet certain requirements to participate in Medicare, including providing services
within their own buildings.
b By law, any Medicare-participating hospital with a dedicated emergency department must provide a med-
ical screening examination and, if necessary, stabilizing treatment to any individual who arrives in its emer-
gency department for examination or treatment, regardless of the ability to pay for the services.
c Entities that submit claims for services furnished pursuant to a prohibited referral are subject to financial
sanctions.
Full Effects of Medicare Waivers Are Not Yet Known
Information on the full effects of Medicare waivers and flexibilities is not yet
available. However, in its Accomplishment Report, CMS provided information on
certain flexibilities in January 2021. For example:
• Expansion of hospital capacity. CMS reported that the waiver permitting
hospitals to use non-hospital buildings and spaces to be used for patient care
and quarantine sites (subject to State approval), has expanded access to care
during the pandemic. For example, according to CMS, as of January 2021,
116 facilities in Texas were enrolled as hospital sites under a waiver that al-
lowed ambulatory care centers and freestanding emergency centers to enroll
as hospitals—thus increasing access to care. Additionally, CMS reported as
of January 7, 2021, it had approved 63 hospitals in 21 States nationwide to
participate in the waiver that allowed hospitals to treat patients in their own
homes.18
• Workforce expansion. CMS reported that the removal of certain barriers
regarding licensure and scope of practice has expanded the provider workforce
enabling health professionals to provide services they were otherwise not eli-
gible to provide, subject to State law. For example,
• Certain non-physician practitioners such as nurse practitioners and phy-
sician assistants can supervise the performance of diagnostic tests, sub-
ject to State law.
• Occupational therapists from home health agencies can now perform ini-
tial assessments on certain homebound patients, allowing home health
services to start sooner and freeing home- health nurses to do more direct
patient care.
However, the Accomplishment Report did not contain information on the extent
to which these added flexibilities have resulted in greater access to services for
Medicare beneficiaries.
CMS’s Accomplishment Report also did not contain information on the effects of
other flexibilities—including waivers granting provider enrollment flexibilities or
waivers that reduced administrative burdens—on Medicare services during the pan-
demic. In future work, we will examine the impact of these and other waivers and
flexibilities that HHS issued in response to the pandemic.
18 These include six health systems with extensive pre-pandemic experience providing acute
hospital care at home—Brigham and Women’s Hospital (Massachusetts); Huntsman Cancer In-
stitute (Utah); Massachusetts General Hospital (Massachusetts); Mount Sinai Health System
(New York City); Presbyterian Healthcare Services (New Mexico); and UnityPoint Health (Iowa).
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Medicare Telehealth Waivers Increased Utilization and Access
As we reported in November 2020, Medicare telehealth waivers resulted in in-
creased utilization of telehealth services, and provided beneficiaries access to serv-
ices that would not have otherwise been available during the early days of the
COVID–19 pandemic. However, the long-term effect of these waivers on spending
and quality of care is not yet known.19 In addition, we reported that careful moni-
toring and oversight is warranted to prevent potential fraud, waste, and abuse that
can arise from these new waivers. Existing research and preliminary observations
from our ongoing work indicate the following effects of telehealth waivers on service
utilization and access to care.
Available analysis from the CMS Accomplishment Report indicates that over the
first 8 months of the pandemic, utilization of telehealth services in Medicare FFS
sharply increased from about 325,000 services in mid-March to a peak of nearly 1.9
million services in late-April.20 Utilization then dropped to about 1.3 million services
by the beginning of June, and generally continued to slowly drop through mid-
October, as shown in figure 2.21
19 See GAO–21–191.
20 The data for this analysis are based on Medicare FFS claims submitted through November
13, 2020. These figures include telehealth services as well as other services such as virtual
check-ins and e-visits, which collectively CMS defines as telemedicine. Virtual check-ins are
short patient-initiated communications with a health-care practitioner through different tech-
nologies including by phone or video. E-visits are non-face-to-face patient-initiated communica-
tions through an online patient portal. Medicare covered and paid for virtual check-ins and e-
visits prior to the pandemic.
21 CMS did not provide data on corresponding utilization of in-person services for all services
furnished via telehealth during this time. An analysis of telehealth utilization of primary care
services from the Department of Health and Human Services’ Office of the Assistant Secretary
for Planning and Evaluation showed similar trends in telehealth utilization. Their analysis also
showed that while telehealth primary care services were peaking from mid-March through mid-
April, in-person services were precipitously dropping during this time, and that the peak in tele-
health services was not sufficient to offset the drop in in-person services. See Department of
Health and Human Services, Assistant Secretary for Planning and Evaluation, Medicare Bene-
ficiary Use of Telehealth Visits: Early Data from the Start of COVID–19 Pandemic (Washington,
DC: July 28, 2020).
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This utilization varied by the type of service, the specialty of the provider, and
the telehealth modality (audio-video or audio only). For example, CMS reported that
nearly 40 percent of beneficiaries receiving office visits received them through tele-
health compared to nearly 60 percent for mental health services. CMS also reported
that internists and family practitioners furnished about one-quarter of their services
through telehealth compared to virtually none for other specialties. In addition,
CMS reported that many (89 out of 146) of the newly available types of telehealth
services could be furnished through landline phones.
Moreover, CMS reported that telehealth waivers played a critical role in main-
taining access to services when beneficiaries and providers were concerned about
the transmission of COVID–19. For example, before the pandemic, approximately
13,000 beneficiaries in Medicare FFS had received telehealth services in a week,
compared to almost 1.7 million in the last week of April. CMS also reported that
there was some variation in the levels of access among various groups of bene-
ficiaries utilizing telehealth services. For example, a slightly higher proportion of
beneficiaries below the age of 65 received a telehealth service, compared to groups
aged 65 and over; the proportion of beneficiaries receiving telehealth services in
urban areas was slightly higher than in rural areas; but the proportion of bene-
ficiaries utilizing telehealth was similar across racial and ethnic groups. (See fig. 3.)
Preliminary observations from our interviews with groups representing providers
and beneficiaries confirmed flexibilities enabled beneficiaries to continue accessing
care. Specifically, representatives we interviewed from two provider groups said pro-
viders quickly adopted and furnished telehealth services in the early days of the
pandemic, but as patients became more comfortable coming into the office or clinic,
in-person appointments resumed. Representatives from one provider group also told
us that they relied more heavily on audio-only or phone visits rather than video vis-
its in the early days of the pandemic and switched later on to offering only in-person
or video visits. Interviews with two groups representing beneficiaries indicated that
telehealth flexibilities have enabled beneficiaries to access care from home during
the pandemic, as well as the ability to seek care in a timely manner, reduce travel
time, and triage their health issues to determine if an in-person visit is needed.
However, as we noted in our June 2020 report, telehealth waivers may not allevi-
ate all access concerns.22 Further, a recent study found that more than 26 percent
of Medicare beneficiaries lack digital access at home in 2018, making it unlikely
that they could have video-based telehealth visits with clinicians.23 The proportion
of beneficiaries in this study who lacked digital access was higher among those with
low socioeconomic status, those 85 years or older, and in communities of color. Pre-
liminary observations from our beneficiary and provider group interviews is con-
sistent with these findings. For example, representatives from the two beneficiary
groups and three groups representing providers told us that some beneficiaries were
unable to access telehealth services due to lack of technology or broadband needed
for a telehealth visit or they did not understand how to use the technology.
Furthermore, the quality of telehealth services provided to Medicare beneficiaries
has not yet been fully analyzed, and evidence from the few existing studies is incon-
clusive. According to MedPAC, some researchers have concluded that, in addition
to increasing access to care, telehealth can also improve the quality of care.24 Other
researchers caution that the convenience of telehealth could harm the quality of pa-
tient care.25 CMS officials told us in February 2021 that they are still exploring how
to measure the quality of care when services are delivered via telehealth.
22 See GAO–20–625.
23 Eric Roberts and Ateev Mehrotra, ‘‘Assessment of Disparities in Digital Access Among Medi-
care Beneficiaries and Implications for Telemedicine,’’ The Journal of American Medical Associa-
tion Internal Medicine, vol. 180, no. 10 (2020): pp. 1386–1389.
24 For example, in 2018 MedPAC reported that telestroke services both expanded access to
care and likely improve the quality of care because the timeliness of stroke treatment could be
improved. MedPAC, Report to Congress: Medicare Payment Policy (March 2018): 496.
25 For example, a 2015 study of patients receiving treatment for acute respiratory infections
found that physicians providing care through telehealth prescribed more expensive antibiotics
that could increase antibiotic resistance in patients than antibiotics prescribed by physicians
providing in-person care. See L. Uscher-Pines, et al., ‘‘Antibiotic Prescribing for Acute Res-
piratory Infections in Direct-to-Consumer Telemedicine Visits,’’ JAMA Internal Medicine, vol.
175, no. 7 (2015).
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Note: These figures include telehealth services as well as other services such as virtual check-ins and e-visits,
which collectively CMS defines as telemedicine. Virtual check-ins are short patient-initiated communications
with a health-care practitioner through different technologies including by phone or video. E-visits are non-face-
to-face patient-initiated communications through an online patient portal. Medicare covered and paid for virtual
check-ins and e-visits prior to the pandemic.
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TEMPORARY STATE MEDICAID FLEXIBILITIES AIMED TO ADDRESS OBSTACLES TO BENE-
FICIARY CARE, PROVIDER AVAILABILITY, AND PROGRAM ENROLLMENT; EFFECTS NOT
FULLY KNOWN
CMS-approved Medicaid waivers and flexibilities in all States were aimed at ad-
dressing obstacles that affect beneficiary care and provider availability, among other
areas. In December 2020, CMS reported that the agency had approved more than
600 different Medicaid waivers, State plan amendments, and other flexibilities to
offer States flexibility in responding to the COVID–19 pandemic. Some of the Med-
icaid flexibilities focused on facilitating beneficiary access to care and beneficiary
safety. For example, CMS approved flexibilities regarding the provision of long-
term services and supports to beneficiaries who receive care in facilities or in their
homes and who were particularly vulnerable to exposure and disease. Other flexi-
bilities focused on ensuring provider availability, such as allowing licensed out-of-
State providers to enroll in a State’s Medicaid program. (See table 2.)
Table 2: Examples of State Medicaid Waivers and Flexibilities
Approved by CMS, March 2020 to May 2021
Focus Specific State Flexibilities Approved
Beneficiary care and • Forty-three States suspended fee-for-service prior authorizations,
safety which are used to demonstrate compliance with coverage and pay-
ment rules before beneficiaries can obtain certain services, rather
than after the services have been provided.a
• Forty-nine States extended the dates for reassessing and reevalu-
ating beneficiaries’ needs, which are normally required for bene-
ficiaries to retain eligibility for some home- and community-based
services.b
• Fifty States permitted virtual evaluations, assessments, and
person-centered planning for beneficiaries receiving long-term
services and supports normally conducted in person.b
• Fifty-one States issued program guidance to expand coverage and
access to telehealth services.c
• Nine States allowed early refills for most medications.c
Provider availability • Fifty-one States waived some requirements to allow licensed out-
of-State providers to enroll in their programs to maintain provider
capacity.a, d
• Twelve States modified facility requirements to allow services to
be provided from practitioner’s location via telehealth.c
• Fifty-one States waived certain provider screening and enrollment
requirements during the pandemic.
Source: GAO analysis of Centers for Medicare and Medicaid Services (CMS) information complied by Kaiser
Family Foundation, Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID–19,
accessed May 10, 2021, https://www.kff.org/coronavirus-covid-19/issue-brief/medicaid-emergency-authority-
tracker-approved-state-actions-to-address-covid-19/. | GAO-21-575T
Note: For purposes of the table, States include the 50 States and the District of Columbia.
a States received approval under section 1135 of the Social Security Act, which authorizes the Secretary of
Health and Human Services to temporarily waive or modify certain Federal health-care program requirements,
including Medicaid requirements, to ensure that sufficient health-care items and services are available to meet
the needs of enrollees when both a public health emergency and a disaster or emergency have been declared.
b States received approval to make changes to their section 1915(c) home- and community-based services
waivers under an Appendix K amendment in order to respond to the emergency.
c States received approval to revise policies in their Medicaid State plan related to eligibility, enrollment,
benefits, premiums and cost sharing, and payments. To make these changes, States must submit a State Plan
Amendment to CMS for approval.
d States approved to temporarily enroll licensed out-of-State providers must follow certain requirements,
which include screening providers to ensure they are enrolled in the Medicaid program and licensed in the
State relating to their Medicaid enrollment. Waiver of these Federal requirements does not affect State or
local licensure requirements.
Among these flexibilities, we have reported that efforts to remove obstacles to
beneficiary access to care, such as the use of telehealth, were among the most im-
portant during the COVID–19 pandemic.26 A Medicaid official we interviewed in one
State said that flexibilities permitting virtual evaluations provided Medicaid bene-
ficiaries with an added sense of security and safety while providing needed care. We
have ongoing work examining States’ experiences using waivers to maintain safe ac-
cess to home- and community-based services. To reduce in- person contact between
26 See GAO–21–387.
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beneficiaries and providers, CMS has approved waivers allowing family to become
paid caregivers. In addition, waivers have been used to make retainer payments to
certain providers to support and maintain the provider network.
In addition to waivers, recent statutory changes have aimed at maintaining Med-
icaid enrollment. For example, the Families First Coronavirus Response Act pro-
vided a temporary increase in the Federal Government’s matching rate for States’
and territories’ spending for Medicaid services for all qualifying States through the
end of the quarter in which the public health emergency, including any extensions,
ends. To receive the increased matching rate, States and territories were required
to meet certain conditions, such as maintaining Medicaid enrollment for certain
beneficiaries through the end of the month in which the public health emergency
ends.27 In March 2021, we reported that from February 2020 through August 2020,
Medicaid enrollment increased by 5.6 million, or 9 percent.28
Some preliminary effects of CMS-approved waivers and flexibilities and other
flexibilities States permitted through law are known. CMS has reported an increase
in telehealth utilization since the pandemic began—in particular, soon after the na-
tional emergency was declared. CMS has also reported variation in the use of tele-
health across States and across ages within States.29 As an example of this vari-
ation, in January 2021, a North Carolina Medicaid official reported that bene-
ficiaries in urban geographies were more likely to use services delivered via tele-
health than beneficiaries in rural geographies.
PROGRAM INTEGRITY, BENEFICIARY HEALTH AND SAFETY, AND EQUITY ARE AMONG CON-
SIDERATIONS FOR THE CONTINUED USE OF WAIVERS AND FLEXIBILITIES IMPLE-
MENTED DURING THE PANDEMIC
The waivers and flexibilities implemented in Medicare and Medicaid during the
COVID–19 pandemic likely benefited providers and beneficiaries, yet determining
whether—and if so, how—to continue them post-pandemic warrants consideration.
CMS has made some Medicare waivers permanent, and, based on interest from pol-
icymakers and stakeholders, is considering doing so for other waivers. With respect
to Medicaid, CMS has set an end date for some of the waivers and flexibilities and
has issued guidance to States in December 2020 on resuming normal Medicaid oper-
ations after the end of the public health emergency.30 In light of these impending
decisions, our past work and the work of others suggest there are several issues,
including program integrity, beneficiary health and safety, and equity, to consider.
Potential for increased spending. As we have previously reported, telehealth
and other waivers pose risks of increased spending in both programs. Specifically,
• Recent data from the CMS Accomplishment Report indicates telehealth serv-
ices continued as in-person visits began to ramp up in the third quarter of
2020. This suggests that increased demand for telehealth may continue even
after the pandemic—an important consideration given payment incentives
that may result from paying the same for telehealth and in-person services.
One provider group that we interviewed also noted that these incentives may
be particularly relevant for specialties that can provide and be paid for both
in-person and additional telehealth services they generate compared to other
procedure-based specialties that receive more global payments regardless of
the number of visits they generate.
• The temporary waiver of sanctions for certain referrals that would otherwise
violate the Physician Self-Referral Law may increase the potential for in-
27 Specifically, States must provide continuous coverage to Medicaid beneficiaries who were
enrolled in Medicaid on or after March 18, 2020, regardless of any changes in circumstances
or redeterminations at scheduled renewals that otherwise would result in termination, through
the end of the month in which the public health emergency ends, among other requirements.
States may terminate coverage for individuals who request a voluntary termination of eligibility,
or who are no longer considered to be residents of the State.
28 See GAO–21–387.
29 See CMS, Medicaid and CHIP COVID–19 Summaries, Preliminary Medicaid and CHIP
Data Snapshot of Services through July 31, 2020, accessed May 10, 2021, https://
www.medicaid.gov/state-resource-center/downloads/covid19-data-snapshot.pdf.
30 See CMS, RE: Planning for the Resumption of Normal State Medicaid, Children’s Health
Insurance Program (CHIP), and Basic Health Program (BHP) Operations Upon Conclusion of
the COVID–19 Public Health Emergency (Baltimore, MD: December 22, 2020).
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creased spending in both programs given our prior work indicating that pro-
viders who self-refer tended to use more health-care services.31
Program integrity. Both the Medicare and Medicaid programs are on GAO’s
High-Risk List, in part due to concerns about fraud, waste, and abuse.32 Increased
program spending, the lack of complete data, and suspensions of some program safe-
guards increase these risks. For example:
• CMS lacks complete data to determine the telehealth modality being used
(audio only or audio-video technology) or if services are originating from pro-
viders’ and beneficiaries’ homes, important information to consider in light of
the aforementioned payment incentives and that the quality of telehealth
services has not yet been fully analyzed.
• The non-enforcement of certain privacy and security rules to allow for tele-
health flexibility raises concerns about the transmission of medical informa-
tion over potentially insecure systems.33
In our ongoing work, CMS officials have noted oversight activities related to pro-
gram integrity. As examples:
• CMS is using its Fraud Prevention System to identify potentially inappro-
priate Medicare claims for telehealth services prior to payment and to flag
providers with suspicious billing patterns through post- payment screens.
• CMS is conducting and updating program integrity risk assessments for all
Medicaid waivers and flexibilities issued as a result of the pandemic.
Beneficiary health and safety. Providing services while limiting beneficiary ex-
posure to COVID–19 has been a difficult balance for CMS and states—and tele-
health has been a large part of these efforts. The pandemic has also given rise to
new levels of need for behavioral health care—both mental health and substance
use disorders—while behavioral health service providers reported increasing de-
mand and decreasing staff size.34 Extending or ending waivers and flexibilities may
affect beneficiary health and safety in unknown ways.
• In Medicare, we have previously reported that the effect of COVID–19 related
waivers on quality of care is not yet known. We also noted earlier that the
quality of telehealth services has not been fully analyzed, and evidence from
the few existing studies is inconclusive.
• In Medicaid, preliminary data from CMS show outpatient mental health serv-
ices for adults age 19 to 64 declined starting in March and continuing through
July—despite CMS approving waivers and flexibilities to help ensure the
availability of care.
• Expedited processes for provider enrollment, including waivers of normal
screening and criminal background checks, could affect the quality of care
provided to beneficiaries in both programs.
Issues of equity. We have previously reported that communities of color have
been disproportionately affected by COVID–19 in terms of cases reported, hos-
pitalizations, deaths, and rates of testing and vaccinations.35 Disparate effects from
COVID–19 extend to beneficiaries’ receipt of services, as well. As we noted earlier,
beneficiaries in urban areas received or were more likely to use telehealth services
than beneficiaries in rural areas both in Medicare and in one State’s Medicaid pro-
31 GAO, Medicare Physical Therapy: Self-Referring Providers Generally Referred More Bene-
ficiaries but Fewer Services per Beneficiary, GAO–14–270 (Washington, DC: April 30, 2014);
GAO, Medicare: Higher Use of Costly Prostate Cancer Treatment by Providers Who Self-Refer
Warrants Scrutiny, GAO–13–525 (Washington, DC: July 19, 2013); GAO, Medicare: Action Need-
ed to Address Higher Use of Anatomic Pathology Services by Providers Who Self-Refer, GAO–
13–445 (Washington, DC: June 24, 2013); GAO, Medicare: Referrals to Physician-Owned Imag-
ing Facilities Warrant HCFA’s Scrutiny, GAO/HEHS–95–2 (Washington, DC: October 20, 1994).
32 GAO, High-Risk Series: Dedicated Leadership Needed to Address Limited Progress in Most
High-Risk Areas, GAO–21–119SP (Washington, DC: March 2, 2021).
33 The HHS Office of Civil Rights (responsible for enforcing certain regulations relating to pri-
vacy and security of protected health information) stated that it would exercise enforcement dis-
cretion and not impose penalties for noncompliance with regulatory requirements during the
pandemic.
34 GAO, Behavioral Health: Patient Access, Provider Claims Payment, and the Effects of the
COVID–19 Pandemic, GAO–21–437R (Washington, DC: March 31, 2021).
35 For example, Non-Hispanic black persons were hospitalized at almost 3 times the rate of
non-Hispanic white persons when adjusting for age, and their death rates were 1.4 times higher
than non-Hispanic white persons. See GAO–21–387.
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gram. To ensure that all beneficiaries receive the best care possible, how waivers
and flexibilities in both programs account for equity is an important consideration.
In summary, my testimony highlighted the various flexibilities and waivers imple-
mented during the COVID–19 pandemic and provided preliminary information on
how these flexibilities have likely benefitted providers and beneficiaries. Continuing
these flexibilities after the public health emergency declarations end could increase
certain risks to the Medicare and Medicaid programs. Careful consideration of these
benefits and risks will be key to determining the path forward, especially given that
both programs are on GAO’s High-Risk List. We look forward to working with Con-
gress as we continue our oversight of the Federal response to the COVID–19 pan-
demic.
Chairman Wyden, Ranking Member Crapo, and members of the committee, this
completes my prepared statement. I would be pleased to respond to any questions
that you may have at this time.
QUESTIONS SUBMITTED FOR THE RECORD TO JESSICA FARB
QUESTIONS SUBMITTED BY HON. CATHERINE CORTEZ MASTO
Question. In your written testimony, you noted that the quality of telehealth serv-
ices has not been fully analyzed.
What kind of information does GAO or CMS need to paint a complete picture of
care quality when it comes to telehealth?
Answer. We will report on CMS’s progress on this topic in our ongoing work on
Medicare and Medicaid telehealth services, which we expect to issue in late 2021
and early 2022, respectively. As we reported in our testimony, CMS officials told us
in February 2021 that they are still exploring how to measure the quality of tele-
health services. Several organizations have been involved in developing quality
measures for services delivered via telehealth. For example, in 2017 the National
Quality Forum (NQF) developed a framework for measuring the quality of tele-
health services, through a project funded by CMS. In January 2021, NQF an-
nounced that CMS had tasked it with updating the framework in light of the recent
uptick in telehealth use.
Question. In your written testimony, you noted a couple of instances where the
COVID–19 flexibilities benefit different populations disproportionately. Telehealth,
for example, was utilized more by urban populations than their rural counterparts.
One of the flexibilities enabled providers to deliver services within their scope of
practice that they’re normally not eligible to provide to Medicare beneficiaries. Typi-
cally, we see these scope expansions as disproportionately benefitting rural areas
where provider shortages are more acute.
Has GAO found any patterns in the benefits of these scope expansions?
Answer. As we reported in our testimony, CMS provided certain Medicare scope
of practice flexibilities during the pandemic to allow health professionals to provide
services that they were not otherwise permitted to provide. For example, CMS al-
lowed certain nonphysicians to supervise the performance of diagnostic tests that
they were otherwise not eligible to provide, as permitted under State law. CMS data
show that the proportion of beneficiaries in rural areas using telehealth significantly
increased from October 2019 through June 2020. It is not clear how much of this
increase was due to expansion of scope of practice versus lifting of other restrictions,
such as allowing beneficiaries to receive services at home. In our ongoing work, we
will report how these flexibilities affected beneficiary access to services in rural
areas during the public health emergency.
QUESTIONS SUBMITTED BY HON. THOMAS R. CARPER
Question. During the pandemic, telehealth has been an essential tool to get chil-
dren the care that they need while minimizing risk. Although telehealth under
Medicare has been a focus, close to 40 million children are enrolled in Medicaid.
What are the main policy changes we need to ensure this broader use of tele-
health can be continued beyond the pandemic for children?
Answer. We have not done work specific to the broader use of telehealth for chil-
dren. CMS-approved Medicaid waivers and flexibilities in all States were aimed at
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addressing obstacles that affect beneficiary care and provider availability, among
other areas. Among these flexibilities, we have reported that efforts to remove obsta-
cles to beneficiary access to care, such as the use of telehealth, were among the most
important during the COVID–19 pandemic. The temporary authorities CMS has ap-
proved will terminate based on the conclusion of the public health emergency unless
the States make certain temporary changes permanent, for example, by submitting
a State plan amendment for CMS’s review and approval. We will continue to mon-
itor CMS and State actions on temporary authorities, including in our ongoing work
examining telehealth in Medicaid during COVID–19, which we expect to issue in
early 2022.
Question. During COVID–19, many States adopted temporary changes to their
telehealth policies, such as expanding the scope of services and providers able to fur-
nish telehealth, relaxing of licensure requirements and modifying reimbursement
policies. Many States legislatures have also begun the work to adopt more perma-
nent telehealth policy changes.
How can the Federal Government best support State Medicaid programs in their
efforts to expand telehealth?
Are there Medicaid supports, incentives, and learnings that Federal policymakers
could provide’?
Answer. Medicaid allows significant flexibility for States to design and implement
their programs. For example, States have the option to determine: whether to cover
services provided through telehealth; which types of services provided through tele-
health to cover, as long as such telehealth providers are recognized and qualified
according to Medicaid statute and regulation; and how much to pay providers for
services delivered through telehealth, as long as such payments do not exceed other
program requirements.
Since the beginning of the COVID–19 pandemic, CMS created and released four
templates to help States obtain Federal waivers and assist them in identifying other
authorities to implement program flexibilities more efficiently. In our ongoing work
examining telehealth in Medicaid during COVID–19, CMS officials have described
efforts to share practices with States, for example through technical advisory group
calls and Medicaid Integrity Institute offerings. We will continue to monitor these
efforts through our ongoing work.
Question. COVID–19 has introduced additional stress and trauma for children and
families. Telehealth, and particularly audio-only telehealth has been a crucial tool
to connect children and adolescents to needed mental health-care services.
How can telehealth be best utilized to meet kids’ mental health-care needs, and
can you speak to the use of audio-only telehealth specifically?
Answer. We have not reviewed how telehealth can best be utilized to meet chil-
dren’s mental health needs. According to preliminary data from CMS, through Octo-
ber 31, 2020, primary, preventive, and mental health service use declined among
children under age 19 starting in March 2020. The agency also noted that of all
services examined in their analysis, the smallest rebound between March and Octo-
ber 2020 has been the mental health service use rates. Our ongoing work examining
telehealth in Medicaid during COVID–19 will review selected States’ considerations
for delivering services via telehealth after the end of the public health. emergency,
including via audio-only telehealth modality. As part of that ongoing work, CMS of-
ficials told us that the agency is monitoring services delivered via telehealth by mo-
dality, and that for services delivered via live audio/video, the agency is also exam-
ining monthly utilization of certain behavioral health services.
Question. As State Medicaid programs look at expanding their use of telehealth,
it is particularly important that vulnerable populations like children are not nega-
tively impacted. Policies must be looked at through a health equity lens, considering
access to reliable and affordable broadband services, access to devices that support
HIPAA-compliant telehealth platforms and coverage policies.
How can Medicaid programs work to ensure telehealth policies are equitable for
children and mitigate potential inequities that may arise?
Answer. We have not conducted work on how to ensure telehealth policies are eq-
uitable for children and mitigate potential inequities across the Medicaid beneficiary
population. However, as part of our ongoing work examining telehealth in Medicaid
during COVID–19, we will continue to monitor CMS and State telehealth policies.
As noted in the testimony statement, to ensure that all beneficiaries receive the best
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care possible, how waivers and flexibilities account for equity is an important con-
sideration.
QUESTIONS SUBMITTED BY HON. ELIZABETH WARREN
Question. The COVID–19 pandemic laid bare the deep systemic inequities that
exist in our Nation’s health system. Telehealth creates opportunities to combat ra-
cial disparities. But, if policymakers fail to center health equity in their discussions
around expanding telehealth and making pandemic-era flexibilities permanent, fu-
ture telehealth policies could exacerbate inequity.
Ensuring that patients receive health services in a language they can understand
is critical to maximizing health outcomes, and studies show that language-concord-
ant care ‘‘enhances trust between patients and physicians, optimizes health out-
comes, and advances health equity for diverse populations.’’1
What specific steps, if any, did CMS take to ensure that telehealth services pro-
vided during the pandemic were offered in languages that patients could under-
stand?
Were these steps sufficient in ensuring that patients with limited English pro-
ficiency could access high-quality care during the pandemic?
What information, if any, exists on improvements that could be made to tele-
health regulations (both generally and regarding flexibilities offered during the pan-
demic) to improve patient access to language-concordant services?
Answer. During the pandemic, CMS compiled a variety of resources on telehealth
for minority populations, including individuals with limited English proficiency. For
example, CMS developed a telehealth guide for health-care providers that included
considerations for providing telehealth to special populations, including non-English
speakers.2 We have not assessed the effectiveness of these resources in ensuring ac-
cess to care for these individuals, but equitable access to care will continue to be
an important consideration in our work on delivery of services to Medicare and Med-
icaid beneficiaries during the pandemic, which we expect to report on in late 2021
and early 2022, respectively.
Question. The COVID–19 pandemic exacerbated substance use disorder across the
country, with impacts disproportionately felt by communities of color.3 In your testi-
mony, you noted that preliminary Medicaid data ‘‘show outpatient mental health
services for adults age 19 to 64 declined’’ from March through July 2020, ‘‘despite
CMS approving waivers and flexibilities to ensure the availability of care.’’ Medicare
data on behavioral health was not yet fully analyzed or conclusive.
What information, if any, exists explaining why Medicaid (and to the extent data
has become available, Medicare) mental health visits declined, despite efforts to ex-
pand access to services via telehealth and other flexibilities?
What lessons should policymakers take from this episode to app y to future efforts
to expand access to mental health services during public health crises?
Answer. We do not have information explaining why Medicaid mental health vis-
its declined for either population during this time frame. As you noted, preliminary
CMS data show that Medicaid outpatient mental health services for adults age 19
to 64 declined from March through July 2020. In addition, preliminary CMS data
through October 31, 2020 show that mental health service use also declined among
children under age 19 starting in March 2020.
Some of our ongoing work could also provide additional information about efforts
to expand behavioral health services to Medicaid beneficiaries. In addition to our
work examining Medicaid telehealth services during COVID–19, we are also exam-
1 BMC Medical Education, ‘‘The power of language-concordant care: A call to action for med-
ical schools,’’ Rose L. Molina and Jennifer Kasper, November 6, 2019, doi: 10.1186/s12909–019–
1807–4.
2 See, U.S. Department of Health and Human Services, Stay Safe: Getting the Care You Need
at Home, Woodlawn, MD: revised May 2020, accessed June 9, 2021, available at https://
www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/c2c/consumerresources/
c2c-covid-19-resources; and U.S. Department of Health and Human Services, Telehealth for Pro-
viders: What You Need to Know, Woodlawn, MD: revised March 2021, accessed June 14, 2021,
available at https://www.cms.gov/files/document/telehealth-toolkit-providers.pdf.
3 Mass.gov, ‘‘Opioid-related overdose deaths rose by 5 percent in 2020,’’ May 12, 2021, https://
www.mass.gov/news/opioid-related-overdose-deaths-rose-by-5-percent-in-2020.
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ining State demonstrations that have established certified community behavioral
health clinics, including steps States have taken to assess the effects of the dem-
onstration on the health outcomes of beneficiaries, including beneficiaries with sub-
stance use disorders.
With respect to Medicare, telehealth for mental health care may be showing prom-
ise for beneficiaries. Specifically, CMS data show that 60 percent of beneficiaries re-
ceiving mental health services received them through telehealth between March
17th and June 13, 2020. In our ongoing work, we are examining trends in bene-
ficiary use of Medicare services in 2019 and 2020, including by service type, such
as mental and behavioral health services.
QUESTIONS SUBMITTED BY HON. PATRICK J. TOOMEY
Question. The improper payment rates in Medicare (6.27 percent in FFS, 6.78 per-
cent in MA) are the lowest in nearly a decade, whereas the Medicaid improper pay-
ment rate has ballooned (21.36 percent).4 Bringing the Medicare improper payment
rate down over the years was surely not an easy feat. Given the propensity for our
Federal health-care programs to be susceptible to waste, fraud, and abuse, policy-
makers and Federal agencies must continue to take action to safeguard these pro-
grams. The Medicare Payment Advisory Commission (MedPAC) previously noted
that telehealth could enhance risks for fraud, waste, and abuse in Medicare, and
the Commission recommended that the Centers for Medicare and Medicaid Services
(CMS) implement additional safeguards to curb the potential for telehealth-related
fraud and waste following the public health emergency.5
What features of the Medicare and Medicaid programs make telehealth services
susceptible to fraud, waste, and abuse? Which feature has the greatest potential for
such behavior?
Does CMS have the tools and resources necessary to expand telehealth services
or provide flexibilities in a manner that does not exacerbate existing vulnerabilities
in the Medicare and Medicaid programs?
Answer. With respect to telehealth in the Medicare program, as we reported in
our testimony, the suspension of some program safeguards-such as the non-enforce-
ment of certain privacy and security rules to allow for telehealth flexibility-can in-
crease these vulnerabilities. Telehealth waivers can also increase spending if these
services are furnished in addition to in-person services. As noted in our testimony,
assessing the impact of some flexibilities will be challenging because CMS lacks
complete data—for example, with respect to the telehealth modality being used
(audio-only or audio-video technology). In the Medicaid program, one-third of im-
proper payments are related to States’ noncompliance with provider screening and
enrollment requirements-an area where flexibilities have been increased, and over-
sight decreased.6
Question. Your testimony noted that CMS is conducting program integrity risk as-
sessments for all of pandemic-related waivers and flexibilities in the Medicaid pro-
gram.
Has the Department of Health and Human Services established a timeline or plan
for the completion of these integrity risk assessments?
Answer. According to CMS officials, the risk assessments are an ongoing process
and may be updated, for example, when certain risk mitigation strategies are imple-
mented. In April 2021, CMS officials said that the agency was developing a webinar
and toolkit for States to conduct risk assessments. We will continue to monitor these
actions as part of our ongoing work examining telehealth in Medicaid during
COVID–19.
4 ‘‘2020 Estimated Improper Payment Rates for Centers for Medicare and Medicaid (CMS) Pro-
grams,’’ CMS, November 16, 2020, https://www.cms.gov/newsroom/fact-sheets/2020-estimated-
improper-payment-rates-centers-medicare-medicaid-services-cms-programs.
5 ‘‘Telehealth in Medicare After the Coronavirus Public Health Emergency,’’ Medicare Pay-
ment Advisory Commission (MedPAC), http://www.medpac.gov/docs/default-source/reports/
mar21_medpac_report_ch14_sec.pdf?sfvrsn=0.
6 GAO, High-Risk Series: Dedicated Leadership Needed to Address Limited Progress in Most
High-Risk Areas, GAO–21 119SP (Washington, DC: March 2, 2021).
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Question. Your testimony also noted that CMS currently lacks data on certain as-
pects of telehealth visits that could be important in determining the quality out-
comes of telehealth services.
What data is needed in order to measure the effects of telehealth services on pa-
tient outcomes? Has the Department of Health and Human Services established a
timeline or plan for developing these type of measures?
Answer. As reported in our testimony, regarding Medicare, CMS lacks complete
data to determine the telehealth modality being used (audio-only or audio-video
technology) or if services are originating from providers’ and beneficiaries’ homes—
important information to consider in light of the fact that the quality of telehealth
services has not yet been fully analyzed. As part of our ongoing work examining
telehealth in Medicaid during COVID–19, CMS officials told us that the agency is
monitoring services delivered via telehealth by modality, and that for services deliv-
ered via live audio-video, the agency is also examining monthly utilization of certain
services.
Several organizations have been involved in developing quality measures for serv-
ices delivered via telehealth. For example, in 2017, the National Quality Forum
(NQF) developed a framework for measuring the quality of telehealth services
through a project funded by CMS and was tasked with updating this framework in
January 2021, in light of the recent uptick in telehealth use. As we reported in our
testimony, CMS officials told us in February 2021 that they are still exploring how
to measure the quality of telehealth services. We will report on CMS’s progress on
this topic in our ongoing work on Medicare and Medicaid telehealth services, which
we expect to issue in late 2021 and early 2022, respectively.
QUESTIONS SUBMITTED BY HON. CHUCK GRASSLEY
Question. Throughout the public health emergency, the Centers for Medicare and
Medicaid Services (CMS) issued over 200 waivers under Medicare and approved
more than 600 waivers and other flexibilities under Medicaid. While some of the
regulations waived are specifically for responding to a pandemic, ensuring patient
safety, controlling costs, and maintaining program integrity its clear innovation and
common sense ideas in our health-care system have been stifled too often by Federal
regulations. For example, CMS permanently added certain new services (including
mental health and care planning services) that it had temporarily added to the ap-
proved list of Medicare telehealth services during the pandemic. Some regulations
play an important role in protecting safety and maintaining program integrity but
others may stifle good ideas.
Is health care too regulated that it’s stifling good ideas?
Should executive agencies sunset regulations in the future to enable more innova-
tion in health care?
Answer. CMS issued hundreds of waivers in the Medicare and Medicaid programs
to ensure beneficiary access to services during the pandemic. We reported in our tes-
timony that telehealth waivers in particular were instrumental in providing safe ac-
cess to services that beneficiaries would otherwise not have had. In addition to im-
plementing rapid innovations through waivers and flexibilities, as we reported in
March 2018, CMS is also testing new approaches to health-care delivery and pay-
ment in both programs through its Center for Medicare and Medicaid Innovation
Center, and, as of March 1, 2018, had implemented 37 models to reduce spending
and improve the quality of care.7
Our prior work examining States’ views on the impact of Federal Medicaid poli-
cies on their programs also highlights key considerations with respect to any poten-
tial changes to program oversight. In this work, States identified a range of Federal
laws, regulations, and procedures that affected their ability to efficiently administer
their Medicaid programs. In considering potential Federal actions to address these
challenges, we identified a series of tradeoffs and considerations, including (1) tar-
geting Federal oversight to critical areas, such as to reduce improper payments or
to manage other program risks; (2) having accurate and complete data on key meas-
ures, such as beneficiary access, service use, and related costs, to inform any poten-
tial change; and (3) balancing States’ ongoing efforts to waive statutory require-
7 GAO, CMS Innovation Center: Model Implementation and Center Performance, GAO–18–302
(Washington, DC: March 26, 2018).
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ments with an appropriate level of oversight, as historically we have identified mul-
tiple instances where improved oversight of such efforts was warranted.8
Question. At the beginning of the public health emergency (PHE), Congress pro-
vided the Health and Human Services (HHS) Secretary with authority to waive
Medicare requirements for telehealth payment during the PHE. This allowed more
than 140 telehealth services to be provided that previously were not allowed or were
limited. Some limitations included a lack of payment parity, geographic limitations
on where services are provided, and restrictions on audio-only telehealth services.
Similar flexibilities were granted to States under Medicaid. Most of these flexibili-
ties will be go away once the PHE ends. MedPAC reports ‘‘there is not yet evidence
on how the combination of telehealth and in-person care affects quality and costs
in the Medicare program.’’
Your written testimony mentioned that the ‘‘Medicare and Medicaid programs are
on GAO’s high-risk list’’ when it comes to telehealth ‘‘in part due to concerns about
fraud, waste, and abuse.’’ While the public health emergency is still in place, what
program integrity measures should CMS put in place to stop these high-risk activi-
ties?
Answer. As reported in our testimony, telehealth services can pose heightened
program integrity risks to the Medicare and Medicaid programs stemming from in-
creased program spending, the lack of complete data, and suspens1dns of some pro-
gram safeguards. Our ongoing work on Medicare telehealth services, which we ex-
pect to issue in late 2021, will examine the telehealth-related vulnerabilities CMS
has identified and control activities the agency has put in place to address them.
We also reported in our testimony that CMS is conducting and updating program
integrity risk assessments for all Medicaid waivers and flexibilities issued as a re-
sult of the pandemic. According to CMS officials, the risk assessments He an ongo-
ing process and may be updated, for example, when certain risk mitigation strate-
gies are implemented. In April 2021, CMS officials said that the agency was devel-
oping a webinar and toolkit for States to conduct risk assessments. We will continue
to monitor these actions as part of our ongoing work examining telehealth in Med-
icaid during COVID–19, which we expect to issue in early 2022.
Question. Your written testimony mentioned that the ‘‘quality of telehealth serv-
ices has not been fully analyzed.’’ What quality metrics should GAO and Congress
be using?
Answer. We will report on CMS’s progress on this topic in our ongoing work on
Medicare and Medicaid telehealth services. CMS has tasked the National Quality
Forum with updating its framework for assessing the quality of telehealth services,
and in February 2021, CMS officials told us that they are still exploring these meas-
ures.
Question. Is GAO looking at the Medicare Advantage telehealth experience pre-
pandemic and throughout the pandemic to inform its recommendations? If so, what
kind of data does GAO have and how is it using that data to inform recommenda-
tions?
Answer. Our ongoing work on Medicare telehealth services focuses on the fee-for-
service program through data analysis and interviews with selected payer and other
stakeholders. To the extent these interviews provide insights into telehealth services
in the Medicare Advantage program, we will discuss these in our ongoing work.
Question. Expanding Medicare FFS telehealth after the PHE ends should consider
implications of federalism including scope-of-practice, medical malpractice, and
credentialing and licensing. What other federalism considerations should Congress
take into account when determining telehealth expansion in Medicare FFS?
Answer. We have no plans at this time to explore these issues in our ongoing
work on Medicare telehealth services.
8 GAO, Medicaid: State Views on Program Administration Challenges, GAO–20–407 (Wash-
ington, DC: April 30, 2020).
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QUESTIONS SUBMITTED BY HON. JOHN BARRASSO
Question. Before coming to the Senate, I had the privilege of practicing medicine
in Wyoming. Rural health care faced challenges prior to the pandemic. In particular,
we know since 2010 more than 135 rural hospitals have closed.
In the Senate, I am proud to help lead the bipartisan Rural Health Caucus. This
group is committed to ensuring patients in rural America can get access to the care
they need.
Can you specifically discuss the changes in Federal health-care policy that you be-
lieve have helped rural providers the most during this pandemic?
Can you please discuss any specific changes that Congress should consider to bet-
ter support rural health-care providers?
Answer. As we noted in our testimony, Medicare telehealth waivers enabled bene-
ficiaries in both rural and urban areas to receive care from their home. A July 2020
Issue Brief from the Assistant Secretary for Planning and Evaluation indicated that
utilization of telehealth in rural areas increased significantly between March and
April 2020.9 However, as we also noted in our testimony, disparate effects from
COVID–19 extend to beneficiaries’ receipt of services. Beneficiaries in urban areas
received more telehealth services or were more likely to use telehealth services than
beneficiaries in rural areas both in Medicare and in one State’s Medicaid program.
Additionally, providers face challenges offering telehealth services due in part to
limited patient access to broadband Internet. Specifically, in March 2021, we re-
ported that as of February 18, 2021, the Federal Communication Commission’s
COVID–19 Telehealth Program had disbursed $143.2 million in awards to eligible
providers, including funding targeted towards patient care in rural populations.10
While we have not assessed the changes that helped rural providers the most dur-
ing the pandemic, we have reported on rural health care in our ongoing COVID–
19 reporting, for example, on Provider Relief Fund allocations and disbursements
to rural health-care facilities and Veterans Health Administration outreach to rural
veterans.11 We will continue to monitor beneficiaries’ receipt of services in urban
and rural areas as part of our ongoing work examining telehealth in both programs
during COVID–19, which we expect to issue in late 2021 and early 2022, respec-
tively.
Question. Prior to the pandemic, I introduced bipartisan legislation with Senator
Tina Smith, which among other things, would allow Rural Health Clinics (RHCs)
to provide more telehealth services.
I was pleased that Congress through the CARES Act authorized both Rural
Health Clinics and Federally Qualified Health Centers to furnish telehealth services
to Medicare beneficiaries during the public health emergency.
Can you discuss the importance of Rural Health Clinics and Federally Qualified
Health Centers continuing to provide telehealth services after the public health
emergency has ended?
Answer. As we noted in our testimony, CMS waived or modified certain telehealth
provisions to increase access to care and give providers more flexibilities in treating
beneficiaries. We also noted in our testimony that telehealth has been a major part
of efforts to provide services while limiting beneficiary exposure to COVID–19, and
that extending or ending waivers and flexibilities may affect beneficiary health and
safety in unknown ways. We will continue to monitor utilization of telehealth serv-
ices, including telehealth services utilized by geographic location, as part of our on-
going work examining Medicare telehealth waivers.
Question. My wife Bobbi and I are passionate about improving access to mental
health services. This pandemic has clearly impacted the mental, as well as the phys-
ical health of our Nation.
9 Department of Health and Human Services, Assistant Secretary for Planning and Evaluation
(ASPE), Medicare Beneficiary Use of Telehealth Visits: Early Data from the Start of COVID–19
Pandemic (Washington, DC: July 28, 2020). ASPE reported that the proportion of weekly rural
primary care visits delivered via telehealth increased from virtually none prior to the pandemic
to about 25 percent mid-April before gradually decreasing to about 10 percent by May.
10 GAO, COVID–19: Sustained Federal Action Is Crucial as Pandemic Enters Its Second Year,
GAO–21–387 (Washington, DC: March 31, 2021).
11 For example, see GAO, COVID–19: Opportunities to Improve Federal Response and Recovery
Efforts, GAO–20–625 (Washington, DC: June 25, 2020); GAO, COVID–19: Urgent Actions Need-
ed to Better Ensure an Effective Federal Response, GAO–21–191 (Washington, DC: November 30,
2020); and GAO–21–387.
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For people living in rural America, getting help from a mental health provider
was challenging before the pandemic. This is why Senator Stabenow and I have long
supported professional counselors and marriage and family therapists participating
in Medicare. We believe that increasing the number of mental health providers able
to care for our Nation’s seniors is an important priority.
Please discuss how telehealth has impacted the ability of patients to receive men-
tal health services during the pandemic.
Can you please identify ways Congress can improve access to mental health serv-
ices, including expanding the number of providers that can participate in Medicare?
Answer. Access to mental health services remains a growing concern as the pan-
demic continues. As we noted in our testimony, in Medicaid, preliminary data from
CMS show outpatient mental health services for adults age 19 to 64 declined start-
ing in March and continuing through July—despite CMS approving waivers and
flexibilities to help ensure the availability of care. In March 2021, we reported on
longstanding concerns about the availability of behavioral health treatment, particu-
larly for low-income individuals.12 Evidence collected during the pandemic suggests
the prevalence of behavioral health conditions has increased, while access to in-
person behavioral health services has decreased. In our March 2021 report, we reit-
erated a 2019 recommendation that the Federal agencies involved in the oversight
of mental health parity requirements evaluate the effectiveness of their oversight
efforts. As of March 2021, the agencies had not yet implemented this recommenda-
tion.
Telehealth may help provide access to mental and behavioral health services for
beneficiaries. In our March 2021 report, we reported that the increased use of and
payment for telehealth has had a positive effect during the pandemic, leading to im-
proved access to behavioral health services for some patients and resulting in fewer
missed appointments, according to most stakeholders. Further, CMS data show that
60 percent of Medicare beneficiaries receiving mental health services received them
through telehealth between March 17th and June 13, 2020. We will continue to
monitor utilization of telehealth services, including mental and behavioral health
services, as part of our ongoing work examining Medicare telehealth waivers.
PREPARED STATEMENT OF NARAYANA MURALI, M.D., BOARD MEMBER,
AMERICA’S PHYSICIAN GROUPS; AND EXECUTIVE DIRECTOR, MARSHFIELD CLINIC
Good morning, Chairman Wyden, Ranking Member Crapo, and members of the
committee. My name is Dr. Narayana Murali, and I serve as the executive vice
president of care delivery and chief strategy officer of the Marshfield Clinic Health
System. I also serve as the executive director of Marshfield Clinic, headquartered
in Marshfield, WI. It is my honor to be here today to discuss this important topic.
It is my privilege to testify on behalf of America’s Physician Groups and myself.
APG is a national professional association representing over 300 physician groups
that employ or contract with approximately 195,000 physicians that provide care to
nearly 45 million patients. It is the vision of APG’s member organizations to transi-
tion from the fee-for-service (FFS) reimbursement system to a value-based system
where physician groups are held accountable for the cost and quality of care they
provide to their patients. APG’s preferred model of capitated, delegated, and coordi-
nated care, eliminates incentives for waste associated with Fee for Service reim-
bursement. I am here to make the case for permanently supporting the telehealth
flexibilities created in during the PHE, with some refinements.
Since the outset of the pandemic, APG members in all 50 States have risen to
the challenge presented by COVID–19. Our members have been at the forefront of
caring for patients, as well as the communities we serve from coast to coast. The
challenges have been immense, and the risks associated with COVID–19 remain se-
rious today. However, the lessons and experiences we have gained—as difficult as
it has been at times—can serve as opportunities to embrace changes, so we can con-
tinually improve services we provide to our patients and communities. This is espe-
cially true when it comes to the waivers and flexibilities made available to address
the Nation’s current public health emergency (PHE). The widespread adoption and
utilization of telehealth services in a variety of health-care settings have been life-
12 GAO, Behavioral Health: Patient Access, Provider Claims Payment, and the Effects of the
COVID–19 Pandemic, GAO–21–437R (Washington, DC: March 31, 2021).
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lines to patients, ensuring access and continuity of care during some of the darkest
days of the pandemic when alternatives were non-existent. This is particularly true
for those physician groups that have moved away from FFS (where earnings are
tied to volume of services rendered) and are participating in models of care where
the provider takes partial or full financial risk for quality, outcomes and total cost
of care (degree of risk may be shared with a health plan or fully absorbed by the
provider—globally capitated contracts).
I joined the Marshfield Clinic in 2006 as a nephrologist, having practiced and
furthered my education in India, Australia, and the United States. I did an internal
medicine residency at Mayo School of Graduate Medical Education, a National Insti-
tutes of Health-sponsored Clinician Investigator Training Program and fellowship in
kidney disease at the Mayo Clinic College of Medicine, Rochester, MN. I serve as
the prime site principal investigator of the Wisconsin Consortium for the All of Us
Research Program, a historic effort to gather data from one million or more people
living in the United States to accelerate research, improve health, and deliver preci-
sion medicine. In addition, I serve as the secretary of American Physicians Group,
the vice chair of the governing council of the Integrated Physician and Practice Sec-
tion of the American Medical Association, and on several other not-for-profit boards.
As a physician with decades of experience treating patients and navigating the
health-care system, I would like to especially commend Congress and the various
relevant Federal agencies for their efforts to address the struggles health-care pro-
viders and organizations have alike faced during the COVID–19 pandemic. Yes, we
have all come a long way and yet much work remains to be done.
Marshfield Clinic Health System (MCHS), which Marshfield Clinic is a part of,
is an integrated health system serving northern, central, and western Wisconsin.
We are one of the Nation’s largest fully integrated systems serving a predominantly
rural population. Our 1,400 physicians and providers accommodate 3.5 million pa-
tient encounters each year across our 10 hospitals and over 60 ambulatory clinical
sites. Our primary service area encompasses over 80 percent of the rural population
of the State of Wisconsin. In fact, over half of our 60+ facilities are located in com-
munities of less than 2,000 people. We are the largest provider of primary and spe-
cialty care in our region. As stewards of our communities and to what we call home
along with our patients, we have been committed to community engagement activi-
ties that support the rural and underserved communities. We are a teaching health
system, providing over 1,300 students with over 2,300 educational experiences
throughout our system. The Marshfield Clinic Research Institute is the largest not
for profit, private medical research institute in Wisconsin with more than 30 Ph.D.
and M.D. scientists and 150 physicians engaged in medical research.
As a fully integrated health system, MCHS has a rich legacy of over 104 years
and a long history of providing accessible, affordable and high quality, compas-
sionate health care. A third of the counties we serve have less than two workers
per Medicare beneficiary, and our patients are older, sicker and poorer than average
in the State of Wisconsin and the Nation. Forty-two percent of the children in our
primary service area are eligible for reduced or free school lunches.
Telehealth at MCHS did not have its genesis in the pandemic. It has been a
foundational element in our clinical delivery of care for rural Wisconsin. In fact, we
have used telehealth services since 1997, and it has become an important resource
to care for patients in often remote and distant locations throughout our service
area, which is approximately 45,000 square miles, just bigger than the State of
Maine. In 2019, by our estimates use of telehealth saved our patients over 1.2 mil-
lion driving miles. For older and sicker patients who cannot transport themselves,
this is very impactful. To this, add the inclement weather and the challenges of
harsh and cold winters. Additionally, in rural areas few, if any, public transpor-
tation systems serve as safety net for our patients. A critical lever we have lever-
aged to manage the cost of care for our patients and communities is our full risk,
globally capitated arrangements with our not for profit Security Health Plan, and
other models of risk based arrangements with payers in the private and govern-
mental markets. Capitated arrangements have allowed us to innovate, invest and
implement effective systems of care for our patients while also passing on the bene-
fits in terms of lower premiums and additional benefits such as hearing aids and
spectacles. These programs have improved outcomes, reduced costs and waste, and
ensured high-quality and accessible health care. Presently, Marshfield serves 68,224
patients in a globally capitated, full risk arrangement. We also serve another 51,131
patients on value-based contracts.
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Relying on the knowledge gleaned from our several decades’ long history of uti-
lizing telehealth services in our clinical care models, and our present experience of
responding to COVID–19, I would like to share the following perspectives and sub-
stantiate why these are relevant for your consideration.
1. Telehealth adoption has increased exponentially. With the Federal waivers and
commercial insurance coverage expansion during the PHE, almost 20 percent
of ambulatory care can be safely provided through telehealth.
2. Expanded utilization of telehealth by baby boomers and senior citizens has re-
sulted in improved patient access, increased convenience, and appropriate care
albeit with less than robust, integrated platforms. Creating such platforms
within the framework of existing health care and EHR systems can reduce
overall cost of health care.
3. Blanket telehealth waivers issued in response to the pandemic have enabled
the industry to continue its population health and health promotion initiatives
and provide innovative programs such as Hospital Without Walls.
As we look forward to the next phases of the pandemic response and the return
to whatever our new paradigm will be, embracing telehealth and stopping its back-
slide is critical. I urge you and your colleagues to fully support and implement effec-
tive and responsible policy that ensures continued accessibility to high-quality tele-
health services that benefits patients, and their overall health.
PATIENT BEHAVIOR AND PREFERENCES, AN MCHS SNAPSHOT, AND AN APG VIEW
Since COVID 19, patient preferences on how they choose to engage with physi-
cians and Health systems has forever changed. In MCHS, we serve around 100,000
outpatients a month with some cyclical drop in Wisconsin winters. Those appoint-
ments have declined to about 90,000 outpatients a month during the PHE. In entire
year of 2019, we registered about 12,500 telehealth encounters, with about 200 clini-
cians providing telehealth services in any given month.
In 2020, across all demographies, telehealth visits skyrocketed from a
pre-pandemic average of about 2 percent of visits a month, by 21-fold in
April 2020. Within 4 weeks of the pandemic, MCHS was averaging 3,000 telehealth
visits per week, and by week 8, we were delivering over 6,500 telehealth and phone
care visits per week. During the time our centers were closed, telehealth and phone
care services were able to provide access to 22 percent of our normally expected pa-
tient volume. Overall, in 2020, MCHS provided 240,000 telehealth and telephone en-
counters. All 1,400 physicians have been trained to provide this service.
In the last 4 months, telehealth visits have plateaued to an average of 15.5 per-
cent. In certain specialties, such as Behavioral health, 30 to 32 percent of our pa-
tients use telehealth or ‘‘phone only’’ visits.
In discussions with my APG colleagues and several health system leaders across
the nations, we all agree there has been a decline in telehealth numbers. Observa-
tional evidence suggests this 15–16 percent fraction of ‘‘telehealth and
51921.004.eps
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phone visits’’ over all appointments per month are a reflection of a new
steady state for consumer behavior across the Nation. Baby boomers have in-
creasingly adopted telehealth visits, as have many of our octogenarian parents.
PATIENT EXPERIENCE, LOYALTY, AND DIRECT-TO-CONSUMER MODELS
Patients seem to be willing to switch to telehealth as tolerance to waiting for ap-
pointments decreases. With increased access to convenient care, patient satisfaction
in the care they receive from their physicians has also increased. In a survey of our
patient population, Marshfield Clinic found that 68 percent of respondents reported
being ‘‘highly satisfied’’ or ‘‘satisfied’’ with their virtual visit. The most common
reason given by patients for frustration with their telehealth visit was poor
quality of Internet connection.
Removal of geographic site origination and other burdensome regulatory burden
would improve access to care. Our child psychologist in Lake Hallie, WI had to move
to Colorado because of family commitments. With the low availability of skilled pro-
viders to cover these patients we worked with the State of Wisconsin for approval
of telehealth services and invested in a telehealth room in Lake Hallie. Patients
were offered the option to continue or switch to new provider. In two years, only
one patient opted for a different provider. He sees about 1,200 encounters annually.
DIGITAL DIVIDE (LACK OF BROADBAND ACCESS)
Phone-only telehealth services have been critical to delivering health care to the
underserved, rural, and racial minorities. Even a year into the pandemic, meeting
the regulatory expectations of audio-video visits for risk adjustment in rural Wis-
consin has been challenging. In April 2021, 57.6 percent of the 12,299 telehealth/
phone patient appointments used ‘‘phone only’’ care. Our patients, who are old, have
chronic illness sit in the parking lots of our schools and clinics to access broadband
Wi-Fi that they lack at home for telehealth services. It is sad how little we, as one
of the most developed nations in the world, are able to support our old, poor, needy
and sick.
According to the Federal Communications Commission, 19 million Americans lack
access to fixed broadband service at threshold speeds—and 14.5 million of those
residents are reside in rural settings.1 According to one study, during the pandemic,
Federally Qualified Health Center audio-only (‘‘phone’’) visits accounted for 65.4 per-
cent for all primary care visits and 71.6 percent of behavior health visits.2 Centers
for Medicare and Medicaid Services (CMS) estimates up to 30 percent of visits dur-
ing the pandemic have been audio-only.3 Rural residents should not be disadvan-
taged in accessing telehealth just because of where they live.
TRAVEL FOR HEALTH CARE AND ITS ECONOMIC IMPACT
The economic impact on patient families of saved miles and time cannot be lost
upon us. Our three pediatric neurologists are the only physicians with the sub-
specialty skills to see complicated neurological patients across a 45,000 square mile
service area. In order for a child with well controlled epilepsy, the parent or parents
are compelled to take time off from work, often for a whole day, all for a 30-minute
physician visit that can be done over telehealth or telephone. This is a wasteful exer-
cise of time, money, and resources. This child is an example of the 20 percent of med-
ical care that is well suited for virtual care.
Other such visits that are well suited for telehealth include follow-up visits, tele-
dermatology, provider-to-provider consulting in subspecialty care, second opinions
for highly specialized counseling, and radiology opinions. The benefits of reducing
unnecessary travel, lost days of production for the family, and improved access to
care along with downstream reduction in urgent and emergency care utilization are
all important drivers of reducing cost of care and improving patient experience.
1 https://www.fcc.gov/reports-research/reports/broadband-progress-reports/eighth-broadband-
progress-report.
2 Uscher-Pines L, et al. ‘‘Telehealth Use Among Safety-Net Organizations in California During
the COVID–19 Pandemic.’’ JAMA. 2021;325(11):1106–1107.
3 Verma, S. ‘‘Early Impact of CMS Expansion of Medicare Telehealth During COVID–19.’’
Health Affairs Blog 2020. https://www.healthaffairs.org/do/10.1377/hblog20200715.454789/
full/.
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GEOGRAPHIC LIMITATION AND IMPROVING ACCESS TO APPROPRIATE
HEALTHCARE IN RURAL AMERICA
Overcoming geographic isolation through telehealth in rural America has critical
relevance. There is limited access to public transportation, and long drive times to
avail medical care. This is further compounded in winter when the roads are treach-
erous with black ice or travel is blinded by blowing winds and snow.
A story that tugs at my heart is that of a 67-year-old diabetic woman who trav-
eled 200 miles to see me, four times a year to titrate medications and optimize her
health. In 2007, MCHS provided me the ability to provide virtual care, do a heart
and lung and physical exam over video, review her vital signs with the assistance
of a nurse, review her lab tests and arrange for diuretic infusions when her heart
failure worsened. For 13 years, every year she has sent me a Christmas card and
even now, when I no longer see her.
INCENT INVESTMENTS FOR INCREASED PHYSICIAN ADOPTION
In the wake of the pandemic, physicians have rapidly adapted to the new para-
digm of care. The additional waivers and regulatory changes surrounding telehealth
services have been vital in creating pathways for organizations facing financial peril
to be creative and expand access to care.
The present state involves working simultaneously with an electronic health
record (EHR), a video platform, and a chat function with their medical teams to co-
ordinate scheduling, lab tests and diagnostics, educating patients how to switch on
their cameras, educating themselves in performing a good virtual physical exam and
good ‘‘web-side’’ manners.
Substantial investments in infrastructure are needed to ensure physicians can
provide high quality, cost-effective, increased access to care through telehealth serv-
ices. As patients become increasingly adroit with technology and physicians with
telehealth workflows, access to critically needed services such as behavioral health,
primary, and specialty care would also increase.
ACUTE CARE WITHOUT WALLS
Since 2016, MCHS has provided, hospital-level care in patients’ homes through
use of telehealth, in-home nursing visits, and virtual visits by hospitalists. We treat
over 100 acute care conditions such as asthma, congestive heart failure, pneumonia
and chronic obstructive pulmonary disease (COPD) safely at home with proper mon-
itoring and treatment protocols.4
Our research highlighted in the August 15, 2019, New England Journal of Medi-
cine Catalyst 5 and those of others have demonstrated high rates of patient satisfac-
tion and improved outcomes, and meaningful reductions in costs. As an author of
this study, I will be the first to admit that the best place for a patient to recover
is where they are most comfortable—and that is not in a hospital room in many
instances.
• Our patients had 44 percent fewer 30-day readmissions, and a 50-percent re-
duction in emergency department visits than Security Health Plan members
within the same group of DRGs who were treated in the hospital.
• HRC patients had 37 percent shorter length of stay, compared with historical
data from SHP members within our diagnosis-related groups. (Length of stay
for HRC patients was measured as number of days in the ‘‘acute’’ phase.)
• Patient satisfaction was greater than 90 percent, based on the number of top-
box responses for all questions administered via the HRC program patient
satisfaction survey.
• The health plan saved approximately 15–30 percent per episode, when com-
pared to our historical baseline costs.
In late 2020, MCHS with bipartisan support from the congressional delegation
that represents our service territory was granted a Section 1135 waiver from CMS
to more broadly implement the Acute Hospital Care at Home program. MCHS, was
one of the first nine, health-care institutions in the country granted this waiver by
4 Centers for Medicare and Medicaid Services. (2020, November 25). CMS Announces Com-
prehensive Strategy to Enhance Hospital Capacity Amid COVID–19 Surge [press release]. Re-
trieved from: https://www.cms.gov/newsroom/press-releases/cms-announces-comprehensive-
strategy-enhance-hospital-capacity-amid-covid-19-surge.
5 NEJM Catalyst, ‘‘No Place Like Home: Bringing Inpatient Care to the Patient,’’ Narayana
Murali and Travis Messina. https://catalyst.nejm.org/no-place-home-recovery-care.
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CMS. MCHS was approved four hospital sites by CMS for Acute Care at Home, dur-
ing the COVID pandemic. This waiver allowed us to expand our Hospital at Home,
and has increased our capacity for the care of patients during the COVID–19 pan-
demic, providing greater flexibility and reducing the burden on providers caring for
the most acutely sick patients.
RECOMMENDATIONS
In response to the committee’s request, below are our recommendations.
I. Allow Acute Care Without Walls flexibilities to extend beyond the PHE waiver
Even in rural areas, this model has successfully improved access and outcomes.
While the CMS allowed a blanket waiver to permit the expanded use of this pro-
gram for the duration of the PHE, we continue to gain data and experience to im-
prove the program. We hope and strongly urge that Congress recognize the success
of these programs, and ensure these programs can continue to grow and increase
access beyond the PHE.
II. Eliminate origination site and geographic limitations
a. These limitations are outdated based on our experience with the present waiv-
ers and can no longer be justified as guard rails to protect against fraud,
waste, and abuse.
b. By creating certainty that telehealth will continue to be reimbursed by Federal
health-care programs, Congress will give providers the certainty they need, to
invest in the technology infrastructure, software and practice redesigns nec-
essary to make telehealth part of their standard business operations. A lack
of certainty could create new disparities among providers, and result in uneven
access for patients.
III. Support and ensure access to reliable broadband
It is imperative to invest in broadband technology to close the digital divide and
ensure living in rural communities is not a barrier to accessing telehealth.
IV. Allow phone-only telehealth services for Medicare Advantage risk adjustment
until we overcome the challenges of Internet access
The disparities in broadband access are exacerbated in rural, underserved and mi-
norities. In fact, over half of our telehealth visits with our patients have been phone-
only because of limited access to broadband, smart phones, or tablets. Medicare Ad-
vantage has allowed both audio and audio/video telehealth services. Audio-only
(phone) has not been allowed for risk adjustment, which impairs appropriate fund-
ing for health-care delivery to the most vulnerable—an impact that will ultimately
affect future Medicare member benefits and premium, given restrictions to formally
document real risks is not true reflection of no risk. Our APG members agree that
barriers that discourage patient participation through phone, when access to
broadband is unavailable, prevent patients from receiving necessary care, and ulti-
mately expose organizations that are in the capitated, value-based models to greater
financial peril.
V. Ensure payment parity
In order to guarantee that clinicians and systems have the appropriate incentives
to invest in telehealth services and capabilities, Congress must ensure payment par-
ity between in-person and virtual visits. Allowing for expanded telehealth without
the guarantee of payment parity will create another barrier to adoption, limit over-
all uptake by providers, and stagnate access to this important treatment mechanism
for patients. Congressional action on this front will also send an important message
to commercial payers to guarantee parity across insurance markets.
VI. Reduce administrative burden on providers
First off, every effort possible should be made to harmonize statutes and regula-
tions at the Federal, State, and local levels to promote the continued adoption and
utilization of telehealth. For example, Congress should explore the establishment of
a form of blanket patient consent to facilitate the provider connecting with them via
the 2-way video method that the patient is most comfortable with. Congress must
also work in concert with the Department of Health and Human Services and the
Centers for Medicare and Medicaid Services to reduce burdensome regulations that
inhibit the expansion of telehealth to smaller physician practices that reduce the
ability of clinicians to focus on their most important task: serving their patients.
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VII. Protect patient data while fostering innovation and access
As patient satisfaction rises with the increased usage of telehealth services, cre-
ating a care environment that best serves patients and their needs is paramount.
HIPAA waivers have been helpful in providing care and allowing patients (senior
patients especially) to use compliant platforms they are familiar with. However, I
am aware that some of these non-HIPAA compliant applications and platforms may
compromise security and thus, it will be important to weigh the benefits of expand-
ing access via the use of consumer-based technology versus potential privacy and
security risks. All payers should be encouraged to align payment policies and coding
requirements in order to ensure a seamless system of care that works in a coordi-
nated manner across all providers and organizations.
VIII. Support integrating telehealth in EHR platforms
Congress should consider supporting regulations and incentives for integrating
telehealth in Electronic Health Record Platforms.
I would again like to thank Chairman Wyden, Ranking Member Crapo, and the
rest of the committee for granting me this opportunity to share these observations
and recommendations with you during this hearing. We look forward to continuing
to work with you on this very important issue and advancing America’s health-care
system.
QUESTIONS SUBMITTED FOR THE RECORD TO NARAYANA MURALI, M.D.
QUESTIONS SUBMITTED BY HON. THOMAS R. CARPER
Question. During the pandemic, telehealth has been an essential tool to get chil-
dren the care that they need while minimizing risk. Although telehealth under
Medicare has been a focus, close to 40 million children are enrolled in Medicaid.
What are the main policy changes we need to ensure this broader use of tele-
health can be continued beyond the pandemic for children?
Answer. Thank you for your question. You are right that while the focus of much
our discussion centers around issues related to Medicare, we must focus on ensuring
patients’ access to telehealth services no matter what type of insurance coverage
they use. When it comes to Medicaid, there are particular rules pertaining to what
services can be provided, and by what type of provider. As telehealth becomes more
ubiquitous in the delivery of care, Medicaid coverage of telehealth services should
grow as well. A patient’s access to telehealth should not be based on what type of
insurance coverage they have. This includes the expansion of the CPT codes where
telehealth is an option for Medicaid enrollees, both in managed care and traditional
fee-for-service reimbursement arrangements.
There are also a number of State-level issues that will have to be addressed on
a case-by-case basis. A good example of this was the passage of Wisconsin 2019 Act
56, which mandated parity in coverage for telehealth services for Medicaid enrollees.
Additionally, patients must not be precluded from accessing telehealth due to lack
of access to technology. This includes providing supports to ensure that individuals
can use technology that allows for video visits, and that they have access to reliable
Internet service. The truth of the matter is that while we take access to broadband
coverage and smart phones for granted, many Americans, and especially those who
rely on Medicaid, do not actually have access to these conveniences of every day life.
Nineteen million Americans lack access to fixed broadband service at threshold
speeds—and 14.5 million of those residents are reside in rural settings. And, many
of our Medicaid patients cannot afford smart phones, or the service to use them. As
a result, CMS should consider creating technology vouchers and reduced-cost
broadband as part of coverage, especially for chronic conditions.
Question. During COVID–19, many States adopted temporary changes to their
telehealth policies, such as expanding the scope of services and providers able to fur-
nish telehealth, relaxing of licensure requirements and modifying reimbursement
policies. Many States legislatures have also begun the work to adopt more perma-
nent telehealth policy changes.
How can the Federal Government best support State Medicaid programs in their
efforts to expand telehealth?
Answer. First and foremost, the Federal Government should continue to support
the flexibilities to Medicaid programs that have been granted throughout the pan-
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demic. While vaccinations are readily available and we are all trying to find ways
to return to normal, we must realize that we are going to be dealing with the fallout
of this pandemic for a very long time. As a result, States and Medicaid providers
need time to recover from the pandemic and adequately prepare for the move away
from the current flexibilities.
CMS needs to develop and implement effective lines of communications with State
Medicaid programs about future changes in the program. Furthermore, State Med-
icaid programs must undertake initiatives now to ensure that when the pandemic
flexibilities expire that Medicaid enrollees are not all of a sudden unable to access
telehealth services. This is an issue of equity and access.
Further, providers need clarity about the scope and parameters of what is allowed
under Medicaid when it comes to telehealth services so they can adequately plan
and implement changes to their service models. Unnecessary and arbitrary obstacles
to telehealth will serve as a disincentive to providers and patients, and result in
missed opportunities to provide high-quality accessible health care, no matter the
patient’s coverage.
Question. Are there Medicaid supports, incentives, and learnings that Federal pol-
icymakers could provide?
Answer. Honestly, the ability to develop Medicaid programs that meet the unique
needs of the patients we care for is the most important tool Federal lawmakers
could provide. It is just a fact that the needs of patients in north central Wisconsin
will be different than those of residents in Texas, Florida, or even Iowa for that mat-
ter. However, everything possible should be done to prevent arbitrary obstacles from
getting in the way, like access to broadband and flexibility in how patients access
care.
Question. COVID–19 has introduced additional stress and trauma for children and
families. Telehealth, and particularly audio-only telehealth has been a crucial tool
to connect children and adolescents to needed mental health-care services.
How can telehealth be best utilized to meet kids’ mental health-care needs, and
can you speak to the use of audio-only telehealth specifically?
Answer. Telehealth has the great potential to increase access and utilization of
mental health services for children enrolled in Medicaid. This is something we must
embrace. The pandemic has been catastrophic in terms of mental health for large
segments of society, but especially children. Children in Medicaid have long been
challenged to access mental/behavioral health services. For children in rural set-
tings like Marshfield Clinic’ service area, access is even more challenging because
a lack of providers. However, throughout the pandemic we have been able to access
care through video visits, and many instances through audio-only visits when they
cannot take advantage of video visits. This has been an important tool to ensure
access to vital mental health services, especially when children face serious mental
health challenges resulting from the disruptions of the pandemic. Congress should
ensure that CMS maintains the telehealth flexibilities that allow Medicaid enroll-
ees, especially children the ability to access mental health services even after the
end of the public health emergency.
An important component to the delivery of this care is the use of audio-only visits.
These visits routinely are the only way children can access mental health services
in some rural areas that lack access to reliable broadband, or the patients and their
families may not have access to video-enabled phones/computers. Additionally,
audio-only visits help maintain regular and consistent engagement between patient
and provider. And, phone-only visits are also great tools for check-ups in between
regular appointments, especially in acute situations.
Question. As State Medicaid programs look at expanding their use of telehealth,
it is particularly important that vulnerable populations like children are not nega-
tively impacted. Policies must be looked at through a health equity lens, considering
access to reliable and affordable broadband services, access to devices that support
HIPAA-compliant telehealth platforms and coverage policies.
How can Medicaid programs work to ensure telehealth policies are equitable for
children and mitigate potential inequities that may arise?
Answer. You concern about the expansion of telehealth services exacerbating
health disparities is certainly valid. First and foremost, we must remember that
telehealth is best integrated into a full spectrum of services available to all patients,
based on their needs and unique circumstances in consultation with their medical
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provider. An individual should not be precluded from a particular care because of
their type of insurance coverage.
Medicaid programs must make efforts to ensure that access to reliable broadband
is not an obstacle to accessing telehealth services. This is not just the issue of hav-
ing broadband available. It also means being able to afford broadband. Broadband
services, no matter whether a patient lives in a rural, urban or even suburban set-
ting can be expensive. Affordability must be taken into account. Medicaid could con-
sider providing broadband subsidies for enrollees, especially children because of the
added value of supporting their educational pursuits, just like transportation sub-
sidies.
And, continuing to allow for phone-only will be an important bridge to ensure care
is accessible, no matter the circumstances of the patient. In the end, it will always
be necessary for a provider to make the final decision on the best way to treat their
patient, but they should not be precluded because of arbitrary obstacles like access
to smart technology like phones or tablets, or broadband access.
QUESTIONS SUBMITTED BY HON. BENJAMIN L. CARDIN
Question. We have seen licensure limits substantially restrict access to cross-State
medical care during this unprecedented COVID–19 emergency period. To maximize
the utility of telehealth options and ensure provider accountability, some experts
have suggested that States should do more to ensure mutual licensing reciprocity
in the post-pandemic environment.
I am a cosponsor of Senator Murphy’s Temporary Reciprocity to Ensure Access
to Treatment Act (TREAT Act, S. 168/H.R. 708)—a narrowly tailored bill to enable
providers licensed in good standing in one State to treat patients in any State for
the duration of the COVID–19 Public Health Emergency.
How have health systems and patients benefited from State licensing reciprocity
during the COVID19 public health emergency?
Answer. You are certainly correct that State licensing reciprocity was an impor-
tant tool to ensure access during the height of the pandemic. The greatest benefit
was in patients being able to access high-quality care without unnecessary delays
or obstacles.
This reciprocity was especially important for rural providers such as Marshfield
Clinic Health System. Our model is to bring as much care as close to home as pos-
sible for our patients. However, as a rural provider, recruiting and retaining talent
can be difficult. According to a recent study, less than 5 percent of current medical
students want to practice care in a town smaller than 50,000 people.
During the pandemic, we were able to use licensing reciprocity to engage physi-
cians in high-demand/need areas more quickly via telehealth, and to bring in nec-
essary staff to bridge gaps in coverage. A perfect example of this is during a signifi-
cant surge of COVID–19 patients in the Midwest, we were able to secure staffing
support from the Federal Emergency Management Administration and the U.S. De-
partment of Defense. The staff that was assigned to our facilities were able to expe-
dite their licensure through reciprocity flexibility. This meant they were not delayed
in getting into clinical settings where they could provide much need support and re-
lief to our permanent staff.
Workforce is a major issue at all levels for rural medical providers, and reciprocity
was an important tool we could use to take care of our patients. And to be frank
with you all, after the harrowing last year and a half, I suspect that the health-
care sector is going to be dealing with long-term staffing challenges. This will neces-
sitate us to be creative and nimble in developing solutions that are not always easy,
or quick. Continued reciprocity flexibility will help us recruit and on-board staff at
multiple levels that could lead to delays in patient care.
Question. I recently reintroduced the Home Health Emergency Access to Tele-
health (HEAT) Act with Senators Collins and Shaheen. This bill would allow Medi-
care home health providers to be reimbursed for the telehealth services during a
public health emergency. I also have heard from other home-based care providers,
like hospice and palliative care as well as home-based primary care about the im-
portance of telehealth during the emergency and into the future as services in the
home and community continue to grow.
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Could you talk about your experiences using telehealth to supplement care for the
populations you take care of ?
Answer. Telehealth at MCHS did not have its genesis in the pandemic. It has
been a foundational element in our clinical delivery of care for rural Wisconsin. In
fact, we have used telehealth services since 1997, and it has become an important
resource to care for patients in often remote and distant locations throughout our
service area, which is approximately 45,000 square miles, just bigger than the State
of Maine. In 2019, by our estimates use of telehealth saved our patients over 1.2
million driving miles. For older and sicker patients who cannot transport them-
selves, this is very impactful. To this, add the inclement weather and the challenges
of harsh and cold winters. Additionally, in rural areas few, if any, public transpor-
tation systems serve as safety net for our patients.
During the peak of COVID, we converted about 35 percent of our out-patient vis-
its to telehealth visits, about 6,000 visits per week. And we leveraged the flexibili-
ties granted by CMS to provide as much care as possible remotely, including inpa-
tient level care of patients at home, mental and behavioral health services, rehabili-
tation and physical therapy services and even chronic care management to just to
name some of the categories of care we transition to virtual platforms. Anecdotally,
patients have had positive experiences and come to realize that the best place to
heal or recuperate is their own home, not in a hospital bed. It has also been a
chance for us as a system to reevaluate some of the services we provide and think
more creatively. And, as a physician myself, I will admit that the pandemic forced
many providers to reevaluate their preconceptions about what they could do via
telehealth and what they have to do as part of an in-person clinical visit. It will
take time to fully adjust our clinical approach and our operations as a health-care
system. But telehealth is here to stay and has the chance to make a huge positive
difference in the lives of our patients.
Palliative care and hospice care are some of our most sacred duties as physicians
to our patients and their loved ones. Even before the COVID–19 pandemic, MCHS
was committed to using new models of care to provide comfort and support to pa-
tients throughout their care journey. Our model of home-based care, Home Recov-
ery, has been deployed to assist patients in these circumstances. This is especially
important in rural areas where palliative care and hospice facilities are less com-
mon. Additionally, because of longer distances between home and facility, virtual
care cuts down on the stress to the patient, as well as burdens to their families/
caregivers. And virtual care in these settings routinely allows for more fulsome dis-
cussion with families and the patients about their wishes, and gives greater peace
to all involved.
Continuing to allow for these types of services through telehealth and other vir-
tual platforms will go a long way to ensuring all patients can go through this type
of care with dignity. For the last 3 years MCHS has been at the forefront of deliv-
ering a large spectrum of services that are traditionally only offered as inpatient
services to our patients in the comfort of their home. This experience has dem-
onstrated that patients routinely prefer to be at home, and that outcomes at home
are usually much better than in a hospital setting. That is because patients are
most comfortable where they live. We should continue to expand on the opportunity
to bring care to the homes of patients leveraging technology and telehealth, and
when that is not possible to deliver it close to home at the best facility for the pa-
tient and their families. That will make a difference in the experience for all in-
volved, the patient, their family and the provider.It is an exciting potential, and one
that we should all work together to realize in the coming months and years.
The number one barrier during this time was lack of technology in people homes
and lack of sufficient broadband. About 65 percent of our telehealth visits during
COVID were audio-only, underscoring both the importance of phone care continuing
to maintain access to patients as well as the need to continue advancing broadband
expansion. Congress must also do everything to ensure that a person’s health-care
coverage does not dictate the type of care they receive. There must be parity when
it comes to access to telehealth services.
Question. What lessons from the pandemic would you like to see brought forward
into the future of care for home health, hospice, palliative, and other home-based
care providers?
Answer. Telehealth has the ability to improve outcomes, increase access and satis-
faction for patients in all settings, and reduce health-care disparities. Some of the
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most important lessons gleaned confirmed long-held ideas about the potential of
telehealth to improve the care we provide our patients.
Telehealth can increase access, improve outcomes and patient satisfaction. Keep
in mind, the cost of health care is not limited to the bill from a doctors’ office. Pa-
tients often take time off of work, often unpaid, to drive up to 3 hours to receive
care. Telehealth can increase access by allowing patient to present closer to home
and this reduces their cost of accessing care.
Telehealth has an important role to play in a comprehensive approach to care de-
livery, especially as we promote the move from volume to value. More frequent low-
acuity contact with your provider is better than less frequent high-acuity contact.
And, telehealth can be integrated to comprehensive care that includes auxiliary
services like case management, physical or occupational therapy and even palliative
care.
Telehealth should continue to be an option for all patients, regardless of their lo-
cation or the type of insurance they have. The site of service and geographic limita-
tions that have been the hallmark of telehealth reimbursement policy in Medicare
are outdated. They do not serve the best interests of the patients or the programs.
While it is important to come up with a comprehensive system to monitor and track
utilization of telehealth services, arbitrary limits will cause us to regress from the
progress we have made. The ones that will ultimately pay the price for that lack
of foresight will not be decision-makers, but instead patients and their loved ones.
QUESTIONS SUBMITTED BY HON. CHUCK GRASSLEY
Question. Throughout the public health emergency, the Centers for Medicare and
Medicaid Services (CMS) issued over 200 waivers under Medicare and approved
more than 600 waivers and other flexibilities under Medicaid. While some of the
regulations waived are specifically for responding to a pandemic, ensuring patient
safety, controlling costs, and maintaining program integrity its clear innovation and
common sense ideas in our health-care system have been stifled too often by Federal
regulations. For example, CMS permanently added certain new services (including
mental health and care planning services) that it had temporarily added to the ap-
proved list of Medicare telehealth services during the pandemic. Some regulations
play an important role in protecting safety and maintaining program integrity but
others may stifle good ideas.
Is health care too regulated that it’s stifling good ideas?
Answer. Health-care regulation is not keeping up with technology and science. As
a result, patients and providers are stuck in a system that is behind the times and
not adequately harnessing all the innovation that is occurring throughout health
care. And we are missing out on taking advantage of the potential fields like artifi-
cial intelligence and data analytics have to deliver new and improved care to our
patients and communities.
Good ideas are being brought to life each and every day. The real challenge is
implementing them in a way that can have a meaningful impact on patients and
their health-care providers, and the health system in general in any timely and use-
ful way. A perfect example of this has been the long-time desire to promote a
health-care system where value is rewarded over pure volume. This catch-phrase
has seemingly been around for decades. But, it is hard to say we are much further
along our journey from volume to value than when we started.
For decades, American Physicians Group has been promoting capitated care. This
model has been demonstrated to be in the best interests of providers, payers and
patients. Experience during the pandemic has born this out. As decreased volumes
imperiled providers reliant on fee-for-service revenues, while many providers in
capitated arrangements were able to manage the ups and downs more effectively.
Regulatory frameworks should not be focused on what is allowed or not allowed.
Instead, it should be focused on giving practitioners guidelines to achieve a shared
goal like promoting value-based care, and then allow stakeholders (including pro-
viders, payers, technologists and leaders) the ability to create systems that they
think will work best for their patients and communities.
It is hard to imagine creating a universal health-care model that works as effec-
tively in Marshfield, WI as it would in Laredo, TX, New York City, or even Manhat-
tan, KS. We should be focusing on creating a regulatory system that lets providers
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tailor a system to the needs of their patients and communities, and promotes uti-
lizing the best available technology and data to promote a culture of health and
well-being.
Question. Should executive agencies sunset regulations in the future to enable
more innovation in health care?
Answer. The current health-care regulatory framework is a hindrance to the de-
velopment and implementation of innovative models of care. We should reorient our
approach to the regulatory system. Instead of overly prescriptive, or restrictive, reg-
ulations that do nothing to advance a culture of health, we should create a frame-
work that allows providers, innovators and patients the power to create systems
that are functional and effective in delivering care for all patients.
When health-care leaders are conceptualizing new models of care and imple-
menting new technology for their patients, they look for certainty. They need to
know that what they are envisioning will be permitted well into the future. Poten-
tially sunsetting, or requiring regulations to be renewed, could actually have the un-
intended consequence of creating uncertainty and cool the embrace of new tech-
nology and methods. Of the 18,000 or so regulations defined in the Code of Federal
Regulations, sunsetting all regulations (SUNSET rule published in the Federal Reg-
ister on November 4, 2020, 85 Fed. Reg. 70096) without adequate review by the im-
pacted stakeholders would likely have far-reaching economic impact and even great-
er impact on the ability to provide care due to regulatory uncertainty it will create
for insurance providers and patients. During the pandemic, it would divert vital re-
sources from HHS, away from providing needed support at the worst of times.
Therefore while there are regulations that need change, the how, what, and when
matters so as not to throw out the baby with the bath water. Instead of automati-
cally sunsetting regulations, agency leadership should reframe how they construct
proposed regulations and regulatory guidance to foster innovation.
Unnecessary or overly burdensome regulations certainly need to be addressed.
The experience we have had during the pandemic when regulatory flexibility was
exercised appropriately is a great illustration. The quality of care a patient received
did change from all indications, and these flexibilities allowed providers to think of
new approaches to new and old problems. Creating an environment that fosters
growth and innovation is imperative to improve the health and well-being of our pa-
tients and communities.
QUESTIONS SUBMITTED BY HON. JOHN BARRASSO
Question. Before coming to the Senate, I had the privilege of practicing medicine
in Wyoming. Rural health care faced challenges prior to the pandemic. In particular,
we know since 2010 more than 135 rural hospitals have closed.
In the Senate, I am proud to help lead the bipartisan Rural Health Caucus. This
group is committed to ensuring patients in rural America can get access to the care
they need.
Can you specifically discuss the changes in Federal health-care policy that you be-
lieve have helped rural providers the most during this pandemic?
Answer. Thank you, Senator, for your focus on the important topic of how to sup-
port rural health-care providers. Even before the onset of the pandemic, rural
health-care providers were struggling financially. This is the result of the unique
challenges associated with delivering medical care to rural communities.
By far, the expansion of telehealth services has made a huge difference for rural
health-care providers. The suspension of geographic restrictions and site of service
rules were a lifeline to patients during the darkest periods of the pandemic. When
we had to curtail in-person care, telehealth became an important lifeline for our pro-
viders, and more importantly for our patients. For example, we went from doing
about 200 telehealth visits per month before the beginning of the pandemic, to about
6000 visits per week in the spring of last year.
And one of the most important lessons for providers and patients from the pan-
demic is the breadth and depth of services that can be provided via telehealth serv-
ices. It is not just routine clinical visits, but behavior health and substance abuse
support, physical therapy, pre-operative and post-operative appointments, and so
much more. The expansion of the types of services allowed to be done through tele-
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health was vital to its broad acceptance at the outset of the pandemic, and even
now.
Furthermore, allowing audio-only telehealth visits was vital for a number of our
patients, especially those in rural areas that do not have access to reliable broad-
band, or may not be comfortable with technology because of their age.
Question. Can you please discuss any specific changes that Congress should con-
sider to better support rural health-care providers?
Answer. First and foremost, Congress must understand that the model to deliver
care in rural areas is just plain different than those in more urban settings. As a
result, as changes are made to the way reimbursement occurs, or rules about oper-
ations of facilities, the unique impacts on rural operations must be considered. And,
it has to be acknowledged that the finances of rural health-care providers are rou-
tinely much more precarious than more populated areas. And, we have to under-
stand that the population we serve is different as well. Rural residents on average
are older, sicker, and poorer than their more urban counterparts. In some of the
counties we serve, there are less than two workers per every Medicare beneficiary,
so our payer mix is very different than a health system in suburban Washington,
DC. Lastly, it should be remembered that access to care is an equity issue for rural
residents as well. A person should not be limited in their medical options just be-
cause of where they choose to live.
Achieving a high-functioning rural health-care ecosystem requires supporting and
strengthening the programs that work well for rural residents. One such program
is Rural Health Clinics. This program can help ensure access to care when other-
wise it would not be economically feasible. However, recent changes to reimburse-
ment at RHCs could restrict their growth moving forward, which is dangerous for
rural communities. A new provision passed in December would cap reimbursement
rates at newly created RHCs. This significant change came as a surprise to many
in the rural health community, and has imperiled plans across the country to create
RHCs in areas of significant medical need, including some of the areas we serve at
MCHS.
In the context of RHCs and telehealth, the long-standing limitation of providing
telehealth services external to the RHC is overly burdensome and creates an unfair
obstacle to accessing care. Before the waivers for COVID–19, a provider in an RHC
could not connect to a facility outside of the RHC to render service. Clinicians would
be required to use space specifically carved out of the RHC to have telehealth visits
with outside clinicians. Further, restrictions on telehealth services at Federally
Qualified Health Centers are unnecessary and again create an unjustifiable barrier
to accessing care for those patients who rely on FQHCs for their care.
Beyond these concrete examples, the issue of workforce is one of the most pressing
for our system, and providers across the country. In the last 16 months, our front-
line staff have truly embodied the moniker they were given as Healthcare Heroes.
However, we are not facing challenges from burnout. And, this has to do with every
level of employee, from frontline staff in the ICUs, to technologists and administra-
tive staff who have been doing more than their fair share at work, while at the
same time having to change their lives at home. This is a burgeoning problem that
has no quick solution. Recruitment and retention in rural areas is always more dif-
ficult because of the unique circumstances of living in smaller communities, and the
overall lack of a ready labor pool.
Question. Prior to the pandemic, I introduced bipartisan legislation with Senator
Tina Smith, which among other things, would allow Rural Health Clinics (RHCs)
to provide more telehealth services.
I was pleased that Congress through the CARES Act authorized both Rural
Health Clinics and Federally Qualified Health Centers to furnish telehealth services
to Medicare beneficiaries during the public health emergency.
Can you discuss the importance of Rural Health Clinics and Federally Qualified
Health Centers continuing to provide telehealth services after the public health
emergency has ended?
Answer. You are absolutely right to highlight the importance of RHCs and FQHCs
in rural health care. For many rural communities that do not have a full hospital,
RHCs and FQHCs are patients’ only consistent connection to care. Every effort
should be made to ensure that the restrictions to telehealth services at RHCs and
FQHCs that were in place before the pandemic are not reinstated when the public
health emergency ends. Otherwise, there will be an unfair difference in access based
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on where individuals access their care. This is wrong and unnecessary. Patients
should be able to get the best care possible, no matter where they get their care,
in consultation with their clinician.
Question. My wife Bobbi and I are passionate about improving access to mental
health services. This pandemic has clearly impacted the mental, as well as the phys-
ical health of our Nation.
For people living in rural America, getting help from a mental health provider
was challenging before the pandemic. This is why Senator Stabenow and I have long
supported professional counselors and marriage and family therapists participating
in Medicare. We believe that increasing the number of mental health providers able
to care for our Nation’s seniors is an important priority.
Please discuss how telehealth has impacted the ability of patients to receive men-
tal health services during the pandemic.
Answer. The COVID–19 pandemic has demonstrated the importance of access to
mental health services for all Americans, and the challenges that occur when we
cannot meet those needs.
A vast majority of behavioral health services are uniquely suited for telehealth.
In fact, at MCHS, the behavioral health service line was the only group to experi-
ence an increase in volume in 2020. We saw an increase of approximately 20 percent
in utilization and appointments. Further, we saw a decrease in no-show appoint-
ments, and greater adherence to a course of treatment. This is accentuated in rural
areas where access to mental health services is more limited due to a dearth of pro-
viders, and because of the usually extra-long distances patients are sometimes re-
quired to travel to seek care.
Telehealth has served as an important bridge to ensure patients have access to
care, and as a way to address a chronic shortage of access to mental health services
in rural areas. A case in point is research we have done about mental health and
farmers. MCHS in partnership with the National Farm Medicine Center published
an article in the Journal of Agromedicine in September 2020 after recognizing that
we were seeing an increase in farmers receiving behavioral health services, a notori-
ously difficult population to engage in BH services, largely due to stigma. Farmers
reported that not having to present in a facility where others were waiting in a
waiting room was a significant reason they didn’t previously request care.
And I agree with you that we have to expand the types of providers eligible to
provide mental health services in Medicare. Doing so will not only address access
issues, but also ensure that patients can get the right type of care.
Question. Can you please identify ways Congress can improve access to mental
health services, including expanding the number of providers that can participate
in Medicare?
Answer. First and foremost, Congress must recognize that telehealth will continue
to play a vital role to ensuring access to mental health services. It pales in compari-
son to the suffering many people have dealt with through this pandemic, but the
emergence of telehealth as an important part of the continuum of care, especially
in behavioral health, must be embraced and supported with the appropriate policy
changes moving forward.
Geographic restrictions and site of service regulations for behavioral health serv-
ices in Medicare must be rescinded. The pandemic has shown that care can be effec-
tive care through telehealth and it should be available to all patients, no matter
where they live and where they get their care.
Furthermore, Congress can move forward with incentives for States to implement
responsible and effective licensing rules that allow for delivery of telehealth services
across State lines in selected fields, like mental health. This will mean that patients
would have access to these important services no matter where they live. And, it
would also fill in coverage gaps, especially in rural areas, where it is hard to recruit
and retain trained mental health professionals. Lastly, it is important to ensure
that there are a variety of providers eligible to provide services in the Medicare pro-
gram, including licensed clinical social workers, family counselors and other non-
physician providers.
Question. I was interested in your testimony where you discussed the need to re-
duce the administrative burdens on health-care providers.
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I agree telehealth is transforming the way we are providing care. However, in Wy-
oming, most of our providers are part of smaller hospitals and practices. We need
to make sure government regulation is not making it more difficult for these pro-
viders to serve their patients.
Can you discuss specific ways Congress can reduce the administrative burden in
providing care through telehealth?
Answer. We must create an environment that supports delivery of high-quality
care and does not unnecessarily burden patients or providers. As the use of tele-
health continues to expand, CMS must simplify the process for coding and billing
of telehealth services. Complexity will serve as a deterrent for providers and their
offices to wholly embrace telehealth. Also, CMS should approach telehealth through
the lens of maximizing the categories of providers eligible to provide care through
telehealth services. This includes advanced practice clinicians, as well as medical
students with appropriate supervision. The future of health care will include tele-
health, and we are doing a disservice to patients and future clinicians if we fail to
provide appropriate training in how to provide care in this medium.
Further, CMS should ensure that there is parity for Medicaid enrollees when it
comes to telehealth services. Providers and their staff should not have to sift
through different regulations to understand what services a patient is eligible for
based on their insurance coverage. We cannot allow a tiered system to emerge. And,
we must figure out a framework that allows for appropriate care across borders, es-
pecially in high priority fields like behavioral health.
Question. Wyoming has many passionate advocates supporting both hospice and
palliative care. These folks are committed to ensuring patients have the highest
quality of life and are able stay out of the hospital and with their families. This
is why I help lead the bipartisan Comprehensive Care Caucus. Our mission is to
improve both palliative and hospice care for patients.
Answer. Palliative care and hospice care are some of our most sacred duties we
have as physicians to our patients, and their loved ones. Even before the COVID–
19 pandemic, MCHS was committed to using new models of care to provide comfort
and support to patients throughout their care journey. Our model of home-based
care, Home Recovery, has been deployed to assist patients in these circumstances.
This is especially important in rural areas where palliative care and hospice facili-
ties are less common. Additionally, because of longer distances between home and
facility, virtual care cuts down on the stress to the patient, as well as burdens to
their families/caregivers. And virtual care in these settings routinely allows for more
fulsome discussion with families and the patients about their wishes, and gives
greater peace to all involved.
Continuing to allow for these types of services through telehealth and other vir-
tual platforms will go a long way to ensuring all patients can go through this type
of care with dignity. For the last 3 years MCHS has been at the forefront of deliv-
ering a large spectrum of services that are traditionally only offered as inpatient
services to our patients in the comfort of their home. This experience has dem-
onstrated that patients routinely prefer to be at home, and that outcomes at home
are usually much better than in a hospital setting. That is because patients are
most comfortable where they live.
We should continue to expand on the opportunity to bring care to the homes of
patients leveraging technology and telehealth, and when that is not possible to de-
liver it close to home at the best facility for the patient and their families. That will
make a difference in the experience for all involved, the patient, their family and
the provider. It is an exciting potential, and one that we should all work together
to realize in the coming months and years. To achieve this grand goal, we must
allow programs like the Hospital Without Walls and other flexibilities to remain in-
tact and to establish new policies that promote home- based care. It will also be nec-
essary to educate providers, payers, and patients about the best practices in deliv-
ering care this way, and how it benefits all parties involved.
PREPARED STATEMENT OF HON. RON WYDEN,
A U.S. SENATOR FROM OREGON
When COVID–19 hit, it was no longer safe to meet face to face, take a bus to
the doctor’s office, or even walk into the hospital for care. Congress, Federal agen-
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cies, and health-care providers had to act fast with bold changes to prevent a dra-
matic disruption of health care in America.
This morning’s hearing is an opportunity to talk about the changes that ought to
stick around post-pandemic, and there’s no better example than telehealth. Right
at the top, I want to thank Senator Crapo for proposing a hearing on this vital topic,
where there’s a big opportunity for the two sides to work together.
The telehealth challenge has always been about balancing the speed and effi-
ciency of new technologies with the need for health-care quality and accountability.
During the pandemic, some patients have felt like they had to jump through too
many hoops to get access to telehealth. My view is, as a general proposition, pa-
tients ought to have telehealth available as an option after seeing a provider for the
first time.
In some cases, the right approach might be to give the green light for telehealth
from the beginning. I hope today the committee is able to discuss how to go about
striking that balance after a year of telehealth experience during the pandemic.
Last year, in the CARES Act, Congress allowed health-care providers in Medicare
to offer telehealth services to all seniors, regardless of whether they lived in the big-
gest city or the smallest rural town. That brought badly needed health-care safely
into the homes of tens of millions of seniors nationwide.
The CARES Act also allowed Federally Qualified Health Centers, including com-
munity health centers and Rural Health Clinics, to receive Medicare payment for
telehealth services, allowing more health-care providers to help meet the over-
whelming demand for remote health services.
Fortunately, the Finance Committee had already paved the way for a lot of these
changes, which means they were a lot easier to adopt. Telehealth has been a Fi-
nance Committee priority for years, particularly when it’s part of the effort to up-
date the Medicare guarantee.
For many years, the Congress fell behind in terms of recognizing the trans-
formation of this flagship health-care program. When the Medicare program was de-
signed, it was built to cover acute conditions—broken ankles under Medicare Part
A, bouts of the flu under Part B. Modern-day Medicare is about cancer, diabetes,
heart disease, and more of the chronic health conditions that are a lot more com-
plicated and more expensive to treat. Telehealth is going to be a bigger part of that
transformation going forward.
The CHRONIC Care Act, passed by this committee in 2017, marked the very first
time seniors could get telehealth at home for kidney disease. The law also made it
easier to use telehealth to diagnose and treat strokes. It allowed more flexibility for
Medicare Advantage plans and Accountable Care Organizations. When the pan-
demic hit, CMS already had a head start for telehealth.
Federal agencies also took advantage of existing law to allow providers to care for
their patients in fresh ways. For example, certain hospital doctors and nurses were
able to travel out into their communities and provide services at home that would
typically be reserved for inpatient care.
Others were able to set up temporary spaces like tents near hospitals themselves.
That wasn’t allowed in ordinary times pre-pandemic. These steps have increased ca-
pacity, kept patients safe, and helped maintain care.
Today the committee will hear from physicians and hospitals who have been on
the front lines, as well as health policy experts. They have seen how these fresh
approaches transformed care. In my view, there is bipartisan interest in building
on the changes that worked well for both seniors and providers.
That bipartisan work has already begun. At the end of last year, Congress passed
legislation that allowed all seniors in Medicare to receive mental health services via
telehealth, including at home. My view is, mental health services ought to be avail-
able via telehealth for all Americans. That provision was part of a bill I authored
that would also permanently allow telehealth for routine health-care visits in Medi-
care, known as evaluation and management services. I’m going to keep working to
make that a reality.
So there’s a lot for the committee to discuss today. I’d like to welcome the wit-
nesses, and again I want to thank Ranking Member Crapo for his partnership on
this bipartisan issue.
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Medicare Payment Advisory Commission (MedPAC)
425 I Street, NW, Suite 701
Washington, DC 20001
202–220–3700
https://www.medpac.gov/
Michael E. Chernew, Ph.D., Chair • Paul B. Ginsburg, Ph.D., Vice Chair
James E. Mathews, Ph.D., Executive Director
Statement of Michael E. Chernew, Ph.D., Chair
The Medicare Payment Advisory Commission (MedPAC) is a small congressional
support agency established by the Balanced Budget Act of 1997 (Pub. L. 105–33)
to provide independent, nonpartisan policy and technical advice to the Congress on
issues affecting the Medicare program. The Commission’s goal is to achieve a Medi-
care program that ensures beneficiary access to high-quality care, pays health-care
providers and plans fairly by rewarding efficiency and quality, and spends tax dol-
lars responsibly. The Commission would like to thank Chair Wyden and Ranking
Member Crapo for the opportunity to submit a statement for the record today.
The Congress and the administration granted temporary modifications to Medicare
policies to enable providers, health plans, and others to effectively respond to the
coronavirus pandemic. While many of these actions have been helpful in addressing
the short-term issues presented by the pandemic, continuing those changes indefi-
nitely would have drawbacks. Therefore, policymakers should be cautious about ex-
tending them beyond the duration of the public health emergency (PHE) or other
scheduled expiration date.
Introduction
The Commission acknowledges the catastrophic consequences the coronavirus pan-
demic has had on all Americans and the health-care delivery system. Medicare
beneficiaries are at particular risk of developing COVID–19, and those over 65 years
old are more likely to suffer complications and die compared to those who are
younger and have fewer comorbidities. Non White beneficiaries have faced dis-
proportionately high rates of mortality due to COVID–19, reflecting, in part, long-
standing inequities in the health-care system. The Commission also recognizes the
heroic work performed by the nation’s health-care workers, who have been on the
front lines of this health crisis for more than a year, and thanks them for their tire-
less dedication and service.
The coronavirus pandemic has put our nation’s health-care system under enormous
strain. Starting in March of last year, cases of patients infected with the coronavirus
began to rise sharply at institutional settings, like hospitals and nursing homes.
Hospital emergency rooms and intensive care units were regularly filled with pa-
tients affected by the pandemic, and beneficiaries in nursing homes have accounted
for a disproportionate share of fatalities from COVID–19.
Meanwhile, the volume of ambulatory care services furnished to Medicare bene-
ficiaries dropped sharply last spring as patients delayed or avoided care, and access
to some services was curtailed to avoid spreading the disease. The number of ambu-
latory care services furnished to Medicare beneficiaries in the spring of 2020 was
about half of the volume of the same services furnished during the same period the
year before. The sudden decline in service volume during this period placed many
providers under financial stress and may have put patient health and well-being at
risk.
Actions Taken to Modify Medicare Policies in Response to the Public
Health Emergency
As the coronavirus emerged in the U.S. and our health-care system confronted ex-
traordinary challenges, the Secretary of Health and Human Services first declared
the public health emergency in January 2020.1 Starting in March 2020, CMS and
the Congress made numerous changes to Medicare policies and granted regulatory
flexibilities aimed at helping health-care providers respond to the pandemic. We ap-
1 Under section 319 of the Public Health Services Act, the Secretary of Health and Human
Services may determine that a disease or disorder presents a public health emergency (PHE)
or that a PHE, including significant outbreaks of infectious disease or bioterrorist attacks, other-
wise exists. On January 31, 2020, the Secretary first determined the existence of a coronavirus
PHE since January 27, 2020, based on confirmed cases of COVID–19 in the U.S. Since then,
the coronavirus PHE has been renewed five times, most recently on April 15, 2021, and is sched-
uled to expire on July 20, 2021 (Office of the Assistant Secretary for Preparedness and Response
2021).
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plaud CMS and policymakers for acting rapidly to provide a comprehensive array
of policy modifications and flexibilities during an unprecedented time.
According to a report from the Commonwealth Fund, the administration and Con-
gress modified more than 200 Medicare program policies and requirements between
January and July 2020 (Podulka and Blum 2020). In addition, CMS has been
issuing subregulatory flexibilities to providers and plans since the PHE began. Some
of these measures have been phased out, but many of these temporary policy
changes are scheduled to remain in effect for the duration of the PHE.
In general, the steps taken by CMS and the Congress are time limited and intended
to support providers in diagnosing and treating COVID–19 patients by reducing or
eliminating certain regulatory requirements and enabling providers to treat Medi-
care beneficiaries under social distancing protocols. The regulatory and legislative
changes fall into nine broad categories (Podulka and Blum 2020):
• Alternative care sites.
• Benefits and care management.
• Conditions of participation.
• Expanded testing.
• Payment systems and quality programs.
• Provider capacity and workforce.
• Reporting and audit requirements.
• Safety requirements.
• Telehealth.
A plurality of the regulatory changes eased some provider eligibility requirements.
Regulatory waivers allowed providers to furnish services outside the state where
they are enrolled and permitted beneficiaries to receive care in settings other than
acute care hospitals (e.g., homes and skilled nursing facilities) to allow for surge ca-
pacity in those hospitals. Some of the changes suspended audits and quality report-
ing requirements or granted more flexibility over which measures to report. CMS
has also expanded access to telehealth services in a variety of ways, including tem-
porarily eliminating geographic restrictions on where such services can be provided
and expanding the types of services that can be furnished remotely.
Although the pandemic-related policy changes and flexibilities have touched almost
every part of the Medicare program, I want to focus on two areas where the changes
are especially important: telehealth and post-acute care.
Telehealth: The changes made to Medicare’s telehealth coverage and payment poli-
cies enabled more types of services to be furnished remotely to more Medicare bene-
ficiaries. These changes contributed to a substantial increase in the number of Medi-
care-covered services furnished via remote technologies, which helped to offset the
decrease in in-person clinician visits.
Post-acute care: CMS modified numerous post-acute care (PAC) policies and re-
quirements to preserve hospital capacity for beneficiaries with COVID–19. These ac-
tions enabled inpatient rehabilitation facilities and long-term care hospitals to treat
certain hospital-level patients that do not meet certain requirements for these PAC
settings and, in some cases, be paid the higher PAC-level payments. These waivers
also extended skilled nursing facility coverage to beneficiaries who normally would
not qualify.
The temporary waivers and other policy changes gave providers the flexibility to
maintain access to care under social distancing guidelines and helped providers to
respond to surges in COVID–19 cases by providing capacity beyond the acute care
setting. These have been important tools for providers during the pandemic, but pol-
icymakers would be remiss in thinking that the extending these measures has only
the potential for good. The underlying policies and regulations that have been
waived or altered are designed to protect beneficiaries, support program integrity,
and minimize potential overuse and misuse based on the incentives of the payment
systems. As decisions are made about which pandemic-related measures should be
continued, policymakers need to account for the fact that not all actors in the
health-care system are well-intentioned, and remain vigilant in protecting the Medi-
care program, beneficiaries, and taxpayers.
Telehealth
Medicare coverage of telehealth services before the PHE was limited by statute
under the physician fee schedule (PFS). Before the PHE, Medicare covered tele-
health services if they were provided to beneficiaries who received the service at a
clinician’s office or certain health-care facilities (known as ‘‘originating sites’’) lo-
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cated in a rural area, with some exceptions.2 Medicare has historically been cautious
about covering telehealth services because of uncertainties about the impact of tele-
health on total spending, quality, and program integrity.
Prior to the PHE, the Commission evaluated the use of telehealth in the Medicare
program and whether telehealth services covered under commercial plans should be
incorporated into the Medicare fee-for-service (FFS) program (Medicare Payment
Advisory Commission 2018). Our analysis of a sample of commercial insurers found
a lack of uniformity in how these insurers covered telehealth services. Consequently,
we did not make recommendations about covering specific telehealth services in
Medicare. Instead, the Commission recommended that policymakers should use a
set of principles (access, quality, and cost) to evaluate individual telehealth services
before covering them in Medicare.
To increase access to care and help limit community spread of COVID–19 during
the PHE, Medicare temporarily expanded coverage of telehealth under the PFS to
all Medicare beneficiaries, including telehealth visits provided to patients at home
(Table 1).
Table 1. Selected Temporary Telehealth Expansions to the
Physician Fee Schedule During the Public Health Emergency
Pre-PHE During the PHE
Who can receive tele- Clinicians can provide tele- Clinicians may provide tele-
health services? health services to Medicare health services to Medicare
beneficiaries in certain origi- beneficiaries outside of rural
nating sites in rural areas (e.g., areas and in the patient’s home.
a clinician’s office or hospital
but not the beneficiary’s home).
Which types of tele- Limited set of services (does not CMS pays for over 140 addi-
health services does include audio-only E&M visits). tional services (e.g., emergency
Medicare pay for? department visits, radiation
treatment management). CMS
allows audio-only interaction for
some of the telehealth services
and covers audio-only E&M
codes.
How much does Medi- PFS rate for facility-based serv- PFS rate is the same as if the
care pay for telehealth ices (less than the nonfacility service were furnished in person
services? rate). (facility or nonfacility rate, de-
pending on the clinician’s loca-
tion). Same for audio-only visits.
What are the costs to Standard cost sharing. Clinicians are permitted to re-
beneficiaries? duce or waive cost sharing.
Note: PHE (public health emergency), E&M (evaluation and management), PFS (physician fee schedule).
Under the PFS, clinicians who provide services in facilities such as hospitals receive a lower payment
rate (the facility rate) than clinicians who provide services in offices (the nonfacility rate).
During the PHE, demand for telehealth services soared as providers and bene-
ficiaries sought to reduce the risk and spread of infection by avoiding in-person vis-
its. According to an analysis of FFS Medicare claims data from the first 6 months
of 2020 and the first 6 months of 2019, there were 8.4 million telehealth services
paid under the PFS in April 2020, compared with 102,000 in February 2020 (Medi-
care Payment Advisory Commission 2021). The number of telehealth services de-
clined to 5.6 million in June 2020, as the number of in-person services began to re-
2 Medicare pays for some telehealth services outside of rural areas and in any location, includ-
ing a patient’s home, including telehealth services for substance use disorders, for end-stage
renal disease patients receiving home dialysis, and for mental health conditions (if the physician
or practitioner has furnished an in-person service to the individual within the 6 months prior
to the first time they furnish the telehealth service, and during subsequent periods that the Sec-
retary would determine). Medicare also covers telehealth services to treat patients with a stroke
in hospitals in urban and rural areas.
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bound. During the first 6 months of 2020, 10.3 million beneficiaries in FFS Medicare
(32 percent of the total) received at least one telehealth service, compared with
134,000 beneficiaries during the first 6 months of 2019. The share of all primary
care services conducted by telehealth rose dramatically from less than 1 percent in
January 2020 to 47 percent in April.3 The share declined to 31 percent in May and
18 percent in June as in-person primary care services rebounded. The Commission
will analyze more recent claims data over the next year.
Rationale for Telehealth Expansion and Potential Safeguards
During the past year, the Commission discussed whether the temporary telehealth
expansions should continue in Medicare after the PHE. Many providers and bene-
ficiaries have described the benefits of increased access and convenience from tele-
health during the PHE. Advocates of telehealth services support making the tem-
porary expansion of telehealth in Medicare permanent after the PHE. They assert
that these services can expand access to care, increase convenience to patients, im-
prove quality, and reduce costs relative to in-person care. However, there is a risk
that under FFS Medicare, telehealth services could supplement—rather than sub-
stitute for—in-person services, thereby increasing spending for Medicare and pa-
tients (Ashwood et al. 2017, Mehrotra et al. 2020). Telehealth could lead to higher
volume if telehealth providers induce demand for their services, if the greater con-
venience of telehealth leads beneficiaries to use telehealth services more frequently
than in-person services, or if additional in-person follow-up visits are required. Al-
though there are some clinical trials comparing telehealth and in-person care, there
is not yet evidence on how the combination of telehealth and in-person care affects
quality of care and outcomes.
Expanding telehealth services also raises program integrity concerns. Telehealth
companies have been involved in several large fraud cases, resulting in billions of
dollars in losses for Medicare. For example, the Department of Justice (DOJ) re-
cently charged defendants—including telemedicine companies—with submitting
false and fraudulent claims worth more than $4.5 billion to federal health programs
and private insurers (Department of Justice 2020). Telehealth technology makes it
easier to carry out fraud on a large scale because clinicians employed by fraudulent
telehealth companies can interact with many beneficiaries from different parts of
the country in a short amount of time. In addition, if beneficiaries become more
comfortable receiving care by telehealth, they might become more vulnerable to
being exploited by companies that pretend to be legitimate telehealth providers.
In considering a permanent expansion of telehealth, it is important to balance the
potential of telehealth to improve beneficiaries’ access to care with the risk of higher
spending due to overuse, while ensuring that beneficiaries receive high-quality care.
In our March 2021 report to the Congress, we present a policy option for expanding
FFS Medicare’s coverage of telehealth services after the PHE (Medicare Payment
Advisory Commission 2021). In developing this policy option, we maintain our pre-
vious recommendation that policymakers should use the principles of access, cost,
and quality to evaluate individual telehealth services before covering them under
Medicare.
Under this policy option, policymakers should continue some telehealth expansions
for a limited duration following the end of the PHE (e.g., one to two years) to gather
more evidence about the impact of the telehealth expansions on total spending, ac-
cess, patient experience, and outcomes of care. Policymakers should use this evi-
dence to inform any permanent changes. First, Medicare should temporarily pay for
specified telehealth services provided to all beneficiaries regardless of their location.
Second, Medicare should temporarily cover selected telehealth services in addition
to services covered before the PHE if there is potential for clinical benefit. Third,
to improve access to those without the capability to engage in a video visit from
their home, Medicare should temporarily cover certain telehealth services when they
are provided through an audio only interaction if there is potential for clinical ben-
efit.
Other telehealth policies that were adopted during the PHE should end when the
PHE ends. First, Medicare should return to paying the fee schedule’s facility rate
for telehealth services instead of paying either the facility or nonfacility rate, as it
3 Primary care services include the following PFS services: office/outpatient evaluation and
management (E&M) visits, home E&M visits, E&M visits to patients in certain non-inpatient
hospital settings (nursing facility, domiciliary, rest home, and custodial care), audio-only E&M
visits, chronic care management, transitional care management, Welcome to Medicare visits, an-
nual wellness visits, e-visits, and advance care planning services.
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does during the PHE. CMS should also collect data from practices and other entities
on the costs they incur to provide telehealth services and make any future changes
to telehealth payment rates based on those costs. We expect the rates for telehealth
services to be lower than rates for in-person services because services delivered via
telehealth likely do not require the same practice costs as services provided in a
physical office. Although telehealth may require upfront investments in technology
and training, in the long run the marginal cost of a telehealth service should be
lower than that of an in-person service (Mehrotra et al. 2020).
In addition, Medicare should require the same share of beneficiary cost sharing for
telehealth as it does for in-person service after the PHE. Because telehealth services
are more convenient for beneficiaries to access, they have a higher risk of overuse
than in-person services, particularly in the context of a fee-for-service payment sys-
tem in which providers have a financial incentive to bill for more services. Requiring
beneficiaries to pay a portion of the cost of telehealth services would help reduce
the possibility of overuse.
After the PHE, CMS should implement other safeguards to protect the Medicare
program and its beneficiaries from unnecessary spending and potential fraud re-
lated to telehealth, including:
• Applying additional scrutiny to outlier clinicians who bill many more telehealth
services per beneficiary than other clinicians;
• Requiring clinicians to provide an in-person, face-to-face visit before they order
high-cost durable medical equipment or high-cost clinical laboratory tests; and
• Prohibiting ‘‘incident to’’ billing for telehealth services provided by any clinician
who can bill Medicare directly.
In future work, we will continue to monitor beneficiaries’ and providers’ experiences
with telehealth in Medicare and the use of telehealth during the PHE. We plan to
continue exploring trends in telehealth use and spending using more recent Medi-
care claims data. This summer, we will ask clinicians and Medicare beneficiaries
about their use of telehealth during focus groups, and we will ask beneficiaries and
privately insured individuals about their use of telehealth during our annual tele-
phone survey. In addition, we continue to meet with telehealth companies and other
stakeholders and will regularly inform the Congress of our work.
Post-Acute Care
Institutional post-acute care (PAC) settings-skilled nursing facilities (SNFs), inpa-
tient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs)-provide
care to patients who need skilled institutional care to recuperate and regain func-
tion, typically following an acute care hospital stay. The Medicare program main-
tains separate conditions/requirements of participation and coverage rules and uses
setting-specific prospective payment systems (PPSs) to pay for stays in each setting.
Distinct facility and patient requirements help ensure that care provided in each
setting is consistent with Medicare coverage rules and help control unnecessary
spending for care in high-cost settings when patients’ conditions do not warrant this
level of care.
During the PHE, CMS used its emergency and other waiver authority to modify nu-
merous policies and requirements intended to preserve hospital capacity for bene-
ficiaries with COVID–19 (Centers for Medicare and Medicaid Services 2021b). Waiv-
ers allowed IRFs and LTCHs to be paid the higher-level payments for some cases
that do not qualify as IRF or LTCH stays, and they extended SNF coverage to bene-
ficiaries who normally would not qualify for SNF stays. The SNF, IRF, and LTCH
facility and patient requirements and PHE-related waivers are summarized below.
Skilled nursing facility requirement. Beneficiaries who need daily, short-term
skilled nursing or rehabilitation care on an inpatient basis following a hospital stay
of at least three days are eligible to receive covered services in SNFs. By limiting
coverage to post-hospital ‘‘skilled’’ services, the program extends coverage for serv-
ices similar to those provided to hospital inpatients, but at a lower level of care, and
effectively excludes long-term care, which is not a covered Medicare benefit.
Skilled nursing facility waiver. During the PHE, CMS is waiving the require-
ment for a three-day prior hospitalization for coverage of a SNF stay for bene-
ficiaries who experience dislocations or were otherwise affected by COVID–19. In
addition, for certain beneficiaries who recently exhausted their SNF benefits, CMS
authorizes renewed SNF coverage without first having to start a new benefit period.
These waivers allowed facilities to ‘‘skill in place’’ beneficiaries who required skilled
care without having to transfer them to a hospital for a three-day hospital stay and
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helped retain hospital capacity for COVID–19 patients. CMS estimated that about
16 percent of SNF admissions in fiscal year 2020 used a waiver, and the majority
of those were attributed to the waived prior hospital stay requirement (Centers for
Medicare and Medicaid Services 2021b).
Inpatient rehabilitation facility requirements. After an illness, injury, or sur-
gery, some beneficiaries need intensive inpatient rehabilitation services, such as
physical, occupational, or speech therapy. For a facility to receive payment as an
IRF, 60 percent of its admissions must be for one of 13 conditions that typically re-
quire intensive rehabilitation therapy (referred to as the ‘‘60-percent rule’’). To qual-
ify for admission to an IRF, a beneficiary must be able to tolerate and benefit from
intensive therapy, typically defined as three hours of therapy a day at least five
days a week (referred to as the ‘‘3-hour rule’’). These Medicare requirements help
ensure that only the most appropriate patients are eligible to receive care at this
relatively costly setting, given that many beneficiaries are able to receive care at
lower-cost settings.
Inpatient rehabilitation facility waiver. CMS is allowing IRFs to exclude from
the calculation of their compliance with the 60-percent rule those patients who were
admitted in response to the PHE. CMS is also waiving the three-hour therapy rule,
as required by Section 3711(a) of the Coronavirus Aid, Relief, and Economic Secu-
rity (CARES) Act. These waivers effectively allow IRFs to admit patients who would
not normally qualify for IRF care and provide additional hospital beds for surge ca-
pacity in communities that need it. These cases may be paid the IRF PPS rates in
freestanding IRFs in areas experiencing a surge during the PHE.4
Long-term care hospital requirements. Some patients with profound debilita-
tion of multiple systems, frequently with ongoing respiratory failure, receive care in
an LTCH. To be paid at the higher standard Medicare LTCH payment rate, a case
must immediately follow an acute care hospital stay, not be a psychiatric or reha-
bilitation case, and the preceding hospital stay must include three or more days in
an intensive care unit or the LTCH case must include mechanical ventilation serv-
ices for at least 96 hours. If these requirements are not met, cases are paid at a
lower ‘‘site-neutral’’ rate. In addition, to qualify for Medicare payment as an LTCH,
a facility must have an average length of stay greater than 25 days for Medicare
cases paid the LTCH PPS standard payment rate. Finally, if less than 50 percent
of Medicare discharges qualify for the standard LTCH PPS rate, the facility is to
be paid under the acute care hospital PPS until that share reaches 50 percent or
higher. As with Medicare’s IRF requirements, LTCH criteria were implemented to
ensure that Medicare does not pay the high LTCH rates for lower-acuity cases that
can be cared for in other, lower-resource intensive settings.
Long-term care hospital waiver. Consistent with section 3711(b) of the CARES
Act, all cases admitted are being paid the LTCH payment rate, even those that nor-
mally would not qualify for the higher LTCH rate, for the duration of the PHE. In
addition, all cases will be counted as discharges paid the LTCH PPS rate for pur-
poses of calculating an LTCH’s share of Medicare discharges that qualify for the
standard LTCH PPS rate. In addition, CMS waived the 25-day average length-of-
stay requirement to participate in the LTCH PPS when an LTCH admits or dis-
charges patients to meet the demands of the PHE. These waivers enable LTCHs to
treat a broad mix of patients, including overflow short-term acute care hospital pa-
tients, and be paid LTCH payment rates.
Waived PAC Criteria Should Be Reinstated When the Public Health Emer-
gency Ends
The waivers of facility and patient requirements for SNFs, IRFs, and LTCHs are
examples of policy changes that provide flexibility to expand capacity and reduce pa-
tient transfers for the duration of the PHE. The waivers allowed providers to be
paid for Medicare patients that would not ordinarily qualify for payment in those
settings or to be paid higher rates for those patients during the PHE, but there are
compelling reasons to reinstate these waived requirements after the PHE is over.
Making these changes permanent would roll back gains in defining appropriate use
4 A state (or region, as applicable) that is experiencing a surge means a state (or region, as
applicable) that satisfies all of the following, as determined by applicable state and local offi-
cials: (1) all vulnerable individuals continue to shelter in place, (2) individuals continue social
distancing, (3) individuals avoid socializing in groups of more than 10, (4) non-essential travel
is minimized, (5) visits to senior living facilities and hospitals are prohibited, and (6) schools
and organized youth activities remain closed (Centers for Medicare and Medicaid Services
2021a).
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123
of costly settings and expose the Medicare program to increased spending. For ex-
ample, until 2016, the lack of meaningful criteria for LTCH use resulted in admis-
sions of less-complex patients who could be cared for appropriately in lower-cost set-
tings. The Commission and CMS had long been concerned that caring for lower-
acuity patients in LTCHs increased spending without demonstrable improvements
in quality or outcomes (Medicare Payment Advisory Commission 2020). When ‘‘site-
neutral’’ payments for less-complex patients were implemented starting in 2016 and
LTCHs received lower acute hospital rates for these cases, providers responded by
reducing the number of site-neutral cases treated in LTCHs (Medicare Payment Ad-
visory Commission 2021).
Studies of the impact of eliminating the SNF prior-hospitalization requirement
(along with other changes) under the Medicare Catastrophic Coverage Act suggest
that spending would increase substantially without the three-day rule to act as a
guardrail for program spending (Aaronson et al. 1994, Laliberte et al. 1997, Office
of Inspector General 1991). To balance the objectives of updating the policy to reflect
current hospital practices yet protect the Hospital Insurance Trust Fund, in 2015
the Commission recommended that the three-day policy be revised to allow up to
two days spent in outpatient observation status to count toward the three-day prior
hospitalization requirement (Medicare Payment Advisory Commission 2015). When
the three day hospital stay waiver is lifted, the Congress should revise it to allow
two of the days in observation status to count towards meeting the required three-
day stay.
While Medicare permitted the SNF three-day stay requirement to be waived for en-
tities participating in bundled payment demonstrations, some entities did not take
advantage of this flexibility (Dummit et al. 2018, Lewin Group 2019, The Lewin
Group 2020). Similarly, not all Next Generation ACOs elected to waive the three-
day stay requirement (NORC at the University of Chicago 2020). However, since
these bundled payment entities and ACOs are at full risk, this experience may not
be relevant to entities operating under traditional FFS Medicare. This is because
they already have a financial incentive to control the total cost of care to Medicare,
unlike providers not at financial risk under traditional Medicare.
In 2016, the Commission recommended design features of a unified payment system
for post-acute care that would pay for PAC services based on patient characteristics
and needs, rather than setting (Medicare Payment Advisory Commission 2016).
Later, it outlined a patient centered approach to align regulatory requirements so
that providers would face similar regulatory requirements for treating similar pa-
tients (Medicare Payment Advisory Commission 2019). Until a uniform payment
system is implemented and regulatory requirements are aligned, institutional PAC
settings’ patient and facility criteria provide important program safeguards against
paying for unnecessary care and help ensure that care provided in costly, intensive
settings is targeted to patients who can benefit from that level of care.
Policymakers Should Be Cautious About Making Current Flexibilities and
Policy Modifications Permanent
It is important to keep in mind the reasons that policies and rules in place prior
to the pandemic exist. Many of the Medicare policy changes made in response to
PHE affect important beneficiary protections, as well as measures designed to deter
fraud, overuse, or inappropriate spending. The intended effects of the regulatory
flexibilities and other changes to Medicare’s policies are to maintain beneficiary ac-
cess to needed services and help the health-care system to respond to the pandemic,
but these flexibilities can also have negative effects. For example, waiving condi-
tions of participation can expand access and minimize provider burden, but looser
regulations may also negatively affect quality of care and quality of life for patients
and put Medicare at higher risk for waste and fraud by creating opportunities for
those who wish to exploit the program to do so.
If it is determined that any temporary policy changes are leading to poor health out-
comes, patient harm, or increases in fraud and abuse, policymakers should take im-
mediate action to curtail those flexibilities prior to the end of the PHE. Likewise,
some of the temporary policy changes that were viewed as necessary during the
worst days of the PHE—such as increased payment rates for certain services—may
no longer be needed as the effects of the pandemic wind down.
In other cases, decisions about whether to extend or make permanent policy modi-
fications after they are scheduled to expire should be made based on evaluation of
data collected not only during the pandemic, but also during more typical cir-
cumstances. That being said, we do not yet have reliable information about how pol-
icy modifications and flexibilities granted during the PHE have affected health sta-
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tus, access, spending, program integrity, and other important considerations. Fur-
thermore, findings on the effects of policy changes based on data collected during
a pandemic may not be generalizable to the post-pandemic environment. For in-
stance, the impact of the modifications that increased use of telehealth on quality
and cost of care are largely unknown and will take time to fully analyze, and find-
ings from 2020 could be shaped by factors that may not be applicable after the pan-
demic.
Conclusion
MedPAC recognizes the tremendous challenges the coronavirus pandemic has im-
posed on beneficiaries, providers, and the rest of the health-care system. We ap-
plaud the quick and decisive actions taken by the Congress and CMS aimed at
maintaining access to care and enabling an effective response to the public health
emergency. In general, the Commission has been supportive of the temporary waiv-
ers, flexibilities, and other changes to Medicare policies implemented during the
PHE. We are supportive of continuing some of the telehealth expansions for a lim-
ited time, beyond the PHE, provided that adequate oversight and protections are in
place to protect the Medicare program and beneficiaries. We would not advise ex-
tending the PAC waivers beyond the PHE.
The Commission is also supportive of efforts by this Committee and others to review
the changes and make determinations about which, if any, flexibilities and policy
changes should be continued, and which should be reinstated once the PHE ends.
We realize many stakeholders see the benefits of less regulatory oversight and ex-
panded coverage of services like telehealth, along with other pandemic-related policy
changes, and wish to see them made permanent. But the Commission is concerned
about the implications of indefinitely continuing Medicare policy modifications and
flexibilities that were granted in direct response to the unique circumstances of the
coronavirus pandemic. There are trade-offs to extending PHE-related modifications,
and the benefits of continuing these changes must be weighed against the potential
drawbacks, including substantial spending and program integrity implications.
Although we are concerned about the potential for some of the waivers and coverage
expansions to lead to overuse of services and reductions in quality of care, these
modifications may not have the same drawbacks when implemented in alternative
payment arrangements to traditional FFS where an entity is at financial risk for
the cost and quality of care. In fact, many existing Medicare alternative payment
models (APMs) contain waivers and flexibilities similar to those granted during the
PHE. As noted earlier, many APMs permit beneficiaries to receive care in a SNF
without a preceding three-day inpatient hospital stay, and there are fewer restric-
tions on telehealth compared to traditional FFS. The Commission is hopeful that the
continued development of such models can help facilitate more flexibility for pro-
viders and expanded coverage of technologies such as telehealth, while minimizing
the negative behaviors.
In closing, MedPAC urges the administration and the Congress to carefully consider
how making waivers permanent will affect the quality of care beneficiaries receive,
the willingness of providers to continue to participate in the Medicare program, and
the already challenging issues of fiscal solvency and Medicare program integrity.
The Commission plans to continue to follow the status of the temporary policy
changes and waivers granted during the PHE and will be closely monitoring their
impact on the program. Ultimately, all decisions about whether to continue these
measures beyond the PHE should balance the benefits of expanding access to care
and reducing administrative burden with the need to minimize the potentially nega-
tive effects that the rules and policies were originally designed to prevent.
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COMMUNICATIONS
ADVENTIST HEALTH
May 26, 2021
Senator Ron Wyden
Chairman
U.S. Senate
Committee on Finance
Washington, DC 20510
Senator Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
Washington, DC 20510
RE: Mayo Clinic Statement for the Record for the Committee hearing entitled:
‘‘COVID–19 Health Care Flexibilities: Perspectives, Experiences, and Lessons
Learned,’’ May 19, 2021
Dear Chairman Wyden and Ranking Member Crapo:
On behalf of Adventist Health and the patients we serve, thank you for holding the
May 19, 2021 hearing on ‘‘COVID–19 Health Care Flexibilities: Perspectives, Expe-
riences, and Lessons Learned.’’ We commend the committee for addressing this im-
portant issue and analyzing critical lessons learned from the hospital and patient
perspectives. We look forward to supporting the evolution and advancement of
health-care flexibilities today and post-pandemic.
Adventist Health is a faith-based, nonprofit integrated health system serving more
than 80 communities in California, Hawaii, and Oregon. Adventist Health provides
compassionate care in 23 rural and urban safety net hospitals. We operate the larg-
est network of rural health clinics in California, with more than 20 percent of Cali-
fornia’s Rural Health Clinics as a part of the system. Our rural Health Clinics
(RHCs) provide care to about 315,000 individuals who mostly live in medically un-
derserved communities.
Adventist Health is transforming the health-care experience, shifting from providing
care to focusing on the overall health of the communities it serves. This includes
embracing technology that makes care more convenient and accessible. The begin-
ning of 2020 introduced a disruption that has created more opportunities for virtual
visits, which are an essential component of health-care innovation that have proven
to be a lifeline during the COVID–19 pandemic. This innovative approach also offers
insights on the virtual hospital of the future. In May of 2020, Adventist Health cre-
ated a new care model that is reshaping the way acute care is delivered to the sys-
tem’s communities. Hospital@Home, in collaboration with Medically Home Group,
Inc. and Huron, is a virtual hospital that harnesses virtual and telemedicine tech-
nologies proven successful in hospitals for the last decade, to provide care in a pa-
tient’s home.
Telehealth services, like those provided by Hospital@Home, are more convenient
and accessible than traditional office visits and can greatly benefit populations who
find it difficult to manage their health-care needs in person. Our virtual visits pro-
vide crucial access to care for high-risk patients who need to stay home to protect
themselves, both during public health crises and in normal times. Our telehealth
services also provide vital access for patients in rural communities, where in-person
clinic visits may require extraneous time and effort to schedule and attend. Virtual
visits are also an essential way for patients to receive mental and behavioral health-
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care services that are increasingly necessary for whole-person care, but often dif-
ficult to access. Telehealth services are an important way for traditionally disadvan-
taged patient populations to easily connect to primary as well as specialty care pro-
viders that may not be accessible in person. It has been a critical lifeline for the
patients and communities we proudly serve.
The past year has demonstrated the undeniable value of virtual care. However,
much work remains to be done to ensure the continued growth of telehealth and
preserving beneficiary choice in how care is furnished. Expedient action from Con-
gress is essential to permanently establish the flexibilities granted to CMS during
the COVID–19 pandemic and to subsequently authorize CMS to build out an accom-
panying regulatory framework.
Virtual Care at Adventist Health
During the pandemic, Adventist Health’s clinical and digital teams provided essen-
tial remote care through 300,000 telephone and video visits. Through our virtual
care we have seen a decrease in missed visits, our patient satisfaction rates have
increased and we are able to create access points to our most vulnerable populations
where we otherwise would not have.
Hospital@Home
In one of the most significant developments in remote care, in May of 2020, Advent-
ist Health launched its Hospital@Home program to furnish acute-level services to
patients in their home. Adventist Health’s Hospital@Home serves patients in 7 loca-
tions throughout California and Oregon. The program has served hundreds of pa-
tients, delivering complex comprehensive acute care to qualifying patients in their
homes. These services, provided in person and virtually, include infusions, nursing
care, medications, laboratory and imaging services, and rehabilitation services from
a network of registered nurses, community paramedics, and an ecosystem of support
team members—all under the clinical direction of credentialed board certified
hospitalists in Adventist Health command centers.
The availability of an acute care option at home was a critical tool in the pandemic
response and Adventist Health’s hospitals are approved participants under the CMS
Acute Care at Home (CMS ACH) program announced in November 2020.
Our model counters isolation created by the COVID–19 pandemic and allows family
members to be at a patient’s bedside in their home, while helping hospitals balance
the increased demand for hospital beds. The Adventist Health Hospital@Home care
model is applied in emergency medicine, acute level COVID–19 care, and for pa-
tients with infections and chronic disease exacerbation (e.g., CHF, COPD). This
broad spectrum of applications unlocks patients’ homes as a meaningful addition to
flexible medical care capacity and supports greater health system resiliency, while
meeting the needs and wants of patients who prefer to be cared for at home or in
a home-like setting. The CMS ACH waiver expires at the end of the PHE, and it
is essential that Congress act to extend the current waivers to enable Medicare
beneficiaries to continue to access safe and effective acute-level care in the comfort
of their home.
Since launching Hospital@Home in May 2020, Adventist Health has been collecting
and analyzing data on Hospital@Home’s impact on patient care, experience, acuity,
readmission rates, and mortality. To date, Adventist Health has cared for over 500
patients and has had over 3,000 patient days, with promising data. For Adventist
Health patients receiving care in the Hospital@Home program, the 30-day hospital
readmission rate is 43.4% lower than the comparable population in the same time-
frame within Adventist Health’s traditional (brick and mortar) hospital practice.
To assess 2020 patient satisfaction, data collected using inpatient HCAHPS surveys
have been generated for Hospital@Home patients, resulting in top decile scores for
overall rating ¥ 89.4% (n=53) ¥ and would recommend ¥ 87% (n=46).
Recommendations for Health Care Flexibilities
Adventist Health supports keeping these important flexibilities in place so that we
can ensure that our forward momentum is built upon and that the significant in-
vestments in telehealth infrastructure and accessible patient care are maintained.
• Geographic and originating site restrictions. Before the pandemic, Medi-
care required that a patient either live in a rural or certain health professional
shortage area or only use telehealth at an approved originating site, such as
a hospital or physician’s office. Together, these restrictions functionally pre-
vented beneficiaries from accessing telehealth at home. Only about 2 percent of
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beneficiaries reside in zip codes that meet the traditional geographic and origi-
nating site criteria.
• FQHC and RHC expansion. Without making permanent the COVID–19 regu-
latory flexibility, Rural Health Clinics (RHCs) and Federally Qualified Health
Centers (FQHCs) will not be allowed to serve as distant site telehealth pro-
viders. This prevents low-income and geographically isolated individuals from
utilizing accessible points of care for telehealth visits, creating barriers to af-
fordable treatment for the populations who often need it most.
• Qualifying providers. When the PHE ends, CMS would currently have to re-
vert to policies that restrict the types of providers that can deliver reimbursable
virtual care to Medicare beneficiaries. Commonly accessed providers like phys-
ical therapists, occupational therapists and speech language pathologists would
no longer be able to bill for telehealth services.
• Audio-Only Services. Audio-only services are critically important for many
populations. Technology challenges, such as access to Internet/broadband and
low digital literacy, is a telehealth barrier for 64% of patients. These patients
require audio-only services to meet their unique needs.
• Hospital Without Walls. Acute Hospital Care at Home waivers mitigate the
residual impacts of COVID–19 on public health and encourage broader adoption
of providing patient centered health-care services in the home.
Thank you again for holding this important hearing. We look forward to continuing
to work with Congress and HHS to ensure that access and quality care are available
to our patients and our communities during and beyond the PHE, as well as to fur-
ther provide groundwork for greater innovations in health-care delivery for the fu-
ture.
Sincerely,
Scott Reiner, CEO
ADVOCATE AURORA HEALTH
June 2, 2021
Hon. Ron Wyden Hon. Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Re: Written Testimony Submitted to the Senate Committee on Finance for the May
19, 2021 Hearing Record, ‘‘COVID–19 Health Care Flexibilities: Perspectives, Expe-
riences, and Lessons Learned’’
Dear Chairman Wyden and Ranking Member Crapo:
On behalf of Advocate Aurora Health (Advocate Aurora), thank you for holding a
hearing on May 19, 2021 titled, ‘‘COVID–19 Health Care Flexibilities: Perspectives,
Experiences, and Lessons Learned.’’ We are grateful for your leadership on—and at-
tention to—this important topic. We appreciate the opportunity to submit this state-
ment for the hearing record and thank you in advance for your consideration of our
recommendations for how to sustain the gains made in telehealth deployment dur-
ing the Public Health Emergency (PHE), fully harness the potential telehealth holds
for tackling many of the challenging health-care issues facing our nation, including
how to increase access to quality care, lower costs, eliminate health-care disparities,
and address socioeconomic determinants of health (SDOH), such as lack of safe, reli-
able transportation.
Our clinicians feel strongly that telehealth, remote patient monitoring, and other
health technology together are a powerful set of tools that can help expand access
to care for rural and underserved communities, such as South Chicago and inner-
city Milwaukee. For many patients, having the option to engage with a clinician via
telehealth offers them a convenient clinical option as it eliminates the need for
transportation, parking, and childcare and reduces absences from school or work.
Further, for some patients with mobility challenges, disabilities, or other special
needs, such as autism, telehealth and remote care can provide a more effective, less
burdensome, and less stressful clinical care experience.
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As enumerated further below, Advocate Aurora has appreciated the waivers and
flexibilities afforded to clinicians during the PHE, and in particular, the waivers as-
sociated with telehealth have supported our ability to maintain continuity of care
for a significant number of our patients and to expand access to care to traditionally
underserved individuals and communities. As we begin to emerge from the PHE, it
will be imperative that we retain the advances in telehealth. We thank you in ad-
vance for your consideration of our recommendations and requests with respect to
making the PHE telehealth and related changes permanent.
Overview of Advocate Aurora
Advocate Aurora is a leading employer in the Midwest with more than 75,000 team
members, including more than 22,000 nurses and the region’s largest employed
medical staff and home health organization. The system serves nearly 3 million pa-
tients annually; across both Illinois and Wisconsin, in particular, we serve an esti-
mated 695,000 Medicare beneficiaries and more than 485,000 individuals with Med-
icaid coverage.
With more than 500 sites of care, Advocate Aurora is engaged in hundreds of clin-
ical trials and research studies, and is nationally recognized for its expertise in car-
diology, neurosciences, oncology, and pediatrics. The organization contributed $2.2
billion in charitable care and services to its communities in 2019. Advocate Aurora
brings its strengths, assets, and commitment to delivering value and outcomes to
individuals, families, and communities throughout Illinois and Wisconsin.
Advocate Aurora also serves as a transformative leader and strong partner with the
federal government in the journey from volume to value. The Centers for Medicare
& Medicaid Services in 2020 announced that Advocate Aurora Health’s three affili-
ated Accountable Care Organizations (ACOs) combined saved taxpayers $87.5 mil-
lion through the Medicare Shared Savings Program, the most of any integrated sys-
tem in the country.
Advocate Aurora and Telehealth
Advocate Aurora has long been engaged in the provision of care through telehealth,
as it is an important tool in reaching rural and underserved communities, including
individuals with special needs, such as people who are deaf and hard-of-hearing. For
example, we are proud that more than 15 years ago we were the only Chicago area
provider to offer tele-psychiatry visits using videoconferencing and clinicians who
speak American Sign Language (ASL) to deaf and hard-of-hearing patients who
were living in southern Illinois. These patients had unmet mental health needs but
there were no providers in the community who spoke ASL and an audio-only visit
is ineffective and inappropriate. By offering video-tele-psychiatry with ASL speak-
ers, patients could access the specialty care they needed without the burden of hav-
ing to travel. Since that time, we have significantly expanded our telehealth and
digital medicine offerings in Illinois and Wisconsin.
We connect to our patients through videoconferencing, remote monitoring, electronic
consults, and wireless communications and we deploy these technologies to provide
primary, urgent care, and specialty services. The strategic utilization of telehealth—
both prior to and during the PHE—allows us to offer patients an important, safe,
and convenient care option.
Advocate Aurora Telemedicine ED Triage
For example, prior to the PHE, we successfully implemented remote video moni-
toring technology to help reduce overcrowding at Aurora Sinai Medical Center’s
Emergency Department (ED) in Milwaukee, Wisconsin, one of our busiest EDs. This
telemedicine program allows patients to be seen initially by an Advocate Aurora cli-
nician via video when they arrive, with a nurse at the patient’s side. By having ad-
ditional clinicians available via telemedicine—with triage assistance and on-site cli-
nician support—patients are seen by a clinician faster and, in turn, they experience
a reduced time to diagnoses and quicker initiation of treatment.
• The program has helped to reduce door-to-provider times from 60 minutes to
about 10 minutes, on average.
• The average length of stay has declined by 40 minutes.
• The leave-without-being-seen rate has plummeted from 8% to 2%.
• Overcrowding in the ED has decreased significantly.
Advocate Aurora’s Experience with Telehealth During the PHE
We are eager to sustain the recent advances made in the utilization and adoption
of telehealth; while the advantages and power of telehealth have been known for
decades, the importance of virtual care has become profoundly clear in the past year
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during the PHE. Starting in March 2020, providers and patients alike sought ways
to interact that reduced their risk of exposure to COVID–19. Many physicians and
Advance Practice Clinicians (APCs) could not be in the office or at the hospital due
to COVID–19 restrictions but could still see patients through virtual care. Tele-
health helped reduce unnecessary patient and provider exposure to COVID–19 and
allowed us to preserve scarce PPE during shortages.
Moreover, many patients, including home care patients, were fearful of seeing their
care providers in person but were eager to engage in a visit through audio or video
means. Further, as noted earlier, many patients have mobility issues, disabilities,
transportation challenges, or home, work, or school obligations that make traveling
to an office, clinic, or hospital campus extremely burdensome even in non-pandemic
times. With vast disruption with public transportation systems and patients experi-
encing greater stress overall, telehealth allowed us to provide convenient, continuity
of care for our patients across the care spectrum—primary, specialty, post-acute,
chronic disease management, etc.
Advocate Aurora’s behavioral health-care physicians and APCs in particular have
noticed a significant reduction in canceled or missed appointments and high patient
satisfaction levels among patients using tele-behavioral health services. Our behav-
ioral health patients consistently gave high daily ratings to virtual treatment with
an average rating of 8.7 out of 10. When questioned about future preferences, 72%
of patients either preferred virtual to in-person treatment or were neutral. Across
the Advocate Aurora system, 90% of patients were satisfied after virtual visits and
likely to use virtual visits again. Further, 91-93% found it either easy or very easy
to interact with their provider via video.
In 2019 and before the pandemic, an estimated 300 Advocate Aurora physicians and
APCs performed 13,026 virtual health visits. By the end of 2020, Advocate Aurora’s
virtual care program:1
• Provided a total of 876,000 virtual visits to 507,375 unique patients;
• Reached a diverse patient population: 17% Black/African American, 10% His-
panic or Latino; and 3% Asian;
• Experienced most demand (45%) within primary care with Family Practice pro-
viders accounting for 27% of visits and Internal Medicine providers comprising
18% of visits, while Behavioral Health services were 14% of visits, followed by
Cardiology at 6%;
• Delivered care to patients in 15 states; and
• Had a payer mix of 32% Medicare, 12% Medicaid, 51% commercial insurance,
and 5% self-paying patients or another payer source.
Advocate Aurora Supports Making Permanent the PHE-Related Telehealth
Policy Changes
Advocate Aurora very much appreciates the changes that both the Centers for Medi-
care and Medicaid Services (CMS) and Congress have made since the start of the
PHE to ensure that patients can receive care via telehealth, should they so choose.
We enumerate below a number of the flexibilities and waivers currently available
that we respectfully request be made permanent. We understand that some of the
waivers and flexibilities can be made permanent under existing CMS authority,
while others require Congressional action. We urge you and your colleagues to work
with CMS to ensure all of these policies are made permanent so patients can con-
tinue to benefit from what telehealth offers them. Specifically, we ask that you con-
tinue to allow:
• All patients, irrespective of their geography (e.g., rural) and physical location
(e.g., home), to receive telehealth services in the location of their choosing.
• Medicare to pay for telehealth services at the same rate as in-office visits for
all diagnoses.
• Practitioners to provide telehealth services to both new and established Medi-
care patients.
We appreciate that audio-only telehealth was an important focus during the hear-
ing. Audio-only telehealth flexibilities have allowed our clinicians a convenient and
effective way to maintain and expand access to care during the pandemic. Currently
these audio-only visits represent approximately 35% of our total virtual health
consults, providing care to 285,601 unique patients. Audio-only visits experienced
most demand from our Family Practice providers (18%) and Internal Medicine pro-
1 Advocate Aurora’s virtual care services are comprised of Quick Care, E-Visits, telephonic,
and virtual clinic visits.
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viders (18%) followed by our Behavioral Health, Oncology and Cardiology special-
ists. 45% of our patients receiving audio-only virtual visits are covered by Medicare,
12% by Medicaid while 36% are covered by commercial insurance with the remain-
der receiving coverage from self-pay or some other source. We strongly support pol-
icymakers continuing to allow:
• Practitioners to provide audio-only telephone evaluation and management visits
for new and established patients; this is especially important for patients who
may not have Internet access or a smart phone.
• Practitioners licensed in one state to be reimbursed for services provided to
Medicare beneficiaries in another state and reduction of burdens preventing rec-
iprocity in state licensures.
• Practitioners such as licensed clinical social workers, clinical psychologists,
physical therapists, occupational therapists, and speech-language pathologists
to provide—and be reimbursed for—telehealth, virtual check-ins, e-visits, and
telephone calls to patients.
• Practitioners to provide a greater range of services to beneficiaries via tele-
health, including ED visits.
• Medical screening exams (MSEs), a requirement under Emergency Medical
Treatment and Labor Act (EMTALA), to be performed via telehealth.
Further, we very much appreciate that CMS and the Office of Inspector General at
the Department of Health and Human Services (HHS) have offered relief from en-
forcement of Stark Self-Referral and Anti-Kickback laws during the PHE. As you
know, while well intended when they were designed, the nature of health-care deliv-
ery has changed significantly in the decades since these laws were passed and their
implementing regulations promulgated. We urge that many of these flexibilities be
made permanent so that patients can have access to the technologies they need to
benefit from advances in virtual care. We are concerned that underserved and vul-
nerable patient populations may not have access to the needed technologies pri-
marily used for telemedicine, including broadband Internet access and smartphones,
yet providers cannot provide financial help so patients can secure these needed
tools.
Without a permanent change, hospitals face significant legal risk if they want to
provide a subsidy to their physicians to purchase telehealth technologies, like spe-
cialized tablets to perform remote patient monitoring, or if they want to give pa-
tients, free of cost or at reduced prices, devices such as wearable ‘‘stethoscopes,’’
blue-tooth enabled-digital blood pressure cuffs, or a virtual care kit for a home ex-
amination. Patients who cannot afford the out-of-pocket costs for these devices,
apps, etc. will be unable to benefit from innovative, patient-centered virtual care.
This further exacerbates inequities and health disparities, and prevents physicians
and APCs from being able to address many SDOH. We appreciate the recent
changes CMS and HHS have made to the Stark and Anti-Kickback regulations but
we urge federal policymakers to further modernize these outdated laws and regula-
tions so that underserved and vulnerable patients can have access to the care and
tools they need and deserve.
Summary
Again, we thank you for the opportunity to submit this statement for the hearing
record and we stand ready to work with you to ensure that the advances made in
leveraging telehealth are maintained so we can continue to improve and transform
health care in America, particularly for our most vulnerable patient populations. To
that end, we urge you and your colleagues to make permanent the PHE-related tele-
health waivers and flexibilities.
On behalf of Advocate Aurora’s physicians, nurses, other health professionals and
associates, and the patients, families, and communities we serve, thank you for your
leadership and commitment to ensuring that we as a nation sustain the gains made
in expanding access to care via telehealth and other virtual care offerings. We look
forward to working with you throughout the 117th Congress to improve the health
and well-being of the communities we serve.
Sincerely,
Meghan Woltman
Chief Government Affairs Officer
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ALLIANCE FOR CONNECTED CARE
1100 H Street, NW, Suite 740
Washington, DC 20005
https://connectwithcare.org/
The Alliance for Connected Care appreciates the opportunity to submit testimony
for this hearing examining COVID–19 health-care flexibilities. The Alliance for Con-
nected Care (the Alliance) is an advocacy organization dedicated to facilitating the
delivery of high-quality care using connected care technology. Our members are
leading health care and technology companies from across the health-care spectrum,
representing insurers, health systems, and technology innovators. Our Advisory
Board includes more than 30 patient and provider groups, including many types of
clinician specialty and patient advocacy groups who wish to better utilize the oppor-
tunities created by telehealth.
The Alliance will focus comments on (1) Research and evidence we have gathered
thus far; (2) recommendations for future telehealth expansion that Congress should
consider—including steps to ensure equitable access; and (3) Recommendations for
telehealth ‘‘guardrail’’ provisions that Congress should consider to prevent fraud,
waste and abuse in the health-care system.
While we prefer the implementation of permanent policies described in our rec-
ommendations below, the Alliance supports a two-year clean extension of telehealth
flexibilities exercised during the COVID–19 pandemic, including 1834(m) Medicare
telehealth waivers, a safe harbor for employer-subsidized telehealth for people with
Health Savings Account eligible High-Deductible Health Plans, and the flexibility
for Critical Access Hospitals to continue to bill telehealth as they have during the
pandemic. We want policymakers to feel comfortable that access to telehealth serv-
ices in Medicare will not negatively impact health-care quality, or the federal budg-
et. Therefore, we recommend Congress wait to make permanent policy until more
peer-reviewed research has been published, government studies—such as the study
underway by AHRQ—have been completed, the Office of the Inspector General has
examined the level of fraud in telehealth during the Public Health Emergency, and
when we have observed what the use of telehealth during ‘‘normal times.’’
Telehealth Research and Evidence
We have a unique opportunity afforded by the PHE to understand the effects of tele-
health on clinical practice—and to make direct apples-to-apples comparisons across
service modality. The sudden shift to virtual services generated fee-for-service (FFS)
data and empirical provider and patient experience that didn’t exist prior to the
pandemic. This data is just now being understood, and peer-reviewed studies and
reports are forthcoming. We believe it is essential to take this new evidence into
account when writing permanent laws especially given that pre-pandemic telehealth
studies were either narrowly-focused or relied on inferences on the impact of Medi-
care using commercial or Veterans Affairs data.
The COVID–19 pandemic has resulted in drastic increases in telemedicine utiliza-
tion, introducing millions of Americans to a new way to access health-care. Data
from the Centers for Disease Control and Prevention (CDC) finds that during the
period of June 26—November 6, 2020, 30.2 percent of weekly health center visits
occurred via telehealth. In addition, preliminary data 1 from the Centers for Medi-
care and Medicaid Services (CMS) show that between mid-March and mid-October
2020, over 24.5 million out of 63 million beneficiaries and enrollees have received
a Medicare telemedicine service during the PHE. Finally, an HHS Office of the As-
sistant Secretary for Planning and Evaluation (ASPE) Medicare fee-for-service (FFS)
telehealth report 2 found that from mid-March through early July more than 10.1
million traditional Medicare beneficiaries used telehealth, including nearly 50 per-
cent of primary care visits conducted via telehealth in April vs. less than 1 percent
before the COVID–19 pandemic. In addition to providing a lifeline to continuity of
care, it is important to note that the net number of Medicare FFS primary care in-
person and telehealth visits combined remained below pre-pandemic levels. As in-
person care began to resume in May, telehealth visits dropped to 30 percent but
there was still no net visit increase. We infer this and other data showing that as
in-person visits increased, telehealth visits decreased, that there was a substitution
1 https://www.cms.gov/newsroom/press-releases/trump-administration-finalizes-permanent-
expansion-medicare-telehealth-services-and-improved-payment.
2 https://aspe.hhs.gov/sites/default/files/private/pdf/263866/hp-issue-brief-medicare-tele-
health.pdf.
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effect. A claims-based analysis 3 suggests that approximately $250 billion in health
care spend could be shifted to virtual care in the long term—roughly 20 percent of
all Medicare, Medicaid and commercial outpatient, office and home health spend.
The effects of the COVID- 19 pandemic on patients seeking or avoiding care still
need further analysis, but these data suggest that telehealth substituted for in-per-
son care without increasing utilization.
In addition to telehealth largely substituting for in-person care, policymakers should
consider telehealth’s ability to increase efficiencies and improve access where bar-
riers to care exist. COVID–19 has dramatically heightened awareness of existing
health disparities and made the call to address these longstanding issues more ur-
gent. Transportation is just one example of a barrier to care that telehealth can al-
leviate. Transportation barriers are regularly cited 4 as barriers to access, particu-
larly for low-incomes or under/uninsured populations—leading to missed appoint-
ments, delayed care, and poor health outcomes. In a 2018 proposed rule,5 CMS esti-
mated that telemedicine is saving Medicare patients $60 million in travel time, with
a projected estimate of $100 million by 2024 and $170 million by 2029. CMS also
noted that these estimates tend to underestimate the impacts of telemedicine. High-
er projections estimate $540 million in savings by 2029.
The experience during COVID–19 has pushed forward a revolution in consumer atti-
tudes toward virtual care. Polling data from the University of Michigan 6 showed
that one in four older adults had used telemedicine during the first three months
of the pandemic, compared to just 4% in 2019. The same poll showed that 64% of
those surveyed in June 2020 were comfortable with using videoconferencing tech-
nology for any purpose, up from 53% in May 2019.
Top Telehealth Priorities
• Remove geographic and originating site restrictions on telehealth in Medicare.
The COVID–19 pandemic has clearly demonstrated the need for telehealth in
rural areas, in urban areas, at work, at school, at home and many other loca-
tions. These provisions are obsolete and outdated and should be removed from
statute entirely. The location of the patient should not matter for telehealth—
only the quality of the care being delivered.
» Please note that the removal of the originating site construct, a relic from
an era in which telehealth was an office-to-office interaction, is better pol-
icy that the addition of the home as a site for telehealth services or a waiv-
er of these restrictions.7
• Remove distant site provider list restrictions to allow all Medicare providers who
deliver telehealth-appropriate services to provide those services to beneficiaries
through telehealth when clinically appropriate and covered by Medicare—in-
cluding physical therapists, occupational therapists, speech-language patholo-
gists, social workers, and others. Additionally, work to ensure that in-person
payment models, such as those in which a facility/provider organization bills on
behalf of a care-team can be fully compatible with virtual care environment.
• Ensure Federally Qualified Health Centers, Critical Access Hospitals, and Rural
Health Clinics can furnish telehealth in Medicare and be reimbursed fairly for
those services, despite unique payment characteristics and challenges for each.
Please note that Critical Access Hospitals (CAHs) are sometimes omitted from
this list, but are a crucial component of a health-care system able to reach all
Medicare beneficiaries and must be able to directly bill for telehealth services
as a distant site provider.
• Make permanent the Health and Human Services (HHS) emergency waiver au-
thority for virtual care so that it can be quickly leveraged during future emer-
gencies. Telehealth has maintained critical connections between patients and
3 https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/tele-
health-a-quarter-trillion-dollar-post-covid-19-reality?_lrsc=a92397a2-f826-4e32-863b-4f1f467784d
1&cid=other-soc-lke.
4 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265215/#:%7E:text=Transportation%20
barriers%20are%20often%20cited,and%20thus%20poorer%20health%20outcomes.
5 https://www.govinfo.gov/content/pkg/FR-2018-11-01/pdf/2018-23599.pdf.
6 https://labblog.uofmhealth.org/rounds/telehealth-visits-skyrocket-for-older-adults-but-con-
cerns-and-barriers-remain.
7 The Alliance strongly supports the Telehealth Modernization Act (H.R. 1332), introduced by
Senators Tim Scott and Brian Schatz, which would eliminate the originating site construct com-
pletely.
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health-care practitioners during the pandemic, and should be enabled for a fu-
ture wildfire, flood, hurricane, or other emergency.
• Make permanent the HDHP/HSA Telehealth Safe Harbor created in Section
3701 of the CARES Act. This provision allows Americans with health savings
account (HSA) eligible high deductible health plans (HDHP) to receive cost-free
or discounted telehealth and remote care services prior to the patient reaching
their deductible. According to the Bureau of Labor Statistics (BLS), only 15 per-
cent of workers employed in the private sector participated in an HDHP in
2010. By 2018, that number had risen to 45 percent. With significant numbers
of American workers now relying on coverage through account-based plans, pol-
icymakers can meaningfully expand access to care by permanently allowing
first-dollar coverage of virtual care under HDHPs.
• Allow employers to offer telehealth benefits for seasonal and part-time workers.
Congress should designate standalone telehealth as an excepted benefit so that
this service can be offered to part-time employees, seasonal workers, interns,
new employees in a waiting period, etc. Currently, standalone telehealth bene-
fits are considered a ‘‘health plan’’ under Affordable Care Act (ACA) rules. That
means they must be paired with a full medical benefit that meets all of the dif-
ferent ACA requirements. In June 2020, the Department of Labor created flexi-
bility 8 for large employers to offer telehealth to non-eligible employees but this
access will end with the PHE.
• Enable the Centers for Medicare and Medicaid Services (CMS) to investigate and
retain some ‘‘Hospital Without Walls’’ authorities after the end of the public
health emergency and encourage that these authorities be used to maintain site
of care flexibility whenever the services provided are clinically appropriate for
virtual delivery. We believe that expanded capability for hospitals to remotely
monitor and care for patients could lead to shorter or avoided hospital stays and
lower costs—a potential benefit for both seniors and the Medicare program.
• Fund a comprehensive study of telehealth during the COVID–19 pandemic using
claims data and qualitative interviews with providers and patients who used
telehealth during the pandemic. The study should to answer specific questions
critical to future telehealth decision-making by Congress and regulators at
CMS. Suggested priorities include:
1. Is telehealth being adequately leveraged to address health disparities, and
what policies could Congress or HHS enact to ensure telehealth is a tool
to increase access to those most in need of health care?
2. To what extent are Medicare telehealth services during the PHE replacing
in-person care?
• How often to telehealth services require a follow-up in person visit and
how often are they fulfilling patient needs?
• Is the availability of telehealth increasing utilization, and if so, are
they primary care or preventative services with the potential to prevent
a more costly encounter downstream?
3. Are there specific, high-cost areas of the Medicare program that might
lower long-term costs through telehealth utilization?
• Are care coordination codes that have been shown to improve care such
as 99495 and 99496 being used more frequently during virtual care?
• Has the shift to using telehealth to manage lower acuity conditions in
skilled nursing facilities prevented unnecessary transfers to hospitals?
4. To what extent have CMS permissions for virtual/remote supervision of
health-care professionals been utilized during the COVID–19 pandemic?
Have these permissions resulted in patient harm? How have health-care
providers expanded their capability and capacity using this tool during the
PHE.
5. In addition to HHS investigations of fraud and abuse, what has been the
health-care provider, patient, and health plan experience with fraud per-
petrated through virtual tools during the PHE?
• Facilitate the removal of remaining telehealth restrictions on alternative pay-
ment models
» Accountable Care Organization’s (ACO) telehealth flexibility is limited a
narrow set of ACOs with downside risk and prospective assignment—even
though other tools apply to all ACOs. Since all participants in the Medicare
8 https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-center/faqs/
aca-part-43.pdf.
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Shared Savings Program are being held accountable for quality, cost, and
patient experience, all of them should have flexibility to use telehealth
tools to deliver care. We recommend eliminating Sec. 1899. [42 U.S.C.
1395jjj] (I)(2) requirements limiting participation to a select set of ACOs.
(We believe CMS may already have the statutory authority to make these
changes under 42 U.S.C. 1315a(d)(1) and 42 U.S.C. 1395jjj(f) if directing
the use of authority instead would keep the score down)
• Allow the Centers for Medicare and Medicaid Services to cover audio-only tele-
health services where necessary to bridge gaps in access to care. This would in-
clude, at a minimum, flexibility for areas with limited broadband service, for
populations without telehealth-capable devices, or in necessary situations such
as a future public health emergency. We anticipate that CMS would also main-
tain a list of services that were appropriate for this emergency audio-only care,
as it has done during the PHE, and that the clinician would document the rea-
son.
• Expand virtual chronic disease interventions with the potential to prevent down-
stream costs to the Medicare program. The most obvious example are virtual di-
abetes prevention programs (DPP), which can produce transformative weight
loss reducing the prevalence of obesity and comorbidities including prediabetes
and type 2 diabetes. These programs can produce better outcomes for patients
and would likely reduce downstream costs to the Medicare program, not only
by expanding access to a broader set of beneficiaries but by keeping patients
engaged and creating more sustainable lifestyle changes. During the COVID–
19 PHE, CMS has allowed DPP providers to practice virtually, but it has not
created a long-term pathway for virtual DPP programs. As much of the com-
mercial market has already moved to virtual care and app-driven interventions,
the DPP program must be able to adapt to meet patients where they are and
expand access to services for individuals not near a physical DPP provider.
• Expand the mandate of the Office for the Advancement of Telehealth at HRSA
and require it to develop tools and resources on telehealth services that can be
distributed to small health-care practices, patients, and consumer organizations.
Additionally, explore partnerships with leading consumer and patient organiza-
tions to educate seniors about telehealth services, including the use of tech-
nology and how to verify the identity of a health-care provider.
• Encourage CMS to continue facilitating greater use of remote patient monitoring
(RPM) technology through policy, including ongoing flexibility for allowing ac-
ceptance of patient-reported data for scales up to meet connected device require-
ments.
Recommendations for Fraud, Waste, and Abuse
The Alliance understands that with change sometimes comes risk, and that Con-
gress holds ultimate authority for protecting the Medicare program. We understand
and respect this responsibility. We also believe that, using the data we are collecting
about the provision of telehealth services during the PHE, the Medicare program
and the Office of the Inspector General at HHS will be able to target and differen-
tiate nearly all fraudulent behavior. Congress must trust this capability and author-
ity, rather than creating barriers to access between Medicare beneficiaries and crit-
ical health services.
The Alliance and its members strongly believe that an in-person requirement, as
Congress created in the Consolidated Appropriations Act, 2021 (Pub. L. 116–260) is
never the right guardrail for a telehealth service. Requiring an in-person visit con-
strains telehealth from helping individuals that are homebound, have transportation
challenges, live in underserved areas, etc. It does not constrain those using tele-
health for convenience. This creates a perversion of the Medicare payment system
by reducing access for those who need it most, while allowing access for others. We
cannot create a guardrail that is an access barrier between patients and their clini-
cians—it will lead to harm the most vulnerable and access-constrained Medicare
beneficiaries.
We also believe it is important to note that nearly all of the fraud Congress may seek
to prevent is fraud that mirrors activities currently occurring during in-person care.
These concerns include fraudulent Medicare enrollment, false claims, fake patients,
and durable medical equipment (DME) prescribing. All of these issues are problems
for the Medicare program—and should be addressed as Medicare fraud problems.
They are not new problems for telehealth services. Therefore, an in-person require-
ment would hinder legitimate telehealth providers while doing very little to stop
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fraudulent actors. Instead of creating barriers to services for Medicare beneficiaries,
Congress must empower CMS to address fraudulent actors.
We are pleased to note that on February 26, 2021, OIG Principal Deputy Inspector
General Grimm issued a statement 9 to this effect—differentiating between fraud
perpetrated through virtual tools and telehealth fraud.
We are aware of concerns raised regarding enforcement actions related to
‘‘telefraud’’ schemes, and it is important to distinguish those schemes from
telehealth fraud. In the last few years, OIG has conducted several large in-
vestigations of fraud schemes that inappropriately leveraged the reach of
telemarketing schemes in combination with unscrupulous doctors con-
ducting sham remote visits to increase the size and scale of the perpetra-
tor’s criminal operations. In many cases, the criminals did not bill for the
sham telehealth visit. Instead, the perpetrators billed fraudulently for other
items or services, like durable medical equipment or genetic tests. We will
continue to vigilantly pursue these ‘‘telefraud’’ schemes and monitor the
evolution of scams that may relate to telehealth.
Recommendations
With the understanding the Congress may still want to pursue additional guardrails
against fraud, waste, and abuse as part of telehealth legislation, we offer the fol-
lowing alternatives. Please note that many of these are simple regulatory changes,
and could be issued as recommendations to CMS.
• Enhance the ability of HHS to fight fraud in Medicare through new resources
and capacity
» Provide additional funding for OIG to strengthen existing fraud, waste, and
abuse mechanisms that have already been proven successful in fighting
fraud perpetrated through virtual tools. The House Ways and Means mi-
nority staff has proposed workable text to this effect that we support.
» We also support the development of OIG telehealth compliance guidance to
health-care organizations to help prevent and mitigate unintentional mis-
takes related to Medicare telehealth billing.
» Strengthen the Public-Private Partnership for Health Care Waste, Fraud
and Abuse Detection created by the Consolidated Appropriations Act of
2021 (Section 1128C(a) of the Social Security Act (42 U.S.C. 1320a–7c(a))).
This public-private partnership must be empowered with experts with ex-
perience in virtual care delivery and payment.
0 After—(6)(E)(i)(II) add ‘‘(III) The executive board shall include no less
than 3 individuals with significant expertise delivering and managing
the delivery of virtual care, including practitioners, medical directors
and individuals with oversight of telehealth programs, and virtual care
experts with experience in corporate fraud prevention.
• Work with CMS to develop restrictions on the solicitation of Medicare Fee-For-
Service telehealth services. It is our understanding that one of the primary ways
in which fraudulent actors exploit virtual services is by calling Medicare bene-
ficiaries to solicit their interested in high-value DME products. We believe a re-
striction on marketing, as currently exists for DME, would significantly hinder
situations in which DME fraud actors exploit telehealth services to drive DME
sales. As long as there was a significant allowance for legitimate marketing
practices, we do not believe this restriction would hinder legitimate telehealth
providers.
• Work with CMS to strengthen the Medicare provider enrollment process. The
provider enrollment process is the best tool to prevent fraudulent actors from
billing the Medicare program. Rather strengthened to identify and screen high-
er risk entrants.
• Encourage CMS to advantage of the enhanced data capabilities present in most
telehealth platforms. Technology platforms that provide telehealth are often ca-
pable of automatically recording times, dates, patient information, prescribing,
and other details which can be used to enhance compliance. These technologies
should allow for the greater use of audits and other forms of retroactive moni-
toring approaches on providers. As long as data capture requirements are very
clear, and that compliance with any requirements do not impose a significant
9 https://oig.hhs.gov/coronavirus/letter-grimm-02262021.asp?utm_source=oig-home&utm_
medium=oig-hero&utm_campaign=oig-grimm-letter-02262021.
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regulatory burden they could be a compliance tool. (Please note that very small-
providers should likely be exempted from these burdens.)
• Work with CMS to develop targeted restrictions on high-value, high-risk DME
prescribing through telehealth. While we continue to believe that there are some
appropriate circumstances for this prescribing, a step like this could signifi-
cantly lower risk to the Medicare program.
Thank you for your consideration of these recommendations. Some combination of
these recommendations could protect the Medicare program while aligning with the
recommendations of the Task Force on Telehealth Policy,10 which stated ‘‘we should
not hold telehealth to higher standards than other care sites, and we should trust
clinicians providing telehealth services to triage patients needing a higher level or
care or in-patient care, as we do in other care settings. As is done in other care set-
tings, patients’ preference for obtaining care in-person or via telehealth should be
respected.’’
Thank you for your consideration—we look forward to working with you on this im-
portant effort. Please contact Chris Adamec at cadamec@connecwithcare.org with
any questions.
Sincerely,
Krista Drobac
Executive Director
AMERICA’S HEALTH INSURANCE PLANS
601 Pennsylvania Avenue, NW
South Building, Suite 500
Washington, DC 20004
Everyone deserves access to affordable, high-quality care and coverage. This is a
core principle for health insurance providers and our industry. America’s Health In-
surance Plans (AHIP) greatly appreciates the Committee holding this hearing on
COVID–19 health-care flexibilities.1
Through temporary flexibilities enacted during the national emergency period,
health insurance providers have expanded access to virtual care via telehealth so
that Americans can get the care they need when and where they need it. Health
insurance providers have also innovated the way care can be delivered, especially
for individuals who are homebound to ensure the safety and well-being of their
members during the COVID–19 pandemic.
AHIP looks forward to working with the Committee to ensure that many of the
flexibilities enacted during the pandemic will endure beyond COVID–19 in order to
continue to provide Americans with affordable, convenient, high quality care.
Telehealth Growth During COVID–19
The COVID–19 crisis led to an exponential increase in telehealth use as a safe and
convenient way for people to access needed care. Telehealth claims increased over
8,000 percent in April 2020 compared to April 2019.2 Several health insurance pro-
viders have seen 50 times the number of telehealth claims as in years past, with
telehealth claims in some cases comprising roughly 25 percent of all claims in 2020.3
Among those experiencing significant growth are Blue Cross of Idaho, which proc-
essed more than 90,500 telehealth claims between March and June of 2020, with
telehealth representing more than one-quarter of all claims.4
Patients and providers understand and experience the value of telehealth. They ac-
cept—and often prefer—digital technologies as an essential part of health-care deliv-
ery. Telehealth delivers convenient access to affordable, high-quality care.
10 https://www.ncqa.org/programs/data-and-information-technology/telehealth/taskforce-on-
telehealth-policy/taskforce-on-telehealth-policy-findings-and-recommendations-overarching-
issues/.
1 America’s Health Insurance Plans (AHIP) is the national association whose members provide
coverage for health care and related services to millions of Americans every day. Through these
offerings, we improve and protect the health and financial security of consumers, families, busi-
nesses, communities, and the nation. We are committed to market-based solutions and public-
private partnerships that improve affordability, value, access, and well-being for consumers.
2 https://www.fairhealth.org/states-by-the-numbers/telehealth.
3 https://www.ahip.org/telehealth-growth-during-covid-19/.
4 https://www.ahip.org/telehealth-growth-during-covid-19/.
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Patients have taken advantage of telehealth from wherever they are, making it a
vital tool to bridge health-care gaps nationwide. For patients in rural communities
or underserved areas with a shortage of practicing clinicians, telehealth programs
and remote patient monitoring can make care more accessible, efficient, and sus-
tainable than it otherwise would be. Patients can connect with a doctor within sec-
onds rather than driving long distances for an office visit. Patients who can access
care remotely can also avoid challenges associated with taking time off work or find-
ing childcare. Those accessing behavioral health services can do so from the privacy
of their own homes and free from stigma. Telehealth is a tool that can connect pa-
tients with care in the most convenient, comfortable settings—without the chal-
lenges of finding in-person care.
Additionally, telehealth costs less. Even before the pandemic, 93 percent of con-
sumers who used telehealth said that it has lowered their health-care costs.5 Fur-
thermore, studies have shown that a virtual visit can save up to $100 compared to
a visit in other care settings (e.g., urgent care, primary care, emergency room) when
accounting for cost of services, cost of travel to a physical care setting, and lost earn-
ings associated with travel and wait times.6
By connecting patients with convenient care, providers are also reporting lower no-
show rates with telehealth.7 Telehealth can lead to better management of chronic
diseases, reduced travel times, reduced emergency department visits, and fewer or
shorter hospital stays.8 Patients are healthier and have better peace of mind by get-
ting the right care at the right time and in the right setting.
Faster expansion of telehealth has been made possible through flexibilities imple-
mented during the COVID–19 crisis. For instance, the Coronavirus Preparedness
and Response Supplemental Appropriations Act (CARES Act) temporarily author-
ized the Secretary of Health and Human Services (HHS) to waive originating site
requirements for telehealth services under Medicare, as well as allowing reimburse-
ment of more video-enabled telehealth and audio-only telehealth services for the du-
ration of the COVID–19 public health emergency (PHE). HHS also expanded the
number and types of providers who are eligible and licensed to deliver care via tele-
health and allowed providers to waive telehealth visit cost-sharing for Federal
health-care programs.9 Medicare Advantage (MA) plans were also allowed to waive
or reduce enrollee cost-sharing for telehealth benefits and expand coverage of tele-
health services beyond those approved in the plan’s benefit package.10 These meas-
ures allowed for greater flexibility in telehealth use for both patients and providers,
leading to exponential growth in use.
The Centers for Medicare and Medicaid Services (CMS) issued guidance allowing
health insurance providers in the individual and group market to amend plan bene-
fits during the 2020 plan year to expand coverage for telehealth services.11 Many
health insurance providers have since reduced or eliminated cost-sharing for tele-
health during the PHE, and broadened coverage of telehealth benefits by expanding
coverage options and increasing telehealth provider networks. CMS issued guidance
on remote supervision of nurse practitioners and physician assistants, expanding
the capacity to treat patients without requiring every element of care to be in-
person. These policies helped many patients remain safe from possible and unneces-
sary exposure to COVID–19 in waiting rooms or other in-person care settings while
still ensuring that patients received high-quality care.
Many states provided similar flexibilities in state Medicaid and CHIP programs and
facilitated the delivery of telehealth by modifying provider licensure restrictions that
have long served as a barrier to the effective delivery of telehealth.12 However, most
of the actions on both the state and federal levels are limited in scope and tem-
porary for the public health emergency. Long-term telehealth policy changes are
5 https://www.prnewswire.com/news-releases/39-of-tech-savvy-consumers-have-not-heard-of-
telemedicine-healthmine-survey-300241737.html.
6 https://news.regence.com/releases/regence-data-measures-real-world-savings-for-telehealth-
users.
7 https://www.healthcareitnews.com/news/telehealth-linked-ehr-drastically-reduces-no-show
-rate-garfield-health-center#:∼:text=Data%20for%20October%202020%20shows,the%20office%20
for%20an%20appointment.
8 https://www.ahip.org/wp-content/uploads/FactSheet_Telehealth-030719.pdf.
9 45 CFR §§ 160, 164 (2020). See www.govinfo.gov/content/pkg/FR-2020-04-21/pdf/2020-
08416.pdf (accessed February 23, 2021).
10 https://www.cms.gov/files/document/updated-guidance-ma-and-part-d-plan-sponsors-
42120.pdf.
11 www.cms.gov/files/document/faqs-telehealth-covid-19.pdf.
12 Spring2021_SummaryChartFINAL.pdf (digitaloceanspaces.com).
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necessary to drive innovation, promote investment, and address patient needs dur-
ing periods of stability and crisis.
Homebound Care During COVID–19
As the COVID–19 crisis disrupted lives and livelihoods, it also worsened health dis-
parities and access to care for vulnerable populations, including homebound popu-
lations and seniors. Additionally, many home health and home and community-
based services (HCBS) providers lacked sufficient supplies of personal protective
equipment (PPE), creating significant risk for providers and patients, and exacer-
bating the challenges in reaching patients who were afraid to receive care out of
concern over potential exposure to COVID–19.
Nationally, between 2 million and 4.4 million older adults are homebound with the
vast majority receiving services from Medicare, Medicaid, or both.13 More than
600,000 people receive Medicaid funded home health services, 1.2 million people re-
ceive Medicaid funded personal care services, and total enrollment in Medicaid
HCBS waivers exceed 2.5 million people. According to a 2019 MedPAC report, about
3.4 million Medicare beneficiaries received home health care in 2017.14
Medicare requires that individuals be homebound to receive home health care.
Given limits on the use of Medicare’s home health benefit, there are significant
numbers of Medicare beneficiaries who are in fact homebound but not receiving
home health services. In 2011, the prevalence of homebound Medicare beneficiaries
was estimated to be 5.6 percent, or about 2 million people.15 Applying the same per-
centage to today’s Medicare population, an estimated 3.5 million Medicare bene-
ficiaries are homebound. During the public health emergency (PHE), CMS expanded
the Medicare definition of homebound to allow patients to be considered such if it
is medically contraindicated for the patient to leave the home. This includes pa-
tients with a confirmed or suspected COVID–19 diagnosis or patients with condi-
tions making them more susceptible to contract COVID–19.
The Biden Administration proposed to increase funding for HCBS by $400 billion
in the American Jobs Plans and recently outlined $1.4 billion in funding from the
American Rescue Plan for Older Americans Act programs, including programs to
support vaccine outreach and coordination, address social isolation, provide family
caregiver support, and offer nutrition support.16 As part of the American Rescue
Plan Act, states can also receive a temporary 10 percentage point increase to the
federal medical assistance percentage (FMAP) for certain Medicaid HCBS from
April 1, 2021, through March 31, 2022.
Health insurance providers know that many Americans are homebound or rely on
caregivers and family members to manage their health even under normal condi-
tions. Plans are playing a leadership role in meeting the medical and social needs
of their members and helping to provide emotional support to members, their fami-
lies, and caregivers, and making sure individuals and caregivers have access to peer
coaches and support specialists with information on social services.
Health Insurance Providers Are Committed to Delivering Affordable and
Convenient Care Through Telehealth and Homebound Care
During the COVID–19 crisis, health insurance providers have expanded and inno-
vated in the way care is delivered. Many of AHIP’s member companies significantly
expanded telehealth accessibility and benefits, effectively encouraging people to con-
tinue to receive care they need despite the public health crisis.
Those who are older, live in rural areas, are a racial or ethnic minority, have a
lower socioeconomic status, or represent other vulnerable populations may have less
access to broadband and other technologies and resources necessary to fully leverage
the promise of telehealth.17 These same populations often face disparities in access
to in-person services.
13 https://www.washingtonpost.com/health/vaccinating-homebound-seniors/2021/03/26/
a06c71f8-7620-11eb-9537-496158cc5fd9_story.html.
14 http://www.medpac.gov/docs/default-source/reports/mar19_medpac_ch9_sec.pdf?sfvrsn=0#
:∼:text=In%202017%2C%20about%203.4%20million%20Medicare%20beneficiaries%20received%20
home%20care,billion%20on%20home%20health%20services.
15 https://www.researchgate.net/publication/277251465_Epidemiology_of_the_Homebound_
Population_in_the_United_States.
16 https://www.whitehouse.gov/briefing-room/statements-releases/2021/05/03/fact-sheet-
biden-harris-administration-delivers-funds-to-support-the-health-of-older-americans/.
17 https://www.pewresearch.org/fact-tank/2019/05/07/digital-divide-persists-even-as-lower-
income-americans-make-gains-in-tech-adoption/; https://www.pewresearch.org/fact-tank/2019/
08/20/smartphones-help-blacks-hispanics-bridge-some-but-not-all-digital-gaps-with-whites/.
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America’s health insurance providers embrace digital solutions that help increase
access to care and want to ensure that the people they serve, regardless of where
they live or their economic situation, can access safe and convenient care. For in-
stance:
• Centene has worked with Samsung Electronics America to supply providers
with 13,000 Samsung Galaxy A10e smartphones to disseminate to patients who
would not otherwise be able to receive their health care virtually.
• CareOregon is working with providers to supply flip phones and basic
smartphones along with data plans for their members.
• Blue Shield Promise (the Medicaid Managed Care Organization of Blue
Shield of California) and LA Care partnered to establish resource centers for
local communities to provide members with wellness programs and to connect
them with local resources to address socioeconomic needs. As their services and
programs moved online due to COVID–19, Blue Shield Promise and LA Care
offered technology and Wi-Fi to help their members access virtual programs,
services, and telehealth.
Health insurance providers are encouraging their vulnerable members, particularly
older people and others who may have delayed care, to get their preventive screen-
ings, routine care, and chronic condition management despite the COVID–19 pan-
demic.
• Bright Health makes non-emergency transportation available for all members,
and ride limits are being waived for non-emergency visits to and from their doc-
tor.
• Priority Health has partnered with technology company Papa to connect col-
lege students with Medicare members with specific chronic conditions who need
assistance with transportation, house chores, technology lessons, companion-
ship, and other senior services.
• Humana mailed more than 1 million in-home preventive screening kits to
members in 2020, helping increase access to routine screenings that many
members have put off during the COVID–19 crisis.
Health insurance providers have also taken proactive actions to provide COVID vac-
cines for vulnerable seniors, individuals who are homebound, and other vulnerable
populations.
Given the vast majority of Medicare beneficiaries are enrolled in Medicare Advan-
tage or Medicare Part D (50.8 million)18 and 40 19 states leverage Medicaid Managed
Care as their delivery system (including 25 20 who use health plans to deliver man-
aged long-term services and supports), health insurance providers are uniquely situ-
ated to help get the homebound population vaccinated quickly, effectively, and equi-
tably.
On March 3, 2021, the White House, America’s Health Insurance Plans (AHIP) and
the Blue Cross Blue Shield Association announced the Vaccine Community Connec-
tors (VCC) pilot initiative. As vaccine supplies expand and appointments become
more available, health insurance providers have committed to use their combined
expertise, data, and insights to:
• Identify seniors who are vulnerable to COVID–19 and who live in areas where
vaccination rates are most inequitable;
• Work with partners in the community to educate seniors on the safety, efficacy,
and value of COVID–19 vaccines;
• Contact those seniors who are eligible to get a vaccine through multiple chan-
nels to facilitate vaccine appointment scheduling;
• Coordinate services to help overcome barriers that may stand between them
and getting vaccinated; and
• Track and report progress to ensure those who need vaccinations most are re-
ceiving them.
18 https://www.cms.gov/research-statistics-data-and-systemsstatistics-trends-and-reportsmcra
dvpartdenroldatamonthly/contract-summary-2021-05.
19 https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-managed-care
/#:∼:text=As%20of%20July%202019%2C%2040,Medicaid%20beneficiaries%20(Figure%201).
20 https://www.macpac.gov/subtopic/managed-long-term-services-and-supports/.
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The VCC has since expanded to include the Medicaid population, many of whom are
members of the at-risk and underserved communities this program aims to reach.21
As part of these broader vaccination efforts, health insurance providers are helping
vulnerable, homebound individuals to receive the COVID–19 vaccine. Examples of
health plans partnering to address the needs of homebound individuals are growing
across the country include:
• Commonwealth Care Alliance (CCA) has partnered with the Commonwealth
of Massachusetts to lead the state’s effort to vaccinate homebound individuals.
In this partnership, CCA serves as the vaccine coordinator for the Massachu-
setts homebound population. CCA manages a technological, logistical, and pro-
vider infrastructure to receive referrals of state-screened homebound residents
for outreach and appointment scheduling, vaccine distribution, delivery of vac-
cines to people’s homes, and reporting on their performance. CCA has expanded
the program to all homebound individuals in Massachusetts, regardless of
health plan.22
• SCAN Health Plan provides in-home COVID–19 vaccinations to homebound
plan members and their families in Los Angeles County. The vaccination pro-
gram is made possible through a unique partnership between SCAN and
MedArrive, a logistics platform that enables health-care payers and providers
to seamlessly extend care services into the home, unlocking access to highly
qualified, trusted EMTs and Paramedics. The vaccines are being administered
by trained EMTs at no cost to the members. Caregivers and other eligible
household members are also receiving the vaccine at no cost.23
• HealthPartners has collaborated with 10 health systems across Minnesota to
coordinate efforts to distribute and administer vaccines, leveraging
HealthPartners’ home health subsidiary to offer vaccines in people’s homes.
• Blue Cross Blue Shield of Tennessee is bringing vaccines to their home-
bound members by working with local health departments, provider partners,
and local emergency services to identify, educate, and deliver vaccines to those
with mobility issues.
Policy Recommendations to Strengthen Health Care Flexibilities, Tele-
health and Homebound Care
AHIP is ready to work with Congress and the Administration to strengthen tele-
health and homebound care and establish policies that ensure the programs’ long-
term sustainability. Policymakers can further advance this work by embracing com-
prehensive, multi-stakeholder approaches:
(1) Make permanent the flexibilities in benefit design implemented during
the PHE. The Coronavirus Preparedness and Response Supplemental Appropria-
tions Act allowed the HHS Secretary to waive certain Medicare telehealth payment
requirements and the CARES Act enacted flexibility for commercial health insur-
ance providers to cover telemedicine. Congress should pass legislation to make these
provisions permanent and redefine how Medicare and commercial (e.g., employer-
sponsored coverage) and individual market enrollees can access telehealth. To solid-
ify several regulations implemented by CMS and HHS during the COVID–19 crisis,
Congress should revise section 1834(m) of the Social Security Act to allow for flexi-
bility in benefit design for originating sites, eligible geographies, eligible services,
and eligible providers. In reviewing this law, we encourage Congress is to leave
room for flexibility and innovation—the speed at which telehealth and virtual care
evolved during the COVID–19 crisis alone shows how quickly the care delivery land-
scape can change. We recommend against lawmakers attempting to strictly define
the future of virtual care and instead allowing health insurance providers and other
innovators the opportunities to connect patients with the most convenient, afford-
able, and high-quality care available.
Additionally, while telehealth may be no more subject to fraud and abuse than other
modalities, it will be essential to monitor the impact of telehealth on health out-
comes, including quality and costs.
(2) Pass S. 150, the Ensuring Parity in MA for Audio-Only Telehealth Act
of 2021. This bipartisan bill would reduce health disparities that result from un-
equal access to health technology, broadband service, and video telehealth plat-
21 https://www.communityplans.net/acap-joins-ahip-bcbsa-in-advancing-vaccine-accessibility-
and-equity-initiative/.
22 https://www.commonwealthcarealliance.org/news/2021/march/commonwealth-care-alli-
ance-to-lead-massachusetts-h.
23 https://www.businesswire.com/news/home/20210426005231/en/.
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forms. It would also ensure that the more than 26.5 million seniors and people with
disabilities who receive their Medicare benefits through Medicare Advantage (MA)
and PACE continue to receive the high-quality care on which they rely.
Rural patients may have trouble accessing technology or broadband services nec-
essary to support video-enabled telehealth. Additionally, seniors or frail populations
may have physical limitations that prevent them from using video-enabled tele-
health platforms. An audio-only telehealth visit may be the only option for these pa-
tients to safely and conveniently access needed care. MA plans have taken decisive
steps to support these patients by expanding telehealth services, including providing
coverage for telephonic (also known as ‘‘audio-only’’) telehealth at the onset of the
COVID–19 pandemic despite CMS’s decision to exclude diagnoses identified during
the delivery of this care in determining the severity of those patients’ health condi-
tions.
In addition, allowing diagnoses from audio-only telehealth services to count for MA
and PACE risk adjustment will help ensure patient health costs are adequately ac-
counted for and reimbursed. Without the accurate documentation of diagnoses for
MA and PACE risk adjustment, the programs will effectively experience cuts, leav-
ing MA and PACE organizations and providers with fewer resources necessary to
care for patients. This could lead to unequal access, fewer choices, higher premiums,
or reduced benefits for beneficiaries in the long run. Given that MA and PACE plan
rates are benchmarked at the county level, this impact could be particularly acute
in areas where accessing video-enabled telehealth posed more significant challenges
for many enrollees, enhancing disparities between communities on either side of the
digital divide.
That is why AHIP strongly supports S. 150, the Ensuring Parity in MA for Audio-
Only Telehealth Act of 2021, introduced by Senators Catherine Cortez Masto and
Tim Scott. This bipartisan legislation would reduce health disparities due to un-
equal access to health technology while supporting the more than 26.5 million
Americans enrolled in MA and PACE and the providers who have cared for them
throughout the COVID–19 crisis.
AHIP recently joined with 17 other health-care organizations in support of the
bill.24 We appreciate the Committee’s focus on the importance of telehealth and the
recognition that for many Medicare beneficiaries, a phone call is their best or only
option for immediately accessing health care. We look forward to working with the
lead sponsors of S. 150 and the Senate Finance Committee to support the MA and
PACE programs, their provider partners, and the 43 percent of Medicare bene-
ficiaries choosing these programs for their care.
(3) Improve Workforce Opportunity and Support for Caregivers and Home
Health Care Providers. Lack of training, lack of opportunity, and low wages lead
to low job satisfaction, high rates of caregiver burnout, and high rates of turnover.
Many in the workforce cite lack of professional development and growth as a reason
for exiting the direct care workforce. Studies have shown a decrease in departures
among workers who are offered training and a career ladder.25 Policymakers and
health insurance providers must champion efforts to create training opportunities
and develop pathways to promotion.
(4) Sustain Funding for HCBS. We support enacting measures that incentivize
adoption and expansion of HCBS as an alternative to institutional care in state
Medicaid programs. Policies such as sustained enhanced federal financial participa-
tion and flexibilities for states in developing HCBS infrastructure are key elements
in making home-based care available to everyone who needs it.
(5) Extend Telehealth Safe Harbor for High Deductible Health Plans. The
CARES Act created a temporary safe harbor for High Deductible Health Plans
(HDHPs) that may be paired with tax-advantaged Health Savings Accounts (HSAs)
to allow health insurance providers offering those plans to pay for telehealth serv-
ices without applying a deductible. This safe harbor has allowed plans to offer bene-
fits that better serve the needs of the more than 32 million Americans enrolled in
these plans, particularly during the pandemic. This flexibility is both cost-effective
and, as with access to virtual care in other plan types, highly responsive to patient
needs. The safe harbor applies only to commercial health plans that begin prior to
24 https://www.ahip.org/wp-content/uploads/04.28.21-Stakeholder-LoS-HR-2166-and-S-150.
pdf.
25 https://www.leadingage.org/sites/default/files/Direct%20Care%20Workers%20Report%20%
20FINAL%20%282%29.pdf.
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December 31, 2021, and many health insurance providers and their employer clients
would like to see this safe harbor extended. There continues to be strong bipartisan
support for extending the safe harbor and promoting greater utilization of telehealth
among commercial plans while helping working families access care when it is con-
venient to them without imposing undue costs. We urge Congress to take bipartisan
action to extend this highly popular change to HDHPs.
Conclusion
Everyone deserves access to affordable, high-quality care, whether delivered directly
to a person in their home or virtually. Together with the Administration, Congress,
and our provider partners, health insurance providers are working to ensure that
patients continue to have access to health care when they need it so that no commu-
nity is left behind. AHIP thanks the Committee for focusing on this important issue,
and we look forward to working together on more initiatives to improve health care
in every community.
AMERICAN ASSOCIATION OF NURSE PRACTITIONERS
On behalf of the more than 118,000 individual members of the American Association
of Nurse Practitioners (AANP), and the over 325,000 nurse practitioners (NPs)
across the nation, we appreciate the opportunity to provide the following statement
for the record to the United States Senate Committee on Finance (the Committee).
We commend Chairman Wyden, Ranking Member Crapo and the members of the
Committee for holding this hearing on the experiences and lessons learned regard-
ing COVID–19 flexibilities. NPs have been on the front lines providing care to pa-
tients since the onset of this pandemic, and many of these flexibilities, specifically
those related to telehealth and workforce expansion, have been integral in their
ability to provide high-quality and timely care to patients. Making these waivers
permanent will increase patient access to health care, particularly in rural and un-
derserved communities, and help alleviate the health-care disparities that were ex-
acerbated by this pandemic.
As you are aware, NPs are advanced practice registered nurses who are prepared
at the masters or doctoral level to provide primary, acute, chronic and specialty care
to patients of all ages and walks of life. Daily practice includes: assessment; order-
ing, performing, supervising and interpreting diagnostic and laboratory tests; mak-
ing diagnoses; initiating and managing treatment including prescribing medication
and non-pharmacologic treatments; coordinating care; counseling; and educating pa-
tients and their families and communities. NPs practice in nearly every health-care
setting including clinics, hospitals, Veterans Health Administration and Indian
Health Services facilities, emergency rooms, urgent care sites, private physician or
NP practices (both managed and owned by NPs), skilled nursing facilities (SNFs),
nursing facilities (NFs), schools, colleges and universities, retail clinics, public
health departments, nurse managed clinics, homeless clinics, and home health. NPs
hold prescriptive authority in all 50 states and the District of Columbia and com-
plete more than one billion patient visits annually.
NPs have a particularly large impact on primary care as approximately 70% of all
NP graduates deliver primary care.1 NPs comprise approximately one quarter of the
primary care workforce, with that percentage growing annually.2 They provide a
substantial portion of health care in rural areas and areas of lower socioeconomic
and health status. As such, they understand the barriers to care that face vulner-
able populations on a daily basis.3, 4, 5 NPs are the second largest provider group in
1 https://www.aanp.org/about/all-about-nps/np-fact-sheet.
2 ‘‘Rural and Nonrural Primary Care Physician Practices Increasingly Rely on Nurse Practi-
tioners,’’ Hilary Barnes, Michael R. Richards, Matthew D. McHugh, and Grant Martsolf, Health
Affairs 2018 37:6, 908–914.
3 Davis, M.A., Anthopolos, R., Tootoo, J., Titler, M., Bynum, J.P.W., and Shipman, S.A. (2018).
‘‘Supply of Healthcare Providers in Relation to County Socioeconomic and Health Status.’’ Jour-
nal of General Internal Medicine, 4–6. https://doi.org/10.1007/s11606-017-4287-4.
4 Xue, Y., Smith, J.A., and Spetz, J. (2019). ‘‘Primary Care Nurse Practitioners and Physicians
in Low-Income and Rural Areas, 2010–2016.’’ Journal of the American Medical Association,
321(1), 102–105.
5 Andrilla, C.H.A., Patterson, D.G., Moore, T.E., Coulthard, C., and Larson, E.H. (2018). ‘‘Pro-
jected Contributions of Nurse Practitioners and Physicians Assistants to Buprenorphine Treat-
ment Services for Opioid Use Disorder in Rural Areas.’’ Medical Care Research and Review,
Epub ahead. https://doi.org/10.1177/1077558718793070.
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the National Health Services Corps 6 and the number of NPs practicing in commu-
nity health centers has grown significantly over the past decade.7
As noted in the testimony before the Committee provided by Jessica Farb, Director
of Health Care for the Government Accountability Office, the Medicare waivers
issued by the Centers for Medicare and Medicaid Services (CMS) for the COVID–
19 public health emergency (PHE) can broadly be broken into three categories: ex-
pansion of hospital services, workforce expansion and telehealth services. Our com-
ments will focus on workforce expansion and telehealth services. First, we would
like to highlight the impact that some of these flexibilities have had for our mem-
bers, their patients and communities. For instance, AANP members have reported
that the waiver authorizing NPs to perform the initial assessment and all other
mandatory assessments in skilled nursing facilities has provided flexibility to meet
the needs of skilled nursing facility (SNF) patients while also meeting the other de-
mands that COVID–19 has placed on their communities. Additionally, increased
coverage of telehealth and remote technologies, particularly coverage and increased
reimbursement for audio-only services, has been an essential lifeline for meeting the
needs of their patients. Many of our members have patients who lack access to
audio-video technology, and they would have had to make the difficult choice be-
tween delaying care or risking exposure to COVID–19 if this authorization had not
been made.
Workforce Expansion
During the PHE, CMS waived multiple barriers to practice within the Medicare pro-
gram that have previously prevented nurse practitioners from practicing to the full
extent of their education, clinical training and State scope of practice. Below are
waivers that should be made permanent before the end of the PHE. These rec-
ommendations are consistent with the National Academies of Science, Engineering
and Medicine report The Future of Nursing 2020–2030: Charting a Path to Achieve
Health Equity which recommends that ‘‘[b]y 2022, all changes in policies and state
and federal laws adopted in response to COVID–19 should be made permanent, in-
cluding those that expanded scope of practice, telehealth eligibility, insurance cov-
erage, and payment parity for services nurses provide.’’8 The World Health Organi-
zation’s State of the World’s Nursing 2020 report also recommends modernizing reg-
ulations to authorize APRNs to practice to the full extent of their education and
clinical training, and noted the positive impact this would have on addressing
health-care disparities and improving health-care access within vulnerable commu-
nities.9
Removing barriers to care for NPs and their patients has also garnered widespread
bipartisan support. In addition to bipartisan support in Congress, reports issued by
the American Enterprise Institute,10 the Brookings Institution,11 the Federal Trade
Commission 12 and the U.S. Department of Health and Human Services under the
past two administrations 13, 14, 15 have all highlighted the positive impact of remov-
ing barriers on NPs and their patients.
State experience has also shown that removing state restrictions on NP practice im-
prove access to care for patients in rural areas, reduce unnecessary complications,
lower costs and improve quality of life. Currently, twenty-three states and DC are
considered Full Practice Authority (FPA) states because their licensure laws allow
full and direct access to NPs. No state has ever moved away from FPA once it has
been enacted.
States that restrict the legal authorization of NPs to practice their profession limit
patient choice and decrease access to care, with particularly acute effects in rural
6 https://www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-justification-fy2021.
pdf.
7 https://www.nachc.org/wp-content/uploads/2020/01/Chartbook-2020-Final.pdf.
8 https://www.nap.edu/resource/25982/FON%20One%20Pagers%20Lifting%20Barriers.pdf.
9 https://apps.who.int/iris/bitstream/handle/10665/331673/9789240003293-eng.pdf.
10 https://www.aei.org/wp-content/uploads/2018/09/Nurse-practitioners.pdf.
11 https://www.brookings.edu/wp-content/uploads/2018/06/AM_Web_20190122.pdf.
12 https://www.aanp.org/advocacy/advocacy-resource/ftc-advocacy.
13 https://www.hhs.gov/sites/default/files/Reforming-Americas-Healthcare-System-Through-
Choice-and-Competition.pdf.
14 https://aspe.hhs.gov/pdf-report/impact-state-scope-practice-laws-and-other-factors-practice-
and-supply-primary-care-nurse-practitioners.
15 https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Rural-Strategy-
2018.pdf.
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areas.16 Recent studies have found that restrictive practice environments are associ-
ated with a lower percentage of NPs obtaining medication-assisted treatment (MAT)
waivers.17 States that adopt FPA have found overall positive rural health-care work-
force trends. Arizona adopted FPA in 2001 and found that ‘‘the number of Arizona
licensed NPs in the state increased 52% from 2002 to 2007’’, with the largest in-
crease occurring in rural areas.18 Other states that have reported similar workforce
trends include Nevada,19 Nebraska 20 and North Dakota.21 South Dakota also re-
ported reduced administrative costs after adopting FPA.22 These results highlight
the importance of removing barriers to practice on NPs to increase access to care
for patients.
Authorizing NPs to perform all mandatory visits in SNFs.
As noted above, authorizing NPs to perform all mandatory visits in SNFs has en-
abled practices and SNFs to maximize their workforce. This waiver improves con-
tinuity of care and infection control by reducing unnecessary contacts among pa-
tients and multiple providers. This is also consistent with the permanent policy for
Medicaid nursing facilities,23 creating further alignment between these two pro-
grams and improving care for dual-eligibles. Patients and health-care providers in
SNFs have been hardest hit by COVID–19. Making this waiver permanent will pro-
vide them with the necessary flexibility to provide the care that patients require for
the duration of the PHE and beyond.
Authorizing NPs in rural health clinics (RHCs) and federally quali-
fied health centers (FQHCs) to practice to the top of their license.
Waiving the requirement for physician supervision of NPs in RHCs and FQHCs has
provided much needed workforce flexibility in rural and underserved communities
where provider shortages are being exacerbated by COVID–19. Our members re-
ported that this waiver has helped the entire health-care workforce because they are
able to increase the focus on patient care instead of unnecessary paperwork and
more expeditiously provide necessary treatments to their patients.
Authorizing NPs in critical access hospitals (CAHs) to practice to the
top of their license.
We support making the waiver of the CAH physician physical presence requirement
permanent. This will enable NPs in CAHs to practice to the full extent of their edu-
cation and clinical training. NPs who stated that this waiver was implemented in
their facilities have reported positive impacts including: reduced regulatory burden
for the clinical workforce, allowing more time to be spent on direct patient care, im-
proved continuity of care, and more timely initiation of necessary treatments. Mak-
ing this waiver permanent would improve the ability of CAHs to appropriately uti-
lize their entire health-care workforce to meet the needs of their patients following
the PHE.
Authorizing Medicare hospital patients to be under the care of an NP.
Waiving the requirement that every admitted hospital patient be placed under the
care of a physician enables NPs in hospitals to practice to the top of their license
and authorizes hospitals to optimize their workforce strategies. Similar to the CAH
waiver, NPs who stated that this waiver was implemented in their facilities re-
ported that this waiver has streamlined the health care delivery process and im-
proved continuity of care. Facilities also increased the utilization of NPs in leader-
ship positions and participation in administrative planning for emergency policies.
While some of the changes that were reported were allowed prior to the PHE, the
removal of this barrier was noted to have positive ancillary impacts on many addi-
tional hospital policies and bylaws.
Telehealth Services
As mentioned previously, increased flexibility to provide telehealth to patients has
been an essential component of providing care during COVID–19 and will continue
16 https://www.ftc.gov/system/files/documents/reports/policy-perspectives-competition-regula-
tion-advanced-practice-nurses/140307aprnpolicypaper.pdf.
17 https://jamanetwork.com/journals/jama/fullarticle/2730102?widget=personalizedcontent
&previousarticle=2737024.
18 http://azahec.uahs.arizona.edu/sites/default/files/u9/azworkforcetrendanalysis02-06.pdf.
19 https://www.healthaffairs.org/do/10.1377/hblog20181211.872778/full/.
20 Holmes, L.R., Assistant, F.C., and Waltman, N. (2019). Increased access to nurse practi-
tioner care in rural Nebraska after removal of required integrated practice agreement, 31(5).
21 https://cnpd.und.edu/research/_files/docs/cnpd-ndnpwfreport.pdf.
22 http://sdlegislature.gov/docs/legsession/2017/FiscalNotes/fn61A.pdf.
23 42 CFR 483.30(f).
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to be integral to clinicians after the PHE. Specific telehealth provisions that we sup-
port making permanent are removing the geographic limitations, removing origi-
nating site restrictions so that patients can receive telehealth in their homes and
increased coverage and reimbursement for audio-only telehealth services. We also
support the expansion of telehealth to previously uncovered services and visits when
the clinician determines that it is clinically appropriate. These flexibilities have en-
abled NPs and other clinicians to reach patients who otherwise may have been un-
able to receive medically necessary health care, particularly in rural and under-
served communities.
Conclusion
AANP appreciates the Committee’s examination of these flexibilities granted under
the PHE. These flexibilities are essential to building back a robust health-care sys-
tem after the pandemic and ensuring that all providers are practicing to the full
extent of their education and clinical training. We look forward to working together
to improve our health-care system in the wake of the COVID–19 pandemic.
AMERICAN HOSPITAL ASSOCIATION
800 10th Street, NW
Two CityCenter, Suite 400
Washington, DC 20001–4956
(202) 638–1100
On behalf of our nearly 5,000 member hospitals, health systems and other health-
care organizations, our clinician partners—including more than 270,000 affiliated
physicians, 2 million nurses and other caregivers—and the 43,000 health-care lead-
ers who belong to our professional membership groups, the American Hospital Asso-
ciation (AHA) appreciates the opportunity to submit this statement for the record.
Since the first COVID–19 cases were diagnosed and the pandemic changed the ways
in which patients were able to access traditional health-care settings, providers were
required to navigate significant challenges to ensure their services were still able
to reach millions of patients. In response, Congress and the Administration granted
various flexibilities intended to improve access and facilitate the delivery of safe,
quality care.
As health-care providers reflect on lessons learned and plan a post-pandemic course
for the future, it is evident that several of the flexibilities have enhanced the patient
experience and led to better outcomes. The AHA believes that, if extended, these
flexibilities can continue to drive significant improvements in patient care long after
the public health emergency (PHE) ends. Given the beneficial impact of those spe-
cific flexibilities, the AHA urges Congress and the Administration to make them
permanent. In addition, a second group of flexibilities will remain critically impor-
tant for some time following the PHE and will require a carefully crafted phase-out
plan to ensure enough time is provided for a necessary transition. Without action
from Congress and the Administration prior to the termination of the PHE, we are
concerned that much of the progress made because of the implementation of many
of these flexibilities may be unnecessarily halted or even lost. America’s hospitals,
health systems and post-acute care providers have taken significant steps to im-
prove the way care can be delivered due to the pandemic, and failing to seize the
opportunity presented by the progress made would be a step back for the nation’s
health-care infrastructure. Following are the AHA’s recommendations for each cat-
egory of flexibilities.
Flexibilities That Should Be Made Permanent
Telehealth Provisions. The increased use of telehealth since the start of the PHE
is producing high-quality outcomes for patients, enhancing patient experience, and
protecting access for individuals susceptible to infection. With the appropriate statu-
tory and regulatory framework, this beneficial shift in care delivery could continue
to improve patient experiences and outcomes and deliver health system efficiencies
beyond the pandemic. The AHA urges Congress and the Administration to consider
making these flexibilities permanent.
Telehealth policies should work together to maintain access for patients by con-
necting them to vital health-care services and their personal providers through
videoconferencing, remote monitoring, electronic consults and wireless communica-
tions. We support the following: elimination of the 1834(m) geographic and origi-
nating site restriction; coverage and reimbursement for audio-only services; an ex-
panded list of providers and facilities eligible to deliver and bill for telehealth serv-
ices, including rural health clinics and federally qualified health centers; a national
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approach to licensure so that providers can safely provide virtual care across state
lines; and, adequate reimbursement for the substantial costs of establishing and
maintaining a telehealth infrastructure, among others.
Payment Flexibility. In addition to the payment flexibilities needed to continue
effectively offering telehealth services beyond the PHE, further payment flexibility
is necessary to ensure access to care for patients. Specifically, Congress and the Ad-
ministration should consider permanently increasing flexibility for site-neutral pay-
ment exceptions for providers seeking to relocate hospital outpatient departments
and other off-campus provider-based departments. These steps would permit hos-
pitals and health systems to better and more effectively serve their communities.
Hospital-at-Home Programs. The pandemic forced providers to rethink ways to
deliver care safely to all patients, while simultaneously responding to surges in
COVID–19 cases. To help providers make necessary adaptations, the Centers for
Medicare & Medicaid Services (CMS) created new opportunities for providers to im-
plement hospital-at-home programs.
These flexibilities permit approved providers to offer safe hospital care to eligible
patients in their homes, and the results have proved pivotal in caring for COVID–
19 and non-COVID–19 patients during the pandemic. While the initial aim of this
flexibility was to increase health-care capacity while keeping patients safe at home
during the PHE, promising outcomes are demonstrating the need for hospital-at-
home to be made permanent.
Hospitals and health systems are increasingly interested in standing up hospital-
at-home programs, yet many hesitate to do so without assurances that their pro-
grams, which are very popular among patients and their families, could continue to
exist beyond the PHE. Extending the hospital-at-home flexibilities permanently can
engage providers who may be hesitant to implement these programs now and will
help transform the way more providers deliver care, while enhancing the patient ex-
perience. Given the benefits provided by this program, AHA anticipates considerable
additional provider interest and growth of hospital-at-home programs should the
flexibilities be made permanent.
Workforce Assistance. The COVID–19 pandemic has exacerbated the strain on an
already overworked and understaffed health-care workforce. To help mitigate that
strain, we support allowing health-care professionals to practice at the top of their
licenses and permanently permitting out-of-state providers to perform certain serv-
ices when they are licensed in another state. We also support extensions of the five-
year cap-building period for new Graduate Medical Education (GME) programs to
account for COVID–19-related challenges and support long-term sustainability of
physician training. Permanently extending these workforce flexibilities would help
alleviate workforce shortages as the PHE ends.
Review of Certain Conditions of Participation. The PHE has shed light on sev-
eral shortcomings and outdated practices across the national health-care infrastruc-
ture; however, it also creates the unique opportunity to reevaluate and improve
upon processes based on the lessons we have learned thus far. Conditions of partici-
pation (CoPs) are a logical starting point for review and reevaluation, as they serve
as the foundation for ensuring high quality care and safety for patients and set the
baseline for hospital participation in the Medicare and Medicaid programs. Compli-
ance with the CoPs and the potential for termination from the Medicare and Med-
icaid programs for non-compliance serve as valuable tools ensuring hospitals are
meeting critical safety and quality requirements. However, the past year’s experi-
ences demonstrated the need to modernize certain CoPs. For example, reexamining
and updating infection control and life safety code requirements would allow hos-
pitals and health systems to continue to employ innovative approaches, such as al-
lowing for separate facility entrances for potentially infectious patients and mini-
mizing personal protective equipment (PPE) use and infection risk by placing IV
tubes outside patient rooms. The AHA has urged CMS to collaborate with providers
to determine how specific CoPs can be revamped to improve quality and safety.
Rural Capacity. CMS should continue to support increased bed capacity in rural
areas when an emergency requires such action. Rural hospitals should be held
harmless for increasing bed capacity during any future emergency, and those pro-
viders should be permitted to maintain pre-emergency bed counts for applicable pay-
ment programs, designations and other operational flexibilities.
Flexibilities Requiring a Transition Period
Emergency Use Authorization (EUA) Transition. The COVID–19 pandemic
placed significant strain on an already fragile medical supply chain and highlighted
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several substantial flaws in the acquisition process. Many of those impacts still exist
today to varying degrees. In response to supply chain disruptions, the Food and
Drug Administration (FDA) issued an unprecedented number of EUAs to help miti-
gate constant disruption and continuous impact. The EUAs covered a broad range
of devices, from respirators and COVID–19 tests to ventilators and decontamination
systems. These EUAs saved lives by opening up new supply lines to ensure pro-
viders have the items they need to safely and effectively care for patients through-
out the pandemic. However, the EUAs are not a silver bullet, and additional disrup-
tions will occur post-pandemic. Congress should reassess how the supply chain oper-
ates and consider modifications to mitigate further disruptions. To ensure supply
chain stability, the FDA should offer full approval to those devices deemed nec-
essary, and provide sufficient transition periods to move away from devices that do
not receive full approval.
Personal Protective Equipment. The COVID–19 pandemic illuminated several
supply chain shortcomings, not least of which was adequate access to PPE necessary
to keep both front-line health-care workers and patients safe. In response to the
massive PPE shortages, the FDA issued EUAs for a number of items, such as res-
pirators and facemasks. To address the short- and long-term challenges associated
with PPE, the FDA should take steps to ensure a reasonable wind-down of PPE
EUA flexibilities to allow the supply chain to recalibrate and providers to use supply
on-hand. In addition, the FDA should examine the long-term fragility of the PPE
supply chain and consider offering certain non-traditional medical PPE manufactur-
ers the opportunity to receive full medical supply authorization from the FDA. Fi-
nally, as this wind-down occurs, the FDA and other federal agencies, including the
Occupational Safety and Health Administration (OSHA), the National Institute for
Occupational Safety and Health (NIOSH) and the Centers for Disease Control and
Prevention (CDC) should work together to ensure a coordinated approach to the
transition.
Health Information and Data Sharing. Robust health information and data ex-
change capabilities among providers and with patients and government agencies are
foundational to improving care delivery, supporting better health outcomes and fa-
cilitating emergency response. Data exchange capabilities support decision-making
at the point of care and the data generated can provide insights into health dispari-
ties and inequities at the patient and population health levels. Yet, to realize these
benefits, robust, secure infrastructure must be in place for all entities, utilizing a
common set of data definitions and standards. Requirements around data collection
and sharing also must be well defined and well understood by health-care providers
and have a clear value proposition. Building this information technology infrastruc-
ture requires significant resources, both capital and workforce, and extensive efforts
to redesign procedures and workflows and train clinicians and staff across the orga-
nization. Until all of these core building blocks are in place across the health infor-
mation exchange continuum, implementation of new requirements on health-care
providers, such as the Office of National Coordination for Health Information Tech-
nology’s information blocking rules and CMS’ admit, discharge and transfer notifica-
tion CoP, should be delayed.
Quality Measurement Reporting. During the pandemic, CMS provided hospitals
relief from quality reporting requirements, including making quality reporting op-
tional in Q1 and Q2 of 2020, and allowing hospitals to apply for reporting waivers
using the pandemic as justification. We note, however, that hospital performance on
the measurement programs, like readmissions, hospital-acquired conditions and
value-based purchasing, will be affected over multiple fiscal years to come, and it
is vital that performance be assessed reliably and fairly. For that reason, CMS
should use its statutory flexibilities to not apply payment adjustments in program
years where it determines that, as a result of measure reporting exceptions, it has
insufficient data to calculate national performance in a reliable manner.
Federal Medical Assistance Percentages (FMAP) Increase. The temporary
FMAP increase in the COVID–19 relief laws has provided critical financial support
for states to ensure their Medicaid programs can provide coverage for millions of
their citizens during the COVID–19 pandemic. The temporary FMAP increase of 6.2
percentage points is set to expire at the end of the quarter in which the PHE ends.
To benefit from the temporary FMAP increase, states must meet certain mainte-
nance of effort requirements, including continuous enrollment for those enrolled in
the program as of March 18, 2020. State governments, advocates and stakeholders
recommend that additional federal funding will be needed for up to a year after the
PHE ends. Extending FMAP will provide a smooth process to reevaluate Medicaid
COVID–19-related coverage extensions.
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Congress addressed a similar situation during the Great Recession of 2008–2009.
Then, the FMAP was increased by 6.2 percentage points for 27 months (through the
end of 2010) and then extended and tapered down from 6.2 % to 3.2% and finally
to 1.2% for another six months ending in June 2011. Congress should consider a
comparable approach for states at the end of the PHE. Congress also should con-
sider an enhanced FMAP for states with high unemployment rates. During the
Great Recession, states with increases in unemployment rates of 3.5% received an
enhanced FMAP above the 6.2%.
Medicaid Coverage, Enrollment and Outreach. The PHE enabled states to le-
verage Medicaid’s emergency authorities to make temporary changes to their pro-
grams that increased access to coverage and care. Most policies adopted by states
helped individuals qualify for and enroll in Medicaid coverage. The two major path-
ways for states to change Medicaid eligibility, coverage and enrollment during the
PHE were: Medicaid disaster relief state plan amendments that allow states to mod-
ify their state Medicaid plans quickly to change eligibility, benefits, cost sharing and
payments; and disaster relief verification plan addenda that allowed state agencies
to verify eligibility and use electronic data sources without prior approval from
CMS.
The coverage needs facing states—and the policy changes needed to respond ade-
quately—will continue to exist beyond the PHE. To provide continued flexibility,
CMS should relax hospital-based presumptive eligibility standards, maximize flexi-
bility for income verification and the use of self-attestation, and continue allowing
qualified entities like hospitals to make presumptive eligibility determinations for
all Medicaid eligibility groups.
Post-acute Care. Post-acute care (PAC) providers continue to play a key role in
the national COVID–19 response. In communities that faced or are facing surges
of the virus, they have treated many of the sickest COVID–19 patients following
hospital discharge, as well as provided important relief to hospitals and other set-
tings overwhelmed by patients with and recovering from the virus. Concurrently,
the prospective payment systems (PPS) of three of the four PAC settings—the long-
term care hospital, inpatient rehabilitation hospital, and skilled nursing facility
PPSs—have been in the midst of major payment transformations during the PHE.
The collective magnitude of the PHE and these PPS redesigns is extensive, and time
is needed for policyholders and stakeholders to disentangle and understand the
longer-term ramifications of each. Thus far, their combined impact includes, as ex-
amples, material reductions in case volume and overall payments, the rise of aver-
age levels of patient acuity, facility closures, personnel shifts and revised clinical
pathways. For example, AHA analysis shows that, in comparison to prior patterns,
case volume for these settings dropped by 6% to 30% while the average case-mix
index rose from between 2.5% and 6.9% over the prior year.i In recognition of this
complex dynamic, the recent FY 2022 PAC proposed rule calls upon stakeholders
to provide guidance on how to account for both of these overlapping and powerful
drivers of change. At this time, it remains unclear which of these and other oper-
ational impacts will persist after the PHE, but given their scope and duration, it
seems possible that the PAC field will not return to its pre-PHE profile. Given this
level of change and uncertainty, key PAC flexibilities should remain in effect during
a transition period that follows the official end of the PHE. In particular, such ex-
tended flexibilities should include PHE-levels of payment and coverage for highest
acuity COVID–19 patients who remain in the PAC setting following the PHE, in-
cluding those ‘‘long-haul COVID–19 patients’’ for whom the virus has concluded but
related symptoms remain.
The AHA is gratified that the Committee is examining the many flexibilities grant-
ed during the COVID–19 pandemic. We stand ready to work with the Committee
as you consider learnings from these flexibilities and how to ensure that the nation’s
health-care system can continue to evolve for the benefit of patients and the health
of their communities.
i These data compare a 12-month period during the PHE, January 27, 2020 through January
26, 2021, to a pre-PHE 12-month period, January 26, 2019 through January 26, 2020. Data
source: Medicare fee-for-service claims, Centers for Medicare and Medicaid Services, Chronic
Conditions Data Warehouse, https://www2.ccwdata.org/web/guest/home.
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AMERICAN MEDICAL ASSOCIATION
25 Massachusetts Avenue, NW, Suite 600
Washington, DC 20001
Division of Legislative Counsel
(202) 789–7426
The American Medical Association (AMA) appreciates the opportunity to provide a
statement for the record to the Senate Finance Committee as part of the hearing
on ‘‘COVID–19 Health Care Flexibilities: Perspectives, Experiences, and Lessons
Learned.’’ We welcome the opportunity to support congressional efforts to ensure pa-
tients and physicians continue to have access to valuable services that flexibilities
during the COVID–19 Public Health Emergency (PHE) enabled. In particular, the
AMA strongly supports congressional efforts to ensure that Medicare beneficiaries
have access to telehealth services and to make permanent valuable flexibilities pro-
vided for the treatment of substance abuse services, hospital at home services, and
the Medicare Diabetes Prevention Model.
Telehealth Flexibilities Should Remain in Place
Telehealth is a critical part of the future of effective, efficient, and equitable delivery
of health care in the United States. Efforts must continue to build capacity and sup-
port access to care centered on where the patient is located (to the greatest extent
it is clinically efficacious), and to ensure physicians and other health-care profes-
sionals have the tools to optimize care delivery. The AMA has been a leader in advo-
cating for expanded access to telehealth services for Americans because it has the
capacity to improve access to care for many underserved populations and improve
outcomes for at-risk patients, particularly those with chronic diseases and /or func-
tional impairments.
In response to the COVID–19 PHE, Congress passed the CARES Act, which, among
other things, provided the Centers for Medicare and Medicaid Services (CMS) the
authority to waive the geographic and originating site requirements for the duration
of the COVID–19 PHE, which CMS subsequently did.1 Following these policy ac-
tions, telehealth usage among Medicare beneficiaries has expanded greatly as pa-
tients could, for the first time, access telehealth services from wherever they are lo-
cated, including their home, regardless of where they reside in the country. The
AMA remains deeply grateful for these flexibilities, which have allowed Medicare
patients across the country to receive care from their homes. With many physician
offices closed, elective procedures postponed, personal protective equipment difficult
to obtain, and an ongoing infectious disease pandemic that has forced patients to
stay home for their safety, the ability to provide services directly to patients regard-
less of where they are located via telehealth has allowed many vital health-care
services to continue. In addition to facilitating continuity of care for patients being
treated for acute and chronic conditions, telehealth has also facilitated initial assess-
ment of patients experiencing potential COVID–19 symptoms and those who have
been in close contact with people diagnosed with COVID–19 to determine if referrals
for testing or treatment are indicated while minimizing risks to patients, practice
staff, and others. With this expansion of services has come a recognition from pa-
tients, physicians, and other providers that telehealth services offer effective and
convenient health care in many circumstances. Congress must act now to ensure
that Medicare patients can continue to access telehealth services from wherever
they are located after the pandemic ends by modernizing the Social Security Act to
keep pace with our digital future.
However, without further legislative action from Congress, Medicare beneficiaries
who have come to rely on telehealth services during the PHE will abruptly lose ac-
cess to these services completely. Under section 1834(m) of the Social Security Act
(SSA), Medicare is prohibited from covering and paying for telehealth services deliv-
ered via two-way audio-visual technology unless care is provided at an eligible site
in a rural area.2 This means that, in order to access telehealth services, patients
must live in an eligible rural location, and must also travel to an eligible ‘‘origi-
nating site’’—a qualified health-care facility—to receive telehealth services, except
in the few cases where Congress has authorized provision of telehealth services in
1 Coronavirus, Relief, and Economic Security (CARES) Act, Pub L. No. 116–136, 134 Stat. 281
(2020), https://www.congress.gov/116/plaws/publ136/PLAW-116publ136.pdf.
2 Special Payment Rules for Particular Items and Services, 42 U.S.C. § 1395m(m), https://
www.ssa.gov/OP_Home/ssact/title18/1834.htm.
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the home of an individual.3 As a result, the 1834(m) restrictions bar the majority
of Medicare beneficiaries from using widely available two-way audio-visual tech-
nologies to access covered telehealth services unless they live in a rural area, and
with a few exceptions, even those in rural areas must travel to an eligible health-
care site.
Congress must act now to remove the origination and geographic restrictions on
telehealth coverage for Medicare patients. Continued access to telehealth services
beyond the PHE is critical for patient populations that have come to rely on its
availability. That is why the AMA supports S. 368/H.R. 1332, the ‘‘Telehealth Mod-
ernization Act of 2021,’’ which would eliminate the 1834(m) statutory restrictions on
originating site and geographic location, thereby ensuring Medicare coverage of tele-
health services regardless of where the patient is located. It is critically important
that Medicare beneficiaries continue to be able to access telehealth services from
their physicians without arbitrary restrictions throughout the COVID–19 public
health emergency and beyond.
The PHE Has Demonstrated the Value of Telehealth
The success of telehealth technology adoption during the COVID–19 public health
emergency has made it abundantly clear that geographic and origination restric-
tions on accessing telehealth services are outdated and arbitrary given today’s tech-
nology that allows for access to digital tools from anywhere. Physicians and patients
have seen the value of telehealth services and should not be forced to stop using
these tools when the public health emergency ends. Some have argued that statu-
tory changes cannot be made without additional data on how telehealth services are
used, however, this has the problem backwards. More data is not necessary to deter-
mine that the underlying policy needs to be permanent, but instead can help CMS
determine which services need to continue to be covered or can be safely removed
from the Medicare telehealth list. In the meantime, the certainty that appropriate
telehealth services will be covered would provide physicians confidence in investing
in new technology and give patients peace of mind that they can continue to access
services in a way that works best for them.
The rapid and widespread adoption of telehealth by physicians in 2020 was one of
the most significant improvements in health-care delivery in decades. The new tele-
health coverage and payment policies enabled physicians to deliver valuable services
they previously could not afford to provide but that their patients needed. With leg-
islative provisions such as the establishment of the CMS Innovation Center and
Medicare’s Quality Payment Program, Congress has sought for many years to sup-
port physician adoption of innovations in the delivery of care. The successful adop-
tion of telehealth throughout the country has demonstrated that, if the financial
barriers are removed, physicians will adopt important innovations in the delivery
of care that are necessary to improve their patients’ health.
Telehealth technologies allow physicians to increase continuity of care, extend ac-
cess beyond normal clinic hours, and help overcome clinician shortages, especially
in rural and other underserved populations. This ultimately helps health systems
and physician practices focus more on chronic disease management, enhance patient
wellness, improve efficiency, provide higher quality of care, and increase patient sat-
isfaction. Telehealth has helped increase provider/patient communication, increase
provider/patient trust, and access to real-time information related to a patient’s so-
cial determinants of health (i.e., a patient’s physical living environment, economic
stability, or food insecurity), which can lead to better health outcomes and reduced
care costs. The ability to gain greater access to chronic disease management services
and better assess the impact of a patient’s social determinants of health will un-
doubtedly contribute to improved treatment and health outcomes for historically
marginalized and minoritized populations as well.
Telehealth services can help patients avoid delaying care that can lead to expensive
emergency department visits and hospitalizations. They also cut down on trips to
the office that may be difficult or risky for patients with functional or mobility im-
pairments, frail elderly who need a caregiver to accompany them, those who need
to stay home to care for other family members, and patients who are immuno-
compromised or vulnerable to infection. Providing access to telehealth services cre-
ates greater safety and efficiencies for both patients and physicians, delivering value
to the Medicare program.
3 For example, substance abuse disorder treatment delivered via telehealth is explicitly ex-
empted from the geographic and origination restrictions.
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Physician practices are ready to invest in the technology required to provide these
services; however, it will be very difficult to provide the sustained financial commit-
ment needed to incorporate delivery of telehealth services into their workflows if the
coverage is only temporary. The removal of coverage and financial barriers has al-
lowed the explosive growth in telehealth and certainty about future coverage is nec-
essary for it to continue. It has allowed CMS to make more informed decisions about
which services to cover, and, in fact, CMS has expanded coverage of telehealth serv-
ices greatly during the PHE.4 While more data behind current telehealth usage
trends may be valuable to gather evidence about which particular Current Proce-
dural Terminology® (CPT®) codes need to stay on the Medicare telehealth list, that
is a much different concern than whether nationwide coverage and ability to deliver
care to patients wherever they are located should be available; these determinations
are already appropriately made by CMS.
While CMS has expanded coverage of telehealth services during the PHE, only Con-
gress can assure all Medicare beneficiaries can receive equal access to those services
moving forward. Delaying action, such as extending the current 1834(m) waiver au-
thority, will only make it more expensive to change the policy permanently in the
future.
CMS Already Makes Coverage Determinations on Telehealth Services
CMS currently has all the tools necessary at its disposal to make determinations
about which telehealth services it should cover and at what payment level. For the
duration of the COVID–19 PHE, CMS has added many services to the list of those
that Medicare pays for when they are provided via telehealth. The newly covered
services include emergency department visits, observation care, hospital and nurs-
ing facility admission and discharge services, critical care, and home care, as well
as services like ventilator management that have been especially necessary for
COVID–19 patients. The newly added services have greatly assisted physicians dur-
ing the PHE when both patients and health professionals needed to maintain phys-
ical distance from others as much as possible. Through telehealth communications,
for example, an emergency physician, potentially assisted by members of the pa-
tient’s household, can diagnose, and treat emergency conditions without sick pa-
tients having to endure difficult travel and expose themselves and others to SARS–
CoV–2 and other dangers. In all, CMS added interim Medicare coverage for more
than 150 services for the duration of the COVID–19 PHE at payment parity with
in- person services. Equivalent payment for telehealth services during the PHE was
crucial to ensure physicians could cover the cost associated with offering virtual
care. In future rulemaking, CMS has indicated it may extend the interim coverage
for a longer period of time to help gather more evidence of how the services are used
when provided via telehealth outside the context of a pandemic.
The only thing holding CMS back from expanding access to appropriate telehealth
services to its beneficiaries are the outdated restrictions currently in the statute.
Since telehealth is simply a modality for delivering health care, AMA continues to
urge Congress and CMS to provide payment parity for two-way audio-visual services
upon conclusion of the COVID–19 pandemic.
Telehealth Helps Provide Access to Health Care to Underserved Communities
Access to telehealth services can help reduce inequalities in care for underserved
communities by providing access to services for patients regardless of where they
are located. Patients in rural areas or underserved urban communities often have
to travel long distances to access care, especially specialty services including emer-
gency and critical care. Telehealth can also help eliminate commutes to physician
offices for those with mobility or transportation difficulties.
In conjunction with expanded access to telehealth services, the AMA supports Con-
gressional efforts to expand high-speed broadband Internet access to underserved
communities and increase digital literacy education efforts. Patients cannot take ad-
vantage of telehealth services if they do not have the requisite Internet connection
to access them or the appropriate skills to use digital technologies. Providing digital
literacy skills is particularly important for non-English speaking patients and is an-
other crucial aspect of ensuring health equity. Solving this problem requires en-
hanced funding for broadband Internet infrastructure in rural areas and support for
underserved urban communities and households to gain access to affordable Inter-
net access, as well as support for patient education on how to use digital tools.
4 Medicare Physician Fee Schedule 2021, 85 Fed. Reg. 84472 (December 28, 2020), https://
www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/2020-26815.pdf.
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Concerns About Fraud and Abuse and Overutilization Are Misplaced
Some have raised concerns that expanded coverage of telehealth services could lead
to greater fraud and abuse or duplication of medical services. The AMA believes
these concerns are misplaced given CMS’ existing tools for combating fraud and
abuse, the increased ability telehealth services provide for documentation and track-
ing, and the lack of data to suggest that fraud and abuse or duplication are of par-
ticular concern for telehealth services. Therefore, Congress should not create artifi-
cial barriers to telehealth by defining an established doctor-patient relationship in-
consistently with the standard of care or otherwise creating unique and burdensome
fraud and abuse requirements that would stifle access to telehealth services. The
AMA supports removing restrictions on access to Medicare tele-mental health serv-
ices that were included in H.R. 133, the Consolidated Appropriations Act, 2021. Spe-
cifically, the new requirement that Medicare beneficiaries must be seen in person
at least once by the physician or non-physician practitioner during the six-month
period prior to the first telehealth services should be repealed. Such restrictions
were not imposed on tele-mental health services covered by Medicare prior to the
passage of the COVID–19 telehealth waiver, or on tele-mental health services cov-
ered by Medicare under the waiver during the PHE. Moreover, they are not sup-
ported by the data we have seen regarding the benefits of increased access and im-
proved patient adherence to treatment in tele-mental health services and they di-
rectly conflict with the standard of care.
CMS and the Office of Inspector General (OIG) at HHS already have all of the
Medicare coverage and payment and fraud and abuse authorities to monitor tele-
health service compliance just as they do any other Medicare covered service. Addi-
tional restrictions do not currently apply under the Medicare Advantage, the Center
for Medicare and Medicaid Innovation, section 1116 waiver authorities, the existing
Medicare telehealth coverage authority, or other technologies such as phone, text,
or remote patient monitoring.
In recent remarks regarding the potential for telehealth fraud, Principal Deputy In-
spector Grimm of OIG never mentioned any concerns with OIG’s authority or ability
to address concerns of fraud and abuse.5 Instead, he described OIG’s concerns with
‘‘telefraud’’ schemes which he distinguished from telehealth fraud, in which bad ac-
tors use ‘‘telehealth’’ as a basis for fraudulent charges for medical equipment or pre-
scriptions which are unrelated to the telehealth service at issue. In those cases,
fraudulent actors typically do not bill for the televisit but instead used the sham
televisit to induce a patient to agree to receive unneeded items and gather their
info. In other words, whether or not the telehealth service itself is covered has no
impact on these kinds of fraudulent schemes.
Moreover, telehealth services may prove even easier to monitor for fraud and abuse
because of the digital footprint created by these services, state practice of medicine
laws requiring documentation of these services, and the ability to track their usage
with Modifier 95. Telehealth services are even more likely to have electronic docu-
mentation in medical record systems than in-person services. Practice of medicine
laws in all 50 states permit physicians to establish relationships with patients vir-
tually so long as it is appropriate for the service to be received via telehealth. In
addition, two-way audio-visual services can be effectively deciphered and tracked by
CMS via the Modifier 95. The Modifier 95 describes ‘‘synchronous telemedicine serv-
ices rendered via a real time Interactive audio and video telecommunications sys-
tem’’ and is applicable for all codes listed in Appendix P of the CPT manual. The
Modifier 95, along with listing the Place of Service (POS) equal to what it would
have been for the in-person service, is also applicable for telemedicine services ren-
dered during the COVID–19 PHE. The requirement to code with the Modifier 95
enables CMS to properly decipher and track telemedicine services, thus improving
the chances of identifying and rooting out fraud, waste, and abuse.
Data analyzed by CMS since the start of the PHE shows that fears of overutilization
are overblown. Data from Medicare claims from Q1 and Q2 show that less than 4%
of telehealth spending was for new patient audiovisual office visits. Moreover, noth-
ing in the data or anecdotal evidence suggests that telehealth services have been
duplicative of in person services rather than used as an alternative or in addition
to in person care. The AMA will continue to monitor and analyze the data as it be-
comes available, but this suggests that there is no reason to think better access to
telehealth will lead to an explosion in unnecessary services.
5 Principal Deputy Inspector Grimm on Telehealth (February 26, 2021), https://oig.hhs.gov/
coronavirus/letter-grimm-02262021.asp.
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As a result, Congress should refrain from imposing new and discriminatory restric-
tions on the use of audio-visual communications technologies, such as restrictions
on how a physician-patient relationship can be established. AMA policy, established
in 2014, states that a valid physician-patient relationship may be established vir-
tually face-to-face via real-time audio and video technology, if appropriate for the
service being furnished.6 It also allows for the relationship to be established in a
variety of other ways such as meeting standards of care set by a major specialty
society. All 50 states and the territories allow a physician-patient relationship to be
established virtually or through other means. The exact parameters vary by state;
however, many state laws are based on an AMA model law. Congress should not
impose a one-size-fits-all requirement on services furnished via telehealth tech-
nology that are in direct conflict with standards of care and that do not exist for
other technologies.
Gains made in access to telehealth will be greatly hampered if unique and arbitrary
barriers are erected around the use of telehealth services. Such barriers will have
a dramatic and negative impact on patients seeking care, particularly during the
current COVID–19 pandemic, and in any future pandemic where patients need ac-
cess to care without the concerns surrounding a visit to a crowded health-care facil-
ity.
Audio-only Services Should Remain Covered
The AMA also strongly supports coverage for audio-only services and has called on
CMS to continue this coverage after the PHE ends. There are numerous patients
and entire communities that have no access to the Internet connectivity necessary
to utilize audio-visual telehealth services in their homes. There are also medical
practices that do not have sufficient connectivity to provide audio-visual telehealth
services. Patients who cannot utilize audio-visual telehealth services include those
in communities lacking broadband access, those where the technological capabilities
are present, but the patient cannot afford it, and others who have access to the tech-
nology and the connectivity but do not know how to use it. Inability to use audio-
visual telehealth services is also a matter of health equity. Too often it is the same
communities that face other barriers to good health outcomes who also face these
technology barriers, such as Native Americans living on reservations and those in
the rural South’s Black Belt. But patients who cannot participate in audio-visual
telehealth services are no less sick than those who can, and it is important to their
health care to retain access to these services.
Pursuant to authority granted under the CARES Act, CMS waived the requirements
of section 1834(m)(1) of the Social Security Act and 42 CFR § 410.78(a)(3) for use
of interactive telecommunications systems to furnish telehealth services, to the ex-
tent they require use of video technology for certain services. This has allowed the
use of audio-only equipment to furnish services described by the codes for audio-only
telephone evaluation and management services, and behavioral health counseling
and educational services. Expanded use of audio-visual telehealth services during
the pandemic has made it clear that requiring the use of video limits the number
of patients who can benefit from telecommunications-supported services, particu-
larly lower-income patients, and those in rural and other areas with limited Inter-
net access. It would be inappropriate to prevent these patients from accessing such
services. In addition, we have heard from many physicians about the need to have
access to audio-only services because a number of their patients, even those who
own the technology needed for two-way real-time audio-visual communication, do
not know how to employ it or for other reasons are not comfortable communicating
with their physician in this manner.
Audio-only services are an important part of a fully integrated care plan and physi-
cians should be able to permanently deliver E/M (evaluation and management) serv-
ices by telephone to patients who need a telecommunications-based service in the
home but who do not have access to a video connection or cannot successfully use
one. Without access to an audio-only option, limitations in Internet and/or tech-
nology access as well as lack of experience with its use will increase inequities in
access to medical care and widen disparities in health outcomes.
Flexibilities for the Treatment of Substance Abuse Disorder Should Be Continued
Early on in the COVID–19 Public Health Emergency, the Drug Enforcement Admin-
istration (DEA) and Substance Abuse and Mental Health Services Administration
6 American Medical Association, H–480.496: Coverage of and Payment for Telemedicine,
https://policysearch.ama-assn.org/policyfinder/detail/telemedicine?uri=%2FAMADoc%2FHOD.
xml-0-4347.xml (last modified, 2019).
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(SAMHSA) put several important flexibilities in place to help DEA-registered physi-
cians manage care for their patients with opioid use disorder (OUD). During this
PHE, physicians who have a waiver allowing them to prescribe buprenorphine for
the treatment of OUD can initiate and continue this treatment based on telehealth
visits and audio-only visits with patients. Opioid Treatment Programs can also ini-
tiate new patients and treat existing patients being managed with buprenorphine
based on telehealth and phone visits. Patients cannot be initiated with methadone
treatment based on telehealth visits, but existing patients on methadone can be
managed via telehealth or phone. Opioid Treatment Programs can also provide pa-
tients who are stable with take-home medication.
Based on a survey led by the American Academy of Addiction Psychiatry and con-
ducted last summer of more than 1,000 physicians and other health professionals
who treat OUD, these new flexibilities were extremely important in allowing them
to continue to manage their patients’ care. A major finding of the survey is that
more than 80% of X-waivered survey respondents want the telehealth options to
continue after the COVID–19 PHE. The AMA has written to the DEA urging that
these flexibilities remain in place at least until the end of the opioid PHE and be-
lieves Congress should support these continued flexibilities.
Hospital at Home Services Flexibilities Should Remain
A number of other countries pay for delivering services equivalent to hospital inpa-
tient care to patients in their own homes. These ‘‘hospital at home’’ services have
been successful in allowing patients with specific types of conditions that qualify for
inpatient care to receive services in the home and avoid the risks associated with
an inpatient admission. The services are more intensive than can be supported
through traditional home health-care payments. Although some hospitals in the
U.S. were delivering hospital at home care and some Medicare Advantage plans
were paying for it before the PHE, the service was difficult to sustain or expand
without payment support from Medicare because a minimum number of patients
need to participate in order for the service to be cost-effective. During the pandemic,
one of the key flexibilities that CMS now has allowed is for hospitals to deliver serv-
ices to patients in their homes. It would be desirable to continue this flexibility after
the national emergency ends for the subset of patients who meet the criteria used
in hospital at home programs in the U.S. and other countries.
Medicare Diabetes Prevention Expanded Model Flexibilities Should be Made Perma-
nent
Through the rulemaking process for the 2021 Medicare physician payment schedule,
CMS adopted important flexibilities that are effective for the duration of the
COVID–19 PHE and in future 1135 waiver emergencies that could cause a disrup-
tion to in-person MDPP services. These MDPP policies will only apply in emergency
situations, however, and not on an ongoing basis. MDPP services are being signifi-
cantly underutilized. If the MDPP flexibilities that have been adopted for COVID–
19 and future emergencies were instead continued as regular, ongoing MDPP poli-
cies, it would significantly strengthen the effectiveness of diabetes prevention serv-
ices for Medicare patients with prediabetes. The AMA strongly urges Congress to
pass H.R. 2807, the PREVENT Diabetes Act.
To furnish virtual services during an emergency period, MDPP suppliers must al-
ready have preliminary or full CDC Diabetes Prevention Program recognition for in-
person services. CMS continues to bar virtual-only suppliers that have achieved
CDC recognition from furnishing MDPP services, even during the PHE. Under its
current regulations, CMS will require MDPP providers to resume in-person services
at the conclusion of the COVID–19 PHE. Against AMA urging, CMS has declined
to allow virtual providers to participate in MDPP to the fullest extent either during
or after the PHE. CMS regulations also prohibit patients from participating in their
MDPP sessions virtually when offered by suppliers who provide both in-person and
virtual services except during an emergency period. Many patients with prediabetes
are unable to effectively participate in in-person MDPP sessions, often because they
live far from any supplier location or because the sessions are not offered at times
that are convenient for them. The MDPP should be modified to allow patients to
obtain their session virtually at any time.
CMS regulations also impose a once-per-lifetime limit on patients obtaining MDPP
services. During an emergency period, patients who continue their MDPP participa-
tion through virtual services will still be subject to the once-per-lifetime limit, but
patients whose MDPP participation is interrupted by an emergency period will be
able to restart MDPP services with the first core session after the emergency period
ends. Other Medicare behavior modification programs such as tobacco cessation and
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obesity counseling do not have lifetime limits and there is no justification for a once-
per-lifetime limit on MDPP services. This limit should be lifted for all patients, not
just those who discontinue MDPP during a declared emergency.
Conclusion
The AMA thanks the Committee for this hearing and for the careful consideration
of the flexibilities that have been put in place for the COVID–19 PHE. We look for-
ward to working with the Committee and Congress to seek solutions that will en-
sure patients can continue to benefit from these flexibilities after the end of the
PHE.
AMERICAN MEDICAL REHABILITATION PROVIDERS ASSOCIATION
529 14th Street, NW, Suite 1280
Washington, DC 20045
Phone: 202–591–2469
Fax: 202–591–2445
The American Medical Rehabilitation Providers Association (AMRPA) commends the
Senate Committee on Finance for its efforts to closely assess the nation’s response
to the COVID–19 public health emergency (PHE) and determine whether and what
type of permanent policy changes should be considered in the PHE aftermath. In
particular, AMRPA was pleased to hear Chairman Wyden remark that there ‘‘is bi-
partisan interest in building on the changes that worked well for both seniors and
providers’’ during the PHE, as we believe that getting patient and provider feedback
is critical in the assessment of COVID–19 waivers. As providers who were able to
furnish critical care to acute COVID- 19 survivors due to the numerous statutory
and regulatory flexibilities granted to our field, we appreciate the opportunity to
offer recommendations from the inpatient rehabilitation hospital perspective.
AMRPA is the national trade association representing more than 650 freestanding
inpatient rehabilitation hospitals and rehabilitation units of general hospitals (re-
ferred to collectively by regulators as inpatient rehabilitation facilities, or IRFs). As
you may be aware, IRFs have and continue to play a vital role in their communities’
PHE response effort, due in large part to their hospital-level care, clinical com-
petence, personnel, quality, equipment, and emergency response/preparedness capa-
bilities that distinguish IRFs from other post-acute care (PAC) settings. Patients’ ac-
cess to IRFs during the pandemic has been particularly critical in light of the un-
precedented surge demands faced by acute-care hospitals and the infection control
and safety issues that restricted patients’ access to other PAC options. Through the
utilization of waivers granted during the PHE, AMRPA members have continually
reported the long-term, positive impact that medical rehabilitation has had for both
COVID–19 survivors and other complex patients who required medical rehabilita-
tion care during the PHE. As the Medicare program now faces a confluence of an
aging population, the new clinical and care delivery challenges presented by ‘‘long-
hauler’’ COVID–19 survivors, and Trust Fund insolvency projections, protecting pa-
tient access to inpatient rehabilitation has never been more important. It is there-
fore vital that Congress takes steps to ensure IRFs have the appropriate regulatory
environment and resources for the duration of the PHE and beyond.
As background, AMRPA engaged extensively with both Congressional offices and
the Centers for Medicare and Medicaid Services (CMS) since the beginning of the
pandemic regarding the flexibilities that would be needed to address the surges of
both COVID–19 and non-COVID–19 patients requiring hospital-level care during
the PHE. Given that IRFs are arguably the most closely-regulated post-acute care
entity within the Medicare program, wide-ranging flexibilities were needed with re-
spect to admission criteria, documentation, and reporting requirements, among oth-
ers. CMS leaders conveyed to AMRPA that the comprehensive flexibilities granted
to IRFs during this time were intended to facilitate timely and effective patient ac-
cess to IRFs and ensure that IRF providers were able to dedicate time and resources
to patient care rather than regulatory burdens. As the Finance Committee con-
templates a legislative response that builds off the ‘‘lessons learned’’ from the
COVID–19 pandemic and protects patient access to care in an evolving health-care
environment, we appreciate your consideration of our legislative recommendations
informed by the PHE. While our recommendations may evolve in future stages of
the PHE and its aftermath, our primary asks currently include:
• Consider commonsense reforms to key IRF coverage requirements to better re-
flect the value of rehabilitation services for patients;
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• Prohibit the use of prior authorization by Medicare Advantage plans in all fu-
ture PHEs and throughout their duration, and implement significant reforms
to current prior authorization practices that harmfully impeded care over the
past year (AMRPA has supported the recently-introduced H.R. 3173, the Im-
proving Seniors Access to Timely Care Act, as a key first step in this regard);
• Permanently implement some of the critical telehealth-related waivers and
flexibilities granted during the PHE (e.g., the recognition of physical therapists,
occupational therapists, respiratory therapists and speech-language pathologists
as telehealth providers);
• Ensure providers can practice across state lines, or at minimum, authorize
interstate licensing immediately upon any future PHE declaration; and
• Reset the implementation of the IMPACT Act timeline to account for the ongo-
ing burdens on each PAC sector and the need to account for the COVID–19
PHE in any future payment reform effort.
We believe many of these asks complement the 117th Congress’ broader focus on
burden reduction and regulatory modernization efforts, and AMRPA stands ready
to work with your offices as specific legislation is considered.
Our more detailed recommendations follow:
Using PHE Flexibilities to Modernize IRF Coverage Rules
At the beginning of the pandemic, two key IRF coverage waivers were granted to
maximize patient access to IRFs—the 60% rule and the 3-hour rule. Even before the
PHE, AMRPA urged policymakers to reexamine these rules and modernize them in
light of the significant policy and operational changes that have occurred since their
implementation. With both rules currently suspended due to the PHE, AMRPA be-
lieves it is an optimal time to reassess and refine these rules.
As background, the current ‘‘60% rule’’ broadly requires that 60% of the IRF’s pa-
tients must have a qualifying condition in order to be paid as an IRF under the
Medicare program. There are currently 13 such conditions, including, stroke, spinal
cord or brain injury, and hip fracture, among others. There have been no major cat-
egories added for decades—despite medical and technological advancements that
have led broader patient populations to gain significant clinical benefits from IRF
care. The waiver of the 60% rule during the PHE has improved access for patients
that had conditions other than those categorized as a compliant condition—such as
oncology and cardiac-related conditions, and COVID–19—and led to improved out-
comes and functional recoveries for such patients. AMRPA therefore urges Congress
to direct CMS to revisit and potentially broaden the 60% rule’s ‘‘compliant’’ condi-
tions before putting the rule back into effect. This would be an important step to both
protect patient access and ensure that Medicare regulations reflect the current state
of medicine.
Similarly, AMRPA asks Congress to modernize the 3-hour rule, which requires an
IRF patient to participate in, and benefit from, at least three hours of rehabilitation
therapy per day, five days per week (or 15 hours per week if documented appro-
priately). Due to a 2010 regulatory change, only physical therapy, occupational ther-
apy, speech therapy, and/or orthotics and prosthetics are countable therapies toward
the 3-hour threshold. AMRPA recognizes that the volume of therapy received by IRF
patients is among the characteristics that distinguish IRF care from other PAC set-
tings. At the same time, AMRPA has advocated for the inclusion of other therapy
modalities that rehabilitation physicians often determine are necessary for patients’
full functional recovery, such as psychological services, neuropsychological services,
and respiratory therapy. AMRPA members already provide these therapies when
needed (despite their exclusion from the 3-hour rule calculation) given the clear ben-
efit that they provide for a range of complex patients in IRFs. Their utilization and
the benefit provided to patients clearly demonstrates that these therapies should be
recognized as part of the ‘‘intensive rehabilitation therapy program’’ for which the
3-hour rule is attributed.
The rationale for counting these modalities toward the 3-hour threshold is all the
more compelling in light of the impact of the PHE waiver. The aforementioned
therapies were particularly beneficial as patients with acute respiratory disease
were treated by IRFs during the pandemic, and AMRPA members expressed appre-
ciation for the flexibility provided through the waiver in this regard. As such,
AMRPA believes that they should permanently be allowed to count toward the
threshold in the PHE aftermath. We have already worked with Congressional offices
to discuss a bill that would deliver these much-needed modernizations, and we look
forward to working with the Finance Committee to facilitate its introduction and ad-
vancement in the 117th Congress.
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On a related issue, AMRPA requests that the full 3-hour rule waiver be included
within the scope of flexibilities that can be granted by CMS (via Section 1135 waiv-
ers) in future PHEs. This would negate the need for Congressional action and en-
sure that this rule be waived promptly by regulators in emergency circumstances.
Significant Reforms to Prior Authorization Practices
In the first quarter of 2020, many Medicare Advantage (MA) plans voluntarily
waived their prior authorization/pre-authorization policies to ensure that patients
were able to access IRF beds in the safest and most timely way possible. These vol-
untary waivers enabled patients that were ready for clinical intervention to receive
such care expeditiously, rather than incur the 3–5 business day delays that these
policies frequently impart. Unfortunately, after the first few months of the pan-
demic, most MA plans reinstated prior authorization requirements. This severely
impeded movement of patients from acute-care hospitals into PAC settings, exacer-
bating an already critical hospital bed shortage. Data that AMRPA has examined
from the time period before, during and after the suspension of prior authorization
made clear that the removal this requirement provided access to complex patients
that otherwise may have been delayed or denied receiving care. The positive impact
of these waivers makes it clear that prior authorization policies must be fully and
immediately suspended in all future public health emergencies for the emergency’s
full duration, and we urge you to include this protection statutorily in future
pandemic- focused legislation.
In addition, AMRPA believes there are a number of reforms that must be made to
prior authorization policies outside of the context of a PHE. Under current practices,
an MA representative who has never seen or examined the patient, and often lacks
training or expertise in rehabilitation medicine, second- guesses the judgement of
the treating physicians that have deemed an admission to an IRF to be medically
necessary and appropriate. In turn, these prior authorization policies often cause
lengthy delays or inappropriate denials for patients needing IRF care, which ad-
versely affects outcomes and functional recovery. With prior authorization practices
now generally back in effect across the nation, AMRPA members report that these
policies are once again compromising timely patient access to timely IRF care.
AMRPA therefore asks Congress to advance H.R. 3173—the Improving Seniors’ Ac-
cess to Care Act—as an initial and commonsense step towards prior authorization
reform. Importantly, the legislation would direct HHS to establish that prior author-
ization decisions to be made in ‘‘real time’’ to address the aforementioned delays and
inappropriate referrals tied to current practices. AMRPA believes that 6 hours is an
appropriate ‘‘real time’’ measure for an inpatient rehabilitation admission authoriza-
tion decision, and we look forward to working with both Congress and ultimately
HHS in this regard. Furthermore, AMRPA asks the Committee to consider other
legislative actions to improve prior authorization practices, such as:
• Strengthen beneficiary protections for all MA enrollees by ensuring prior au-
thorization requests are reviewed by physicians with appropriate training and
experience in inpatient rehabilitation.
• Limit or eliminate the use of proprietary guidelines/decision tools to ensure en-
rollees’ statutory right to Medicare fee-for-service benefits are fulfilled and that
admission decisions take into account patient-specific characteristics and condi-
tions.
Telehealth Expansion
Some of the most important waivers granted during the COVID–19 PHE relate to
telehealth expansion, particularly for medical rehabilitation patients. In particular,
AMRPA strongly supported policymakers’ decision to (1) expand the list of tele-
health services that can be provided in the Medicare program via telehealth to in-
clude therapy services, (2) recognize therapists—including physical therapists, occu-
pational therapists, and speech-language pathologists—as eligible telehealth pro-
viders, (3) relax distant site guidelines, and (4) permit a broader range of telemedi-
cine in the context of inpatient care—such as remote consultations and virtual team
meetings. Many of our hospital members report that these waivers allow patients
to continue the outpatient therapy component of their intensive rehabilitation pro-
gram without undertaking the risk of entering the hospital or outpatient care set-
ting. We therefore urge Congress to enact legislation to make these flexibilities perma-
nent in the PHE aftermath.
Even before the COVID–19 pandemic, AMRPA is on record expressing support of
efforts—such as the CONNECT for Health Act (which was again recently reintro-
duced in the 117th Congress)—to modernize telehealth rules in the Medicare pro-
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gram to better reflect the state of medicine and technology. Consistent with this po-
sition, AMRPA believes that these outpatient therapy-focused waivers will prove
beneficial outside of a PHE, such as when patients face other obstacles (e.g., weath-
er, protests, or mobility restrictions) that prevent them from traveling to an IRF or
outpatient therapy site. At the same time, clearer billing rules—particularly for hos-
pital outpatient departments—may be required to ensure sufficient uptake. Further,
Congress should consider flexibility within the definition of telehealth, such as al-
lowing audio-only services for those patients unable to use or without access to video
technology or Internet connectivity. AMRPA therefore believes that permanent imple-
mentation of these telehealth waivers and requisite guidance to the industry is a com-
monsense way to improve patient access to care without compromising quality or
safety.
Implementing Interstate Licensing Flexibilities
During the PHE, numerous AMRPA members were able to provide critical capacity
to acute-care hospitals across state lines and provide both surge and COVID–19 pa-
tients with the acute beds they required. The interstate licensing flexibilities offered
by CMS were utilized broadly by IRF providers and helped ensure that patients re-
ceived the timely care they required for survival and recovery, without jeopardizing
the quality of the care they received. AMRPA therefore requests that these flexibili-
ties be made permanent to alleviate patient access issues and address arbitrary re-
strictions on care options when patients live near state lines. At minimum, AMRPA
urges Congress to ensure that interstate licensing flexibilities are automatically
triggered whenever a PHE is declared to ensure that partner hospitals in different
states can immediately assist each other in furnishing the capacity and provider ac-
cess required for their patients. Additionally, and consistent with our telehealth-re-
lated recommendations, AMRPA also recommends that providers be allowed to prac-
tice across state lines via telehealth in the same way they would be permitted to
do so in-person.
Delaying the Implementation Timeline and Considering Other Potential
Changes to the IMPACT Act
As Congress assesses policy changes informed by COVID–19 waivers and flexibili-
ties, AMRPA urges Members to also be mindful of the lessons learned by and about
post-acute care providers in the context of other legislative efforts. Specifically,
AMRPA believes the PHE requires policymakers to reconsider the timing and un-
derlying goals of the unified post-acute care (UPAC) prototype required under the
IMPACT Act. With respect to timing, AMRPA has long been concerned about the
data being used to develop a UPAC prototype given the significant changes in each
of the post-acute care setting payment systems since the implementation of the IM-
PACT Act. The current PHE now raises new and serious concerns about the use of
claims and cost data for any year that the PHE is/was in effect and the years imme-
diately following. Therefore, as policymakers consider how the COVID–19 PHE
should impact future work related to post-acute care reform, the development of a
UPAC prototype should at the very least be delayed for several years until useable
data is available.
This delay would also allow policymakers to consider the seismic impact of the
COVID–19 PHE on the post-acute care continuum and the permanent changes in
care delivery that will stem from the exact policy changes being considered through
the Committee in this line of work (for example, the impact of future telehealth ex-
pansions). Therefore, AMRPA urges the Committee to support The Resetting the IM-
PACT Act (H.R. 2455), which would make these commonsense reforms and reset the
timeframe in a way that could improve the accuracy of a prototype (and ensure
more meaningful stakeholder engagement). We also look forward to working with
the Committee to ensure that any future payment and coverage changes are in-
formed by the lessons the Committee seeks to glean from the PHE.
In closing, AMRPA applauds the leadership of the Committee and greatly appre-
ciates the opportunity to provide comments on how COVID–19 waivers should in-
form future policy changes. Should you wish to discuss our comments further, please
contact Kate Beller (kbeller@amrpa.org; 973–224–4501) or Kristen O’Brien
(klobrien@mcdermottplus.com).
Sincerely,
Anthony Cuzzola
Chairman, AMRPA Board of Directors
Vice President/Administrator
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JFK Johnson Rehabilitation Institute
Hackensack Meridian Health
AMERICAN OCCUPATIONAL THERAPY ASSOCIATION
6116 Executive Boulevard, Suite 200
North Bethesda, MD 20852–4929
fad@aota.org
301–652–6611
https://www.aota.org/
Pandemic Experience Demonstrates Need to Continue OT Telehealth
Options for Medicare Beneficiaries After the Public Health Emergency
The American Occupational Therapy Association (AOTA) is the national professional
association representing the interests of more than 230,000 occupational therapists,
occupational therapy assistants, and students of occupational therapy. The science-
driven, evidence-based practice of occupational therapy enables people of all ages to
live life to its fullest by promoting participation in daily occupations or activities.
In so doing, growth, development, and overall functional abilities are enhanced, and
the effects associated with illness, injuries, and disability are minimized.
Telehealth and Occupational Therapy Before the Pandemic
As noted in AOTA’s Telehealth in Occupational Therapy backgrounder (attached),
some occupational therapy professionals were providing occupational therapy (OT)
services via telehealth before the COVID–19 pandemic struck, with significant inno-
vation occurring at the Veterans Administration. The number of OT telehealth en-
counters increased dramatically, however, as Congress and CMS reacted quickly to
enable Medicare beneficiaries to receive OT and other therapy services via tele-
health during the declared Public Health Emergency (PHE) to minimize infection
risk.
Congressional action was essential to waive statutory restrictions on CMS that pre-
vented occupational therapy practitioners and other therapy providers’ ability to
provide services to Medicare beneficiaries via telehealth. CMS responded to Con-
gressional waivers included in the CARES Act by issuing an emergency rule that
added a series of therapy CPT® codes to the telehealth services list, and then subse-
quently issued another rule that included occupational therapy practitioners as eli-
gible Medicare telehealth providers. This effectively enabled OTs to provide services
via telehealth to Part B Medicare beneficiaries during the COVID–19 emergency;
however, these waivers are not permanent.
The delivery of OT services via telehealth expanded exponentially after the CMS
waivers were issued, and in response to actions by state Medicaid plans and private
insurance to also allow patients to receive OT services via telehealth to reduce infec-
tion risk. This enabled occupational therapy professionals to continue to provide es-
sential OT services, while gaining the necessary experience to fully appreciate po-
tential benefits to patients that are unrelated to minimizing in-person contact dur-
ing a pandemic.
Congressional action is now essential to enable OT services to continue to be pro-
vided to Medicare beneficiaries via telehealth when appropriate, as CMS has indi-
cated that it does not have the authority to do so under existing statute. The Ex-
panded Telehealth Access Act (H.R. 2168) was introduced in the House by Reps.
Mikie Sherrill (D–NJ) and David McKinley (R–WV) to enable OT professionals as
well as physical therapists (PTs), speech-language pathologists (SLPs), and audiol-
ogists to provide services via telehealth under Section 1834(m) of the Social Security
Act. Unless Congress acts, Medicare beneficiaries will face a telehealth ‘‘cliff ’’ when
the PHE ends, whereby beneficiaries who are now accustomed to receiving some OT
services via telehealth, suddenly lose access to such services.
Experience During PHE Demonstrates Effectiveness
of OT Services via Telehealth
The rapid expansion of telehealth as a delivery mechanism for OT services during
the PHE has enabled occupational therapists and occupational therapy assistants
to demonstrate the clear value of these services provided alone or in conjunction
with in-person services. Telehealth has been especially beneficial for people in rural
and other underserved areas and to those for whom travel to receive services was
already a barrier to access, including people with disabilities.
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OT practitioners report that telehealth has enhanced the effectiveness of OT serv-
ices for Medicare beneficiaries in many ways. It has enabled more patients to start
care on the day ordered and to minimize cancellations, postponements, and schedule
changes that are commonly connected to transportation, mobility, caregiver avail-
ability, weather, and other issues related to treatment in a clinical setting. This in
turn has enabled some patients to complete treatment sooner and with fewer visits,
which can reduce the cost of care.
Telehealth has also made it much easier to connect with beneficiary caregivers who
are often unable to take the time required to travel with the patient to in-person
visits. This is especially important for some patients in the Medicare population who
rely more heavily on a caregiver for assistance during appointments and for follow-
up in the home. In addition, telehealth visits have enabled OT professionals to bet-
ter identify home safety issues, which are often minimized or not referenced at all
by patients during an office visit. This can be crucial in preventing falls, addressing
functional decline, and avoiding costly emergency room visits and hospital admis-
sions which, in turn, can reduce the cost of care.
Research Demonstrates Efficacy of OT Delivered via Telehealth
A study (infographic attached) by Focus on Health Outcomes (FOTO), one of the
major health data registries used by therapists, reported on five data-driven benefits
of therapy when provided via teleheatlh utilizing differing proportions of in-person
and telehealth visits per patient. The study indicated that therapy provided via tele-
health can promote patient confidence, drive better attendance numbers, and sus-
tain the continuity of care for existing patients. It also indicated that therapy serv-
ices provided via telehealth and non-telehealth were equally effective in relation to
improving the functional status of patients, with differing mixes of teleheatlh and
in-person visits utilized as needed/desired by the patient. In addition, the study
demonstrated a reduced number of visits per episode of care when telehealth was
involved, and equal patient satisfaction.1
The AOTA Telehealth Position Paper 2 summarizes how occupational therapy practi-
tioners use telehealth technologies as a method for service delivery for evaluation,
intervention, consultation, monitoring, and supervision of students and other per-
sonnel. Further, it references the results of research on the use of telehealth in re-
habilitation or habilitation, which includes occupational therapy.
There is a growing base of evidence demonstrating the efficacy of technologically
mediated occupational therapy.3 Ongoing research at University of Southern Cali-
fornia Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy
Faculty Practice has shown that increased use of telehealth for pain-management
patients decreased cancellations, increased access, and improved treatment effec-
tiveness. Patient satisfaction with telehealth is also high. A more detailed list of
their findings follows:
• Ability to access more people with chronic pain by eliminating the geographic
barrier of having to drive to an in-person session. A recent evaluation of a tele-
health group intervention for pain management, specifically for patients living
in rural or remote areas, revealed that participants benefited from telehealth
specialty pain management services.4
• Decreased cancellation rates due to pain flare ups or symptom exacerbations be-
cause patients do not have to commute to in-person sessions, but can participate
from the comfort of their own home where they can access many of their pain
management tools (i.e., medication, heat/ice, self-massage units, lying down as
needed, more control over ambient temperature).
1 Data-Driven Benefits of Telehealth for Rehab Therapists (2020). Net Health, https://
www.nethealth.com/5-data-driven-benefits-of-telehealth-for-rehab-therapists/.
2 American Occupational Therapy Association (2013). Telehealth. American Journal of Occupa-
tional Therapy, 67(6 Suppl.), S69–S90, http://dx.doi.org/10.5014/ajot.2013.67S69.
3 Cason J (2009). A Pilot Telerehabilitation Program: Delivering Early Intervention Services
to Rural Families. International Journal of Telerehabilitation, 2009;1(1):29–37. Hoffmann T,
Russell T, Thompson L, Vincent A, Nelson M. (2008). Using the Internet to assess activities of
daily living and hand function in people with Parkinson’s disease. NeuroRehabilitation, 23, 253–
261. Ng EM, Polatajko HJ, Marziali E, Hunt A, Dawson DR (2013). Telerehabilitation for ad-
dressing executive dysfunction after traumatic brain injury. Brain Inj. 2013;27(5):548–64.
4 Scriven, H., Doherty, D.P., and Ward, E.C. (2019). Evaluation of a multisite telehealth group
model for persistent pain management for rural/remote participants. Rural and Remote Health,
19(1).
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• Improved treatment effectiveness due to improved ability to assess and evaluate
a person’s home environment and contextual factors, rather than through verbal
discussion or photos. This allows for more effective problem solving and identi-
fication of environmental barriers. This is especially clear in OT interventions
for pain regarding body mechanics, ergonomics, physical activity routines, sleep
positioning, falls prevention and recovery, and placement of durable medical
equipment for optimal safety.
• Improved continuity of care because patients who would travel long distances
to come to the clinic may only be seen for treatment 1x/month, but with tele-
health services, they can be seen weekly for improved accountability and to sup-
port long-term, sustainable behavior change.
• Improved patient satisfaction—patients are reporting improved participation
and effectiveness of treatment because commuting to the clinic and driving can
often be a trigger of pain or stress. By eliminating this factor, patients avoid
starting treatment sessions in pain or fatigue and are able to participate more
effectively during session.
• Reduced social isolation and occupational deprivation—due to compounding fac-
tors of managing a chronic condition and the long-term effects of pandemic-
related restrictions, patients are reporting feelings of isolation and reduced
functional participation in daily routines and meaningful activities. Experi-
encing occupational deprivation can have detrimental effects on health and
wellness, self-efficacy, and identity.5 With OT telehealth, patients can collabo-
rate with their OT to identify strategies and opportunities to engage in occupa-
tions and social activities to combat isolation, occupational deprivation, and as-
sociated adverse health consequences.
Additional research has shown strong strength of evidence that motivational inter-
viewing, fatigue management, and medication adherence performed via telehealth
lead to positive outcomes.
Based on this research, both Medicare beneficiaries and the Medicare Program
would see great benefits in quality care, reduced costs, and reduced hospitalizations
if occupational therapy is utilized fully. AOTA asserts that the same ethical and
professional standards that apply to the traditional delivery of occupational therapy
services also apply to the delivery of services received via telehealth. Occupational
therapy interventions delivered via telehealth can assist patients to regain, develop,
and build functional independence in everyday life activities to significantly enhance
a Medicare beneficiary’s quality of life. Telehealth may also address provider short-
ages and access problems, making necessary occupational therapy services available
to underserved beneficiaries in remote, inaccessible, or rural settings and to bene-
ficiaries with limited mobility outside their home. Further, occupational therapy is
the chief profession with expertise in activities of daily living and community envi-
ronments, which may be better observed and evaluated through telehealth services
when the beneficiary is in their home environment.
Occupational Therapists Describe Benefits of
OT via Telehealth During PHE
AOTA commends the Government Accounting Office for conducting a study on the
use of telehealth during the PHE, and we look forward to seeing the results of their
work. In addition, examples of the use of telehealth to provide OT services during
the PHE follow, as described by OT professionals:
• Telehealth has been crucial for service to our CMS patients in our Post-ICU
multidisciplinary clinic during the pandemic and would continue to be a vital
resource for these patients. Many of these patients will not be able to access
the services for a variety of reasons if we cannot continue with telehealth.
• Telemedicine has been a very helpful but unexpected resource for service deliv-
ery. One of the primary barriers to clients participating in the 55+ Program in
the past has been transportation. Many clients are fearful of driving, unable to
drive due to other health conditions, or do not have access to a vehicle and al-
ternative transportation is too expensive. Telemedicine has allowed these clients
access to treatment now.
• Initially many of my older adult clients struggled and were fearful of technology
and did not think they would be able to participate in online treatment. With
coaching and assistance, many clients have overcome these barriers and now
5 Whiteford, Gail. (2000). Occupational deprivation: global challenge in the new millennium.
British Journal of Occupational Therapy, 63(5).
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are using technology more to connect with family, friends, and other community
resources. It has helped to decrease isolation for many both for treatment and
in the community.
• I am an occupational therapist in an outpatient neurological clinic. The majority
of my patient caseload includes adults and older adults with comorbidities and /
or [who] are immuno-compromised. During the global pandemic, taking months
off of therapy could have resulted in significant decrease in function for some
of the patients I serve. Our clinic was on the edge of our seats while waiting
to hear the CMS changes to allow occupational therapy providers to provide
telehealth services. Once the change had been made, it opened up a new world
of opportunity for us to serve these patients who so needed skilled therapy, but
were unable to physically come into the clinic. As occupational therapists, we
adapt. I am able to provide individualized, client-centered care through a new
medium that was aligned with the patient’s plan of care to reach their func-
tional goals. Without the ability to provide the skilled services via telehealth,
our clients would not have received the care they needed. Patients have been
surprised with the effectiveness of telehealth therapy services. If CMS allows
these changes to be permanent, we would be able to better serve those patients
in effective ways through the use of this technology.
• Clients who have difficulty with transportation to the clinic or consistent trans-
portation have been able to receive services and those that have anxiety with
new providers or leaving home have benefitted in that this is a great bridge to
start with to start to expose to social skills and situations and still provide them
with the therapy that they need to succeed.
• One particular patient was a woman with Parkinson’s. She and her husband
were sleeping on an air mattress in their den because she had a hip fracture
and was not steady enough to climb the stairs to her bedroom. After her OT
eval, she refused further in-person visits. I trialed telehealth visits with great
success. I was able to have the husband aim the camera so that I was able to
provide placement of recommended grab bars in the bathrooms, both upper and
lower levels, as well as get a tour of the second level, something I had not been
able to assess at the eval. I was able to help with technique and positioning
for upper extremity exercises, and eventually, I was able to teach the husband
how to assist the patient up/down the stairs, safely, as well as teach bed mobil-
ity so that the patient was able to sleep in her own bed upstairs versus an air
mattress on the floor on the main level. She and her husband looked forward
to my weekly visits and always updated me on the progress she had made. They
were so grateful for the therapy I was able to provide remotely.
Global Telehealth Issues of Specific Concern to AOTA
While Congressional action is urgently needed now to allow occupational therapy
professionals to provide services via telehealth after the PHE, AOTA also notes that
for telehealth to move forward in any way, several other issues must also be ad-
dressed. In order to maximize the benefit of telehealth services, the origi-
nating site for a telehealth visit must be the patient’s home, especially for
OT services as described above. In addition, there is no justification for a pay-
ment differential for telehealth services, as practice expenses are unlikely to go
down since practitioners need to maintain an office to perform both telehealth and
in-person visits. Additionally, practice expense may increase as practitioners invest
in HIPAA-compliant software and other technology to assist in telehealth visits.
AOTA appreciates the relaxation of HIPAA requirements during the PHE for tele-
health software; however, these restrictions should be reinstated after the PHE ends
to protect the security of Personal Health Information. Finally, Congress must allow
some limited services to be provided via audio only, especially in the area of mental
health and substance abuse, with self-care as an example of a code used by OT pro-
fessionals.
Summary—Congressional Action Essential
to Avoid Therapy Telehealth Cliff
In summary, OT interventions delivered via telehealth have enabled patients to de-
velop, regain, and build functional independence in everyday life. Telehealth has
also demonstrated advantages over in-person visits in some situations, especially for
people in rural and underserved areas, and for the large number of seniors in all
communities who face transportation and mobility issues, especially those with dis-
abilities. Telehealth is also an ideal platform for conducting home safety evaluations
as it provides a window into the person’s home and often great access to their care-
giver.
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As noted, Congressional action is essential to enable Medicare beneficiaries to con-
tinue to receive OT services via telehealth when appropriate. Passage of the Ex-
panded Telehealth Access Act (H.R. 2168) would enable OT professionals as well as
PTs, SLPs, and audiologists to provide services via telehealth under Section
1834(m) of the Social Security Act. Unless Congress acts, Medicare beneficiaries
will face a telehealth ‘‘cliff ’’ when the PHE ends, whereby beneficiaries who are now
accustomed to receiving some OT services via telehealth suddenly lose access to
such services. We urge Congress to prevent this outcome.
AMERICAN PHARMACISTS ASSOCIATION
2215 Constitution Avenue, NW
Washington, DC 20037
Chairman Wyden, Ranking Member Crapo, and Members of the Committee, the
American Pharmacists Association (APhA) is pleased to submit the following State-
ment for the Record for the U.S. Senate Finance Committee Hearing, ‘‘COVID–19
Health Care Flexibilities: Perspectives, Experiences, and Lessons Learned.’’
APhA is the largest association of pharmacists in the United States advancing the
entire pharmacy profession. APhA represents pharmacists in all practice settings,
including community pharmacies, hospitals, long-term care facilities, specialty phar-
macies, community health centers, physician offices, ambulatory clinics, managed
care organizations, hospice settings, and government facilities. Our members strive
to improve medication use, advance patient care, and enhance public health.
APhA thanks the Committee for holding this important hearing examining COVID–
19 health-care flexibilities. During the COVID–19 public health emergency (PHE),
pharmacists have demonstrated the ability to significantly expand access to care
and equity in care,1 and they will continue to do so if certain regulatory barriers
are permanently removed. The pandemic has demonstrated how essential and acces-
sible pharmacists are in the United States. Pharmacists and pharmacies’ lights
stayed on from the start of the pandemic and are essential components of public
health infrastructure.
As you know, the fight against COVID–19 has demanded the federal government
take action to allow pharmacists and other health-care professionals to do more of
what they are trained to do. By being more flexible about certain requirements and
expanding scope of practice through new authorities, the federal government made
it easier for pharmacists to provide care to patients during the COVID–19 PHE. The
problem is many of these flexibilities and authorities are not considered permanent
and further action is needed to expand access to pharmacist-provided services. If ac-
tion is not taken, patients will not be able to receive needed care at pharmacies
across the country once the PHE ends.
Accordingly, APhA urges Congress to expeditiously use its authority to
pass legislation to make permanent:
• Pharmacists’ ability to order, authorize, test, treat, and administer immuniza-
tions and therapeutics against infectious diseases;
• Removal of operational barriers that address workforce and workflow issues
which previously prevented pharmacists from engaging in patient care;
• Including pharmacists under existing and future telehealth flexibilities; and
• Maintaining compounding flexibilities to address current and future drug short-
ages.
Securing Ability of Pharmacists to Order, Authorize, Test, Treat, Immunize,
and Provide Other Services
Many of these new authorities and flexibilities, including pharmacists’ ability to
order and administer COVID–19 and childhood vaccines and COVID–19, influenza,
and RSV tests, as well as pharmacy interns and technicians to administer COVID–
19 tests and vaccinations to persons aged 3 years or older as well as childhood vac-
cines to individuals ages 3 to 18 years old should continue as they have significantly
increased patient access and care.
1 National Pharmacy Organizations Unite to Take a Stand Against Racial Injustice. June 5,
2020, available at: https://www.accp.com/docs/news/Pharmacy_Statement_On_Racial_Injus
tice.pdf.
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Removal of Operational Barriers for Pharmacists
The COVID–19 pandemic has stressed and strained our health-care system and re-
vealed generations of health inequities in communities of color, medically under-
served, and rural areas. In order to protect public health, detect and respond to fu-
ture epidemics, and improve the equitable delivery of health care, every pharmacist
needs to be able to support health-care teams.
In January 2021, the Department of Health and Human Services (HHS), under the
Public Readiness and Emergency Preparedness Act (PREP Act), authorized any
health-care provider, including pharmacists, who are licensed or certified in a state
to prescribe, dispense, and /or administer COVID–19 vaccines across state lines, dur-
ing the public health emergency.2 Congress needs to make this authority permanent
to maintain the ability of pharmacists to fill gaps in primary care and surge to meet
public health crises.
Additionally, the Centers for Medicare and Medicaid Services (CMS) has encouraged
insurance plans to practice flexibility regarding prior authorization protocols, refills,
deliveries, and pharmacy audits. These practices have reduced the administrative
burden on clinicians and allowed for more efficient patient care, testing and vaccine
delivery. Given the benefits to patients and the system, we recommend that Con-
gress pass legislation to require all Medicare Advantage (MA) and Part D plans to
continue offering these flexibilities to prevent decreased medication adherence in
vulnerable populations, especially older adults and people of color. CMS has also
issued policies relaxing Medicare Part D audit requirements for signature logs. Ac-
cordingly, we recommend Congress make the following policies permanent for MA,
Part D plans and contracted pharmacy benefit managers (PBMs):
• Relaxing to the greatest extent possible prior authorization requirements, where
appropriate;
• Suspending plan-coordinated pharmacy audits during any PHE; and
• Waiving medication delivery documentation and signature log requirements to
limit unnecessary contact with sick and potentially infectious patients.
Including Pharmacists under Existing and Future Telehealth Flexibilities
The rapid shift to telehealth services during the COVID–19 PHE has illustrated the
value of telehealth long-term, particularly for patients with mobility issues and
those in rural and /or medically underserved areas. Prior to the PHE, pharmacists
were already actively involved in virtual care delivery for Medicare beneficiaries
through provision of Part B services such as Chronic Care Management (CCM),
Transitional Care Management (TCM), Continuous Glucose Monitoring (CGM), Re-
mote Patient Monitoring (RPM), and Behavioral Health Integration (BHI), as well
as Medication Therapy Management Services in the Part D program. The onset of
the COVID–19 pandemic has brought about additional opportunities to leverage
pharmacists in telehealth services, including medication management services,
chronic disease management, education on healthy lifestyle interventions, patient
counseling on point of care diagnostic tests, and more.
APhA recommends Congress take the following steps to enhance patient access to
telehealth services:
• Make permanent the authority allowing direct supervision to be provided using
real-time interactive audio and video technology under incident to physician
services arrangements;
• Make permanent the authority allowing Medicare-enrolled pharmacies offering
accredited diabetes self-management training (DSMT) programs to offer DSMT
services via telehealth;
• Designate pharmacists as practitioners (providers) for the Medicare Telehealth
Benefit, and add patient care services provided by pharmacists using telehealth
to the Medicare Telehealth List;
• Ensure Medicare payment for pharmacist-provided telehealth and in-person
services is commensurate with the time and complexity of the services provided;
• Allow for telephonic or video prescription counseling of patients to facilitate
contactless care; and
• Make permanent Medicare coverage and payment of audio-only telephone calls
for opioid treatment program therapy, counseling, and periodic assessments.
2 https://www.phe.gov/Preparedness/legal/prepact/Pages/COVID-Amendment5.aspx.
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Maintaining Compounding Flexibilities to Address Current and Future
Drug Shortages
Drug shortages are another factor that can negatively affect patients in terms of
medication cost and the availability of their treatments. APhA urges the Committee
to consider mechanisms to both better control the price of medications in shortage
and improve tracking and prediction systems used to identify drugs in shortage. For
example, FDA issued temporary guidance granting flexibility for pharmacists to
compound certain necessary medications under 503A and 503B for hospitalized pa-
tients without patient-specific prescriptions to address COVID–19. Many of our
members have told us FDA’s compounding flexibility is the only reason hospitals
were able to keep up with patient demand. Accordingly, the recent flexibility to com-
pound medications under both sections 503A and 503B are likely to be necessary
for the foreseeable future, and we strongly urge the Committee to pass legislation
to codify this flexibility to address drug shortages. We believe maintaining stability
within the supply chain during the global COVID–19 pandemic is crucial. We
strongly urge the Committee to focus on solutions that harness existing relation-
ships with international trading partners to promote supply chain resiliency and di-
versity while avoiding measures that could undermine our ability to work with the
international community.
S. 1362/H.R. 2759, the Pharmacy and Medically Underserved Areas En-
hancement Act
The COVID–19 pandemic has further illustrated how difficult it is for some patients
living in medically underserved communities to access care and achieve optimal
medication therapy outcomes. A strong body of evidence has shown that including
pharmacists on interprofessional patient care teams with physicians, nurses, and
other health-care providers produces better health outcomes and cost savings. Phar-
macists are one of the most accessible health-care providers in the nation, with
nearly 90% of Americans living within five miles of one of the nation’s 88,000 phar-
macies.3
Despite the fact that many states and Medicaid programs are turning to phar-
macists to increase access to health care, Medicare Part B does not cover many of
the impactful and valuable patient care services pharmacists can provide. As proven
during the COVID–19 pandemic, pharmacists are an underutilized and accessible
health-care resource who can positively affect beneficiaries’ care and the entire
Medicare program.
Accordingly, APhA strongly urges the Committee to include S. 1362, the Pharmacy
and Medically Underserved Areas Enhancement Act, recently introduced by Com-
mittee members Charles Grassley (R–IA), Robert Casey (D–PA), and Sherrod Brown
(D–OH), in the Committee’s legislative package to allow pharmacists to deliver vital
patient care services in medically underserved areas to help break down the bar-
riers to achieving health-care equity in this country, improve patient care, health
outcomes, the impact of medications,4 and consequently, lower health-care costs and
extend the viability of the Medicare program.
By recognizing pharmacists as providers under Medicare Part B, S. 1362 would en-
able Medicare patients in medically underserved communities to better access
health care through state-licensed pharmacists practicing according to their own
state’s scope of practice. In medically underserved communities, pharmacists are
often the closest health-care professional and the most accessible outside normal
business hours. S. 1362 recognizes that pharmacists can play an integral role in ad-
dressing these longstanding disparities to help meet health equity goals 5 and en-
sure that our most vulnerable patients have access to the care they need where they
live. Helping patients receive the care they need, when they need it, is a common
sense and bipartisan solution that will improve outcomes and reduce overall costs.
3 NCPDP Pharmacy File, ArcGIS Census Tract File. NACDS Economics Department.
4 See, Avalere Health. Exploring Pharmacists’ Role in a Changing Healthcare Environment.
May 2014, available at: http://avalere.com/expertise/life-sciences/insights/exploring-phar-
macists-role-in-a-changing-healthcare-environment. Also, see, Avalere Health. Developing Trends
in Delivery and Reimbursement of Pharmacist Services. October 2015, available at: http://
avalere.com/expertise/managed-care/insights/new-analysis-identifies-factors-that-can-facilitate-
broader-reimbursement-o.
5 The White House. Executive Order on Advancing Racial Equity and Support for Underserved
Communities Through the Federal Government. January 20, 2021, available at: https://
www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-
racial-equity-and-support-for-underserved-communities-through-the-federal-government/.
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Conclusion
APhA would like to thank the Committee for holding this important hearing and
for continuing to work with us by making key COVID–19 health-care flexibilities
permanent and including S. 1362 in your legislative package to increase access to
pharmacist-provided patient care services for medically underserved communities to
promote health-care equity. Please contact Alicia Kerry J. Mica, Senior Lobbyist, at
AMica@aphanet.org or by phone at (202) 429–7507 as a resource as you consider
this legislation. Thank you again for the opportunity to provide comments on this
important issue.
AMERICAN PHYSICAL THERAPY ASSOCIATION
3030 Potomac Ave., Suite 100
Alexandria, VA 22305–3085
703–684–2782
https://www.apta.org/
May 18, 2021
Senator Ron Wyden Senator Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Dear Chairman Wyden and Ranking Member Crapo,
On behalf of our more than 100,000 member physical therapists, physical therapist
assistants, and students of physical therapy, the American Physical Therapy Asso-
ciation appreciates the opportunity to provide a statement for the record on the com-
mittee’s hearing ‘‘COVID–19 Health Care Flexibilities: Perspectives, Experiences,
and Lessons Learned.’’ APTA is dedicated to building a community that advances
the physical therapy profession to improve the health of society. As experts in reha-
bilitation, prehabilitation, and habilitation, physical therapists play a unique role in
society in prevention, wellness, fitness, health promotion, and management of dis-
ease and disability for individuals across the age span—helping individuals improve
overall health and prevent the need for avoidable health-care services. Physical
therapists’ roles include education, direct intervention, research, advocacy, and col-
laborative consultation. These roles are essential to the profession’s vision of trans-
forming society by optimizing movement to improve the human experience.
Value of Physical Therapy Through Telehealth
The ongoing coronavirus pandemic has highlighted the need for patients, health sys-
tems, payers, and providers to rapidly adopt or expand models and modes of care
delivery that minimize disruptions in care and the risks associated with those dis-
ruptions. The expansion of telehealth payment and practice policies under the sec-
tion 1135 waivers during this Public Health Emergency, including permitting phys-
ical therapy services to be furnished via telehealth by physical therapists and phys-
ical therapy assistants across settings has demonstrated that many needs can be
safely and effectively met via the use of technology and that patients can have im-
proved access to skilled care by leveraging these resources.
Physical therapy is well-suited for telehealth—primarily as an enhancement of in-
person services, although a telehealth visit also may replace an in-person visit when
needed or indicated. Physical therapists and physical therapist assistants can use
telehealth as a supplement to in-person services to evaluate and treat a variety of
conditions prevalent in the Medicare population, including but not limited to Alz-
heimer’s disease, arthritis, cognitive/neurological/vestibular disorders, multiple scle-
rosis, musculoskeletal conditions, Parkinson disease, pelvic floor dysfunction, frailty,
and sarcopenia.
Physical therapists make determinations, in consultation with patients and care-
givers, regarding the appropriate mix of in-person and telehealth services to meet
the goals in the plan of care. The evaluation and treatment of a patient via the use
of telehealth allows the physical therapist to interact with the patient within the
real-life context of their home environment, which is not easily replicable in the clin-
ic. Patient and caregiver self-efficacy are inherent goals of care, and telehealth not
only allows a physical therapist to maintain the continuity of care anticipated in the
plan of care but also allows for immediate and effective engagement when a specific
challenge arises. A patient’s and /or caregiver’s ability to interact in their own envi-
ronment with a physical therapist when they are facing a challenge, rather than
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waiting for the next appointment, can be invaluable in supporting the adoption of
effective strategies to improve function, enhance safety, and promote engagement.
Skilled physical therapy interventions delivered through an electronic or digital me-
dium have the potential to prevent falls, functional decline, costly emergency room
visits, and hospital admissions and readmissions. Further, physical therapists al-
ready are experienced in modifying exercises for the patient to perform them safely
at home, as a home exercise program is a common element of a treatment plan for
patients who are treated in person. Education and home exercise programs—includ-
ing those focused on falls prevention—function particularly well with telehealth be-
cause the physical therapist can evaluate and treat the patient within the real-life
context of their home environment. This is not easily replicated in the office setting.
Physical therapy progresses patients toward total independence of their program in
their own homes. Telehealth facilitates this objective,1 as the physical therapist can
progress the patient in their native environment rather than in a ‘‘simulated’’ one
in the clinic. Moreover, a patient’s and /or caregiver’s ability to interact in their own
environment with a physical therapist can be invaluable in supporting the adoption
of effective strategies to improve function, enhance safety, and promote engagement.
Telehealth expands the clinical impact of physical therapy by providing patients on-
demand access to their physical therapist to promote increased adherence, access to
booster sessions to ensure sustainability of therapeutic gains and functional per-
formance, and access to supplemental care in-between in-person visits to reduce the
length of the episode of care and to lower costs.
Moreover, physical therapy is not synonymous with exercise. Although much of
skilled physical therapy is high-touch, a significant component is transition of
skills—promoting self-efficacy, environmental assessment and modification, training
and education, and, most important, ongoing assessment, analysis, and clinical deci-
sion-making. A critical component of physical therapy is the prescription of carry-
over techniques, tasks, and activities—not just exercise—by a patient in their own
environment. Physical therapy services performed via telehealth enhance this com-
ponent of care.
Examples of physical therapy providers using telecommunications technology to pro-
vide real-time, interactive audio and video care include the following:
• Physical therapy practitioners use telehealth technologies to conduct evalua-
tions or reevaluations 2 or provide quicker screening, assessment, and referrals
that improve care coordination.
• Physical therapy practitioners provide interventions use telehealth by inter-
acting with the patient in real time to provide instruction in exercise and activ-
ity performance, observing return demonstration and instruction in modifica-
tions or progressions of a program, providing caregiver support, and promoting
self-efficacy.
• Physical therapy practitioners provide verbal and visual instructions and cues
to modify how patients perform various activities. They also may suggest that
the patient or caregiver modify the environment for safety reasons, or to poten-
tially produce even more optimal outcomes.
• Physical therapy practitioners use telehealth technologies to provide prehabili-
tation and conduct home safety evaluations.
• Physical therapy practitioners use telehealth technologies to observe how pa-
tients interact with their environment and /or other caregivers, and to provide
caregiver education.
• Physical therapy practitioners can assess the carryover of the activity modifica-
tion strategies and activities to determine effectiveness immediately rather than
waiting for the next in-person visit.
• Physical therapists use telehealth to reduce the number of ‘‘in-clinic’’ visits and
still maintain important follow-up care. This might reduce travel time and /or
burden for a patient—which, for some conditions, might result in faster healing.
This also prevents any delays in modifying a program when it needs to be up-
graded or downgraded.
• Physical therapists can use technology to satisfy supervision requirements.
• A physical therapist can co-treat with another clinician who is treating via real-
time audio and visual technology.
1 https://clinicaltrials.gov/ct2/show/NCT02914210.
2 https://pubmed.ncbi.nlm.nih.gov/26658151/.
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• A treating physical therapist can consult directly with another physical thera-
pist or physical therapist assistant for collaboration and /or to obtain specialty
recommendations to incorporate into an existing plan of care.
• Physical therapists use telehealth for quick check-ins with established patients.
Telehealth services furnished by physical therapists and physical therapist assist-
ants offer cost savings, allow for coordination of care, and may improve adherence
and patient satisfaction. Many studies 3 have illustrated the clinical benefit of tele-
rehabilitation for a variety of conditions, including pelvic floor dysfunction 4 and
multiple sclerosis.5
A 2019 study 6 examined the efficacy of home-based telerehabilitation versus in-
clinic therapy for adults after stroke, finding that poststroke activity-based training
resulted in substantial gains in patients’ arm motor function whether provided via
telerehabilitation or in person. Other studies 7 show that home-based telerehabilita-
tion significantly improved veterans’ functional independence, cognition, and patient
satisfaction. See Appendix A for additional studies. Physical therapists also have
been collecting a variety of data related to health outcomes and ease of use of tech-
nology. To promote data collection, APTA developed a patient satisfaction survey 8
for providers to share with their patients, which is available in both English and
Spanish.
When considering the value of telehealth furnished by physical therapists and phys-
ical therapist assistants, Congress should consider the effects of telehealth on down-
stream spending. Hospital admissions and readmissions, emergency department vis-
its, and urgent care visits, among other expenses, potentially will decrease if pa-
tients have access to both in-person and telehealth services.
Patient Access
Telehealth helps to overcome access barriers caused by distance, lack of availability
of specialists and /or subspecialists, impaired mobility, and the burden associated
with commuting/arranging transportation to a physical therapy appointment. Using
virtual engagement tools can prevent unnecessary exposure during a pandemic, epi-
demic, or even the annual flu season—a feature especially important for frail and
immunocompromised persons. Furthermore, access to telehealth services is critical
for beneficiaries who live in areas with inclement weather, which is a deterrent to
traveling outside of the home.
For patients who have difficulty leaving their homes without assistance, lack trans-
portation, or need to travel long distances, the ability to supplement or replace in-
person sessions with those furnished via telehealth greatly increases access to care
and ensures uninterrupted courses of therapy. Telehealth is a tool to overcome ac-
cess barriers caused by distance, unavailability of specialists and /or subspecialists,
inclement weather, and impaired mobility. For example, a Colorado physical thera-
pist practice that offers treatments for neurological conditions provides a significant
portion of the care via telehealth, for several reasons: (1) the area’s sometimes se-
vere inclement weather; (2) the patient’s vestibular condition that renders them un-
able to drive, forcing them to rely on friends or family to drive them; and (3) a lack
of physical therapy providers within a reasonable driving distance—particularly pro-
viders that address dizziness and balance issues.
Access to health-care services is critical to good health and functional performance,
yet Medicare beneficiaries, particularly those who reside in rural areas, face a vari-
ety of access barriers. Individuals across the lifespan want the ability to appro-
priately access telehealth, and telehealth is key to helping individuals age in place.
If we as a nation truly wish to help individuals age in their homes, telehealth is
a key to making this a reality. As demand for care to help individuals with chronic
conditions continues to grow, Congress should recommend telehealth payment and
coverage policies that will improve beneficiary access and increase collaboration and
efficiency of care across the care continuum.
Further, access to physical therapy in rural, medically underserved, and health pro-
fessional shortage areas often depends on the availability of physical therapist as-
3 https://pubmed.ncbi.nlm.nih.gov/26940798/.
4 https://www.researchgate.net/publication/330736628_Telerehabilitation_for_Treating_
Pelvic_Floor_Dysfunction_A_Case_Series_of_3_Patients%27_Experiences.
5 https://pubmed.ncbi.nlm.nih.gov/31042118/.
6 https://pubmed.ncbi.nlm.nih.gov/31233135/.
7 https://pubmed.ncbi.nlm.nih.gov/26658151/.
8 https://www.aptahpa.org/page/COVID19.
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sistants to provide care under the supervision of physical therapists. Unfortunately,
the 15% Medicare Physician Fee Schedule payment reduction for services furnished
in whole or in part by physical therapist assistants beginning in 2022 will have a
detrimental impact on the ability of physical therapy providers, particularly in rural
areas, to continue to deliver care. The payment reduction will unfairly penalize pro-
viders in rural, medically underserved, and health professional shortage areas. Ac-
cess to medical care already is dwindling in rural localities. Physical therapists and
physical therapist assistants play a crucial role in bridging these gaps in access to
care.
Quality
APTA developed a patient satisfaction survey 9 about the use of telehealth for pro-
viders to share with their patients in English and Spanish based on AHRQ’s guid-
ance. Copied below are the results from a physical therapist vestibular practice in
Colorado that asked some of the questions from this survey:
• The experience was an effective way to get my physical therapy: 70% of re-
spondents strongly agreed; 30% agreed.
• Feelings of comfortability being evaluated and treated via telehealth: 67% of re-
spondents strongly agreed; 20% agreed; 10% were neutral.
• Feelings of physical safety receiving physical therapy treatment via telehealth:
83% of respondents strongly agreed; 17% of respondents agreed.
• Overall satisfied with the experience: 93% strongly agreed; 7% agreed.
• In response to the question: If a telehealth visit was not available to you from
this PT clinic, how would you plan to receive PT in future? 10% of respondents
said they would seek telehealth from another clinic, 10% said they would not
seek care, 60% said they would seek in-person care with the clinic, and 17%
provided other answers, including:
» ‘‘I don’t know what I would do.’’
» ‘‘I might not seek care. This is the safest way for me to receive care.’’
In addition, the following are stories shared by Medicare beneficiaries during the
COVID–19 pandemic:
Medicare Beneficiary #1:
• The beneficiary was experiencing severe back pain, had significant physical lim-
itations, and used pain medications daily. She was ‘‘high risk’’ for COVID–19,
so she engaged in physical therapy via telehealth. After an initial evaluation
in the clinic and several telehealth sessions at her home, she is now walking
pain-free, can engage in more physical activity, and has reduced her pain medi-
cations. These telehealth visits have allowed her to care for her husband, who
is in hospice.
Medicare Beneficiary #2:
• I am writing to express my gratitude for the telehealth services that were pro-
vided during the COVID–19 pandemic. I was happy to start in the clinic and
then transition to a home-based program so that I could carry the work into
my daily routine, while staying safe at home. After every meeting, I felt better
and felt that I had gotten a good workout. I would recommend telehealth serv-
ices to a friend or family member. Even out of quarantine, I feel as though the
telehealth services may be beneficial to those who cannot go to an appointment
in person. I advocate that Medicare continues to allow telehealth services to be
furnished by physical therapists in the future.
Medicare Beneficiary #3:
• I was being treated for thoracic outlet syndrome and referred to physical ther-
apy. I found my experience most successful. Due to COVID–19, I was able to
do telehealth therapy from home. Once the clinic was able to reopen, I was able
to resume office visits and have continued to make good progress. I have had
a very positive experience.
Medicare Beneficiary #4:
• I am writing to express my appreciation for the telehealth services that were
provided during this COVID–19 pandemic. About 7 or 8 weeks ago I had to
have physical therapy for a pinched nerve. I contacted you since my husband
was already participating in your telehealth program. I have been working with
the DPT and have had wonderful results. I have used my 1- and 2-pound
weights as well as my wall to do push-ups. I also use my banister to do rowing
exercises. I would recommend telehealth services to a friend or family member
or anyone who should ask and I’m hoping that these telehealth services con-
9 https://www.aptahpa.org/page/COVID19.
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tinue in the future. This is a great way to remain safe at home, which is critical
during this pandemic
Recommendations
Current statutes limit Medicare beneficiaries from receiving telehealth services, in-
cluding a geography limitation, site limitation, and provider limitation. Congress
must pass legislation that permanently affords providers and patients the ability to
furnish and receive telehealth, just as they have done during the COVID–19 PHE.
Congress should:
(1) Enact the Expanded Telehealth Access Act of 2021 (H.R. 2168). This legisla-
tion would permanently allow rehabilitation providers to use telehealth under
Medicare after the PHE is declared over. Specifically, the bill adds physical
therapists, physical therapist assistants, occupational therapists, occupational
therapy assistants, audiologists, and speech language pathologists and facili-
ties that furnish outpatient therapy, as authorized providers of telehealth
under Medicare.
(2) Enact changes to Section 1834(m)(4)(C)(i) of the Social Security Act so that
telehealth services, including therapy services, will no longer be restricted by
geographic location of the beneficiary or the originating site. All Medicare
beneficiaries should be eligible to receive telehealth services from their home,
whether that home is in the community or part of an institutional setting.
Federal policies also should advance a definition of parity that includes equal cov-
erage, reimbursement, and cost-sharing (copayments, coinsurance, and deductibles)
for audio-only telehealth, audio and visual telehealth, and in-person visits, particu-
larly given the fact that telehealth is merely a modality to enable physical thera-
pists and physical therapist assistants, for example, to provide care within their
scope of practice. In addition, such policies should promote outreach to patients with
limited technology and connectivity and offer flexibility in platforms that can be
used for audio and visual (live video) interactions, audio-only options, online patient
portals, etc.
Conclusion
We appreciate the opportunity to provide the committee with our perspective on the
role of telehealth in physical therapy and the need to continue to provide Medicare
beneficiaries this option beyond the PHE. Should you have any questions, please do
not hesitate to contact David Scala, APTA congressional affairs senior specialist, at
davidscala@apta.org. Thank you for your consideration.
Sincerely,
Sharon L. Dunn, PT, Ph.D.
Board-Certified Clinical Specialist in Orthopaedic Physical Therapy
President
AMERICAN TELEMEDICINE ASSOCIATION
901 North Glebe Road, Suite 850
Arlington, VA 22203
T: 703–373–9600
May 19, 2021
The Honorable Ron Wyden The Honorable Mike Crapo
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20515 Washington, DC 20515
RE: ATA Testimony for Senate Finance Committee Hearing on ‘‘COVID–19 Health
Care Flexibilities: Perspective, Experience, and Lessons Learned’’
On behalf of the American Telemedicine Association (ATA), thank you for thought-
fully considering the future of telehealth during the upcoming Finance Committee
hearing entitled, ‘‘COVID–19 Health Care Flexibilities: Perspective, Experiences,
and Lessons Learned’’ on Wednesday, May 19. Federal flexibilities over the past
year have allowed patients to continue to access much-needed care even as the
health-care system was shuddered by the pandemic. This hearing is an essential
step toward determining and enacting commonsense policies that will ensure Medi-
care seniors are not pushed off the telehealth cliff at the end of the current COVID–
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19 Public Health Emergency (PHE). Please accept this letter as testimony by the
ATA and continue to consider the ATA as a resource as we work together on this
important bipartisan issue.
As the only organization exclusively devoted to expanding access to care through
telehealth, the ATA appreciates the opportunity to share our federal policy priorities
for 2021. During the COVID–19 PHE, telehealth has finally become a reality for
millions of Americans out of necessity. This has been possible because of swift, deci-
sive actions by Congress and the Department of Health and Human Services (HHS).
However, unless Congress acts again before the end of the PHE, telehealth access
will vanish for millions of Medicare beneficiaries overnight. As you consider how to
address this looming telehealth cliff, we request that you review ATA’s Permanent
Policy Recommendations 1 as well as ATA’s Federal Legislative Priorities.2
We encourage you to ensure policies reflect beneficiaries’ and providers’ growing in-
terest in having telehealth as a choice when accessing care. Data continues to show
that Medicare beneficiaries like telehealth and want to keep it. The nonpartisan
Medicare Payment Advisory Commission’s 3 annual beneficiary survey this year
found that 90% of Medicare respondents were satisfied with telehealth. The ATA
has worked with partners to identify similar trends,4 including nearly two thirds of
patients expecting telehealth to continue post-pandemic. To ensure these patients
have the choice to access telehealth in the future, the ATA has prioritized the fol-
lowing policies for consideration in the 117th Congress and would greatly appreciate
the Committee’s taking these priorities into consideration when drafting potential
telehealth legislation.
• Remove provisions in law that mandate, for telehealth delivery of care or reim-
bursement, a prior in-person relationship between practitioner and patient.
• Allow state licensing boards and practitioners to determine the appropriate
standards of care for patients. This includes removing the in-person require-
ment for telemental health services in the recently signed Consolidated Appro-
priations Act.
• Permanently remove the geographic and originating site barriers in statute.
• The originating site should be wherever the patient is located, including but not
limited to a patient’s home.
• Enhance HHS authority to determine appropriate telehealth services and pro-
viders.
• Ensure Federally Qualified Health Centers (FQHCs) and Rural Health Clinics
(RHCs) can furnish telehealth and receive equitable reimbursement.
• Make permanent HHS’s temporary waiver authority for future emergencies.
• Support existing fraud, waste, and abuse resources within HHS, including the
Health Care Fraud and Abuse Control Program.
The ATA is proud that telehealth is a strong bipartisan issue in Congress. The
above listed priorities have been reflected in several bipartisan bills already under
consideration this Congress, including the Telehealth Modernization Act (S. 368,
H.R. 1332), the Protecting Access to Post-COVID–19 Telehealth Act (H.R. 366), and
the soon-to-be-reintroduced CONNECT for Health Act. The ATA would greatly ap-
preciate your support of each of these important pieces of legislation.
At minimum, the ATA urges Congress to remove existing statutory barriers that
limit access to care and not simply replace existing statutory access restrictions with
new ones. For far too long, 1834(m) of the Social Security Act has categorically ex-
cluded too many patients from even having the option to access care via telehealth
because of the law’s antiquated and arbitrary barriers whose only purpose is to limit
access to health care. Providers and patients are best suited to determine clinical
appropriateness of medical services, not federal law. The 1834(m) restrictions are
nearing 20 years old, and by allowing them to persist, Congress will only punish
Medicare beneficiaries by banning their access to technology already available to
non-Medicare patients. As such, the ATA urges the Committee to take great care
in considering the consequences of having restrictions specifically codified in statute
as opposed to allowing these issues to be decided at the regulatory level. By explic-
itly and arbitrarily limiting care in statute through so-called ‘‘guardrails,’’ legislators
1 https://www.americantelemed.org/policies/ata-recommendations-for-permanent-telehealth-
policy/.
2 https://www.americantelemed.org/policies/atas-federal-telehealth-legislative-tracker/.
3 http://medpac.gov/docs/default-source/reports/mar21_medpac_report_to_the_congress_sec.
pdf.
4 https://www.americantelemed.org/in-the-news/covid-19-healthcare-coalition-surveys-pa-
tients-on-telehealth-impact-during-covid-19/.
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will unnecessarily stifle innovation and tie the hands of regulators, providers, and
patients. Should the Committee have concerns with cost, utilization, or telefraud,
the ATA stands ready to work with you on our shared goal of ensuring program in-
tegrity. As such, please consider ATA’s recently released Program Integrity Over-
view 5 as a resource.
While the ATA appreciates Congress’s recent actions to expand access to care, spe-
cific restrictions on patients, providers, services, or the modality of care in statute
only add to complexities in the health-care system. One of the ATA’s main federal
policy priorities is removing the in-person requirement for telemental health serv-
ices which was included in the Consolidated Appropriations Act, 2021, Pub. L. 116–
260 (e.g., Section 123 establishes coverage and reimbursement of a telemental
health service only if the practitioner has conducted an in-person examination of the
patient in the prior six months and subsequently continues to conduct in-person
exams at such a frequency to be determined by HHS). The ATA strongly opposes
statutory in-person requirements as they create arbitrary and clinically unsupported
barriers to accessing affordable, quality health care.
Today, not a single state in the U.S. requires a prior in-person relationship. At the
national level, the association of state regulators who oversee standards of medical
care, the Federation of State Medical Boards, stated that ‘‘. . . the relationship is
clearly established when the physician agrees to undertake diagnosis and treatment
of the patient, and the patient agrees to be treated, whether or not there has been
an encounter in person between the physician (or other appropriately supervised
health-care practitioner) and patient.’’
We cannot ignore the importance of providing all Americans, regardless of whether
they have a medical provider with whom they have an established relationship, the
opportunity to access health care. Requiring a physician and patient to meet in per-
son before receiving certain telehealth services would be a huge step backward, and
we hope to work with you to find an alternative to in-person requirements.
Thank you again for holding this important hearing and for your thoughtful delib-
eration on how your committee can enable access to quality health-care services for
Medicare beneficiaries. The ATA’s policy development and ultimate recommenda-
tions are guided by a specific set of policy principles 6 which all support the goal
of promoting a health-care system where people have access to safe, effective, and
appropriate care when and where they need it. Please know the ATA is honored to
continue to be a resource for you, the Committee, and your dedicated staff. If you
have any questions or would like to further discuss the ATA’s perspective, please
contact kzebley@americantelemed.org.
Kind regards,
Kyle Zebley
Public Policy Director
ASSOCIATION FOR CLINICAL ONCOLOGY
2318 Mill Road, Suite 800
Alexandria, VA 22314
T: 571–483–1300
F: 571–366–9530
https://beta.asco.org/
May 19, 2021
The Honorable Ron Wyden The Honorable Mike Crapo
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo,
The Association for Clinical Oncology (ASCO) commends the Committee for holding
the May 19, 2021, hearing, ‘‘COVID–19 Health Care Flexibilities: Perspectives, Ex-
periences, and Lessons Learned.’’ We are pleased to provide the attached comments
5 https://www.americantelemed.org/wp-content/uploads/2021/03/ATA-Program-Integrity-
One-Pager-3-1-21.pdf.
6 https://www.americantelemed.org/policy/.
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on regulatory flexibilities during the pandemic that have made a difference in can-
cer care.
ASCO is the world’s leading professional society representing physicians who care
for people with cancer. With nearly 45,000 members, our core mission is to ensure
that patients with cancer have meaningful access to high quality, equitable cancer
care.
In addition to the attached comments on regulatory policies, ASCO urges Congress
to address the 4% PAYGO cuts before they are scheduled to take effect in Medicare
and extend the Medicare sequestration moratorium. We appreciate Congress’ exten-
sion of the Medicare sequestration moratorium through the end of 2021 but are seri-
ously concerned about the impact a 6% Medicare cut will have on cancer care if
PAYGO and sequestration are not addressed before the end of this year.
Thank you for examining these important issues. If you have questions on our com-
ments or any other issues related to the treatment of patients with cancer, please
do not hesitate to contact Jennifer Brunelle at Jennifer.brunelle@asco.org.
Sincerely,
Monica Bertagnolli, M.D., FACS, FASCO
Chair of the Board
December 23, 2020
Alex Azar
Secretary
Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Dear Secretary Azar,
The nature of the COVID–19 pandemic and resulting public health emergency re-
quired unprecedented response and flexibility across the health-care sector to avoid
disruption in care delivery, continuity of research activities and to ensure the pro-
tection and safety of patients and health-care workers. Additionally, in the face of
economic pressures created by the pandemic, practices, health-care facilities and in-
stitutions—functioning as employers and businesses—required similar response and
flexibility from state and federal policymakers. The Association for Clinical Oncology
(ASCO) appreciates the opportunity to provide feedback on The Agency’s Request
for Information on Regulatory Relief Efforts to support Economic Recovery.
ASCO is a national organization representing more than 45,000 oncology profes-
sionals who care for people living with cancer. Through research, education, and
promotion of the highest-quality patient care, our members are committed to ensur-
ing that evidence-based practice for the prevention, diagnosis, and treatment of can-
cer are available to all Americans. ASCO supports major quality initiatives that en-
hance performance measurement and improvement, clinical practice guidelines, big
data analytics, and the value of cancer care.
Cancer patients and survivors are one of the most vulnerable patient populations,
and face increased risk related to COVID–19. Prior to the public health emergency,
certain longstanding policies, care delivery practices and research procedures posed
barriers to the efficient delivery of care and effective clinical research. During the
pandemic, temporary regulatory relief offered by the Agency on some of those same
policies, coupled with the nimbleness of the health-care sector, proved beneficial to
patients and enabled the nation’s health-care system to continue to operate safely
during the time of crisis. ASCO commends the Administration and the Department
of Health and Human Services (HHS) for recognizing the need to modify existing
policies that would have significantly affected care for cancer patients. Like many
organizations, ASCO has taken the opportunity to evaluate whether the changes in
care delivery and research prompted by the pandemic could inform new approaches
to delivery of high quality, high value care and research moving forward.
ASCO recently published the Road to Recovery Report: Learning from the COVID–
19 Experience to Improve Clinical Research and Cancer Care, which outlines rec-
ommendations based on lessons learned during the pandemic. Proposed actions and
policies aim to make cancer care delivery and research opportunities more accessible
and equitable for patients in every community. With these recommendations, ASCO
intends to address long-standing cancer care disparities that have been highlighted
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176
by the pandemic. To achieve these goals, certain regulatory flexibilities driven by
the pandemic may need to be permanent—or at least extended for a minimum of
24 months following expiration of the PHE. This would enable cancer patients to
continue access to life-saving treatments for their disease, for providers to continue
delivery of high-quality cancer care, and all in the cancer community to benefit from
protections against personal and economic the impacts COVID–19.
Part I: Cancer care delivery—Policies and regulatory action must build on strate-
gies that have helped to meet patients’ most urgent needs in the worst of the pan-
demic. Specifically:
Increased access to and equity of care—by making expanded coverage for tele-
medicine permanent; preventing Medicaid cuts; ensuring accessible, affordable and
comprehensive insurance plans, and preventing other threats to patients’ health
coverage; enhancing grants and other support for oncology practices in underserved
communities; and sustaining federal safety net programs.
Protecting patient safety—for example, by creating new chemotherapy infection
control standards that account for viral threats like the novel coronavirus; ensuring
reliable access to personal protective equipment (PPE) and future COVID vaccines;
and limiting home infusion of potentially risky chemotherapy to exceptional cir-
cumstances.
Supporting patient and provider well-being—by expanding access to behavioral
health care and psychosocial support for patients; and enhancing training and sup-
port for care teams, which have been disrupted by staffing changes and burnout in
the face of the pandemic.
Additional recommendations related to Cancer Care Delivery can be found in the
Road to Recovery Report.1
Below, ASCO outlines recommendations for regulatory policies implemented tempo-
rarily during the PHE to be permanently implemented.
A. Telemedicine—Generally, ASCO supports the flexibility CMS has imple-
mented to ensure telemedicine is available to more practitioners and
patients during the COVID–19 PHE, and we urge CMS to extend those
expanded telemedicine policies after the expiration of the PHE. In addi-
tion to Medicare beneficiaries, we support the permanent implementa-
tion of these policies for Medicare Advantage as well as Medicaid enroll-
ees.
4—Notification of Enforcement Discretion for Telehealth Remote Communica-
tions
ASCO supports the use of HIPAA compliant audio/visual technology after the expira-
tion of the PHE.
Privacy and data security issues and concerns related to health care information
technology (HIT) have been key barriers to adoption of telemedicine and impact the
confidence of patients and practitioners using these tools. As the use of telemedicine
continues to increase, it will necessarily generate large quantities of personal health
information and data, highlighting the need for data protection. Clear direction on
the application of HIPAA requirements and necessary liability protections for pro-
viders is needed.2
111—Communication Technology Based Services (CTBS); and
112—Direct Supervision by Interactive Telecommunications Technology
ASCO supports the permanent implementation of policies allowing the provision and
reimbursement of CTBS for new and established patients. Additionally, ASCO sup-
ports permanent implementation of provisions allowing direct supervision through
interactive telecommunications technology. However, ASCO does not support direct
supervision through interactive telecommunications technology in the context of home
infusion for anti-cancer therapies outside of the PHE.
Mitigating the need for an in-person visit is critical for cancer patients, who are at
an increased risk during the PHE, but may also experience similar risks because
of compromised immune systems during cancer treatment. Allowing both new and
established patients use of CTBS to access necessary care during brief communica-
1 https://ascopubs.org/doi/full/10.1200/JCO.20.02953.
2 https://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/docu-
ments/2020-ASCO-Interim-Position-Statement-Telemedicine-FINAL.pdf.
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177
tion mitigates the need for an in-person visit that could represent an exposure risk.
Granting physicians flexibility to provide clinically appropriate and high-quality
care to these beneficiaries via telemedicine can help keep these vulnerable patients
in their homes, reducing unnecessary exposure to all illnesses, not just COVID–19.
Regarding direct supervision for home infusion of anti-cancer therapies, ASCO be-
lieves that guardrails need to be in place as this temporary policy introduces the
potential for risk.3 There is a paucity of evidence directly comparing the safety of
chemotherapy infusions in the home with treatments delivered in outpatient set-
tings. Most of the literature examines home infusion in general, which is of limited
utility given the toxicity and hazardous materials specific to chemotherapy. How-
ever, multiple criteria in ASCO’s existing safety standards may be difficult to satisfy
in the home infusion context. For example, safety principles emphasize using more
than one practitioner to verify and document patient name, drug name, dosage, in-
fusion volume, route/rate of administration, etc., to minimize errors and prevent pa-
tient harm. Within a health-care setting additional trained staff are available for
such verification. In the home infusion setting, these verifications need to be per-
formed virtually and with multiple forms of identification, as sending multiple
health workers to supervise home infusions may not be practical or feasible. Most
importantly, certain adverse events that may quickly escalate and become life-
threatening emergencies may not be able to be safely resolved in the patient’s
home.4
In addition to safety concerns outlined above, there are workforce and reimburse-
ment issues that present challenges with home infusion of anticancer therapy. An
oncology nurse in a clinical setting can safely supervise infusion of multiple patients
at once, compared to single-patient oversight in the home setting. There may there-
fore be insufficient oncology nursing expertise to widely adopt home infusion and
substituting generalist infusion nurses does not provide the same level of patient
safety.5
113—Telephone Evaluation and Management (E/M) Services Codes
ASCO supports the implementation of permanent policies to allow Telephone Evalua-
tion and Management Services. ASCO encourages Policymakers and payers at the
national and state levels to ensure robust, adequate reimbursement and coverage of
telemedicine for care delivery via audio and /or audio and visual formats regardless
of site of service.6
State and federal policymakers should make permanent coverage and reimburse-
ment for audio- visual and when appropriate, audio-only services and continue to
expand coverage for all modes of delivery of telemedicine. The lack of broadband
and /or access to technology for both patients and physicians will not be limited to
the time during the PHE; therefore, we urge that all respective agencies extend
these regulatory changes beyond the PHE. Patient populations who lack computer
skills or broadband access could potentially benefit especially from audio-only serv-
ices.7
ASCO is committed to supporting efforts that ensure oncologists have the resources
they need to provide high-quality cancer care regardless of where that care is deliv-
ered; therefore, we believe CMS should cover and reimburse audio-only services.
Analysis of data from ASCO practices shows that of all services provided through
technology-based communications from mid-March through mid-June, audio-only
visits make up 35%–50% of these technology-based visits; virtual check-ins made up
less than 1%.8 Cancer patients are relying heavily on audio-only E/M services and
need CMS to ensure they have access to the care they need.
ASCO’s Policy Statement on Cancer Disparities and Health Equity commits ASCO
to ‘‘support and promote policies, systems, environments, and practices to address
persistent barriers to equitable receipt of high-quality cancer care across the care
3 https://www.asco.org/sites/new-www.asco.org/files/content-files/2020-COVID19-IFC1-Com-
ment-Letter.pdf.
4 https://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/docu-
ments/2020_Home-Infusion-Position-Statement.pdf.
5 https://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/docu-
ments/2020_Home-Infusion-Position-Statement.pdf.
6 https://ascopubs.org/doi/pdf/10.1200/jco.2008.21.1680.
7 https://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/docu-
ments/2020-ASCO-Interim-Position-Statement-Telemedicine-FINAL.pdf.
8 https://www.asco.org/sites/new-www.asco.org/files/content-files/practice-and-guidelines/
documents/2020-PracticeNET-COVID19-Insights.pdf.
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continuum.’’9 CMS should work to promote health equity through encouraging the
use of telemedicine in all care settings, including but not limited to rural and safety
net providers. CMS should cover and reimburse audio-only services in order to pre-
vent the unintentional exacerbation of health inequities.
While we agree with the agency that telehealth platforms incorporating both audio/
visual two-way communication—when available—is preferred, there are instances
when this is not possible. This lack of access to technology, often impacting patients
vulnerable to other disparities in care, will not be limited to the time during the
PHE; therefore, we urge the agency to permanently cover and reimburse audio-only
services beyond the PHE.10
115—Use of Telecommunications Technology Under the Medicare Home Health
Benefit
ASCO supports CMS’ proposal to permit patient services and /or monitoring per-
formed through telecommunication technology on a permanent basis when such serv-
ices are included as part of the home health plan of care.
ASCO supports CMS’ proposal to make this temporary flexibility provided during
the COVID–19 PHE a permanent part of the Medicare home health program. This
proposal will ensure patient access to the latest technology and give home health
agencies the confidence that that they can continue to use telecommunications tech-
nology as part of patient care beyond the PHE. Cancer patients, because they are
often immuno-compromised, are an especially vulnerable subset of the Medicare
population. Granting HHAs the flexibility to provide clinically appropriate and high-
quality care to these beneficiaries through technology can help keep these vulner-
able patients in their homes, reducing unnecessary exposure to all illnesses, not just
COVID–19.11
122—Physician Supervision Flexibility for Outpatient Hospitals—Outpatient Hos-
pital Therapeutic Services Assigned to the Non-surgical Extended Duration Thera-
peutic Services (NSEDTS) Level of Supervision
We believe this flexibility to change the generally applicable minimum required
level of supervision for hospital outpatient therapeutic services from direct super-
vision to general supervision for services furnished by all hospitals and critical ac-
cess hospitals (CAHs) may have many positive effects on physician workload. Per-
manent implementation could allow physicians to devote more time to clinical work
and allow more flexibility on the part of cancer clinics to provide more timely care.
ASCO remains committed to ensuring that cancer patients have access to high qual-
ity and safe care. While we support CMS’s proposal, we urge CMS to carefully mon-
itor its implementation to ensure that it does not unintentionally place some pa-
tients at elevated risk for medical errors.
125—Payment for Medicare Telehealth Services Under Section 1834(m) of the Act;
and 149—Updating the Medicare Telehealth List on a Sub-regulatory Basis
ASCO supports the permanent coverage and inclusion of additional services on the
Medicare telehealth list, and we encourage CMS to continue soliciting stakeholder
comments and feedback regarding potential future additions.
In our interim position statement,12 ASCO urges CMS to extend the expanded tele-
medicine policies after the expiration of the PHE. We support the permanent and
temporary addition of services to the telehealth list, as this has the potential to in-
crease access to services for cancer patients.
Additionally, ASCO urges CMS to evaluate the safety, quality of care, and outcomes
resulting from telehealth visits and to consider such evidence and specialty input
when considering additions in future rulemaking.13 Since CMS has the authority to
add services to the list of covered Medicare telehealth services, we support updates
9 https://ascopubs.org/doi/pdf/10.1200/jco.2008.21.1680.
10 https://www.asco.org/sites/new-www.asco.org/files/content-files/ASCO-MPFS-QPP-2021-
Comments.pdf.
11 https://www.asco.org/sites/new-www.asco.org/files/content-files/2020-2021-Home-Health-
Comment-Letter.pdf.
12 https://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/doc-
uments/2020-ASCO-Interim-Position-Statement-Telemedicine-FINAL.pdf.
13 https://www.asco.org/sites/new-www.asco.org/files/content-files/ASCO-MPFS-QPP-2021-
Comments.pdf.
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to the Medicare Telehealth list on a sub-regulatory basis where there is dem-
onstrated clinical benefit to the patient and other requirements are met.
B. Testing/PPE—ASCO supports long-term and widespread distribution of
any COVID–19 testing, treatment, or vaccine, to ensure accessibility to
health-care providers and disadvantaged populations. ASCO urges the
Agency to consider prioritizing resources in a transparent and ethical
way.
74—Policy for Coronavirus Disease 2019 Tests During the Public Health Emer-
gency (Revised)
ASCO believes there is a need for FDA premarket regulatory review for high risk
tests in addition to CMS CLIA oversight. Physicians rely on high quality and ac-
curate tests to appropriately diagnose and treat patients. There is also a need
for flexibility in the review and approval of these tests particularly to inform
cancer treatment planning. This flexibility is particularly important in oncology,
as new information develops rapidly and is disseminated widely, leading to de-
mand by both physicians and patients for new tests that impact medical deci-
sion-making.
C. Access—As the leading organization for physicians and oncology profes-
sionals caring for people with cancer, ASCO is committed to promoting
access to high quality, high value cancer care.
29—Notifying FDA of a Permanent Discontinuance or Interruption in Manufac-
turing Under Section 506C of the FD&C Act Guidance for Industry;
30—Exemption and Exclusion from Certain Requirements of the Drug Supply
Chain Security Act During the COVID—19 Public Health Emergency; and
61—Notifying CDRH of a Permanent Discontinuance or Interruption in Manu-
facturing of a Device Under Section 506J of the FD&C Act During the COVID–
19 Public Health Emergency
ASCO supports the continuation of policies to enhance transparency in the drug
supply chain, assess and strengthen the Food and Drug Administration’s (FDA)
efforts to prevent shortages, and empower the FDA to have drug makers identify
and address vulnerabilities in the supply chains to ensure access to critical medi-
cations.
The spread of novel viruses such as COVID–19, and natural disasters such as
hurricanes, have highlighted vulnerabilities in the drug supply chain that can
lead to significant shortages of critical medications throughout the world. United
States drug manufacturers currently rely on China for a majority of their active
pharmaceutical ingredients, and this issue is being highlighted by the current
COVID–19 epidemic. A disruption in the supply chain, whether caused by manu-
facturing or quality issues, will likely leave many patients without the critical
medications they need.
ASCO urges CMS to make permanent policies that would ensure information
about shortages is publicly available. Providing the FDA with the necessary au-
thority to ensure that drug makers increase transparency in their supply chains
and identify and address potential manufacturing and quality issues, is critical
to guaranteeing patient access to needed medications.
221—Part D ‘‘Refill-Too-Soon’’ Edits and Maximum Day Supply;
226—Prior Authorization;
227—Home or Mail Delivery of Part D Drugs;
285—Prior Authorization [Medicare Advantage]; and
288—Prior Authorization for Part D Drugs.
ASCO urges HHS to implement long-term policies to eliminate longstanding bar-
riers to access associated with utilization management policies within the Medi-
care program, including Medicare Advantage and Medicare Part D, as well as
Medicaid.
ASCO has always advocated for adherence to high quality clinical pathways as
a mechanism to drive appropriate use of medications, rather than arbitrary utili-
zation management policies that largely focus on cost rather than clinical evi-
dence. Temporary policies during the pandemic have relaxed certain utilization
management strategies during the pandemic. ASCO appreciates the relaxation
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of policies like ‘‘refill-too-soon’’ edits, giving patients the ability to obtain the
maximum extended day supply available under their plan to allow an uninter-
rupted supply of critical medications. This is critical support at a time when dis-
ruptions to routine care may be expected.14 However, despite the attempt to
relax utilization policies, ASCO members report they still experienced significant
delays in care resulting from prior authorization requirements, particularly re-
lated to imaging. The pandemic has highlighted the need for permanent solu-
tions to utilization barriers. ASCO continues to work with the AMA and others
to achieve reforms related to utilization management. We call on the Agency to
put renewed emphasis on addressing this longstanding and increasing burden on
patients and their providers.
Restrictive networks and requirements for patients to use designated specialty
pharmacies for Part D drugs can impair patient care and access. Patients with
cancer should be allowed to seek the services of their preferred pharmacy, in-
cluding dispensing physicians. For cancer patients, this is important as some
studies have suggested that practices with medically integrated services may im-
prove patient adherence to treatment regimens.
D. Quality Payment Program—ASCO encourages the Agency to continue
flexibilities in quality reporting across all programs for two years, al-
lowing these flexibilities to remain in effect through performance year
2022. This offers critical time for physician practices to adjust and begin
to recover from the repercussions of the COVID–19 pandemic.
106—Merit-based Incentive Payment System (MIPS) Updates
ASCO supports the flexibilities provided to MIPS eligible clinicians to receive
hardship exemptions for performance years 2020 and 2021. We encourage the
Agency to enable these flexibilities through performance year 2022 to allow prac-
tices to recover from the impact of the PHE.
ASCO thanks CMS for recognizing that during this public health crisis it may
be challenging or impossible for physicians, groups, and virtual groups to meet
the data submission deadline due to circumstances beyond their control. We sup-
port flexibilities provided to MIPS eligible clinicians and group practices to
choose to submit data or to apply for—and in some circumstances, receive auto-
matically—a hardship exemption. Allowing these flexibilities to remain in effect
through performance year 2022 will be important to recovery from the repercus-
sions of COVID–19 and to preserving access to care in communities across the
U.S.15
ASCO supports submission of patient data to a COVID–19 clinical data registry
for participation in Improvement Activity IA—ERP—3 and for extending this
through the 2021 performance period.
ASCO supports CMS’ designation of data entry to clinical registries as a quali-
fied Improvement Activity for clinicians who are caring for COVID-positive pa-
tients. ASCO established a COVID–19 registry to help the entire cancer commu-
nity learn about the pattern of symptoms and severity of COVID–19 among pa-
tients with cancer. The ASCO Registry is designed to collect both baseline and
follow-up data on how the disease impacts cancer care and cancer patient out-
comes during the COVID–19 pandemic—up to 12 months after a patient’s
COVID–19 diagnosis. Cancer patients with a COVID diagnosis are a special sub-
group of individuals whose clinical condition need to be understood to ensure ef-
fective treatment protocols and positive health outcomes. ASCO thanks CMS for
confirming that ASCO’s Survey on COVID–19 in Oncology Registry is an accept-
able registry for the attestation of this highly weighted practice improvement ac-
tivity.
ASCO supports the extension of this IA into 2021. It is likely that this improve-
ment activity will remain relevant throughout the next year and possibly beyond,
given the unknowns around how long the virus will persist in the community
and possible long-term effects stemming from infection. Given the impact the
coronavirus has on caring for cancer patients, it is imperative that oncologists
14 https://www.asco.org/sites/new-www.asco.org/files/content-files/2020-COVID19-IFC1-
Comment-Letter.pdf.
15 https://www.asco.org/sites/new-www.asco.org/files/content-files/2020-COVID19-IFC1-
Comment-Letter.pdf.
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submit meaningful improvement activity data that reflect real-world events and
that are of value to patients and clinicians.16
With the following recommendations, we aim to make cancer research opportunities
more accessible and equitable for patients in every community.
Part II: Clinical cancer research—Implementation of policies to ensure the clin-
ical trials system is more resilient and flexible, and more accessible to patients must
be a priority. Specifically:
Increase patient access and equity—by continuing remote and virtual ap-
proaches to consent, and other trial procedures; and by better integrating trials into
routine cancer care.
Increase trial efficiency—by streamlining and standardizing regulatory and
training requirements; and using central Institutional Review Boards and innova-
tive trial designs, including adaptive trials, master protocols, and common control
groups.
Increase flexibility so research will be more resilient in future crises—for
example, by ‘‘cross training’’ research teams so that key functions can be led by var-
ious team members; and by sustaining flexibility, adopted during the pandemic, for
site selection, initiation, and data collection.
ASCO also encourages the Agency to support enhanced data collection efforts to un-
derstand the impact of COVID–19 on patients with cancer, including its effect on
social determinants of health.
Additional recommendations related to Cancer Care Delivery can be found in the
Road to Recovery Report.
ASCO recommends the following policy be permanently implemented after the PHE.
33—Institutional Review Board (IRB) Review of Individual Patient Expanded Ac-
cess Requests for Investigational Drugs and Biological Products During the
COVID–19 Public Health Emergency.
ASCO continues to support the use of central IRBs as one way to promote effi-
ciency, oversight, and review of clinical trial conduct, reduce costs and eliminate
duplicative reviews by multiple institutions. During COVID–19, central IRBs
were important in expediting research on testing and treatment. ASCO supports
expanded access to address unmet needs for many patients and the approval to
access investigational therapies should continue to be done so with establish
standards of safety and efficacy.
Many of the flexibilities implemented during the PHE have indeed provided relief
in managing the unprecedented crisis presented by the COVID–19 pandemic. We
encourage the agency to make determinations regarding the future implication of
policies and practices based emerging data, and lessons learned, and the experiences
of patients, physicians, care teams and health systems, researchers, and research
programs during the COVID–19 pandemic. We thank you for the opportunity to pro-
vide feedback. Should you have any questions, please contact Gina Baxter at
gina.baxter@asco.org or Karen Hagerty at karen.hagerty@asco.org.
Sincerely,
Monica M. Bertagnolli, M.D., FACS, FASCO
Chair of the Board
ASSOCIATION OF AMERICAN MEDICAL COLLEGES
655 K Street, NW, Suite 100
Washington, DC 20001–2399
T 202–828–0400
https://www.aamc.org/
The AAMC (Association of American Medical Colleges) thanks the Senate Finance
Committee for convening the May 19 hearing, ‘‘COVID–19 Health Care Flexibilities:
Perspectives, Experiences, and Lessons Learned,’’ and for the opportunity to provide
written comments for inclusion in the public record.
The AAMC is a not-for-profit association dedicated to transforming health through
medical education, health care, medical research, and community collaborations. Its
16 https://www.asco.org/sites/new-www.asco.org/files/content-files/ASCO-COVID-19-
IFC3.Comment-Letter.pdf.
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members are all 155 accredited U.S. and 17 accredited Canadian medical schools;
more than 400 teaching hospitals and health systems, including Department of Vet-
erans Affairs medical centers; and more than 70 academic societies. Through these
institutions and organizations, the AAMC leads and serves America’s medical
schools and teaching hospitals and their more than 179,000 full-time faculty mem-
bers, 92,000 medical students, 140,000 resident physicians, and 60,000 graduate
students and postdoctoral researchers in the biomedical sciences.
The AAMC appreciates the work that this Committee, the Congress, and the Cen-
ters for Medicare and Medicaid Services (CMS) have done to provide important
flexibilities to ensure that providers can continue to deliver quality health care for
patients during the public health emergency (PHE). Many of these flexibilities have
proven to expand access to care and should continue to be integrated into the
health-care system beyond the end of the PHE. Specifically, the AAMC urges Con-
gress to:
• Remove patient location and rural site requirements to allow patients access to
telehealth visits in any location.
• Reimburse providers the same amount for telehealth services as in-person vis-
its.
• Allow Medicare payment for audio-only services.
• Allow patients to access telehealth services across state lines as appropriate.
• Allow for virtual supervision of residents by teaching physicians.
• Allow ‘‘authorized practitioners’’ to prescribe buprenorphine via telehealth.
• Improve access to broadband technology.
• Eliminate the skilled nursing facility (SNF) three-day prior hospitalization re-
quirement.
• Expand the delivery of inpatient care in patients’ homes.
• Consolidate all health-related waivers under the authority of the Health and
Human Services (HHS) Secretary.
Telehealth Flexibilities
Teaching hospitals, faculty physicians, and other providers have responded to the
PHE and the waivers and flexibilities provided by Congress by rapidly imple-
menting telehealth in their settings and practices in order to provide continued ac-
cess to medical care for their patients.Telehealth provides both patients and pro-
viders with a variety of benefits and expands access to care, especially to those in
rural and other underserved areas.
• Increased Access for Patients Improves Care: Data from the Clinical Prac-
tice Solutions Center (CPSC),1 which contains claims data from 90 physician
faculty practices, shows that in March and April 2020, faculty practices on aver-
age were providing approximately 50% of their ambulatory visits via telehealth,
a dramatic increase from the use of telehealth prior to the pandemic. This is
consistent with reports from CMS regarding telehealth services provided to
Medicare beneficiaries during that time frame.2 The use of telehealth expands
care for the frail or elderly, for whom travel to a provider or facility is risky
or difficult even when there is no pandemic. Telehealth also protects patients
from exposure to infectious diseases, including COVID–19 and the seasonal flu.
Physicians can effectively use telehealth to monitor the care of patients with
chronic conditions, such as diabetes and heart conditions, reducing their risk of
hospital admissions.
• Increased Access to Specialist Care: The use of telehealth enables special-
ists, such as pediatric specialists, cancer specialists, and critical care physicians,
to bring their skills to rural areas and other areas that may not have sub-
specialty care in their communities. Immediate availability of a pediatric infec-
tious disease specialist or a stroke critical care physician via telehealth can be
life saving for those in remote, rural, or small size communities. In addition,
telehealth can be used effectively to provide asynchronous consultation for front
line providers. Patients can benefit from more timely access to the specialist’s
guidance and payers benefit from a less costly service by avoiding the new pa-
tient visit with a specialist.
1 The Clinical Practice Solutions Center (CPSC), owned by the Association of American Med-
ical Colleges and Vizient, is the result of a partnership that works with member practice plans
to collect data on provider practice patterns and performance. This analysis included data from
65 faculty practices.
2 Health Affairs, Early Impact of CMS Expansion of Medicare Telehealth During COVID–19.
July 15, 2020. https://www.healthaffairs.org/do/10.1377/hblog20200715.454789/full/.
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• High Patient Satisfaction: Analyses of surveys of more than 30,000 patients
conducted by Press Ganey for services in March and April 2020 show that pa-
tients feel overwhelmingly positive about their virtual interactions with health-
care providers.3 According to a recent Health Affairs article, 79% of patient re-
spondents reported satisfaction with their telehealth visit and 78% felt that
their health concern could be addressed via telehealth.4
Due to statutory limitations, most of the current flexibilities are only in place until
the end of the PHE. The AAMC believes telehealth is an important method to de-
liver health care in many circumstances and urges Congress to make legislative
changes that would preserve these new practices and the gains we’ve made in tele-
health to date, and to ensure that reimbursement remains at a level that supports
the infrastructure needed to provide this level of telehealth services.
The AAMC recommends the following:
Congress Should Remove Patient Location Restrictions and Rural Site Re-
quirements
The AAMC strongly supports changes made by Congress that waived patient loca-
tion restrictions that applied to telehealth service during the PHE. These changes
have enabled CMS to pay for telehealth services furnished by physicians and other
health-care providers to patients located in any geographic location and at any site,
including the patient’s home, during the PHE. We also thank Congress for including
changes in the Consolidated Appropriations Act, 2021 that permanently allow pa-
tients to receive mental health services via telehealth regardless of the geographic
location requirements ordinately applicable to Medicare telehealth services.
These changes have allowed patients to remain in their home, reducing their expo-
sure to COVID–19 and reducing the risk of exposing another patient or their physi-
cian to COVID–19. Maintaining such a change even after the threat of the pandemic
is contained would allow patients who find travel to an in-person appointment chal-
lenging to receive vital care, especially for patients with chronic conditions or dis-
abilities who need regular monitoring. The AAMC encourages Congress to remove
the rural site requirements and allow the home to be an originating site.
Providers Should be Paid the Same Amount for Telehealth Services as
Services Delivered In-Person
The AAMC strongly recommends that providers be paid the same for furnishing
telehealth services as services delivered in person. The quality and cost of care de-
livered is not different if the patient is seen via telehealth. We recommend Congress
provide a facility fee under the outpatient prospective payment system for telehealth
services provided by physicians that would have been provided in the provider-based
entity.
Teaching hospitals and faculty practice plans have highlighted significant infra-
structure costs to fully integrate their electronic health record systems with HIPAA-
compliant telehealth programs. Physicians and hospitals employ medical assistants,
nurses, and other staff to engage patients during telehealth visits and to coordinate
care, regardless of whether the services are furnished in person or via telehealth.
Before the virtual visit occurs, the physicians and other health-care professionals
must be provided the technology they need and acquire a platform to use for the
visits. Other staff will contact patients to complete registration, obtain consent for
a telehealth visit, and ensure that the patient receives the email with a link to par-
ticipate in the virtual visit. In addition, staff will educate the patients on the use
of technology as needed to ensure they are able to participate in the visit.
On the day of the visit, clinical staff reach out to the patient to provide intake serv-
ices (e.g., ask for chief complaint, symptoms, weight, temperature and help the pa-
tient identify a review of current medications and therapies) prior to the patient
visit with the physician or health-care professional. The patient then participates
in the visit with the physician, and at the conclusion of the visit, the physician must
arrange any follow-up plan for the patient related to their care. Staff will follow-
up as needed to schedule any additional visits for the treating physician or sub-
specialty referral, tests, or laboratory studies.
3 Press Ganey, The Rapid Transition to Telemedicine: Insights and Early Trends. May 19,
2020. https://www.pressganey.com/resources/white-papers/the-rapid-transition-to-telemedicine-
insights-and-early-trends?s=White_Paper-PR.
4 ‘‘Congress: Act Now To Ensure Telehealth Access for Medicare Beneficiaries,’’ Health Affairs
Blog, May 10, 2021. https://www.healthaffairs.org/do/10.1377/hblog20210505.751442/full/.
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Without sufficient reimbursement, providers may no longer be able to continue to
provide the current level of telehealth services to their patients.
Congress Should Allow Payment for Audio-Only Services
CMS established a separate Medicare payment for specific audio-only services to
provide reimbursement at the same rates as in-person visits. However, the final
2021 physician fee schedule rule stated that this separate payment will no longer
exist after the PHE ends, since CMS does not have the statutory authority to allow
coverage and payment for telephone evaluation and management services.
Audio-only calls improve access to virtual care for patients who do not have access
to the devices or broadband for audiovisual calls, are not comfortable with digital
technology, or do not have someone available to assist them. During the PHE, cov-
erage and payment for audio-only calls has been critical to ensure access to care for
many patients. Physicians have been able to provide a wide array of services effi-
ciently, effectively, and safely to patients using the telephone.
Data from the CPSC shows that approximately 30% of telehealth services were pro-
vided using audio-only telephone technology in April and May 2020. The proportion
of telephone/audio-only visits increased with the age of the patient. CMS data show
that nearly one-third of Medicare beneficiaries received telehealth by audio-only
telephone technology from March through June 2020,5 which is consistent with
CPSC data.
Many factors contribute to the high use of audio-only services. Patients in rural
areas or those with lower socioeconomic status are more likely to have limited
broadband access and may not have access to the technology needed for two-way
audio-visual communication. The Pew Research Center found that about a third of
adults with household incomes below $30,000 per year do not own a smartphone
and about 44% do not have home broadband services.6
Some providers report that even when their patients have access to technology that
would allow for audio-visual communication, they may be unable to use the tech-
nology without assistance, thus limiting them to telephone use. For these patients,
the only option to receive services remotely is through a phone. Without coverage
and payment for these audio-only services, there will be inequities in access to serv-
ices for these specific populations. We urge Congress to permanently make changes
to allow coverage and payment for audio-only services.
Congress Should Allow Patients to Access Telehealth Services Delivered
Across State Lines
As part of the COVID–19 response, Congress and CMS have allowed providers to
be reimbursed by Medicare for telehealth services across state lines. This waiver
creates an opportunity to improve patient access to services and to help improve
continuity of care for patients who have relocated or who have traveled to receive
their surgery or other services from a specialist in another state. While CMS has
the authority to allow for payment under federal programs, states need to act to
allow practice across state lines to occur.
The AAMC urges Congress to pass the Temporary Reciprocity to Ensure Access to
Treatment Act (TREAT Act, S. 168, H.R. 708). This bipartisan, bicameral legislation
would expand care for patients by creating a temporary uniform licensing standard
for all practitioners and professionals that hold a valid license in good standing in
any state to be permitted to practice in every state—including in-person and tele-
health visits—during the COVID–19 public health emergency.
Congress Should Allow for Virtual Supervision of Resident Physicians
During the PHE, CMS has allowed resident physicians to furnish telehealth services
that are virtually supervised by the teaching physician. In the physician fee sched-
ule final rule, CMS states that this policy regarding telehealth will be allowed on
a permanent basis only in rural sites.
Resident education is a crucial step of professional development before autonomous
clinical practice and requires varying levels of faculty supervision depending on
5 ASPE issue brief: Medicare Beneficiary Use of Telehealth Visits: Early Data from the Start
of the COVID–19 Pandemic (7/18/2020); Health Affairs Blog; Early Impact of CMS Expansion
of Medicare Telehealth During COVID–19. July 15, 2020. https://www.healthaffairs.org/do/
10.1377/hblog20200715.454789/abs.
6 Pew Research Center, Digital divide persists even as lower-income Americans makes gains
in tech adoption. May 7, 2019. https://www.pewresearch.org/fact-tank/2019/05/07/digital-di-
vide-persists-even-as-lower-income-americans-make-gains-in-tech-adoption/.
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where the resident is in training and developing competency. As part of this devel-
opment, it is essential for residents to have the experience with telehealth visits
while supervised as they will be providing them in the future to their patients when
they practice autonomously.
The AAMC recommends that CMS allow residents to provide telehealth services
permanently while a teaching physician is present via real-time audio-visual com-
munications technology after the PHE ends in all regions of the country. This
change to CMS policy will improve patient access to care while also enhancing the
resident’s skills.
Congress Should Allow ‘‘Authorized Practitioners’’ to Prescribe Buprenor-
phine via Telehealth
The AAMC supports the Substance Abuse and Mental Health Services Administra-
tion’s and Drug Enforcement Agency’s temporary change to allow ‘‘authorized practi-
tioners’’ to prescribe buprenorphine to new and existing opioid use disorder patients
for maintenance or detoxification treatment via telehealth examination without the
need for a prior in-person visit. We urge Congress to make this change permanent
to ensure this important expansion is not limited solely to the current PHE.
Congress Should Takes Steps to Improve Access to Broadband Technology
In many parts of the country, providers and their patients have limited access to
broadband connectivity, which has been a major barrier to use of telehealth. This
is particularly true for rural areas and underserved communities. The Federal Com-
munications Commission has reported that 30% of rural residents lack broadband
services.7 Also, racial and ethnic minorities, older adults, and those with lower lev-
els of socioeconomic status are less likely to have broadband access. In order to ex-
pand access to telehealth and other important online services, we recommend that
Congress take steps to increase funding for broadband access and infrastructure de-
velopment.
Other Targeted Health Care Flexibilities
Eliminate the SNF three-day prior hospitalization requirement.
CMS has waived the requirement for a three-day prior hospitalization for coverage
of a SNF stay, which provides temporary emergency coverage of SNF services with-
out a qualifying hospital stay for those people who experience dislocations or are
otherwise affected by COVID–19. The AAMC supports this waiver and recommends
that the SNF three-day prior hospitalization requirement be eliminated perma-
nently to better coordinate and improve care for patients. Eliminating the three-day
stay would rely on physicians’ judgment to ensure that their patients receive the
most appropriate care in the most appropriate settings without creating the possi-
bility of an unforeseen financial burden on the patient.
Expand the Delivery of Inpatient Care in Patients’ Homes
CMS launched the Hospital Without Walls program in March 2020 to allow hos-
pitals to provide services beyond their existing walls to help address the need to ex-
pand care capacity and to develop sites dedicated to COVID–19 treatment. The
Acute Hospital Care At Home program is an expansion of this initiative that allows
eligible hospitals to have regulatory flexibility to treat certain patients, who would
otherwise be admitted to the hospital, in their homes and receive Medicare payment
under the Inpatient Prospective Payment System.
The Acute Hospital Care At Home program launched with six health-care systems
that have experience with providing acute hospital care at home. To date, 129 hos-
pitals within 56 systems located in 30 states—including many academic medical
centers—have received waivers from CMS to participate in the program.8 The in-
crease in hospital participation underscores the need for flexibility to meet the
health-care needs of certain patients without having to admit them into the inpa-
tient setting.
The AAMC supports the flexibility and benefits this program provides for patients
and urges Congress to maintain these flexibilities after the end of the PHE.
7 Federal Communications Commission, 2018 Broadband Deployment Report, February 2,
2018. https://www.fcc.gov/reports-research/reports/broadband-progress-reports/2018-broad
band-deployment-report.
8 Updated as May 14, 2021. Updated list available at: https://qualitynet.cms.gov/acute-hos-
pital-care-at-home/resources.
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Consolidate All Health-Related Waivers Under the Authority of the HHS
Secretary
The AAMC is appreciative of the temporary health care-related regulatory flexibili-
ties and emergency authorities granted by the federal government in response to the
coronavirus. These flexibilities have been granted by the White House, HHS, and
CMS, among others. To better coordinate these flexibilities, the AAMC recommends
that all health-related waivers be consolidated under the authority of the HHS Sec-
retary.
For example, Section 1135 waivers have offered essential relief and assistance for
health-care providers during the pandemic by relaxing several requirements, includ-
ing practice across state lines and timelines for federal reporting requirements. For
the 1135 waivers to remain in effect, both a public health emergency and a national
emergency must be declared by the HHS Secretary and President, respectively. The
AAMC recommends that all health-related flexibilities be under the direction of the
HHS Secretary, and not reliant upon the declaration of a national emergency.
Conclusion
The AAMC is very grateful for the work that this Committee, the Congress, and the
Administration have done to provide important flexibilities to allow for the expan-
sion of health-care delivery during the COVID–19 pandemic. We appreciate that the
Senate Finance Committee is reviewing many of these flexibilities and thinking
about how to incorporate them into the health-care system beyond the end of the
public health emergency.
Please feel free to contact AAMC Chief Public Policy Officer Karen Fisher, JD
(kfisher@aamc.org) or AAMC Senior Director of Government Relations Leonard
Marquez (lmarquez@aamc.org) with any questions or if we can provide more infor-
mation. We look forward to continuing to work with you on these important issues.
BETTER MEDICARE ALLIANCE
1411 K Street, NW, Suite 1400
Washington, DC 20005
202–735–0037 (office)
202–885–9968 (fax)
BetterMedicareAlliance.org
Statement of Allyson Y. Schwartz, President and CEO
Better Medicare Alliance, on behalf of our Alliance and the 26 million beneficiaries
enrolled in Medicare Advantage, is pleased to submit the following statement for the
record related to the May 19, 2021 Committee on Finance hearing titled COVID–
19 Health Care Flexibilities: Perspectives, Experiences, and Lessons Learned.
Better Medicare Alliance is a community of 160 ally organizations and more than
500,000 grassroots beneficiary advocates who value Medicare Advantage and the af-
fordable, high-quality, coordinated care it provides to over 26 million beneficiaries.
Together, our diverse alliance of health plans, provider groups, aging service organi-
zations, and beneficiaries share a commitment to ensuring Medicare Advantage is
a high-quality, cost-effective option for current and future beneficiaries.
As a public-private partnership where seniors and individuals with disabilities re-
ceive Medicare benefits through a private integrated managed care plan, Medicare
Advantage plans are paid a capitated monthly amount per beneficiary by the Cen-
ters for Medicare and Medicaid Services (CMS). The health plans then take full fi-
nancial risk for care and services to enrollees. Capitated payments are determined
six months prior to the start of the contract year and are used to provide coverage
of health-care benefits to enrolled beneficiaries. Payments are adjusted by the
health status of each beneficiary to ensure health plans receive adequate payment
to cover the costs of all beneficiaries.
To ensure the capitated payments reflect the health status and demographic charac-
teristics of individual beneficiaries, payment to Medicare Advantage plans are risk
adjusted using demographic and diagnostic information. Risk assessment is required
annually for each beneficiary to calculate a risk score that predicts costs for the up-
coming year. For the risk adjustment process to function properly, it is necessary
to collect data on beneficiaries each year through in-person office visits, telehealth
visits, or in-home health risk assessments. Accurate documentation of diagnoses by
clinicians is a critical component of the risk adjustment process and ensures bene-
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ficiaries receive the appropriate care management and quality of services based on
their conditions.
Transition to Telehealth During COVID–19 Pandemic
The COVID–19 pandemic, stay-at-home guidance, and advice to avoid clinical in-
person settings unless necessary, particularly for at-risk populations like those over
65 years old and those with chronic conditions, led to a nationwide avoidance of in-
person clinical care and delay of elective services. Among Medicare beneficiaries, 8
percent report forgoing care despite needing health-care services because of the pan-
demic.1 Reports like this highlight the importance of providing patients access to
health-care services outside the physician office and resulted in a dramatic and
rapid transition of clinical care being offered through telehealth visits starting in
2020. The use of telehealth visits has contributed meaningfully to allowing providers
and health plans to reach out to beneficiaries and replace in-person visits—ensuring
those with new medical concerns and those with ongoing chronic conditions have
been able to interact with their providers to manage their health. Yet, while pro-
viders and health plans work together to provide needed care and reduce the impact
of this pandemic for their patients, utilization of care and services was significantly
lower in 2020 and has not yet fully returned to pre-pandemic levels.2
Between May 2019 and June 2020, the University of Michigan’s National Poll on
Healthy Aging found telehealth visit participation increased from 4 percent to 30
percent, respectively, among older adults.3 The same poll found the number of pro-
viders offering telehealth services increased from 14 percent to 62 percent during
the same period of time.4 More recently, CMS found 64 percent of Medicare bene-
ficiaries report their provider currently offers telehealth visits, and 45 percent had
a telehealth visit since July 2020.5
In Medicare Advantage, recent polling shows 40 percent of beneficiaries used tele-
health services during the pandemic and gave the experience a 91 percent satisfac-
tory rating.6 The risk-bearing payment arrangements in Medicare Advantage fur-
ther facilitated the implementation and expansion of telehealth visits during the
pandemic. Compared to Traditional fee-for-service (FFS) Medicare, Medicare Advan-
tage had a quicker transition to telehealth visits.7 Looking forward, 48 percent of
people 65 years and older report a willingness to use telehealth despite not having
used telehealth before, and 35 percent expect to use telehealth with more frequency
in the future.8
Impact on Risk Adjustment
Medicare Advantage is unique in requiring an accurate assessment of each
beneficiary every year to determine their health conditions and ensure risk
adjusted payments reflect a beneficiary’s current diagnoses and conditions.
It is critical to make use of the tools available to obtain this data.
Action has been taken by CMS to permit data obtained during audio-video tele-
health visits to provide diagnoses for risk assessment, but the same is not allowed
for data obtained during audio-only visits. Better Medicare Alliance urges Congress
to address this inequity and permit the same use for audio-only telehealth visits.
There are numerous reasons to support this allowance, most prominently because
beneficiaries do not have equal ability or equivalent access to the technology needed
for audio-video visits. Moreover, providers use audio-video and audio-only telehealth
visits interchangeably to account for patient preference or capabilities. The distinc-
tion for risk assessment purposes inhibits the ability of providers to utilize these
patient visits to obtain data required under Medicare Advantage.
1 https://www.cms.gov/files/document/medicare-current-beneficiary-survey-covid-19-data-
snapshot-infographic-fall-2020.pdf .
2 https://www.healthsystemtracker.org/chart-collection/how-have-healthcare-utilization-and-
spending-changed-so-far-during-the-coronavirus-pandemic/#item-covidcostsuse_marchupdate_3.
3 https://www.healthyagingpoll.org/report/telehealth-use-among-older-adults-and-during-
covid-19.
4 Id.
5 https://www.cms.gov/files/document/medicare-current-beneficiary-survey-covid-19-data-
snapshot-infographic-fall-2020.pdf.
6 https://bettermedicarealliance.org/wp-content/uploads/2021/01/BMA_Seniors-on-Medicare-
Memo_.pdf.
7 https://bettermedicarealliance.org/wp-content/uploads/2020/07/CIMA-July-2020-Tele-
health-Report-FIN.pdf.
8 https://static.americanwell.com/app/uploads/2020/09/Amwell-2020-Physician-and-Con-
sumer-Survey.pdf.
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188
Omitting the use of data obtained during audio-only telehealth visits un-
reasonably limits the use of available, timely, and clinically accurate data
on these patients that could be used to provide the required information
for millions of Medicare beneficiaries. Without this information, the data re-
quired by CMS to inform adequate payment based on health status will be incom-
plete and may impact payment stability for health plans and providers in subse-
quent years, as well as out-of-pocket costs and supplemental benefits for bene-
ficiaries.
Better Medicare Alliance appreciates the opportunities provided to Medicare Advan-
tage plans to offer telehealth visits and provide audio-video devices to beneficiaries.
Over the last year, health plans and providers have been able to routinely hold vir-
tual visits with beneficiaries to ensure those most at risk due to chronic conditions
have the attention and medications they need. In addition, health plans and pro-
viders have been able to assess general wellness and identify and address social risk
factors as part of care management available in Medicare Advantage. Medicare Ad-
vantage has been a leader in the rapid transition to telehealth and in providing at-
tention to non-clinical needs of beneficiaries to better help beneficiaries maintain
their health and well-being during this unprecedented public health emergency.
Telehealth has ensured continuity of care for millions of Medicare Advantage bene-
ficiaries during COVID–19.
Barriers to Use of Telehealth Visits
The transition to virtual visits accelerated by the pandemic has revealed
the reality that many older, lower-income, and rural seniors lack the tools
or access necessary to complete audio-video telehealth visits.9
The rapid uptake in telehealth visits showed the flexibility and innovation of health
plans, providers, and beneficiaries during this critical time. Nevertheless, the transi-
tion is not without barriers, and the distinction between audio-video and audio-only
visits has highlighted the disparities present in telehealth. Though half of people
over age 65 are willing to try telehealth, many beneficiaries have limitations that
inhibit the use of audio-video telehealth visits.10 The reasons vary, but the potential
barriers must be considered to ensure over 26 million Medicare Advantage bene-
ficiaries continue to receive care without disruption.
Beneficiaries must be able to access the technology and devices necessary for tele-
health visits. Access also includes having adequate Internet, financial means, and
functional and cognitive ability. Together, such limitations of access inhibit a bene-
ficiary’s use of telehealth visits, specifically audio-video visits. While 92 percent of
seniors own a cellphone, only 61 percent have a smartphone.11 The distinction be-
tween having a cellphone and smartphone is important because unlike cellphones,
smartphones have the video capability necessary for an audio-video telehealth visit.
Lower income beneficiaries are less likely to have a smartphone, further limiting ac-
cess to audio-video telehealth visits.12 A recent study found 32 percent of people 65
and older do not have a smartphone, tablet, or computer with Internet access at
home.13
According to the FCC’s 2018 Broadband Deployment Report, 24 million Americans
do not have access to broadband Internet at the benchmark speed of 25 Mbps/
3Mbps, which is considered the minimum speed standard and offers good Internet
access. Additionally, the same report found rural areas lag behind urban areas in
the deployment of mobile broadband and fixed broadband with 68.6 percent of peo-
ple in rural areas having access to both compared to 97.9 percent in urban areas.14
Limited, or inadequate access to Internet prevents beneficiaries from using audio-
video telehealth visits.
Access problems are not limited to the Internet or devices, as some beneficiaries
with functional or cognitive impairments are unable to utilize audio-video tech-
9 https://bettermedicarealliance.org/wp-content/uploads/2020/07/CIMA-July-2020-Tele-
health-Report.pdf.
10 https://static.americanwell.com/app/uploads/2019/07/American-Well-Telehealth-Index-
2019-Consumer-Survey-eBook2.pdf.
11 https://www.pewresearch.org/Internet/fact-sheet/mobile/.
12 https://bettermedicarealliance.org/wp-content/uploads/2020/07/CIMA-July-2020-Tele-
health-Report.pdf.
13 https://www.kff.org/policy-watch/possibilities-and-limits-of-telehealth-for-older-adults-dur-
ing-the-covid-19-emergency/.
14 https://www.fcc.gov/reports-research/reports/broadband-progress-reports/2018-broadband-
deployment-report.
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nology. These beneficiaries prefer audio-only over audio-video telehealth visits. Oth-
ers may be limited by financial constraints that prevent them from purchasing the
necessary devices and Internet services. Research found 34 percent of Medicare Ad-
vantage beneficiaries living under the Federal Poverty Level reported no Internet
usage at all.15
In addition, not all beneficiaries are comfortable with the necessary technology used
for audio-video visits. Nearly seven in ten adults 65 and older say they have a com-
puter, smart phone, or tablet with Internet access at home, but only 11 percent say
they have recently used a device to talk to a health-care provider through an audio-
video visit.16 During COVID–19, a survey of more than 1,000 Medicare Advantage
beneficiaries in December 2020 found 40 percent used telehealth during the pan-
demic, an increase from 24 percent in May 2020.17 However, nearly one-third of
beneficiaries said they are uncomfortable using telehealth.18
Lack of experience or comfort using audio-video technology appears to influence sen-
iors’ preference for audio-only because even those who are willing to use telehealth
often choose audio-only rather than audio-video visits. When given the option, 60
percent of Medicare Advantage beneficiaries prefer the telephone over other tech-
nology.19 Health providers are also reporting the usage of audio-only telehealth vis-
its is vastly higher than audio-video telehealth visits. Security Health Plan reported
75 percent of their telehealth visits as audio-only, and Kaiser Permanente reported
85 percent of their telehealth visits as audio-only. CMS found nearly one-third of
telehealth visits with Medicare beneficiaries between mid-March and mid-June 2020
were conducted by audio-only telephone.20 This is equivalent to over 3 million visits
and indicates a preference for audio-only telehealth visits.
More recent data show a majority, or 56 percent, of Medicare beneficiaries that had
a telehealth visit since July 2020 used audio-only telephone for their visit while only
28 percent used video and 16 percent used both telephone and video.21 The share
of Medicare beneficiaries that used audio-only for their telehealth visit was higher
among certain demographics, including beneficiaries 75 years or older (65 percent),
enrolled in both Medicare and Medicaid (67 percent), or living in rural areas (65
percent).22 Additionally, the share of Hispanic (61 percent) and non-Hispanic Black
(61 percent) beneficiaries using audio-only telehealth visits is higher than White
beneficiaries (54 percent).23 The differences among demographics further highlight
the disparities present in telehealth and illustrate the impact omitting data ob-
tained during audio-only telehealth visits may have on Medicare Advantage bene-
ficiaries.
Action Needed to Address Constraints on Use of Audio-Only Telehealth Vis-
its
The public health emergency has led to the recognition of the need to
eliminate barriers and burdens in accessing clinically appropriate care, es-
pecially for those in the Medicare Advantage population. The importance
of telehealth visits during the pandemic in 2020 and 2021 is unquestionable
and calls for Congress to take action to eliminate the unnecessary and po-
tentially harmful constraints on the assessment and documentation of cur-
rent health status to ensure the continuity of care for millions of people.
Bipartisan legislation introduced in the Senate, the Ensuring Parity in Medicare
Advantage and PACE for Audio-Only Telehealth Act of 2021, acknowledges and ad-
dresses the disparities in the use of telehealth visits for data collection essential for
risk assessments. Audio-only telehealth has proven to be an extremely valuable tool
to ensure ongoing care is available during this unprecedented national public health
emergency to beneficiaries who cannot access or use audio-video technology. Clini-
15 https://bettermedicarealliance.org/wp-content/uploads/2020/07/CIMA-July-2020-Tele-
health-Report-FIN.pdf.
16 https://www.kff.org/policy-watch/possibilities-and-limits-of-telehealth-for-older-adults-dur-
ing-the-covid-19-emergency/.
17 https://bettermedicarealliance.org/news/poll-seniors-give-telehealth-high-marks-medicare-
advantage-satisfaction-smashes-new-record-2/.
18 Id.
19 https://bettermedicarealliance.org/wp-content/uploads/2020/07/CIMA-July-2020-Tele-
health-Report-FIN.pdf.
20 https://www.healthaffairs.org/do/10.1377/hblog20200715.454789/full/.
21 https://www.kff.org/medicare/issue-brief/medicare-and-telehealth-coverage-and-use-during-
the-covid-19-pandemic-and-options-for-the-future/.
22 Id.
23 Id.
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190
cians have been conducting audio-only visits in response to the needs and abilities
of beneficiaries and these visits have been vital to the provision of necessary ongoing
care for beneficiaries. Earlier research showed that telehealth visits produce similar
outcomes as face-to-face appointments for chronic care management and the diag-
noses and treatment were also equivalent. Research also shows that risk scores do
not fluctuate much year over year.24 Excluding clinical data from audio-only visits
that may not have been obtained otherwise means the data may be entirely absent
for those beneficiaries utilizing audio-only visits, despite being available for report-
ing in each year of the pandemic.
Call for Congress to Act
Data obtained during audio-only visits should be permitted to be used for
risk adjustment purposes as it is essential for accurate risk adjustment for
beneficiaries in the following year and may not have been collected in any
other way due to the pandemic. These visits are recognized as clinical encoun-
ters in every other sense, making it only reasonable for diagnoses obtained through
these patient-clinician encounters to be permitted to be used for risk adjustment.
By allowing audio-only visits during the ongoing pandemic to be used for risk as-
sessment purposes, the health and well-being of over 26 million Medicare Advantage
beneficiaries will be protected now and in the future. We strongly urge Congress to
take action that recognizes beneficiary circumstances with respect to and preference
for audio-only telehealth technology and necessitates the flexibility to use audio-only
technology in the collection of clinical and diagnostic data for risk adjustment pur-
poses.
Better Medicare Alliance thanks the Committee for the opportunity to submit these
comments. We recognize the sponsors of the legislation, Ensuring Parity in Medi-
care Advantage and PACE for Audio-Only Telehealth Act of 2021, for their leader-
ship. We hope to see the Committee consider this bill in the near future and support
its passage in the Senate. We welcome the opportunity to continue to engage with
the Committee on this important and timely issue.
CENTER FOR FISCAL EQUITY
14448 Parkvale Road, Suite 6
Rockville, MD 20853
fiscalequitycenter@yahoo.com
Statement of Michael G. Bindner
Chairman Wyden and Ranking Member Crapo, thank you for the opportunity to
submit these comments for the record to the Committee. These comments are simi-
lar to those provided on Telehealth to the Ways and Means Subcommittee on Health
on April 28, 2021.
Flexible health-care delivery, especially Telehealth is part of increased automation
in medicine. It began with electronic charting. The emergence of telehealth predates
the pandemic. It started as a cutting edge way for experts to consult on cases. In
recent years, it has included using radiologists in South Asia to read all manner
of X-Rays and scans, delivering a diagnosis to emergency rooms, urgent care and
doctor’s offices.
The question of taxation must be discussed at this point. Perhaps duties should be
included for such off-shore medicine. They certainly must be in the event value
added taxes are established in the United States. This would bring us into the
OECD norm. Senator Hatch has retired, so it is now safe to talk of such things.
If we adopt Medicare for All, such taxes would be counter-productive. Without some
kind of employer-paid subtraction value added tax, it is hard to see the creation of
an affordable public option, let alone Medicare for All. Part of any transition would
have to include an asset value added tax, which would include ending Pease and
Affordable Care Act SMI taxes on non-wage income over $200,000. See the attach-
ment for more information on these proposals.
The pandemic has made telemedicine the new normal. I will be glad to see it go,
or at least play a smaller role. It is hard to get a good medical history and list of
24 Flodgren G, Rachas A, Farmer AJ, Inzitari M, Sheppard S. Interactive telemedicine: effects
of professional practice and health-care outcomes. Cochrane Database of Systematic Reviews
2015, Issue 9. Art. No.: CD002098. DOI: 10.1002/14651858.CD002098.pub2 .
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symptoms on a video conference or phone call. People likely died, either of complica-
tions from the pandemic (like suicide) or SARS–Cov–2. This requires explanation.
The disease occurs in five phases. In phase one, the patient experiences symptoms
of a heavy cold which goes away after a week. This phase is largely ignored by the
medical community because it is impossible to get to see a doctor in person. To be
fair, most patients manage these symptoms with over-the-counter medication.
Symptoms last for a week. Phase two is asymptotic.
People believe they are well, even if they assume they were suffering from COVID.
In reality, most of the spread of the disease happens during phases one and two.
During this period, people do not have fevers, coughing and all but one of the symp-
toms which are used to screen for COVID.
The intense symptoms start with phase three (SARS2) or phase four (assuming indi-
viduals have some degree of immunity from pulmonary disease, or possess inhal-
ers—especially steroids—to manage them.
The patients who eventually die do not know that they have COVID. They
believe that symptoms will go away in a week, just as they did in phase
one. Access to primary care at this stage, as well as vital information on
the disease would have saved lives at this point. Add fear of dying of
COVID in the Intensive Care Unit and this fear became a self-fulfilling
prophesy.
The main feature of phase four is crushing fatigue, either from lung symptoms or
the development of immunity. These symptoms are a two week version of the reac-
tion to either the first shot (for people who have had the disease) or the booster (for
people who have not been sick previously).
Phase five is the long-term healing, which includes coughing up mucus. Medications,
such as Robitussin, are valuable for these symptoms. This phase takes a long time
to clear.
Deaths are still declining, as the current available vectors are less likely to die. For
a few weeks, they just wish they would. Younger patients are experiencing the third
wave. Minnesota, Michigan and Ontario are likely still experiencing their first wave.
This disease is spread by sneezing on people you know, usually at home or work.
It has spread from Seattle and New York to the rest of the nation, meeting in the
southwest and moving north. It is running out of places to go.
As more and more people get vaccinated or simply have the disease and recover,
it likely will disappear, like magic. When it does, we can get back to normal medical
practice. Quite a bit of care has been foregone during the pandemic. There is a lot
of catching up to do.
Thank you for the opportunity to address the committee. We are, of course, avail-
able for direct testimony or to answer questions by members and staff.
Attachment —Tax Reform, Center for Fiscal Equity, March 5, 2021
Individual payroll taxes. These are optional taxes for Old-Age and Survivors In-
surance after age 60 for widows or 62 for retirees. We say optional because the col-
lection of these taxes occurs if an income sensitive retirement income is deemed nec-
essary for program acceptance. Higher incomes for most seniors would result if an
employer contribution funded by the Subtraction VAT described below were credited
on an equal dollar basis to all workers. If employee taxes are retained, the ceiling
should be lowered to $85,000 to reduce benefits paid to wealthier individuals and
a $16,000 floor should be established so that Earned Income Tax Credits are no
longer needed. Subsidies for single workers should be abandoned in favor of radi-
cally higher minimum wages.
Wage Surtaxes. Individual income taxes on salaries, which exclude business taxes,
above an individual standard deduction of $85,000 per year, will range from 6.5%
to 26%. This tax will fund net interest on the debt (which will no longer be rolled
over into new borrowing), redemption of the Social Security Trust Fund, strategic,
sea and non-continental U.S. military deployments, veterans’ health benefits as the
result of battlefield injuries, including mental health and addiction and eventual
debt reduction. Transferring OASDI employer funding from existing payroll taxes
would increase the rate but would allow it to decline over time. So would peace.
Asset Value-Added Tax (A–VAT). A replacement for capital gains taxes, dividend
taxes, and the estate tax. It will apply to asset sales, dividend distributions, exer-
cised options, rental income, inherited and gifted assets and the profits from short
sales. Tax payments for option exercises and inherited assets will be reset, with
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192
prior tax payments for that asset eliminated so that the seller gets no benefit from
them. In this perspective, it is the owner’s increase in value that is taxed.
As with any sale of liquid or real assets, sales to a qualified broad-based Employee
Stock Ownership Plan will be tax free. These taxes will fund the same spending
items as income or S–VAT surtaxes. This tax will end Tax Gap issues owed by high
income individuals. A 26% rate is between the GOP 24% rate (including ACA–SM
and Pease surtaxes) and the Democratic 28% rate. It’s time to quit playing football
with tax rates to attract side bets.
Subtraction Value-Added Tax (S–VAT). These are employer paid Net Business
Receipts Taxes. S–VAT is a vehicle for tax benefits, including
• Health insurance or direct care, including veterans’ health care for non-
battlefield injuries and long term care.
• Employer paid educational costs in lieu of taxes are provided as either
employee-directed contributions to the public or private unionized school of their
choice or direct tuition payments for employee children or for workers (including
ESL and remedial skills). Wages will be paid to students to meet opportunity
costs.
• Most importantly, a refundable child tax credit at median income levels (with
inflation adjustments) distributed with pay.
Subsistence level benefits force the poor into servile labor. Wages and benefits must
be high enough to provide justice and human dignity. This allows the ending of
state administered subsidy programs and discourages abortions, and as such enact-
ment must be scored as a must pass in voting rankings by pro-life organizations
(and feminist organizations as well). To assure child subsidies are distributed, S–
VAT will not be border adjustable.
The S–VAT is also used for personal accounts in Social Security, provided that these
accounts are insured through an insurance fund for all such accounts, that accounts
go toward employee-ownership rather than for a subsidy for the investment indus-
try. Both employers and employees must consent to a shift to these accounts, which
will occur if corporate democracy in existing ESOPs is given a thorough test. So far
it has not. S–VAT funded retirement accounts will be equal-dollar credited for every
worker. They also have the advantage of drawing on both payroll and profit, making
it less regressive.
A multi-tier S–VAT could replace income surtaxes in the same range. Some will use
corporations to avoid these taxes, but that corporation would then pay all invoice
and subtraction VAT payments (which would distribute tax benefits. Distributions
from such corporations will be considered salary, not dividends.
Invoice Value-Added Tax (I–VAT). Border adjustable taxes will appear on pur-
chase invoices. The rate varies according to what is being financed. If Medicare for
All does not contain offsets for employers who fund their own medical personnel or
for personal retirement accounts, both of which would otherwise be funded by an
S–VAT, then they would be funded by the I–VAT to take advantage of border
adjustability. I–VAT also forces everyone, from the working poor to the beneficiaries
of inherited wealth, to pay taxes and share in the cost of government. Enactment
of both the A-VAT and I–VAT ends the need for capital gains and inheritance taxes
(apart from any initial payout). This tax would take care of the low-income Tax Gap.
I–VAT will fund domestic discretionary spending, equal dollar employer OASI con-
tributions, and non-nuclear, non-deployed military spending, possibly on a regional
basis. Regional I–VAT would both require a constitutional amendment to change the
requirement that all excises be national and to discourage unnecessary spending, es-
pecially when allocated for electoral reasons rather than program needs. The latter
could also be funded by the asset VAT (decreasing the rate by from 19.5% to 13%).
As part of enactment, gross wages will be reduced to take into account the shift to
S–VAT and I–VAT, however net income will be increased by the same percentage
as the I–VAT. Adoption of S–VAT and I–VAT will replace pass-through and propri-
etary business and corporate income taxes.
Carbon Value-Added Tax (C–VAT). A Carbon tax with receipt visibility, which
allows comparison shopping based on carbon content, even if it means a more expen-
sive item with lower carbon is purchased. C–VAT would also replace fuel taxes. It
will fund transportation costs, including mass transit, and research into alternative
fuels (including fusion). This tax would not be border adjustable.
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Summary
This plan can be summarized as a list of specific actions:
1. Increase the standard deduction to workers making salaried income of $425,001
and over, shifting business filing to a separate tax on employers and eliminating
all credits and deductions—starting at 6.5%, going up to 26%, in $85,000 brack-
ets.
2. Shift special rate taxes on capital income and gains from the income tax to an
asset VAT. Expand the exclusion for sales to an ESOP to cooperatives and in-
clude sales of common and preferred stock. Mark option exercise and the first
sale after inheritance, gift or donation to market.
3. End personal filing for incomes under $425,000.
4. Employers distribute the child tax credit with wages as an offset to their quar-
terly tax filing (ending annual filings).
5. Employers collect and pay lower tier income taxes, starting at $85,000 at 6.5%,
with an increase to 13% for all salary payments over $170,000 going up 6.5% for
every $85,000—up to $340,000.
6. Shift payment of HI, DI, SM (ACA) payroll taxes employee taxes to employers,
remove caps on employer payroll taxes and credit them to workers on an equal
dollar basis.
7. Employer paid taxes could as easily be called a subtraction VAT, abolishing cor-
porate income taxes. These should not be zero rated at the border.
8. Expand current state/federal intergovernmental subtraction VAT to a full GST
with limited exclusions (food would be taxed) and add a federal portion, which
would also be collected by the states. Make these taxes zero rated at the border.
Rate should be 19.5% and replace employer OASI contributions. Credit workers
on an equal dollar basis.
9. Change employee OASI of 6.5% from $18,000 to $85,000 income.
ERISA INDUSTRY COMMITTEE
701 8th Street, NW, Suite 610
Washington, DC 20001
Main 202–789–1400
http://www.eric.org/
Introduction and About ERIC
Chairman Wyden, Ranking Member Crapo, and members of the Committee, thank
you for this opportunity to submit a statement for the record on behalf of The
ERISA Industry Committee (ERIC) for the hearing entitled ‘‘COVID–19 Health Care
Flexibilities: Perspectives, Experiences, and Lessons Learned.’’ This is a critical
hearing, because the Senate Finance Committee’s jurisdiction far exceeds
Medicare—policies determined by this Committee govern the benefits pro-
vided by employers, especially as they affect the rules regarding high deductible
health plans (HDHPs) and the Affordable Care Act (ACA). Our statement details
ways that the Committee and Congress can take decisive action to consolidate the
telehealth gains made by private sector employers during COVID and consider ex-
panding telehealth policies to the private sector so that employees and their families
can access virtual care.
ERIC is a national nonprofit organization exclusively representing the largest em-
ployers in the United States in their capacity as sponsors of employee benefit plans
for their nationwide workforces. ERIC’s member companies voluntarily provide ben-
efits that cover millions of active and retired workers and their families across the
country. With member companies that are leaders in every sector of the economy
and with stores, factories, offices, warehouses, and other operations in every state,
ERIC is the voice of large employer plan sponsors on federal, state, and local public
policies impacting their ability to sponsor benefit plans and to lawfully operate
under ERISA’s protection from a patchwork of different and conflicting state and
local laws, in addition to federal law.
You are likely to engage with an ERIC member company when you drive a car or
fill it with gas, use a cell phone or a computer, watch TV, dine out or at home, enjoy
a beverage, fly on an airplane, visit a bank or hotel, benefit from our national de-
fense, receive or send a package, go shopping, or use cosmetics.
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ERIC member companies voluntarily offer comprehensive health benefits to millions
of active and retired workers and their families across the country. Our members
offer these great health benefits to attract and retain employees, be competitive for
human capital, and improve health and provide peace of mind. On average, large
employers pay around 85 percent of health-care costs on behalf of our bene-
ficiaries—that would be a gold or platinum plan if bought on anExchange. But we
don’t buy or sell health insurance; these plans are self-insured. In other words, ulti-
mately it is the company that is on the hook for the vast majority of the costs of
our patients’ care. Prior to COVID–19, there were an estimated 181 million Ameri-
cans who got health care through their job, with about 110 million of them in self-
insured plans like ours.
Employers like ERIC member companies roll up their sleeves to improve how health
care is delivered in communities across the country. They do this by developing
value-driven and coordinated care programs, implementing employee wellness pro-
grams, providing transparency tools, and adopting a myriad of other innovations
that improve quality and value to drive down costs. These efforts often use networks
to guide our employees and their family members to providers that offer high value
care. ERIC member companies’ ERISA plans are not subject to many of the state
and local requirements that apply to fully-insured products such as those sold on
an ACA Exchange, because employers do not profit from health benefits—in fact,
they’re a huge expense.
The entire purpose of these benefits is to meet the needs of plan beneficiaries. Large
employers have been essential in connecting employees and their families to pro-
grams and care such as through telehealth benefits. ERIC’s member companies have
been pioneers in offering robust access to telehealth. Telehealth enables our bene-
ficiaries to obtain the care they need, when and where they need it, affordably and
conveniently. It reduces the need to leave home or work and risk infection at a phy-
sician’s office, provides a solution for individuals with limited mobility or access to
transportation, and has the potential to address provider shortages, especially re-
lated to mental health, and improve choice and competition in health care. And tele-
health is an important tool to help minority communities connect with doctors who
share identity and culture, thus helping these individuals feel comfortable accessing
the health-care system, no matter where they may be.
Nearly every ERIC member company offers comprehensive telehealth benefits and
did so long before the COVID pandemic. As in most aspects of health insurance and
value-driven plan design, self-insured employers have been the early adopters and
drivers of telehealth expansion. With the onset of the pandemic, ERIC’s member
companies led the way in rolling out telehealth improvements—held back only by
various federal and state government barriers. Congress should take decisive
action to consolidate the telehealth gains made by private sector employees
during COVID and consider expanding telehealth policies to the private
sector so that employees and their families can access virtual care.
Federal Actions Greatly Improve Telehealth for Medicare Beneficiaries but
Leave the Private Sector Behind
Early on in the pandemic, the Administration and Congress quickly realized that
unnecessary barriers to telehealth care would be a significant problem for Medicare
beneficiaries. Many of those individuals were quarantined or in areas undergoing
lockdowns. Many were in different states and regions that were experiencing peaks
in hospital and provider capacity. And Medicare’s own coverage of telehealth was
nowhere near broad enough to replace much of the care that would otherwise be
foregone due to medical facilities being closed to non-COVID patients.
The Administration and Congress acted quickly and decisively:
• Medicare promptly eliminated state licensure barriers, allowing a willing and
qualified provider to see a willing Medicare patient via telehealth, without re-
gard to their locations;
• Medicare promptly eliminated state telehealth barriers, such as requirements
that patients travel to specific originating sites before they can access tele-
health, limitations related to modality (e.g., video-only requirements, etc.), re-
quirements that the provider and patient have a pre-existing relationship, and
more; and
• Medicare expanded coverage to include more services for more patients, covered
via telehealth.
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These changes massively improved telehealth benefits for Medicare beneficiaries, in-
stantly unleashing telehealth’s vast potential to fill the voids created by the pan-
demic and its response—and paving the way for permanent improvement. In fact,
in a December 4, 2020 letter, 49 Congressional leaders called for making these
changes permanent. While ERIC member companies are primarily outside of the
Medicare system, we support making these Medicare improvements permanent. We
have endorsed Senator Schatz’s CONNECT for Health Act (S. 1512) to do just this.
Medicare’s embrace of telehealth is a boon to private sector patients, because it ad-
vances the creation of infrastructure, the adoption of telehealth by more providers,
and provides proof that telehealth expansion can produce better access to care and
savings.
Unfortunately, very few improvements have been made for patients in the private
sector not covered by Medicare, despite employer efforts to expand and improve tele-
health. Below we detail how private-sector patients are harmed by the current situ-
ation and what the Committee and Congress can do about it:
Care is still limited in many states only to a patient and provider both
physically located in that state. Many states have failed to join interstate med-
ical licensing compacts that provide reciprocity for mental health and other medical
providers in other states, expanding the network of available providers for state
beneficiaries to access. Congress waived these requirements for Medicare and should
do the same for private sector beneficiaries or otherwise effectuate interstate prac-
tice. While some states have signed limited interstate reciprocity compacts, to recog-
nize limited practice by limited types of providers, many have provided little or no
licensure relief.
Restrictive licensure rules help some providers by essentially outlawing competition
from out of state, but it hinders other providers from expanding their practice. The
failure to recognize interstate medical licensure reciprocity for telehealth means
that for many patients, the state government has banned them from logging on to
their computer or smartphone and connecting with a readily available and qualified
provider.
Many states still impose unnecessary barriers to the use of telemedicine.
These barriers can range from requiring that a patient travel to a specific telehealth
site before they can connect to a provider, limiting telehealth to specific technologies
(for instance, requiring two-way video, which may be out of reach by those in rural
or other areas without broadband access or the sophistication to work it, outlawing
the use of ‘‘portals’’ and store-and-forward communications particularly helpful to
identify skin conditions, pink eye, etc.), mandating that a patient can only do a tele-
health visit with a doctor they already have a relationship with, and other barriers.
While these barriers may be imposed under the guise of setting a standard of care
or protecting patients, these requirements really serve to stymie telehealth, driving
more care to (more expensive) in-person settings—or preventing patients from ob-
taining care at all—and hampering wider telehealth adoption.
These restrictions also have significant equity impact creating barriers that dis-
proportionately affect low-income populations, persons of color, or those with disabil-
ities. At the same time, they serve to protect profits for high-income professions.
Rules imposed by the federal government prevent employers from offering
telehealth to many beneficiaries. Employers generally cannot offer telehealth as
an employee benefit, separate from health coverage, because, under Department of
Labor regulations, telehealth benefits are deemed to be ‘‘a plan’’ for the purposes
of ACA rules. This determination requires telehealth benefits to be paired with a
full medical benefit that meets all of the different ACA requirements—1st-dollar
coverage of vaccines, essential health benefits and annual limit rules, and much
more. Because telehealth is, by definition, limited and conducted remotely, it simply
cannot meet all of the ACA requirements on its own.
To be clear, telehealth is not a ‘‘modality’’ of care. For employers, it is often an en-
tirely different benefit, part of a suite of programs that are offered to employees and
their families. In fact, employers often use a separate vendor to design and admin-
ister their telehealth benefits, rather than the insurance company or third-party ad-
ministrator that services their full medical plan. But the result of treating this sepa-
rate benefit as a ‘‘group health plan’’ is that telehealth cannot be offered as a stand-
alone to anyone not enrolled in the full medical plan, which effectively bans employ-
ers from extending telehealth to all populations, including:
• Full-time employees who are not enrolled in the medical plan, or employees’
family members, if the employee is on a self-only plan;
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• Part-time employees ineligible for the medical benefit;
• Seasonal, agricultural, or other temporary workers;
• Interns, trainees, and the like; and,
• New employees on a waiting period for the full medical plan, among others.
ERIC notes that this is a serious anomaly—perhaps the first time in living memory
that beneficiaries of government programs have more access, more flexibility, and
in some ways, better benefits than private sector workers on employer-sponsored
plans. Employers are generally the pioneers in health benefits, experimenting with
and leading the way in driving value, innovation, quality, and flexibility for pa-
tients. Now, because of government barriers, private sector workers are
being left behind.
Administrative action has provided limited relief. On June 23, 2020, the Depart-
ment of Labor issued a Frequently Asked Question (FAQ Part 43)1 that for the first
time, allowed employers to expand standalone telehealth offerings, but with two key
debilitating restrictions:
(1) Standalone telehealth may only be offered to individuals ineligible for the
full medical/surgical benefit; and
(2) Standalone telehealth may be offered to these individuals only until the end
of the public health emergency.
While this FAQ was a step in the right direction, it unfortunately leaves a number
of potential beneficiary cohorts behind (again, younger workers and those of less
economic means are hardest hit), while the temporary nature served as a significant
disincentive for large employers to implement a major benefit change. It is critical
that Congress make permanent the allowance to offer standalone tele-
health benefits, and expand the offering to unenrolled individuals, in addi-
tion to just those who are ineligible. If not, millions of people will lose this ben-
efit that has enabled them to access providers, especially mental health providers,
in a timely manner.
We will note one considerable improvement in telehealth that Congress has made
for private sector workers: individuals enrolled in a HDHP with a health savings
account (HSA) can now benefit from 1st-dollar coverage of telehealth, thanks to the
enactment of the ‘‘Telehealth Expansion Act’’ (S. 3539), which was passed into law
as part of the CARES Act (H.R. 748). Unfortunately, this telehealth improvement
is time-limited and set to expire at the end of 2021.
Senators Daines (R–MT) and Cortez Masto (D–NV) have introduced a new version
of the Telehealth Expansion Act, which would make the CARES Act policy perma-
nent. ERIC strongly supports this legislation. We urge Congress to swiftly pass
the Daines-Cortez Masto bill, and make 1st-dollar coverage of telehealth
permanent, so that workers in these plans can receive the care they need.
Key Steps the Finance Committee Should Consider to Improve Telehealth
The solutions to many of these problems are within the Committee’s jurisdiction,
and employers look forward to continuing to provide technical assistance to Con-
gress to implement solutions. We urge the Committee to advance provisions to ad-
dress each of these barriers to care for private sector workers and put them on equal
footing with Medicare beneficiaries.
First, Congress should pass the Temporary Reciprocity to Ensure Access to
Treatment (TREAT) Act (S. 168) and enable providers to practice telehealth
across state lines during the COVID–19 pandemic. Telehealth use has dras-
tically increased over the past year, and some state licensing restrictions continue
to disrupt patients’ care. The TREAT Act would provide temporary state licensing
reciprocity for all licensed and certified practitioners or professionals (those who
treat physical and mental health conditions) in all states for all types of services
(in-person and telehealth) during the COVID–19 Public Health Emergency. A pro-
vider who has achieved a medical license in their own state should be permitted to
practice on the Internet, without states blocking them from seeing patients—and
likewise, a patient who goes online to see a doctor should not be prevented by state
rules from seeing a qualified provider who is licensed in another state. States should
retain their rights to determine whether providers licensed in that state will be
1 https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-center/faqs/
aca-part-43.pdf.
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qualified to write prescriptions or otherwise develop a scope of practice. However,
if a provider in another state has been deemed qualified, a state should not be per-
mitted to prevent patients from seeing that provider or prevent the provider from
operating to the fullest extent of their license in that interaction. For example, not
allowing a qualified provider to prescribe medication during a medical visit or dis-
cuss treatment options during a mental health visit.
Congress should act immediately to ensure that patients who use telehealth for
physical and mental health services will have the best chance of finding a provider
ready and willing to see them on the other end during the public health emergency.
Mental health-care providers prior to the pandemic were difficult to access, espe-
cially for those not living in urban areas. More than 60 percent of rural Americans
live in mental health professional shortage areas, and the need for care has only
been exacerbated during the COVID–19 pandemic.
Congress’ immediate action will enable more competition and access in telehealth,
creating incentives for providers to improve quality and affordable access for pa-
tients. At a time when anxiety and depressive disorders are at an ultimate high,
access for patients is sorely needed in offering mental health-care services through
telehealth.
In the longer term, we urge Congress to enact a permanent solution to inter-
state licensure. While this will require addressing some thorny questions, we have
seen significant leadership in the past with respect to the issue. For instance, in
a previous Congress, Congressmen Pallone and Nunes introduced the TELE-MED
Act 2 to permanently allow interstate practice for Medicare providers. Congress pre-
viously fixed this issue in the realm of sports medicine as well. While there are dif-
ferent possible paths forward (national reciprocity, a national license, one com-
prehensive interstate compact with financial incentives for states), employers urge
Congress to work through this challenge and come to consensus on a solution.
Second, Congress should establish a simple set of federal standards for
telehealth, eliminating state barriers. We can think of no better example of
interstate commerce than a willing doctor and willing patient connecting electroni-
cally via the Internet to do a telehealth visit. While it is entirely appropriate for
a state to place standards to regulate the practice of medicine at brick-and-mortar
medical facilities within the state’s geographic boundaries, it makes little sense to
have 50 different sets of rules for telehealth (practiced remotely on the Internet or
via phone) depending on where a provider or patient may be located at any given
moment.
Congress can also develop a set of rules that protect patients while maximizing
flexibility and care, rather than some of the current protectionist rules that serve
to block patients from care on the state level. The new set of rules should:
• Allow telehealth to establish a patient-provider relationship through an initial
telehealth visit;
• Apply the same medical standard of care used for in-person to telehealth visits;
• Ensure that reimbursement is privately negotiated between providers and pay-
ers;
• Encourage cross state practice among providers;
• Promote continuity of care by encouraging telehealth providers to coordinate
with a patient’s primary care provider and interdisciplinary care team;
• Implement ‘‘technology-neutral’’ rules for telehealth, to ‘‘future-proof ’’ rules for
advances in technology and best practices, and eliminate discrimination for pa-
tients who may not have access to broadband Internet or the sophistication to
operate video, forward information, etc.;
• Eliminate all ‘‘originating site’’ requirements that arbitrarily limit patient ac-
cess to telehealth;
• Preserve the same informed consent requirements for patients in telehealth
that apply in person; and
• Ensure that telehealth providers may prescribe medication to patients with rea-
sonable limits.
2 https://pallone.house.gov/press-release/pallone-and-nunes-introduce-tele-med-act.
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This simple, streamlined set of rules will provide clarity to providers and maximize
access for patients.
Third, Congress should designate standalone telehealth as an ‘‘excepted
benefit’’ so that it can be offered to more patients. This is the way Congress
treats other ‘‘add-on’’ benefits like vision, dental, long-term care, cancer-only plans,
hospital indemnity insurance, and other benefits that are health-related but do not
constitute a full medical plan. It would be a simple change by adding the word ‘‘tele-
health’’ into the appropriate sections of the Internal Revenue Code (IRC), the Public
Health Service Act (PHSA), and the Employee Retirement Income Security Act
(ERISA).
Doing so would not affect an employer’s responsibility to offer minimum es-
sential coverage to employees, nor would it weaken an individual’s responsibility
to enroll in such. Employers or insurers could not swap out telehealth, which is lim-
ited in scope and closer to a supplement than a full medical plan, for a full medical
benefit. It would simply open up employers’ ability to offer telehealth benefits to
millions of patients who currently are not allowed—by Congress—to access those
benefits. There is precedent for Congress expanding the definition of excepted bene-
fits (e.g., Congress previously acted to allow ‘‘limited duration long term care’’ bene-
fits to be offered outside a medical plan).
In a recent survey, more than 25 percent of ERIC member companies stated that
they would expand telehealth offerings immediately if Congress permitted it to be
offered as a standalone benefit. This represents billions of dollars in private sector
money that is currently being left on the table, and millions of Americans who could
have access to telehealth coverage and care, if only the government would get out
of the way. Many ERIC member companies are currently taking advantage of the
DOL FAQ allowing limited telehealth expansion, but action by Congress could
greatly increase these numbers, and thus, greatly increase patients’ access to care.
While the Committee considers telehealth advancements for the private sector, more
can be done for the millions of workers (approximately half the workforce) with
HDHP plans. Congress should allow patients with a HDHP paired with a
HSA to access worksite health centers via 1st-dollar coverage as well. Work-
site health and wellness centers are more critical today than ever before, as employ-
ers provide their employees with more widespread and easy access to preventive and
primary care services, including vaccination and diagnostic testing services at the
workplace. And during COVID, many of these health centers have gone virtual, pro-
viding care to workers throughout a given region, not just confined to a specific
worksite. However, under current law, individual taxpayers may not contribute pre-
tax dollars to an HSA if they also receive certain supplemental health benefits,
which currently includes access to care at a worksite health center. The resulting
policy is that individuals with an HDHP are required to pay the full price, no dis-
counts, until they have paid through their full deductible. It’s unfair and counter-
productive, when employers want our beneficiaries to use the clinics. ERIC encour-
ages Congress to address the inequity by permitting individuals to both benefit from
discounted services offered at worksite employee centers and still be eligible to par-
ticipate in and provide pre-tax contributions to HSAs.
Counterproductive, Protectionist, Anti-Market Proposals: Worse Than
Doing Nothing
Meanwhile, some stakeholders are asking Congress to implement telehealth changes
that would go in the exact opposite direction, eliminating competitive markets, pro-
moting low-value care, and reducing the potential for telehealth to be trans-
formational for the medical system.
For instance, the Health Care at Home Act would mandate ERISA health plans to
cover telehealth for any service that is covered in person, as well as mandate that
telehealth services be reimbursed at the same amount as in-person services. Both
of these changes fail to expand and improve telehealth and instead would uproot
the blossoming market.
Large employers that offer health coverage through ERISA plans make decisions on
services to cover based on clinical guidelines, evidence, and best practices. We learn
from experience, advice from medical professional societies, bodies that evaluate
quality and efficiency in health care, and other sources, and then use this informa-
tion to develop benefits that drive the most value for our beneficiaries. The prospect
of government imposition of a sweeping coverage mandate within ERISA plans
would be an extreme break from precedent, not to mention a counterproductive en-
deavor that would inject more unproven and potentially low-value care into
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199
employer-sponsored coverage. This, in turn, would reduce the quality of coverage,
while increasing costs for participants. It should be the responsibility of ERISA plan
sponsors, not the government, to determine what care is appropriate to cover via
telehealth settings.
Under current law, providers are free to negotiate telemedicine rates with payers—
which has given rise to a thriving market in which competition drives cost effi-
ciency, value, quality, and innovation. So, it should come as no surprise that certain
provider groups are eager to destroy this market and instead set reimbursement by
government fiat. It is wholly inappropriate and unprecedented for the federal gov-
ernment to mandate payment rates between two private parties.
Further, telehealth is cheaper than in-person care. Telehealth enables providers to
treat more patients more efficiently, with less overhead cost, fewer staff, and lower
expenses associated with operating brick-and-mortar retail health settings. This has
enabled telehealth providers to offer more competitive rates than in-person, which
has been in no small part responsible for the telehealth renaissance. This has
caused many employers to adopt and offer telehealth benefits long before the
COVID emergency and driven the continuing exploration and innovation that serves
to produce ongoing improvements for patients. Losing this successful competitive
market would be a significant setback for patients and employers, and ultimately
for up-and-coming providers who otherwise could cultivate opportunities in the tele-
health space.
Conclusion
Thank you for this opportunity to share our views with the Committee. The ERISA
Industry Committee and our member companies are committed to working with
Congress to expand and improve telehealth for millions of patients in the private
sector, and to defeat proposals that would impose government mandates that make
the situation worse, not better. We look forward to working with you to develop and
perfect telehealth proposals that can be passed in Congress and signed into law by
President Biden.
HEALTHCARE LEADERSHIP COUNCIL
750 9th St., NW, Suite 500
Washington, DC 20001
202–452–8700
May 20, 2021
The Honorable Ron Wyden The Honorable Mike Crapo
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20510 Washington, DC 20510
Dear Chair Wyden and Ranking Member Crapo:
On behalf of the Healthcare Leadership Council (HLC), we thank you for holding
a hearing on, ‘‘COVID–19 Health Care Flexibilities: Perspectives, Experiences, and
Lessons Learned.’’
HLC is a coalition of chief executives from all disciplines within American health
care. It is the exclusive forum for the nation’s health-care leaders to jointly develop
policies, plans, and programs to achieve their vision of a 21st century health-care
system that makes affordable high-quality care accessible to all Americans. Mem-
bers of HLC—hospitals, academic health centers, health plans, pharmaceutical com-
panies, medical device manufacturers, laboratories, biotech firms, health product
distributors, post-acute care providers, home care providers, and information tech-
nology companies—advocate for measures to increase the quality and efficiency of
health care through a patient-centered approach.
The COVID–19 public health emergency (PHE) has highlighted significant chal-
lenges to current models of care delivery. The unprecedented cooperation between
private and public partners creating innovations in care delivery, information shar-
ing and improved coordination have served as a guide for future pandemics. HLC
thanks Congress and federal agencies for their work on providing flexibilities so that
stakeholders were able to swiftly adjust to a changing environment. HLC encour-
ages the Committee to examine lessons learned from the following areas to make
meaningful improvement to health outcomes after the PHE ends:
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Data Sharing
A successful COVID–19 response has required coordination among a diverse set of
public and private stakeholders. Each of these groups is uniquely situated to re-
spond to disaster scenarios. Leveraging their individual strengths in a systemic, co-
ordinated manner will lead to greater successes. One critical area where such co-
ordination could be used is in data access and exchange. Public health officials re-
quire real-time information on a variety of metrics (e.g., PPE levels, hospital bed
count, number of individuals vaccinated) so that they can tailor their responses as
necessary. Private sector health-care organizations stand at the ready to provide
input to government officials on how best to share information in times of emer-
gency to support supply chain management and surge redeployment.
Telehealth
One of the greatest lessons from the COVID–19 health pandemic has been the op-
portunity to deliver care through telehealth. State imposed stay-at-home orders lim-
ited access to care to vulnerable populations, but increased use of telehealth has
helped to deliver care to these populations. A recent study found that telehealth use
increased over 3,000% during the 12 month period between October 2019 and Octo-
ber 2020.1 We greatly appreciate the flexibilities permitted by Congress and the De-
partment of Health and Human Services (HHS) to expand access to telehealth serv-
ices. These waivers, however, are only temporary and are set to expire at the end
of the current PHE. HLC encourages the Committee to examine regulatory barriers
to long-term telehealth use, particularly the existing prohibition under Section
1834(m) of the Social Security Act that prevents patients from receiving telehealth
services in their homes and other locations. Limiting where a patient can access
telehealth unnecessarily reduces care options for patients already underserved by
the U.S. health-care system. HLC also encourages the Committee to examine how
to further encourage telehealth use after the PHE ends. Patients have been over-
whelmingly satisfied with their telehealth experiences and imposing additional reg-
ulatory barriers would limit the ease of such care.2 HLC has concerns that adding
clinically unnecessary in-person requirements as a prerequisite to receiving virtual
care would limit the ability of providers to meet patients where they are and extend
access to underserved patient populations that do not have an existing relationship
with a provider. We encourage the Committee to examine the impact on care for
vulnerable populations before any regulatory guardrails are imposed.
Workforce
The PHE has highlighted the need for a robust health-care workforce so that it can
be quickly scaled and deployed during future disaster events. HLC supports legisla-
tion that would implement a federal waiver of state licensure and allow for practice
at the top of the scope of license for physicians, nurses, pharmacists, pharmacy tech-
nicians and other health-care professionals in times of disaster. This should also
allow health professionals to work in centralized locations to provide services, in-
cluding remote patient monitoring across state lines. We also encourage Congress
to examine legislation that would expedite the visa authorization process for highly
trained nurses who could support hospitals facing staffing shortages, ensuring hos-
pitals are better able to respond to rising COVID–19 caseloads in the months ahead.
An adequate supply of nursing staff is critical for hospitals to maintain services
while ensuring that patients are properly cared for during the public health emer-
gency. The Healthcare Workforce Resilience Act is critical to strengthening health
systems’ capacity as we continue to combat the COVID–19 pandemic, the growing
opioid crisis, and other significant health challenges.
HLC, through its National Dialogue for Healthcare Innovation (NDHI) initiative on
Disaster Preparedness and Response has also partnered with the Duke-Margolis
Center for Health Policy to recommend future strategies that will lead to better dis-
aster readiness efforts. In this report,3 we focus on three different areas: improving
data and evidence generation, strengthening innovation and supply chain readiness
and improving care delivery approaches. The report highlights many of the current
challenges public and private entities have had in responding to the COVID–19
health pandemic and makes recommendations on how to ease future burdens. HLC
1 Iain Carlos, Telehealth claim lines jump 3,000% in 1 year, Becker’s Hospital Review (January
7, 2021), https://www.beckershospitalreview.com/telehealth/telehealth-claim-lines-jump-3-000-
in-1-year.html.
2 Telehealth Patient Satisfaction Surges During Pandemic but Barriers to Access Persist, J.D.
Power Finds, J.D. Power (October 1, 2020), https://www.jdpower.com/business/press-releases/
2020-us-telehealth-satisfaction-study.
3 https://www.ndhi.org/files/1816/1281/7553/disaster_preparedness_report_FINAL.pdf.
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has also compiled a compendium 4 of best practices, highlighting the efforts of our
members in responding to disaster events such as the COVID–19 pandemic as well
as natural disasters.
HLC looks forward to working with you on developing lasting flexibilities for health-
care stakeholders so they can quickly respond to disaster events. Please feel free to
contact Tina Grande at tgrande@hlc.org or 202–449–3433 with any questions.
Sincerely,
Mary R. Grealy
President
HEALTHEQUITY
15 W. Scenic Pointe Dr.
Draper, UT 84020
P. 855–437–4727
F. 801–727–1005
https://www.healthequity.com/
info@healthequity.com
May 18, 2021
The Honorable Ron Wyden The Honorable Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510–6200 Washington, DC 20510–6200
Dear Chairman Wyden and Ranking Member Crapo:
We write to you today to thank you for holding a hearing entitled, ‘‘COVID–19
Health Care Flexibilities: Perspectives, Experiences, and Lessons Learned.’’ Your at-
tention to this critical issue is appreciated by HealthEquity and by the millions of
Americans who utilize telehealth services.
HealthEquity administers health savings accounts (‘‘HSAs’’) and other consumer-
directed benefits for more than 12 million accounts on behalf of American workers.
We partner with employers, benefits advisors, and health and retirement plan pro-
viders who share our mission to connect health and wealth and value our culture
of remarkable ‘‘Purple’’ service.
In response to the COVID–19 pandemic, Congress included temporary provisions in
the CARES Act (Pub. L. 116–136) permitting an HSA-eligible high deductible health
plan to cover telehealth and other remote services without a deductible or before
the deductible has been met. These temporary provisions providing access to vital
care expire at the end of 2021.
While these provisions are temporary, the growth in telehealth is likely not. Surveys
have shown explosive growth in telehealth since the pandemic began:
• A study in Health Affairs found that 30.1% of all health care visits—a 23-fold
increase—were conducted via telemedicine between January and June 2020;1
• A coalition of self-insured plan sponsors reported a 28-fold increase in telemedi-
cine visits between January and May 2020;2 and
• A major telemedicine company reported a 156% increase in appointments for
2020 compared to 2019.3
These statistics show how critically important telemedicine has become. Few observ-
ers believe the practice of medicine will return to the way it was before COVID. As
society and technology evolve, so should health and tax policy.
4 https://www.hlc.org/wp-content/uploads/2021/02/DP-Compendium-Final-Final.pdf.
1 Population of 16.7 million participants with commercial insurance or a Medicare Advantage
plan. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2020.01786?journalCode=hlthaff.
2 https://www.prnewswire.com/news-releases/patient-officehospital-visits-down-telemedicine-
visits-up-for-non-covid-19-health-issues-based-on-claims-analysis-by-health-transformation-alli-
ance-301236052.html.
3 https://ir.teladochealth.com/news-and-events/investor-news/press-release-details/2021/
Teladoc-Health-Reports-Fourth-Quarter-and-Full-Year-2020-Results/default.aspx.
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202
We respectfully request that you make the CARES Act telehealth provisions perma-
nent and support the millions of Americans who have found telemedicine to be a
safe and effective means of receiving medical care.
Thank you for your attention to this issue. We are happy to be of assistance in any
way.
Sincerely,
Jody L. Dietel, ACFCI, CAS, HSAe
Senior Vice President, Advocacy and Government Affairs
jdietel@healthequity.com
650–577–6372
KAISER PERMANENTE
One Kaiser Plaza, 27th Floor
Oakland, CA 94612
510–271–5999
June 3, 2021
The Honorable Ron Wyden
Chair
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510
The Honorable Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510
RE: Kaiser Permanente statement for the record on the committee’s May 19, 2021,
hearing, ‘‘COVID–19 Health Care Flexibilities: Perspectives, Experiences, and Les-
sons Learned’’
Dear Chair Wyden and Ranking Member Crapo:
On behalf of Kaiser Permanente, we thank you for holding the ‘‘COVID–19 Health
Care Flexibilities: Perspectives, Experiences, and Lessons Learned’’ hearing on May
19, 2021. We commend the committee for addressing these important issues and
offer this statement for the record.
Kaiser Permanente comprises Kaiser Foundation Health Plan, Inc., the nation’s
largest not-for-profit health plan, and its health plan subsidiaries outside of Cali-
fornia and Hawaii; the not-for-profit Kaiser Foundation Hospitals, which operates
39 hospitals and 724 clinical facilities; and the Permanente Medical Groups, self-
governed physician group practices that employ more than 23,000 physicians and
exclusively contract with Kaiser Foundation Health Plan and its health plan sub-
sidiaries to meet the health needs of Kaiser Permanente’s 12.5 million members.
The COVID–19 pandemic has demonstrated the potential of programs that provide
acute-level care in the home and the inherent value of making such programs a du-
rable feature of our health care delivery system. We hope that you will find our ex-
periences in implementing our Kaiser Permanente Advanced Care at Home pro-
grams useful—particularly in the dynamic and demanding environment of the
COVID–19 pandemic—as you consider policies to expand the availability of these
beneficial innovations to all patients.
Innovating home-based care. Over the past decade, Kaiser Permanente and sev-
eral other prominent, well-respected health-care organizations have pioneered care
models that enable patients to receive, from the comfort of their own homes, care
for acute and chronic conditions that traditionally has been provided in hospital and
other medical facility settings. Many patients benefit immensely from this model of
care, including those with cancer, COVID–19, organ transplants, and chronic ill-
nesses such as renal failure. The model brings a range of hospital equipment and
services into the patient’s home. This can include infusions; skilled nursing services;
medication delivery; and laboratory, imaging, behavioral health, and rehabilitation
services.
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Kaiser Permanente at home. At Kaiser Permanente, we have provided safe and
effective advanced care at home for more than 500 patients across several Kaiser
Permanente regions since 2020, and we are working to expand availability in the
coming years. Leveraging advances in technology that support the virtual delivery
of health-care services, the Kaiser Permanente Advanced Care at Home program
temporarily installs state-of-the-art technology in patients’ homes, and our care at
home ‘‘command centers’’ direct and coordinate care delivered by our Permanente
Medical Group physicians and care teams. Our specialized health-care teams deliver
the same high-quality, hospital-level care in patients’ homes that they would receive
during a traditional hospital stay.
Through our programs, home-based patients can access their care teams around-the-
clock by phone and video; have their vital signs monitored virtually; receive in-home
visits with a nurse practitioner and other clinicians such as community paramedics;
and have diagnostic testing, mobile imaging, and various therapies performed safely
in their homes. To facilitate patients’ connections to their care teams, we also equip
them with devices and technology, which may include: a computer tablet for video
visits with their care team, a phone with a direct line to their care team, an emer-
gency-response bracelet, remote-monitoring devices, and backup Internet access and
power supply. Personnel entering the home are trained to provide excellent patient
care, identify and address challenges associated with the social determinants of
health, and attend to any information technology questions that might arise during
the course of a medical episode. The command center is staffed by physician special-
ists in hospital medicine, inpatient nurses, and program coordinators who can assist
patients with the logistics of timely delivery of medications, materials, and per-
sonnel into the home.
Better outcomes for patients. Programs that provide hospital-level care at home
have been shown to produce better outcomes for patients when compared with in-
hospital care. Several studies have found that home-based patients had improved
outcomes, including reduced lengths of stay, readmissions, and mortality.1 These
programs also mitigate the health risks that patients can face during a traditional
hospitalization, including those from health care—acquired conditions such as
nosocomial infections, delirium, and other harm events. Hospital care at home takes
the infection prevention principles afforded by a single room in a hospital to the
next level of safety. Delirium events can be reduced because elderly patients are not
removed from their familiar environment.2 Nationally, a third of hospitalized pa-
tients will decline from their baseline functional status after a traditional hos-
pitalization.3 These patient harms—which can be the direct result of hospital
stays—are known to be costly, and they can be reduced or avoided altogether by en-
rolling the patient in a program that provides hospital-level care at home.
Studies confirm that acute-care-at-home programs can result in cost savings. For ex-
ample, one study determined that the average cost of hospital-level care at home
was $5,081, compared with $7,480 for acute hospital care.4 On average, these pro-
grams reduced costs by more than $2,000, or 32%.5
Increased patient satisfaction. Acute care-at-home programs have also been
shown to enhance patient satisfaction with their care experience. Patients over-
whelmingly prefer to receive care at home when possible. According to one national
poll, 77% of Americans over the age of 40 would prefer to receive care in the famil-
iar surroundings of their homes.6 In our own experience with Kaiser Permanente
Advanced Care at Home, patients report satisfaction levels across key areas consist-
ently at or above national averages. On a scale of 1 to 100, our surveyed patients
1 Johns Hopkins Medicine, ‘‘Hospital at Home,’’ www.johnshopkinssolutions.com/solution/hos-
pital-at-home; The Commonwealth Fund, ‘‘ ‘Hospital at Home’ Programs Improve Outcomes,
Lower Costs But Face Resistance from Providers and Payers,’’ www.commonwealthfund.org/
publications/newsletter-article/hospital-home-programs-improve-outcomes-lower-costs-face-resist-
ance.
2 Caplan GA, Coconis J, Board N, Sayers A, Woods J. Does home treatment affect delirium?
A randomised controlled trial of rehabilitation of elderly and care at home or usual treatment
(The REACH-OUT trial). Age Ageing. 2006 Jan;35(1):53–60.
3 Chodos AH, Kushel MB, Greyson SR, et al. Hospitalization-associated disability in adults ad-
mitted to a safety net hospital. J Gen Intern Med. 2015; Covinsky KE, Pierluissi E, Johnson
CB. Hospitalization-associated disability. JAMA Oct. 26, 2011;306(16).
4 Ibid.
5 Ibid.
6 Associated Press and National Opinion Research Center at University of Chicago, ‘‘Long-
Term Care in America: Expectations and Preferences for Care and Caregiving,’’ www.
longtermcarepoll.org/long-term-care-in-america-expectations-and-preferences-for-care-and-
caregiving.
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rated their overall experience with Kaiser Permanente Advanced Care at Home at
78 (compared with 73, nationally for all hospitalized patients) and their willingness
to recommend the program at 78 (compared with 72, nationally for all hospitalized
patients).7
Advancing health equity. Programs that provide hospital-level care in the home
also advance health-care equity by enabling additional support for more-vulnerable
patients. Understanding patients’ home environments firsthand allows us to better
assess patient needs related to social determinants of health and enables the care
team to treat the whole person. When a patient needs additional support, such as
healthy food or transportation assistance, Kaiser Permanente can integrate this crit-
ical information into their care plan and connect the patient to available community
resources to meet these needs, thereby promoting better care and outcomes. The
care team visiting a patient in the home can assess the patient’s diet, medication
regimen, safety risks, and other factors; and, where appropriate, they may intervene
in those underlying contributors to the medical condition in ways that are not pos-
sible for facility-based patients. These valuable insights into the patient’s home en-
vironment and our enhanced ability to provide extra support for their recovery
would not be possible with a traditional hospitalization.
Investments in advanced care at home. Kaiser Permanente has long been an
industry leader in developing and implementing home-based care models, and we
believe that this approach will continue to grow in importance. For years we have
provided traditional post-acute hospital care, home health care, hospice services,
and home therapies using intravenous medications. Today’s technologies now facili-
tate more advanced, real-time monitoring that is scalable and cost effective. The
regulatory flexibilities issued in response to the pandemic have allowed additional
practitioners to extend the reach of traditional, hospital-based care teams. The fu-
ture holds tremendous opportunity to provide seamless, high-quality, patient-
centered care outside of the four walls of a hospital. Programs that safely bring
acute care into the home environment are most likely to be successful in the context
of an integrated care system that manages the continuum of care, inclusive of tradi-
tional inpatient and outpatient services. Kaiser Permanente will continue to lever-
age our clinical expertise in developing and improving these care delivery models
for our patients and communities and to share our insights for the benefit of the
health-care system at-large.
Policy investment in home-based care innovation. The COVID–19 pandemic
has accelerated the revolution in virtual health care, and these advancements have
been hard-won. In response to the pandemic, the Department of Health and Human
Services and the Centers for Medicare and Medicaid Services implemented key pol-
icy waivers—Hospital Without Walls and Acute Hospital Care at Home—that en-
abled providers such as Kaiser Permanente to deliver patient-centered, high-quality
acute care seamlessly and safely in patients’ homes. Currently, these waivers are
set to expire at the end of the public health emergency.
We believe that the time is now to make the investments that those waivers have
enabled a permanent part of health-care delivery in the United States. We look for-
ward to working with Congress, the Department of Health and Human Services,
and the Centers for Medicare and Medicaid Services, including the Center for Medi-
care and Medicaid Innovation, to accelerate the realization of the future of health-
care delivery and develop a permanent hospital-at-home model for Medicare and
Medicaid beneficiaries.
We thank you and the committee for your engagement on these critically important
issues affecting the future of our health care delivery system. We would value the
opportunity to provide additional information to you and your staff. Please do not
hesitate to contact Laird Burnett in our Washington, DC office by calling (202) 236–
7883, or to contact either of us.
Very respectfully,
Anthony A. Barrueta Stephen Parodi, M.D.
Senior Vice President Executive Vice President
Government Relations External Affairs
Kaiser Foundation Health Plan, Inc. The Permanente Federation
Kaiser Foundation Hospitals
7 Internal Kaiser Permanente data.
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MEDICALLY HOME GROUP, INC.
133 Brookline Avenue
Boston, MA 02215
Chairman Wyden, Ranking Member Crapo, and Members of the Committee, thank
you for allowing Medically Home the opportunity to submit a statement for the
record on COVID–19 health-care flexibilities, perspectives, experiences, and lessons
learned. Particularly, our statement will address Hospital Without Walls and Acute
Hospital Care at Home waivers and their impact on driving patient centered care
during the COVID–19 public health emergency (PHE).
Medically Home is a Boston-based company that enables hospitals and health sys-
tems to safely care for acutely ill patients in the comfort and safety of their own
homes. Many patients benefit from this model of care, also referred to as ‘‘Hospital
at Home,’’ including cancer patients, COVID–19 patients, transplant patients, and
patients with the exacerbation of chronic illnesses that plague millions of Americans
(e.g., COPD, heart failure, pneumonia, cellulitis, and many other conditions acute
enough to require inpatient level care and safe enough to be provided at home).
Leading medical providers including Mayo Clinic and Kaiser Permanente have re-
lied on Medically Home to provide a platform to successfully implement Hospital at
Home programs that improve patients’ health, well-being, and experience, while re-
ducing costs at the same time. Medically Home’s platform achieves these goals by
providing clinical and technological support to hospitals, and by coordinating the de-
livery of medically appropriate and necessary equipment, medication, and supplies
to patients’ homes on behalf of its hospital customers. Our hospital partners, cur-
rently operating in 7 States, are using their clinicians to provide care to their pa-
tients and receive reimbursement from public and private payers. Given our unique
experience working with hospitals/providers to safely shift advanced medical care to
the home setting before and during the COVID–19 PHE, we believe we can provide
valuable input on the need to extend the telehealth, Hospital Without Walls, and
Acute Hospital Care at Home flexibilities on behalf of patients across the country.
Unprecedented collaborations driven by COVID–19 and the opportunity to expand
hospital inpatient care in the home are important to note—specifically Mayo Clinic
and Kaiser Permanente announced last week their partnership to enable more pa-
tients to receive acute care and recovery services in the comfort, convenience, and
safety of their homes through their investment in, and partnership with, Medically
Home. Their collective goal is prioritizing the democratization of the finest level of
care by providing real time access to Hospital at Home to rural and underserved
communities, including Medicaid beneficiaries. Today, Mayo Clinic, using Medically
Home’s platform is already providing patient care in rural Wisconsin, with patients
being referred by multiple hospitals there, including a critical access hospital.
Perspectives: Background on Hospital at Home
Caring for acutely ill patients in their homes is not a new concept and has existed
for decades. However, the PHE has heightened and reaffirmed the necessity for
acute level services in the home. The telehealth, Hospital Without Walls, and Acute
Hospital Care at Home flexibilities alleviated hospital overcrowding and, hence,
mitigated the spread of COVID–19.
With over 65 clinical trials published on Hospital at Home models, previous re-
search on Hospital at Home has indicated that patients who received hospital care
in the home had improved outcomes including reductions in lengths of stay (LOS),
readmissions, and mortality, as well as increased patient satisfaction.1 Studies have
also shown that providing hospital services in the home has resulted in cost savings
and lower utilization. More specifically, they found the average cost for Hospital at
Home care was $5,081 compared to the average $7,480 for acute hospital care.2
Prior to the PHE, Hospital at Home had not been widely adopted due to current
regulatory barriers that limit Medicare reimbursement, and therefore, discourage
investment in the program. Specifically, the interpretation of Section 482.23 of the
Medicare Condition of Participation for Nursing Services, which requires 24-hour
nursing services to be provided in person.
1 https://www.johnshopkinssolutions.com/solution/hospital-at-home/; https://www.common
wealthfund.org/publications/newsletter-article/hospital-home-programs-improve-outcomes-lower-
costs-face-resistance.
2 Ibid.
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Experiences: Hospital Without Walls and Acute Hospital Care at Home
Waiver
Upon the onset of the COVID–19 pandemic, several leading health systems took the
initiative to implement Hospital at Home models to address the emerging needs of
their patients and communities.3 CMS announced Hospital Without Walls to enable
hospitals to provide inpatient services outside of traditional inpatient settings, in-
cluding the patient’s home. However, the interpretation of Section 482.23 of the
Medicare Condition of Participation for Nursing Services remained a barrier.
We applaud HHS for subsequently waiving this requirement via the Acute Hospital
Care at Home waiver, and we request Congress and HHS to consider permanently
extending this waiver to allow the 24-hour nursing requirement to be fulfilled vir-
tually. According to CMS data,4 since announced in December 2020, the number of
approved waivers has increased to 129 hospitals, 56 hospital systems, in 30 states.
Due to this waiver being specific to the COVID–19 PHE and the upfront investment
(cost, time, etc.) required to operate a Hospital at Home program, we believe partici-
pation will likely level off in the future if there is no long-term extension of the
waiver (or worse, without CMS participation, some of these hospitals may stop offer-
ing the program altogether). As well, those currently operating programs will lose
their investment and no longer receive Medicare payment for hospital inpatient care
provided in the home.
Lessons Learned: Regulatory Barriers Continue Outside of Current Waiv-
ers
After the PHE ends, the home will no longer be a permissible originating site for
telemedicine and telehealth services, as well as for acute level of care services. Ex-
tending the Hospital Without Walls and telehealth flexibilities to allow the home
to be a permissible originating site for these services is critical to reduce stress on
the system, allow providers to determine the best and safest setting for their pa-
tients to receive care, and improve access for patients in rural and underserved com-
munities.
We believe these regulatory flexibilities should be made permanent beyond the PHE
and will be an effective foundation for establishing Medicare reimbursement that is
specific to Hospital at Home services. We applaud HHS for providing these flexibili-
ties to ensure hospital services in the home during the PHE, and we encourage Con-
gress and HHS to consider extending these flexibilities as a new model of care that
prioritizes patient safety, patient choice, and patient care needs while providing ac-
cess to those who need it most.
Recommendations: Future of Patient Centered Care Post-PHE
Beyond the PHE, the United States health system should move towards a more re-
silient health-care delivery future where patients are empowered to choose their
homes as a location for their care because we now have the technical and logistical
capabilities to make safe and cost-effective high quality inpatient care in the home
a reality nationwide. Moreover, equipping patients and hospitals with the flexibility
to determine the best and safest setting to receive care has been and will continue
to be critical for access to care and resiliency as hospitals address the variations in
patient demands, facility capacity, and staffing following the PHE.
Maintaining the current waivers and flexibilities beyond the PHE will be critical to
optimize all efforts by our health-care systems to meet the changing needs of their
communities. The COVID–19 PHE has changed the landscape of health-care deliv-
ery. The industry has discussed innovations in telehealth and health-care delivery
outside of traditional care settings for some time, and the PHE has been a catalyst
for the industry’s implementation of these new care delivery methods (after all, Hos-
pital at Home is not a new concept in health care and has been practiced by some
systems for the last 20 years). These flexibilities have proven to be effective methods
for care delivery during the PHE and we are advocating for the extension of these
regulatory flexibilities to allow the model to fully scale. Indeed, these tools make our
health-care system more resilient and accessible, enabling it to meet the operational
3 See, e.g., At-Home Care Designed for COVID Likely Here to Stay at Cleveland Hospital,
available at, https://khn.org/news/at-home-care-designed-for-covid-likely-here-to-stay-at-cleve-
land-hospital/; Mayo Clinic to Launch National Hospital-at-Home Model, available at, https://
l.e.crainalerts.com/rts/go2.aspx?h=686177&tp=i-1NGB-E0-7AV-HEuj8-1n-1efb-1c-HEsTa-l4mTp
LeEm0-dJjLK; Pandemic Forced Insurers to Pay for In-Home Treatments. Will They Now Dis-
appear?, available at, https://www.leavenworthtimes.com/zz/news/20200616/pandemic-forced-
insurers-to-pay-for-in-home-treatments-will-they-now-disappear.
4 https://qualitynet.cms.gov/acute-hospital-care-at-home/resources.
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and financial challenges presented by the pandemic and other potential health
emergencies.
Extending these waivers is an important step towards advancing the future of
health-care delivery. Hospital at Home can offer a future where patients and their
providers can determine the most appropriate care settings and provide population-
specific targeted approaches to care delivery. In 2017, the Physician-Focused Pay-
ment Model Technical Advisory Committee (PTAC) recommended two Hospital at
Home proposals to the HHS Secretary for implementation: Mt. Sinai’s Hospital at
Home Plus Model (HaH-Plus) and Marshfield Clinic’s the Home Hospitalization: An
Alternative Payment Model for Delivering Care in the Home (HH-APM). Former
Secretary Azar had expressed interest in testing home-based, hospital-level of care
models and agreed with PTAC that these models hold promise for testing. To date
neither model has been implemented. Medically Home and our partners are inter-
ested in developing similarly proposed reimbursement pathways for Hospital at
Home.
Conclusion
Due to the regulatory barriers outlined above, which will return post-PHE, hospitals
have been and/or will again be wary about and disincentivized from implementing
or scaling hospital at home. This includes the access to care for underserved commu-
nities, and the innovations and superior financial, clinical, and satisfaction outcomes
of providing acute level care in the home that Hospital at Home provides. Therefore,
we request Congress and HHS to consider a permanent extension of the telehealth,
Hospital Without Walls, and Acute Hospital Care at Home waivers beyond the PHE
to mitigate the residual impacts of COVID–19 on public health and encourage
broader adoption of providing patient centered health-care services in the home.
We again thank you for the opportunity to submit a statement for the record to the
Committee, on behalf of our hospital customers and their patients across the coun-
try, we look forward to continuing to work with Congress and HHS to ensure that
access and quality care are available to citizens during and beyond the PHE, as well
as to further provide groundwork for greater innovations in health-care delivery for
the future.
MOVING HEALTH HOME COALITION
1100 H Street, NW
Washington, DC 20005
https://movinghealthhome.org/
June 2, 2021
The Honorable Ron Wyden
Chair
U.S. Senate
Committee on Finance
Washington, DC 20515
The Honorable Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
Washington, DC 20515
RE: Moving Health Home Testimony for Senate Finance Committee Hear-
ing on ‘‘COVID–19 Health Care Flexibilities: Perspectives, Experiences, and
Lessons Learned’’
On behalf of Moving Health Home (MHH), we appreciate your thoughtful consider-
ation of the COVID–19 flexibilities that allow clinical care to be provided in the
home during the Committee’s hearing entitled, ‘‘COVID–19 Health Care Flexibili-
ties: Perspectives, Experiences, and Lessons Learned’’ held on Wednesday, May 19,
2021. MHH is a coalition of pioneering health-care organizations with a bold vision
to make the home a site of clinical service. We are thankful for the opportunity to
submit testimony outlining the need for a temporary extension of the Hospitals
Without Walls (HWW) flexibilities to collect additional data and lessons learned.
However, a comprehensive Hospital at Home model is needed to fully leverage the
promise of home as a clinical site for care.
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We ask that Congress temporarily extend the HWW program for an additional two
years while simultaneously authorizing a permanent model that allows hospitals to
deliver inpatient hospital services to Medicare beneficiaries at home.
The value of home care was demonstrated during the COVID–19 pandemic, as con-
tinued to be seen as hospitals leverage temporary waivers to offer a greater range
of inpatient services in alternate sites of care, including the home. To date, more
than 100 hospitals have leveraged temporary authority to deliver care outside their
four walls; 132 hospitals and 58 health systems across 31 states are delivering care
to patients in their homes through the Acute Hospital Care at Home (AHCAM)
waiver.1, 2 Hospital at Home programs have been studied for decades both in the
United States and internationally. The research overwhelmingly demonstrates that
Hospital at Home programs are at least as safe as traditional in-patient care, im-
prove clinical outcomes and patient satisfaction, and reduce the total cost of care.
Background: Hospitals Without Walls Flexibilities and Acute Hospital Care
at Home Waiver
In March 2020, the Centers for Medicare and Medicaid Services (CMS) introduced
the Hospitals Without Walls (HWW) initiative, which provided broad regulatory
flexibility for hospitals to provide services in locations beyond their existing walls.
This temporary, blanket waiver authority is focused on reducing hospital capacity
to better address COVID–19.
Later that year in November, CMS announced the Acute Hospital Care at Home
(AHCAH) program that would cover hospital-level care at home for Medicare fee-
for-service (FFS) beneficiaries at approved sites. This temporary, individual waiver
requires that prospective health systems apply to the program and are subject to
approval by CMS based on their ability to meet certain requirements. The HWW
initiative built the foundation for the AHCAH program, operating sequentially.
Comprehensive Hospital at Home Model Is Needed
With the help of nearly 25 leading health-care organizations and experts in the
field, MHH is advocating for legislation that would permanently implement a Medi-
care Hospital at Home program, which is currently in draft form. MHH’s proposal
is built on decades of research and would allow for sustainable, long-term adoption
of inpatient services at home designed to improve patient experience and outcomes,
reduce federal spending, and increase access and patient choice.
That said, MHH asks that Congress temporarily extend the HWW program for an
additional 2 years while simultaneously authorizing a permanent model that allows
hospitals to deliver inpatient hospital services to Medicare beneficiaries at home.
While MHH is supportive of a two-year extension of the HWW flexibilities, including
the AHCAH program, we believe it is not the correct long-term solution for broad
adoption of inpatient services at home for the following reasons:
– We Should Not Build Programs Based on Waivers—Temporary waivers
are a bridge to enable care in the home to continue for a time-limited period
post-pandemic, but do not fully leverage the promise of home-based care. They
continue to rely on fee-for-service payment, while our goal would be to integrate
a value-based mechanism into the program.
– Hospital at Home Models Reduce Costs—Home care models that combine
inpatient hospital services with post-acute care post-discharge from the home
can result in 44 percent lower total cost of care.3 In general, Hospital at Home
programs have realized savings of 30 percent or more per admission, while
maintaining equivalent or better outcomes.4
– Hospital at Home Models Improve Quality—Quality results for care in the
home are comparable to or better than those realized for facility-based care.
Published data of Hospital at Home programs from across the U.S. demonstrate
reduction in average length of stay by one-third, readmissions by 24 percent,
1 https://qualitynet.cms.gov/acute-hospital-care-at-home/resources.
2 https://www.gao.gov/assets/gao-21-575t.pdf.
3 https://www.carecentrix.com/news/avalere-report-finds-carecentrix-model-of-post-acute-care-
lowers-total-cost-of-care-by-improving-outcomes-and-reducing-readmissions-ed-visits.
4 https://pubmed.ncbi.nlm.nih.gov/16330791/.
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mortality by 20 percent, complications (e.g., delirium and falls), and emergency
department visits.5, 6, 7, 8
– Consumers Prefer to Receive Care in the Home—The pandemic has
taught us that home-based care is preferred by many patients. According to a
recent study, 61 percent of seniors would like to receive health-care services in
their home.9 Long before COVID–19, evidence pointed to home as a preferred
site of care, including a study that found three in four adults 50 years and older
would prefer to age in their homes and communities.10
– Pandemic Experience Has Further Demonstrated it Is Safe to Provide
Care in the Home—The pandemic caused an explosion of home-based care, in
part due to regulatory flexibilities such as the AHCAH waiver. Early data com-
paring pre-pandemic to now show that utilization of home- based services, such
as home visits, has increased sevenfold in some cases.11 These experiences dem-
onstrate that care in the home is possible and safe.
Building on the longstanding evidence base, the success of delivering more care at
home during the pandemic, and patient preference for home-based care, Congress
has an opportunity to act by temporarily extending the HWW program for an addi-
tional two years while simultaneously authorizing a permanent model that allows
hospitals to deliver inpatient hospital to Medicare beneficiaries at home.
Thank you again for holding this important hearing and for your thoughtful delib-
eration on how your committee can enable Americans the freedom to choose home
as a clinical site of care. We look forward to working with you on this critical effort.
Please contact Jeremiah McCoy at jmccoy@movinghealthhome.org with any ques-
tions.
Sincerely,
Krista Drobac
Founder
NATIONAL ASSOCIATION OF CHAIN DRUG STORES
1776 Wilson Blvd., Suite 200
Arlington, VA 22209
703–549–3001
www.nacds.org
Statement of Steven C. Anderson, FASAE, CAE, IOM,
President and Chief Executive Officer
Introduction
The National Association of Chain Drug Stores (NACDS) appreciates the oppor-
tunity to submit a statement for the record for the Senate Finance Committee’s
hearing, ‘‘COVID–19 Health Care Flexibilities: Perspectives, Experiences, and Les-
sons Learned.’’ NACDS represents nearly 40,000 pharmacies (traditional drug
stores, supermarkets and mass merchants with four or more pharmacies) who em-
ploy nearly 3 million individuals, including pharmacists and pharmacy technicians,
among others.
NACDS commends the Committee’s work to build better health by considering flexi-
bilities granted during the Public Health Emergency. The nation called on phar-
macies to deliver COVID–19 testing, vaccination, and other critical preventive care
services to communities during the pandemic. Pharmacies seamlessly rose to the
challenge, in large part due to more than a decade of pandemic preparedness and
collaborative planning. Importantly, the COVID–19 flexibilities granted to phar-
macies were instrumental in driving better health and fostering equity across com-
munities. In reviewing lessons learned with an eye toward the future, these flexibili-
5 https://www.commonwealthfund.org/publications/newsletter-article/hospital-home-program-
new-mexico-improves-care-quality-and-patient.
6 https://www.acpjournals.org/doi/10.7326/M19-0600.
7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6143103/.
8 https://pubmed.ncbi.nlm.nih.gov/16330791/.
9 https://www.signifyhealth.com/blog/for-older-americans-the-home-must-become-a-choice-for-
patients.
10 https://www.aarp.org/research/topics/community/info-2018/2018-home-community-pref-
erence.html.
11 https://academic.oup.com/gerontologist/article/61/1/78/5921231.
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ties should be made permanent to foster sustained and equitable access to pharmacy
care.
I. A Decade of Pharmacy Preparedness Significantly Strengthened the Na-
tion’s COVID Response
Pharmacies have spent the last decade building upon lessons learned from the 2009
H1N1 pandemic, including piloting pharmacy vaccination strategies. These planning
efforts across industry and government paved the way for pharmacy’s central posi-
tion in the nation’s COVID–19 response.
Consider these highlights demonstrating how this preparedness translated into re-
sults for communities across America:
• Vaccination: Building on years of pandemic planning and exercises, the Fed-
eral Retail Pharmacy Program (FRPP) was established to leverage pharmacy’s
strengths for public benefit:
» Americans can conveniently get COVID–19 vaccines at 40,000 pharmacies
nationally thanks to the FRPP, leveraging 21 national pharmacy chains
and independent pharmacy networks.1
» More than 40% of these sites are already in zip codes with high social vul-
nerability—a Centers for Disease Control and Prevention (CDC) index
identifying communities needing more care.2
» In March, a fraction of these pharmacies provided over 5 million vaccina-
tions in just 4 days.3 And, recent data show that of all FRPP vaccination
doses 46% have been administered to people of color.4
• Testing: Pharmacies ramped up across states establishing more than 6,000 live
testing sites that processed nearly 10 million samples under a public-private
partnership with the Department of Health and Human Services (HHS).5
» Nearly three-quarters of these sites serve areas with moderate to high-so-
cial vulnerability.6
• Everyday Care: Beyond providing COVID–19 vaccinations and testing, phar-
macies kept their doors open throughout the pandemic, offering needed preven-
tive care, dispensing critical medications, administering routine and catch-up
vaccinations to adults and children, and providing patients with education and
referrals.
II. Critical Flexibilities Paved Way for Expanded Access to COVID–19 Care
at Pharmacies
The significant contributions made by pharmacies in supporting their communities
throughout the COVID–19 pandemic were largely made possible by flexibilities
granted during the Public Health Emergency. Specifically, federal actions taken
under the PREP Act 7, 8, 9 leveraged pharmacies to provide enhanced public access
to COVID–19 testing, COVID–19 vaccines, and routine and catchup vaccines for
those 3–18 years old. Such actions, along with Congress requiring health insurers
to cover COVID–19 testing and vaccination costs without out-of-pocket expenses,10
were monumental. Collectively, these actions unleashed pharmacy teams from oner-
ous and unnecessary federal and state barriers that have historically prohibited
1 https://www.cdc.gov/vaccines/covid-19/retail-pharmacy-program/index.html.
2 https://www.whitehouse.gov/briefing-room/statements-releases/2021/03/29/fact-sheet-presi-
dent-biden-announces-90-of-the-adult-u-s-population-will-be-eligible-for-vaccination-and-90-will-
have-a-vaccination-site-within-5-miles-of-home-by-april-19/.
3 https://www.politico.com/news/2021/03/29/covid-vaccine-sites-478233.
4 President Biden Meets Virtually with a Bipartisan Group of Governors. Remarks by Dr.
Nunez-Smith. May 11, 2021. https://www.youtube.com/watch?v=e-8oTbbPA94.
5 By the Numbers—Coronavirus Pandemic Whole-of-America Response. March 8, 2021.
https://content.govdelivery.com/attachments/USDHSFEMA/2021/03/09/file_attachments/171
7220/By%20the%20Numbers.COVID.FINAL.Mar.%208.2021.pdf.
6 https://www.hhs.gov/about/news/2021/01/07/hhs-continues-community-based-testing-sites-
covid-19.html.
7 U.S. Department of Health and Human Services, August 2020, available at HHS Expands
Access to Childhood Vaccines during COVID–19 Pandemic.
8 U.S. Department of Health and Human Services, October 2020, available at Advisory Opin-
ion 20–03 on the Public Readiness and Emergency Preparedness Act and the Secretary’s Dec-
laration under the Act.
9 U.S. Department of Health and Human Services. (December 2020). Fourth Amendment to
the Declaration Under the Public Readiness and Emergency Preparedness Act for Medical Coun-
termeasures Against COVID–19 and Republication of the Declaration, available at https://
www.phe.gov/Preparedness/legal/prepact/Pages/4-PREP-Act.aspx.
10 https://www.healthaffairs.org/do/10.1377/hblog20200326.765600/full/.
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them from providing such services to populations more broadly. These actions also
removed cost barriers for patients.
Briefly, a high-level overview of flexibilities that were instrumental for expanding
access to care at pharmacies include:
• COVID–19 Testing at Community Pharmacies: Critical actions taken by
Congress, HHS, and the Centers for Medicare and Medicaid Services (CMS)
abolished barriers in a stepwise manner to accelerate availability of pharmacy-
based COVID–19 testing locations. Effectively, this helped spearhead efforts to
break down barriers to pharmacy-based testing across many states and expand
community access to the clinical expertise of pharmacies.
» Through multiple actions under the PREP Act, HHS authorized phar-
macists to order and administer COVID–19 tests, and to leverage phar-
macy technicians for COVID–19 testing.11, 12 HHS further clarified that
federal guidance under the PREP Act preempts any state or local restric-
tions.13 Additionally, CMS released guidance supporting pharmacy enroll-
ment in Medicare as CLIA labs 14 and limiting cost sharing for COVID–19
testing.
• COVID–19 Vaccinations and Routine Childhood Vaccinations at Phar-
macies: Similar to testing, the federal government took critical actions to clear
the pathway for vaccinations at pharmacies throughout the pandemic. Doing so
removed barriers that otherwise would have greatly limited the pharmacy
team’s ability to serve the public.
» In addition to expanding access to COVID–19 vaccination, HHS aimed to
improve childhood vaccination rates—hindered by stay-at-home orders and
a decline in provider office visits. This was accomplished by expanding the
ability for the pharmacy team (pharmacists, pharmacy interns, and phar-
macy technicians) to provide immunizations to children more comprehen-
sively across states.15 This action was further clarified and reaffirmed by
the agency.16, 17
» Specifically, these actions authorized:
0 Pharmacists to order and administer, and appropriate pharmacy staff
to administer, Advisory Committee on Immunization Practices (ACIP)-
recommended childhood vaccines for persons 3–18 years old; and Food
and Drug Administration (FDA)-authorized or FDA-licensed COVID–
19 vaccinations to persons ages 3 and older.18
These government actions supporting pharmacy-based immunization and COVID–
19 testing have been paramount in helping smooth the complex and erratic nature
of state-by-state rules and regulations. The existing patchwork outside of temporary
flexibilities can create significant patient access barriers, especially in states that
have yet to modernize their statutory limits. While not all barriers have been abol-
ished, pharmacies have leveraged these flexibilities effectively to operationalize
broader delivery of care services.
11 Guidance for Licensed Pharmacists, COVID–19 Testing, and Immunity under the PREP
Act. (April 2020). https://www.phe.gov/Preparedness/legal/prepact/Documents/pharmacist-
guidance-COVID19-PREP-Act.pdf.
12 U.S. Department of Health and Human Services Office of the Assistant Secretary for
Health. October 20, 2020. Guidance for PREP Act Coverage for Qualified Pharmacy Technicians
and State-Authorized Pharmacy Interns for Childhood Vaccines, COVID–19 Vaccines, and
COVID–19 Testing. https://www.hhs.gov/sites/default/files/prep-act-guidance.pdf.
13 https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/advisory-opin-
ion-20-02-hhs-ogc-prep-act.pdf.
14 See Section 6003 of the Families First Coronavirus Response Act and Section 3713 of the
CARES Act.
15 U.S. Department of Health and Human Services. (August 2020). HHS Expands Access to
Childhood Vaccines during COVID–19 Pandemic.
16 U.S. Department of Health and Human Services. (October 2020). Advisory Opinion 20–03
on the Public Readiness and Emergency Preparedness Act and the Secretary’s Declaration under
the Act.
17 U.S. Department of Health and Human Services. (December 2020). Fourth Amendment to
the Declaration Under the Public Readiness and Emergency Preparedness Act for Medical Coun-
termeasures Against COVID–19 and Republication of the Declaration. https://www.phe.gov/
Preparedness/legal/prepact/Pages/4-PREP-Act.aspx.
18 https://www.hhs.gov/sites/default/files/third-amendment-declaration.pdf; https://www.
hhs.gov/sites/default/files/licensed-pharmacists-and-pharmacy-interns-regarding-covid-19-vac-
cines-immunity.pdf; and https://www.hhs.gov/sites/default/files/prep-act-guidance.pdf.
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III. Recommended Permanent Changes to Drive Health and Foster Equity
Beyond the COVID–19 Pandemic
Communities have long relied on pharmacies to deliver quality care to all popu-
lations, including the high-risk and socially vulnerable.19, 20 Through the COVID–
19 response, the nation has built an infrastructure that allows Americans to benefit
from quality, accessible, and equitable pharmacy care services. As we shift to
COVID–19 becoming endemic and a return toward a focus on routine care services,
communities ought to maintain their access to pharmacy care. And, as we look
ahead to the next pandemic, tremendous opportunities exist to transform these
flexibilities from temporary to permanent, preventing duplicative efforts in the fu-
ture. NACDS urges Congress to retain and build on the existing flexibilities to imple-
ment permanent pharmacy authority and payment mechanisms. Doing so would help
Americans continue reaping the benefits of care services at pharmacies they know
and trust into the future.
Conclusion
As we look beyond the COVID–19 pandemic, pharmacies will continue to be impor-
tant care destinations for patients. Health equity will rightfully remain a driving
force in health care moving forward with care destinations, like pharmacies, meet-
ing patients where they are. Further, mental health and substance abuse likely will
emerge as lasting behavioral health impacts of the pandemic. We raise these for-
ward leaning issues to say that pharmacies have experience providing destigma-
tizing care and routinely provide for patients essential screenings, counseling, treat-
ment, and linkage to care. Oftentimes, pharmacies are the entry point for patients
into the health-care system, further underscoring their value on a patient’s health-
care team. As the COVID–19 response shifts into recovery, pharmacies continue to
serve their communities on the frontlines to meet their evolving health-care needs.
NACDS thanks the committee for the opportunity to offer our support for your tre-
mendous work. We implore you to build on these lessons learned by transforming
temporary flexibilities into permanent pharmacy authority and payment mechanisms
to support the health and wellness of Americans beyond the pandemic. We welcome
the opportunity to discuss these issues further. Please reach out to NACDS’ Chris
Krese, Senior Vice President of Congressional Relations and Communications at
CKrese@NACDS.org or 703–837–4650.
NATIONAL INDIAN HEALTH BOARD
910 Pennsylvania Ave., SE
Washington, DC 20003
Chairman Wyden, Ranking Member Crapo, and Members of the Committee, thank
you for holding this critical hearing ‘‘COVID–19 Health Care Flexibilities: Perspec-
tives, Experiences, and Lessons Learned.’’ On behalf of the National Indian Health
Board (NIHB) and the 574 federally-recognized sovereign American Indian and
Alaska Native (AI/AN) Tribal Nations we serve, NIHB submits this testimony for
the record.
Background—COVID–19 Flexibilities and Impact in Indian Country
As of June 1, 2021, the Indian Health Service (IHS) reported 197,459 positive
COVID–19 cases, with a cumulative percent positive rate of 8.8% across all 12 IHS
Areas.1 However, IHS numbers are highly likely to be underrepresented because
case reporting by Tribally-operated health programs, which constitute roughly two-
thirds of the Indian health system, are voluntary. According to data analysis by
APM Research Lab, AI/ANs are experiencing the second highest aggregated
COVID–19 death rate at 51.3 deaths per 100,000. On March 12, 2021, the CDC re-
ported that AI/ANs were 3.7 times more likely than non-Hispanic white people to
be hospitalized and 2.4 times more likely to die from COVID–19 infection. Reporting
by state health departments has further highlighted disparities among AI/ANs
19 Gaskins RE. Innovating Medicaid: The North Carolina Experience, NC Med J. 2017, avail-
able at https://www.ncbi.nlm.nih.gov/pubmed/28115558.
20 Berenbrok LA, Gabriel N, Coley KC, Hernandez I., Evaluation of Frequency of Encounters
With Primary Care Physicians vs Visits to Community Pharmacies Among Medicare Bene-
ficiaries, JAMA Netw Open. 2020;3(7):e209132, available at doi:10.1001/jamanetworkopen.
2020.9132.
1 Indian Health Service. COVID–19 Cases by IHS Area. https://www.ihs.gov/coronavirus/.
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• According to the Centers for Disease Control and Prevention (CDC), AI/AN Peo-
ple are 1.7 times (70%) more likely to be diagnosed with COVID–19 when com-
pared to non-Hispanic white people.
• According to the CDC, AI/ANs are 3.7 times (370%) more likely to require hos-
pitalization when compared to non-Hispanic white people.
• According to the CDC, AI/ANs are 2.4 times (240%) more likely to die from
COVID–19-related infection when compared to non-Hispanic white people.
• There have been 6,206 AI/AN deaths related to COVID–19 complications since
the pandemic was declared. Nearly 60% of these deaths are from New Mexico,
Arizona, and Oklahoma.2
• In Alaska, 34.8% of the total state’s deaths are reported to be AI/ANs.3
• The disparity in COVID–19-related death rates is not evenly shared across all
AI/AN age groups. Young AI/ANs are experiencing the most significant dispari-
ties. Among AI/ANs aged 20–29 years, 30–39 years, and 40–49 years, the
COVID–19-related mortality rates are 10.5, 11.6, and 8.2 times, respectively,
higher when compared to their white counterparts.4
• Across 23 states, the cumulative incidence rate of laboratory-confirmed COVID–
19 infections was 3.5 times (350%) higher among AI/ANs persons than non-
Hispanic white persons.5
Unfortunately, the adverse effects of COVID–19 in Indian Country extend beyond
these sobering public health statistics. Collectively, the IHS, Tribal, and Urban
health system (known as the I/T/U), has been chronicly underfunded since its incep-
tion, and has relied on third-party revenue to stay afloat. Despite its underfunding,
Indian Health Care Providers (IHCPs) have found innovative ways to provide qual-
ity care, even during the pandemic. The I/T/U system has taken full advantage of
the flexibilities that CMS extended, allowing for leverage of new technologies; and
recouping what would have otherwise been lost revenue, which is sorely needed.
One key flexibility is the ‘‘Four Walls’’ waiver that is extended through October
2021.This waiver, while not direcetly a result of the pandemic, has been crucial for
the I/T/U system in dealing with COVID–19 This extension allows I/T/U clinics to
receive the Medicaid 100% Federal Matching Assistance Percentage (FMAP) for
services provided to an AI/AN Medicaid Beneficiary at sites outside the ‘‘for walls’’
of a clinic. These external sites can include remote vaccination and testing sites that
have been commonplace in the public health emergency and allow treatment in oth-
erwise underserved communities. These ancillary sites for care have long been im-
portant to providing quality care throughout Indian Country. Still, once this exten-
sion expires, an essential source of revenue for the I/T/U system will be diminished.
Telehealth has proven to be an invaluable tool to provide quality care during the
public health emergency, and the flexibilities for its usage and reimbursement have
been crucial to its expanded adoption. According to IHS, since initiating telehealth
expansion, the agency has experienced an 33-fold increase in telehealth visits.6 Ad-
ditionally, the Government Accountability Office (GAO) released a report analyzing
the federal response to COVID–19, showing IHS allocated $95 million of the $1.032
billion in total funding received under the CARES Act toward telehealth. While this
adoption of telehealth as an alternative to in-person care is useful, much of Indian
Country faces structural challenges to leveraging this new technology. Due to a sig-
nificant lack of broadband infrastructure, only 46.6% of houses on Tribal lands have
access to fixed terrestrial broadband at standard speeds established by the Federal
2 National Indian Health Board. May 26, 2021. CDC Provisional Death Report, 6,533 Deaths,
an increase of 51 weekly Deaths. https://public.tableau.com/app/profile/nihb.edward.fox/viz/
May262021CDCProvisionalDeathReport6533Deathsanincreaseof51weeklyDeaths/May262021CDC
ProvisionalDeathReport6533Deathsanincreaseof51weeklyDeaths_.
3 National Indian Health Board. May 26, 2021. CDC Provisional Death Report, 6,533 Deaths,
an increase of 51 weekly Deaths. https://public.tableau.com/app/profile/nihb.edward.fox/viz/
May262021CDCProvisionalDeathReport6533Deathsanincreaseof51weeklyDeaths/May262021CDC
ProvisionalDeathReport6533Deathsanincreaseof51weeklyDeaths_.
4 Arrazola J, Masiello MM, Joshi S, et al. COVID–19 Mortality Among American Indian and
Alaska Native Persons—14 States, January–June 2020. MMWR Morb Mortal Wkly Rep
2020;69:1853–1856. DOI: http://dx.doi.org/10.15585/mmwr.mm6949a3external icon.
5 Hatcher SM, Agnew-Brune C, Anderson M, et al. COVID–19 Among American Indian and
Alaska Native Persons—23 States, January 31–July 3, 2020. MMWR Morb Mortal Wkly Rep
2020;69:1166–1169. DOI: http://dx.doi.org/10.15585/mmwr.mm6934e1.
6 Todet, R.A.M. (2021, April 28). IHS expanded telehealth to provide care during COVID–19
pandemic. Indian Health Service Newsroom. https://www.ihs.gov/newsroom/ihs-blog/april2021
/ihs-expanded-telehealth-to-provide-care-during-covid-19-pandemic/.
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Communications Commission (FCC).7 Many of our Tribal citizens are unable to ac-
cess necessary telehealth-based care from the safety of their homes.
Our Tribal communities have endured a great many pandemics and tragedies in our
history. Our people experience significant historical and intergenerational trauma
resulting from genocide, forced relocation from our homelands, forced assimilation
into western culture, and persecution of our Native cultures, customs, and lan-
guages. As a result, AI/ANs experience some of the highest rates of suicide, drug
overdose, post-traumatic stress, and mental illness compared to all other races.
While Indian Country remains resilient and committed to solutions, the COVID–19
emergency has reignited the historical trauma experienced at the hands of historical
plagues such as smallpox and tuberculosis.
Congress reaffirmed the federal trust responsibility for health care under the per-
manent reauthorization of the Indian Health Care Improvement Act (IHCIA) when
it declared that ‘‘. . . it is the policy of this Nation, in fulfillment of its special trust
responsibilities and legal obligations to Indians . . . to ensure the highest possible
health status for Indians and urban Indians and to provide all resources to effect
that policy.’’
It is essential to remember that these obligations exist in perpetuity. As such, the
federal government must ensure that Tribes are meaningfully and comprehensively
included in any congressional review of COVID–19 flexibilities and support. While
we appreciate the resources and flexibilities allocated for Indian Country thus far—
including the $1.032 billion appropriated to Indian Health Service (IHS) under the
CARES Act, the $64 million under the Families First Coronavirus Response Act, the
$1 billion under the Consolidated Appropriations Act of 2021, and the $6.094 billion
under the American Rescue Plan—these one-time additional funding increases and
temporary regulatory flexibilities are not sufficient to stem the tide of decades of
underfunding and neglect.
Policy Recommendations
To ensure that the efficiencies in health-care delivery, put in place as a response
to the public health emergency, are built upon and not lost, we urge the committee
to pass the following policy priorities.
1. Amend the Social Security Act to ensure that all services provided
through an Indian health-care program are eligible for reimbursement
at the OMB all-inclusive rate.
In 2016, CMS issued a Dear State Health Official (SHO) letter explaining that only
services rendered within the Four Walls of an IHS or Tribal (I/T) clinic are eligible
for Medicaid reimbursement at the all-inclusive rate (100% FMAP). CMS’s interpre-
tation means that if a service is rendered outside the Four Walls of a clinic by an
IHS or contracted provider, the provided health service is not eligible for the same
reimbursement under Medicaid. It is common practice within the Indian health-care
system to use an ancillary site (like a school) or send providers into the community
to deliver health-care services. In the SHO letter, CMS offered a solution that re-
quires two actions, one by the Indian health program and another by the State Med-
icaid Agency. If IHS or Tribal clinics want to receive the ‘‘clinic’’ rate for Medicaid
services provided outside the four walls, the I/T facilities must first convert to Fed-
erally Qualified Health Centers (FQHC). The state also needs to file a State Plan
Amendment (SPA) to grant the Tribal FQHCs authority to bill at the ‘‘clinic’’ rate.
With CMS approval, the Indian health program can receive the encounter rate, and
the state is automatically paid at the 100% FMAP—increasing reimbursement to
the I/T clinics while reducing the state’s contribution to Medicaid
This presents multiple issues—first, Indian health programs may not want to con-
vert to FQHCs for reasons other than to receive the reimbursement, as the conver-
sion itself is burdensome. Second, not all States have good working relationships
with the Tribes, and if no relationship (or a poor one) exists, the state may not see
the benefits of amending its Plan. (One advantage is that Medicaid services to AI/
ANs are reimbursed at 100 percent FMAP). Because this reimbursement depends
on the state’s action, it adds to the uncertainty for the Tribes, and in some ways,
undermines the Tribes’ status as sovereign governments.
This year CMS authorized an extension to its four walls grace period through Octo-
ber 31, 2021, to allow more I/T clinics to convert to Tribal FQHCs. One can expect
7 U.S. Department of the Interior. (2020). Expanding Broadband Access. Indian Affairs.
https://www.bia.gov/service/infrastructure/expanding-broadband-access.
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215
that another extension will be requested given the CMS solution’s onerous burden.
The solution CMS proposed in its SHO letter and subsequent Frequently Asked
Questions (FAQs) was only a band-aid. The agency’s actions do not sufficiently ad-
dress the reimbursement parity Tribes seek for delivering Medicaid services in a
community-centered way. NIHB and other Tribal Organizations have advocated for
a permanent fix to CMS’s Four Walls issue for more than three years.
2. Expand the Medicaid 100% FMAP to Urban Indian Organizations.
The COVID–19 pandemic has created significant financial hardships for IHCPs.
While I/T/U clinics receive 100% FMAP for services provided to AI/AN Medicaid
beneficiaries, this FMAP does not permanently extend to Urban Indian Organiza-
tions (UIOs). In the American Rescue Plan, signed into law on March 11th, the
100% FMAP was expanded to UIOs for two years. While this temporary extension
is crucial in providing additional federal dollars to UIOs to provide quality care, this
FMAP increase must be made permanent to fulfill the Federal Government’s trust
responsibilities to AI/AN individuals.
3. Increase flexibility in Medicare Definition of Telemedicine Services.
COVID–19 has demonstrated the importance of telehealth to increase access to pro-
viders during the pandemic. But it has also demonstrated it can increase access to
needed primary, specialty, and behavioral health services, particularly in rural
areas. The telehealth flexibilities Medicare has made available during the public
health emergency should be made permanent to the maximum extent possible. In
addition, much of Indian Country is located in rural areas and lacks access to more
advanced audio and video real-time communication methods. As a result, Medicare
should allow telehealth to be provided through audio-only telephonic and two-way
radio communication methods when necessary, and grant maximum reimbursement
for services rendered through these modalities.
4. Expand access to telehealth in the Indian Health System through in-
creased funding and technical fixes.
Limitations in the availability of AI/AN-specific COVID–19 data are contributing to
the invisibility of the adverse impacts of the pandemic in Indian Country within the
general public. Senior IHS officials, including Chief Medical Officer Dr. Michael
Toedt, have stated publicly that existing deficiencies with the IHS health IT system
are inhibiting the agency’s ability to adequately conduct COVID–19 disease surveil-
lance and reporting efforts.8 Lack of health IT infrastructure has also seriously
hampered the ability of IHS and Tribal sites to transition to a telehealth-based care
delivery system. While mainstream hospitals have been able to take advantage of
new flexibilities under Medicare for the use of telehealth during the COVID–19 pan-
demic, IHS and Tribal facilities have not because of insufficient broadband deploy-
ment and health IT capabilities. The IHS Tribal Budget Formulation Working
Group previously outlined the need for a roughly $3 billion investment to fully equip
the Indian health system with an interoperable and modern health IT system. It
is critical that Congress provide meaningful investments in health IT technologies
for the Indian health system to ensure accurate assessment of AI/AN COVID–19
health disparities and equip IHCPs with the tools to seamlessly provide telehealth-
based health services.
5. Permanently Extend Waivers under Medicare for Use of Telehealth
CMS has temporarily waived Medicare restrictions on the use of telemedicine. Yet,
for many Tribes that lack broadband and /or telehealth capacity and infrastructure,
it is not financially feasible to purchase expensive telehealth equipment for a short-
term authority. Making the telehealth waivers permanent would ensure that the
telehealth delivery system remains a viable option for delivering essential medical,
mental and behavioral health services in Indian Country, and helps close the gap
in access to care.
Conclusion
The federal government’s trust responsibility to provide quality and comprehensive
health services for all AI/AN Peoples extends to every federal agency and depart-
ment. As the only national Tribal organization dedicated exclusively to advocating
8 Toedt, R.A.M. (2021, May 21). Testimony from RADM Michael Toedt on Examining the
COVID–19 Response in Native Communities: Native Health Systems One Year Later before
Senate Committee on Indian Affairs. HHS.gov. https://www.hhs.gov/about/agencies/asl/testi-
mony/2021/04/14/examining-covid-19-response-native-communities-native-health-systems-one-
year-later.html.
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for the fulfillment of the federal trust responsibility for health, NIHB is committed
to ensuring the highest health status and outcomes for those affected with COVID–
19 and all Indian Country. We continue to appreciate your dedication to Indian
health priorities and remain committed to working with you to protect and preserve
the mental, physical, behavioral, and spiritual health of Indian peoples in the fu-
ture.
98POINT6
701 5th Ave, #2300
Seattle, WA 98104
(866) 657–7991
https://www.98point6.com/
U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510–6200
RE: Hearing held Wednesday, May 19, 2021, ‘‘COVID–19 Health Care Flexibilities:
Perspectives, Experiences, and Lessons Learned’’
To Members of the Senate Finance Committee:
98point6 is pioneering a new approach to primary care. By pairing artificial intel-
ligence (AI) and machine learning technology with board-certified physicians, our vi-
sion is to make primary care more accessible and affordable, leading to better health
outcomes. 98point6 believes in meeting patients where they are by offering private,
modern communication-enabled diagnosis and treatment via a HIPAA-compliant
mobile application to increase primary care utilization and enable earlier medical
intervention with reduced costs of overall care. As Congress debates lessons learned
from the COVID–19 pandemic, we believe there are two changes that should become
long term policy improvements: (1) making telehealth benefits an ‘‘excepted benefit’’
under Employee Retirement Income Security Act (ERISA), which is consistent and
in-line with a current Tri-Agency (Department of Labor (DOL), Department of
Health and Human Services (HHS), and Department of Treasury) temporary relief;
and (2) making permanent a waiver that allows a high deductible health plan
(HDHP) to retain its status as an health savings account (HSA)-qualified HDHP—
wherein participants may make contributions to a HSA—if telehealth coverage is
provided before the deductible. These changes will allow for continuity of coverage
and access to virtual care for many individuals.
During the COVID–19 medical demand surge, 98point6 clinic volume exceeded
200% growth from the start of the year, with COVID-related concerns accounting
for over 40% of all patient visits. The physician team at 98point6 and our tech-
nology-assisted approach to care enabled quality care delivered expediently, with
the platform incorporating standards based on research, outcomes, and clinical qual-
ity monitoring of pandemic guidelines. Telehealth services offer a transformative
paradigm shift for the uninsured, underinsured, and populations with limited access
to physician care to readily access quality, inexpensive basic medical and primary
care services. Amid the COVID–19 pandemic, telehealth has emerged as a viable
and cost-effective solution across all demographic groups, including racial and ethnic
minorities and rural populations lacking access to brick and mortar medical facili-
ties.
Health disparities among racial and ethnic minority populations have been both
highlighted and exacerbated by the COVID–19 pandemic. Disproportionately rep-
resented among ‘‘essential worker’’ categories, racial and ethnic minorities experi-
ence lower rates of employer-provided or other private health-care coverage. Em-
ployers representing more than three million part-time, non-benefits-eligible em-
ployees stand ready and willing to provide telehealth or virtual care benefit options
at no cost to these employees, but are prohibited from doing so without exposure
to penalties under, for example, the ERISA.
Under current law, when telehealth or virtual health-care services are provided by
an employer, the benefit is considered a ‘‘group health plan’’ under ERISA (subject
to mandates absent an exception, which trigger per-day penalties). ERISA § 733 and
DOL regulations (29 CFR § 2590.732)—and conforming Internal Revenue Service
(IRS) and HHS statutes and regulations—do not include telehealth or virtual care
as an excepted benefit under ERISA. On June 23, 2020, DOL, HHS, and Treasury
jointly issued an FAQ pertaining to the Families First Coronavirus Response Act,
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the Coronavirus Aid, Relief, and Economic Security Act (CARES) and other health
coverage issues related to COVID–19, that provided temporary relief from most
group market reforms under part 7 of ERISA, title XXVII of the Public Health Serv-
ice Act, and chapter 100 of the Internal Revenue Code to employers wishing to pro-
vide telehealth or other remote care services to employees ineligible for any other
employer-sponsored group health plan. This temporary relief has proven to be bene-
ficial as a short-term fix, subject to the public health emergency, but a permanent
solution is required to ensure long-term benefits of telehealth services can be
accessed, across the spectrum of Americans in need.
Telehealth and remote care services should be an ERISA-excepted benefit when paid
entirely by the employer or other plan sponsor. To that end, Representative Jackie
Walorski (R–IN) introduced legislation in the 116th Congressional session, the Tele-
health Benefit Expansion for Workers Act, to permit telehealth services offered
under a group plan or group health insurance coverage as ERISA-excepted benefits
(by adding, ‘‘Benefits for telehealth services’’ to Section 2791(c)(2)). This legislation
is expected to be re-introduced in the current Congressional session.
In addition, the CARES Act clarified in Section 3701 that a HDHP retains its status
as an HSA-qualified HDHP—wherein participants may make contributions to a sav-
ings account (HSA)—if telehealth coverage is provided before the deductible. This
exception ends December 31, 2021. Most employers have taken advantage of this
provision to waive fair market value charges for telehealth and remote care services
through December 31, 2021, further enabling the policy goal of health-care access
and inclusivity.
As employers begin preparing for coverage requirements and changes affecting off-
calendar year plan years, however, potential mid-year changes may subject unwit-
ting participants to billing inconsistencies upon termination of the CARES Act tele-
health deductible waiver (impacting HDHP/HSAs). Similarly, employers utilizing
calendar year plans are now considering how and when to communicate the impend-
ing elimination of the CARES Act telehealth or other remote care services waiver.
Elimination of the waiver will require employees to pay the fair market value for
telehealth benefits if the employees participate in a HSA-qualified HDHP. To ad-
dress this irregularity and the fact that employees’ out-of-pocket expenses are in-
creased, the Internal Revenue Code should be amended to provide a permanent ex-
emption for telehealth services by adding, ‘‘or telehealth and other remote care,’’ to
Section 223(c)(1)(B).
Permanent relief for telehealth services under ERISA penalties and HDHP waivers
would enable employers to continue to provide important access to safe, high-quality
health care for many of the 21 million part-time workers in America as well as the
28 million uninsured. Provision of telehealth services will improve health outcomes
across the demographic spectrum, with highest gains among ethnic and racial mi-
norities and those most impacted by the COVID–19 pandemic. Telehealth is esti-
mated to save the health-care system up to $6 billion, factoring preemptive care and
early detection, as well as ensuring communities have a lifeline to reliable health
information. The statutory corrections requested would neither add to the federal
budget nor be subject to a Congressional Budget Office score, as the telehealth serv-
ices contemplated would continue to be employer-funded.
The COVID–19 pandemic has illustrated the immense benefits of telehealth serv-
ices. The technology is available now to ensure that more Americans, including part-
time ‘‘essential’’ workers—and the racial and ethnic minorities disproportionately
comprising this category—as well as rural Americans without ready access to med-
ical care, can access quality basic medical and primary health-care services.
Telehealth has proven benefits and public policy should reflect the technological
shifts and consumer preferences that incentivize employers to provide telehealth
services for expanded groups of employees (part-time workers) and at lower em-
ployee cost (in HDHP/HSA models). These two minor changes would bring signifi-
cant benefits across the U.S. public health landscape.
Sincerely,
Robbie Cape
CEO and co-founder
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OCHSNER HEALTH
1514 Jefferson Highway
New Orleans, LA 70121
phone (504) 842–3000
www.ochsner.org
Hon. Ron Wyden Hon. Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Re: May 19th Hearing: ‘‘COVID–19 Health Care Flexibilities: Perspectives,
Experiences, and Lessons Learned’’
Dear Chairman Wyden and Ranking Member Crapo:
On behalf of Ochsner Health (Ochsner), our physicians, nurses, and other health
professionals and the tens of thousands of patients and communities we serve in
Louisiana and Mississippi, we thank you for this opportunity to submit to you and
your Senate Committee on Finance colleagues comments regarding the May 19th
hearing on ‘‘COVID–19 Health Care Flexibilities: Perspectives, Experiences,
and Lessons Learned.’’ We commend you for your recognition to take time now
to hold a hearing to examine the impact of telehealth on the COVID–19 response,
and how those lessons learned may inform future federal policy with respect to tele-
health.
We thank you in advance for your attention to our recommendations and the com-
ments that may be submitted by our colleagues from associations representing
health and hospital systems. Making permanent a number of the current federal
telehealth waivers and other policy changes, expanding coverage and payment for
telehealth and digital medicine services and devices, and otherwise supporting and
facilitating the utilization of virtual care will help ensure that more patients have
access to care, not just during emergency circumstances. These much-needed
changes will help facilitate access to care for individuals from underserved and/or
rural communities, and enable better access for those with mobility, transportation,
and other challenges.
We stand ready to share our lessons learned over the past 14 months as we have
addressed the myriad challenges associated with COVID–19 and how we have suc-
cessfully deployed telehealth and digital medicine to care for patients with COVID–
19 as well as maintain continuity of primary and specialty care for patients, fami-
lies, and communities during this challenging and unprecedented time. We welcome
the opportunity to be a resource to you, your staff, and Finance Committee members
as you examine this critically important topic.
Summary of Policy Recommendations
We know that the topic of telehealth is an incredibly important and time sensitive
issue and as such, wish to draw your immediate attention to our policy rec-
ommendations below, which can be found in further detail on pages 6–10 of this doc-
ument. Background on Ochsner and our digital medicine and telehealth programs
can be found on pages 2–5. Our COVID–19 telehealth and virtual care lessons
learned are enumerated on pages 5–6.
The following provides a summary of the policy changes we urge Congress and CMS
to support. These recommendations are informed by our experience in providing
care throughout the public health emergency (PHE) and, in particular, being an
early ‘‘hot spot’’ for the pandemic. With these changes, patients will have improved
access to the primary, specialty, urgent, and emergency care they need and deserve.
• Make permanent the range of waivers associated with the provision of tele-
health. Specifically, make permanent the flexibilities associated with: patient lo-
cation, relationship between patient and provider, and the types of services that
can be provided via telehealth. Further, maintain reimbursement for telehealth
services at the in-person rate and permanently waive the application of copay-
ments to remote patient monitoring services and other non-face-to-face services.
• Given the significant focus during the hearing on audio-only telehealth, we
wish to note that the provision of audio-only telehealth services is an impor-
tant aspect of telehealth, particularly for individuals who may not have ac-
cess to broadband, smart devices, or other technology that enable a video-
visit. Audio-only telehealth can help bridge the health care digital divide,
address equity, and otherwise expand access to care for certain individuals
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219
and communities. Audio-only also is a clinically appropriate way to conduct
low acuity visits, communicate with established patients, and coordinate
care with patients as part of a remote patient monitoring program. To that
end, we urge that reimbursement for audio-only telehealth be maintained
under traditional Medicare (fee-for-service) beyond the PHE.
• Ensure that during a PHE cross jurisdictional licensure can be automatic, pre-
suming certain conditions are met.
• Modify the Emergency Medical Treatment and Labor Act (EMTALA) to allow
new types of medical screenings, such as pre-screenings that use technology
that can help divert non-emergent cases to other, appropriate settings.
• Expand covered remote monitoring services to allow for beneficiary participa-
tion and Medicare coverage and reimbursement for more than one program,
which will increase access, ease patient day-to-day care, and improve health
outcomes.
• Provide digital medicine and telehealth tools/devices to Medicare patients at no
cost to increase patient uptake of these services.
• Ensure patient access to TeleStroke services by establishing separate Medicare
payment for providers giving both TeleStroke consult and same day inpatient
care to Medicare beneficiaries experiencing acute stroke.
• Expand Medicare beneficiary access to non-stroke telehealth services for acute
neurological conditions.
• Expand access to intensive care unit (ICU) telehealth.
• Provide payment to providers who are offering additional levels of remote moni-
toring for patients through programs such as TeleStork.
About Ochsner
Ochsner, headquartered in New Orleans, is one of the nation’s leading integrated
not-for-profit academic health systems. Ochsner—as a leader in value-based care
and delivery system innovation—provides a comprehensive range of services
through its clinically integrated network of a combination of owned, managed and
affiliated hospitals, and nearly 200 total sites of care located throughout Louisiana
and Mississippi. We are proud that our innovative partnership model through the
Ochsner Health Network (OHN) allows many communities to maintain local owner-
ship and control of their hospitals, while bringing to bear the benefit of the experi-
ence and breadth of the Ochsner clinical and operational teams. Ochsner offers a
wide array of specialized and nationally ranked services with its 4,500 affiliated
physicians, including more than 1,600 employed physicians practicing in over 90
specialties and subspecialties, and more than 30,000 employees. Each year Ochsner
and its physician partners serve over 1 million individual patients who come from
every state in the nation and more than 70 countries.
Louisiana regularly ranks near the bottom of the United States in nearly all health
indicators, with a population that has a high prevalence of a number of risk factors
for poor health outcomes, including obesity, tobacco use, poverty, diabetes, and car-
diovascular disease. More than five years ago, Ochsner leaders recognized that it
would take innovative strategies and deployment of new technologies and interven-
tions to tackle these myriad challenges.
In response to the demand for better care at a lower cost and greater convenience
to patients, Ochsner created an innovation lab, innovationOchsner (iO) to improve
health through innovation with the following quadruple aim: improve the patient
experience of care, improve the health of populations, reduce the per capita cost of
health care, and improve the work life of the provider of care. The strategies to
achieve these goals are: operational efficiency, differentiate product or service, cre-
ate customer intimacy, and improve quality and safety. We are proud that our in-
vestment and focus in this area has resulted in ground-breaking innovations, which
are measurably improving patient care and outcomes, and are reducing inefficien-
cies and costs.
iO has developed numerous digital medicine programs, particularly for those af-
fected by chronic disease, in particular hypertension and diabetes, that are trans-
forming the patient experience, enhancing health, and well-being, while reducing
costs. More than 19,000 patients have been cared for in the Digital Medicine pro-
gram, 80% of which are still enrolled. In addition, Ochsner provides more than 100
telehealth services to more than 185 hospital and clinic partners. Further, Ochsner
continues to innovate in the direct-to-consumer market, with offerings such as
Ochsner Anywhere Care for primary and urgent care needs.
Ochsner’s innovative digital medicine approach using wearable technologies, remote
monitoring, and virtual provider visits is substantially improving patient health out-
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220
comes at a lower cost. Particularly for patients who are managing complex diag-
noses and chronic disease we are easing the patient care experience by allowing
them to receive the care they need, when and where they need it. And, critically,
our pioneering telehealth program is meaningfully increasing patient access to med-
ical services in rural areas of Louisiana and Mississippi where, in certain cases, no
such access existed before. For many—and a growing population of our patients—
telehealth and digital medicine are the standard of care and a preferred way in
which they interface with the health-care system.
Examples of Ochsner Digital Medicine Offerings 1
Ochsner’s Hypertension Digital Medicine (HTNDM) program uses a connected blood
pressure cuff to transmit blood pressure readings from the patient’s home to be
monitored by an Ochsner care team, which includes a pharmacist and health coach.
This program has been shown to be three times more effective than traditional care
at having patients achieve blood pressure control over 180 days, while also increas-
ing patients’ medication adherence and patient activation, and reducing the total
cost of care.
An analysis by Blue Cross Blue Shield found that participants in the
HTNDM medication adherence program led to an overall decrease in emer-
gency department visits and inpatient hospital stays. The same analysis
also found that the program saved $77 per member, per month, based on
claims data and total cost of care.
Our Digital Diabetes Medicine (DDM) program uses a prescription, Bluetooth-
enabled digital glucometer to monitor a patient’s blood sugar levels and other health
indicators. This program also has achieved results that are better than traditional
care methods, including reductions in A1C, decreases in hypoglycemic events and
diabetes distress, and increases in adherence to recommended health maintenance
activities.
The Connected Maternity Online Monitoring (MOM) program provides pregnant pa-
tients with a Bluetooth-enabled blood pressure cuff and scale that interfaces with
the electronic health record. This allows patients to perform remote monitoring dur-
ing pregnancy, and as appropriate, decrease the number of in person prenatal visits,
while increasing the frequency of monitoring for potential pregnancy complications.
Analysis of data from early implementation of the program demonstrates that not
only does it allow for earlier detection of hypertension in pregnancy, but also in-
creases compliance with post-partum blood pressure monitoring in the initial days
and weeks following delivery.
Examples of Ochsner’s Telehealth Offerings
Ochsner deploys telehealth to deliver specialty, primary, and urgent care to patients
near and far. We are proud to have created a network of hundreds of physicians
who reside out of state and who—through multi-state licensure and the telehealth
licensure compact—can deliver high quality care to our patients via telehealth, help-
ing to ensure better access to care for underserved communities.
Access to specialty care has been expanded through the utilization of physicians
with multi-state licensure who can treat patients via telehealth. Our ‘‘hub’’ and
‘‘spoke’’ model allows us to leverage our specialty physician workforce and expertise
located in New Orleans to locations throughout Louisiana and Mississippi. For ex-
ample, Ochsner provides emergency virtual psychiatric services, cutting emergency
room wait times for psychiatric care at our partner sites by 50%. Telehealth can
meaningfully increase patient access to telepsychiatry and telebehavioral health
services for many patients in rural and underserved areas who are currently with-
out access to such care.
Ochsner’s TeleStroke program provides 24-hour/7-days per week coverage by vas-
cular neurologists who—through telehealth—are immediately available to emer-
gency department physicians in rural hospitals to help them quickly diagnose and
treat patients presenting with symptoms of a possible stroke. The program has been
instrumental in successfully treating thousands of patients (more than 300 patients
per month) in a timely manner, and allows these facilities to remain open and suc-
cessfully caring for patients in their own communities. Seventy percent of Tele-
1 To learn more about Ochsner’s digital medicine programs see the following article: Wash-
ington Post: https://www.washingtonpost.com/business/economy/these-louisiana-physicians-
can-monitor-your-blood-pressure--and-you-dont-even-have-to-leave-your-living-room/2018/07/11/
6d57f198-7beb-11e8-93cc-6d3beccdd7a3_story.html.
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Stroke patients now stay local; prior to the program’s implementation,
nearly all patients were transferred.
Ochsner’s TeleStork program, using live streaming of maternal and fetal health
records, provides 24/7 monitoring to laboring mothers. Rapid detection of labor dis-
tress and maternal or fetal decompensation and facilitating early interventions by
our specialty care team is helping reduce adverse maternal and neonatal outcomes.
Since initiated in August 2016, there has been a 50% decrease in term unexpected
Neonatal Intensive Care Unit (NICU) admissions in TeleStork facilities. Not only
are the interventions effective in improving outcomes, but they have also been suc-
cessful in driving changes in clinical practice that result in a decrease in the need
for interventions, all of which ultimately lead to improvements in birth outcomes
of newborns within the program.
In 2019, we announced a partnership with Tyto Care, the health-care industry’s
first all-in-one modular device for remote medical exams. This partnership expands
Ochsner’s current telehealth offering, a consumer-facing virtual visit platform called
Ochsner Anywhere Care, which is powered by national telehealth leader American
Well®. The Ochsner Anywhere Care Health Kit, powered by Tyto Care, is a portable
health kit that enables patients to capture physical examination data at home using
a handheld device with a digital camera and various attachments and then share
it with a provider using the Ochsner Anywhere Care app. It is designed to replicate
the exams performed during an in- office visit, by providing high-quality digital
sounds of the heart and lungs, digital images and video of the ears, throat and skin,
and body temperature. Special adaptors are included for examining the ears, throat,
skin for taking body temperature, and listening to heart and lung sounds. To see
a demonstration video visit: https://ochsner.tytocare.com/.
Since the pandemic began, we have sold thousands of Ochsner Anywhere Care
Health Kits and through their deployment expanded access to primary and urgent
care, allowing these patients to have access to care from the safety of their own
homes. It is important to note that an Ochsner Anywhere Health Kit is not required
for an Ochsner Anywhere Care or other telehealth visit, but it does provide tools
to capture and share exam data, which can prove to be helpful for a provider mak-
ing a diagnosis and treatment recommendation.2 This offering has potential to ex-
pand access to care, particularly for individuals with mobility limitations, including
disabilities and transportation challenges, as well as provide access to individual
and families in rural and underserved communities. Further, through funding we
received through the Federal Communications Commission (FCC) COVID–19 Tele-
health Program, we have been able to purchase and are actively disseminating—
at no cost to patients—nearly 12,000 devices to support patients in participating in
our HTNDM, DDM, and Connected MOM programs.
Having additional resources allowed us to expand the reach of our digital medicine
programs, which in turn, supported our ability to maintain continuity of care—and
in some cases begin important health monitoring—of patients with hypertension
and/or diabetes as well as support our patients during an important time during
their pregnancy. With the availability of the FCC telehealth device funding, we are
particularly pleased that we have been able to expand enrollment of Medicare and
Medicaid beneficiaries in our digital medicine programs, as making the devices
available free of charge has removed a significant participation barrier for many pa-
tients.
Lessons Learned from COVID–19
Prior to the COVID–19 PHE, Ochsner had long-advocated that Congress, the U.S.
Department of Health and Human Services (HHS), and the Centers for Medicare
and Medicaid Services (CMS) expand coverage and reimbursement for telehealth
and digital medicine services and associated connected devices. We theorized that
improvement in how these services and the associated devices are covered and reim-
bursed would accelerate their adoption, increase access to care, and in turn, lever-
age their potential in supporting patient engagement, expand provider access to
more accurate and timely patient data, and enhance the patient experience.
2 The Ochsner Anywhere Health Kit, powered by Tyto Care, retails for $299 with $10 flat
shipping if ordered online at www.ochsner.org/healthkit. It is also available for purchase at
Ochsner pharmacy locations https://www.ochsner.org/services/pharmacy/, O Bar retail stores
https://www.ochsner.org/shop/o-bar, Ochsner Fitness Centers https://www.ochsnerfitness.
com/, and Ochsner Total Health Solutions https://www.ochsner.org/locations/ochsner-total-
health-solutions. Some insurance providers may provide a discount or partial reimbursement; it
is recommended that consumers contact their insurance provider for more information.
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Now, more than a year into the pandemic, we have real world experience and have
seen this theory come to fruition. These technologies and care delivery modalities
are making a difference in the lives of people diagnosed with COVID–19, those sus-
pected as having COVID–19, and for patients who need access to non-COVID-re-
lated primary or specialty care. Fully deploying telehealth and digital medicine to
our Medicare, Medicaid, and commercially insured patients has helped to maintain
continuity and coordination of care, as well as allowed for expanded access to care
to patients who previously had been underserved. In many cases, Ochsner has been
able to reach patients who previously have had limited or no access to such serv-
ices—particularly in rural and underserved areas where health-care disparities per-
sist.
Over the course of the COVID–19 pandemic, Ochsner has observed in patient re-
ported data a significant increase in utilization of telehealth services by minority
populations, particularly among Blacks, where the percentage of patients completing
virtual visits doubled. At the height of the COVID–19 outbreak in the ‘‘hot spot’’
state of Louisiana, Ochsner delivered more than 60 percent of visits to patients via
telehealth—making Ochsner the leading health-care system in the South in the de-
livery of telehealth during the public health crisis. From the March to December
2020 period, we are proud to have deployed virtual visits in a robust manner to sus-
tain continuity of care and reduce the risk of COVID–19 exposure for patients, fam-
ily members, and providers. Specifically, during this period:
• We provided an estimated 291,100 total virtual visits to adult and pediatric pa-
tients;
• Virtual visits were delivered across all primary, medical and surgical special-
ties, with the bulk of care being primary care, behavioral health, and medical
specialties;
• Approximately 30% (87,389) of our virtual visits were with Medicare bene-
ficiaries; and
• Almost 40,000, or 14%, of virtual visits were with people with Medicaid cov-
erage.
While Ochsner was able to quickly and adeptly expand our telehealth and digital
medicine offerings due to our existing programs and infrastructure, other hospitals,
health systems, and providers required significant time, resources, equipment, and
training—of health professionals and patients—to scale up their remote care offer-
ings, which in turn, caused some delay in patients receiving health-care services and
outpatient treatment. We feel strongly that the nation’s health-care system must
maintain these advances during non-pandemic times to ensure that the infrastruc-
ture, practice, familiarity, and resources are in place so irrespective of what threat
may emerge—natural disaster, bioterrorism, or infectious disease—that we have a
strong, existing system so physicians, nurses, and hospitals can continue to provide
health-care services across the care continuum.
Ochsner Policy Recommendations
The telehealth waivers granted by HHS and CMS have been critical to Ochsner’s
quick expansion and implementation of telehealth and digital medicine services.
Since the start of the PHE and the advent of the waivers, in our telehealth program,
we have seen an 89% increase in Louisiana patients from rural areas, as defined
by the Health Resources and Services Administration. This increase is due to nu-
merous factors, including a significant boost in patient interest in remote care and
quick patient adoption to remote care. We commend HHS and CMS for providing
these flexibilities and respectfully request that the Congress work with CMS and
HHS to enact legislation and modify regulations, as applicable, to make these waiv-
ers permanent and ensure that we do not lose the gains made in telehealth and vir-
tual care.
Telehealth Waivers Prioritized for Permanent Change
While all of the telehealth waivers provided by HHS and CMS have enhanced our
ability to serve patients throughout the COVID–19 public health crisis, Ochsner be-
lieves that the following waivers, in particular, have enabled and fostered successful
deployment of telehealth services to patients and these policy changes should be
maintained once the pandemic has abated so that more patients—especially those
in rural and underserved areas—can access treatment and receive more comprehen-
sive and coordinated care.
1. Patient location: The ability of patients to receive telehealth services from
any location, including their homes, has given patients access to services where
in many cases they could not have accessed care. Telehealth has reduced the
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need to travel for patients who are not as mobile and provides scheduled or
on demand care and support through difficult stages of well-being. For exam-
ple, telehealth has allowed patients in rural and remote areas without reliable
transportation to more easily receive treatment by eliminating travel burden.
For those patients with limited resources, telehealth has eliminated the cost
of travel time and additional time away from work to receive an in-person visit.
Further, for institutional-based patients such as those residing in skilled nurs-
ing facilities (SNFs), telehealth has given them the ability to remain in their
care setting, minimizing both health risk and burden. Hence, making perma-
nent the waiver permitting patients to receive telehealth from any location will
eliminate a significant barrier for many patients who, before the telehealth ex-
pansion, faced challenges in accessing the services they need to get well and
stay healthy.
2. Reimbursement at the in-person visit rate: Reimbursing for telehealth vis-
its at the in-person rate has enabled Ochsner to offer services to patients in
a financially sustainable and scalable manner. Adequate reimbursement for
telehealth at the in-person visit rate ensures that providers receive appropriate
payment for the full range of care they provide in the context of a remote visit.
For example, often patients submit photographs, videos, and other medical in-
formation (e.g., blood pressure readings, blood sugar data, etc.) in advance that
their providers take time to review and analyze prior to—or following—a tele-
health encounter. In a face-to-face encounter this often is done in real time and
is reflected in the in-person payment amount. Further, providing reimburse-
ment at the same rate as in-person care recognizes that the provision of tele-
health services requires resources, such as technology and other infrastructure.
3. New services eligible for telehealth delivery: The significant expansion in
the types of health-care services that can be delivered via telehealth has given
Ochsner a way to reach patients previously not possible in many instances. For
example, delivering occupational, speech/language, and physical therapy serv-
ices via telehealth to patients in their homes or in SNFs has given patients
new or increased access to care that improves quality of life and health out-
comes. Pain management and palliative care and hospice patients and families
have also benefited from the ability to connect with their providers through
telehealth.
4. No required established relationship between practitioner and patient:
Without the requirement of an established relationship between the patient
and provider, Ochsner has been able to immediately serve a wider population
of patients and address their care needs. Many patients living in rural and un-
derserved communities do not have a regular source of health care and there-
fore do not have an established relationship with a provider. Making this waiv-
er permanent will remove a significant barrier in access to treatment, espe-
cially for those many patients in rural and underserved communities who in
many cases historically have received fragmented care.
5. Waiver of Medicare remote patient monitoring and other non-face-to-
face services copayments: The HHS Office of the Inspector General (OIG)’s
waiver of the Anti-Kickback Statute (AKS) for cost-sharing obligations for non-
face-to-face services furnished through various modalities, including remote pa-
tient monitoring, remote monthly care management, virtual check-ins, and
telehealth visits has eliminated a substantial barrier in patient access to care
where, in many cases, patients simply do not have the resources to pay for
services that are not immediate care needs but who could benefit from the care
provided.
For example, as noted earlier, primary and secondary preventive services like Ochs-
ner’s DDM and HTNDM programs have reduced unnecessary emergency depart-
ment visits, decreased inpatient admissions, increased medication adherence, and
improved annual screening compliance, but unfortunately have been hindered by co-
payment barriers. Given the demographics of the Ochsner patient population, af-
fordability of care is a serious impediment to our ability to manage chronic disease
for too many of our patients. According to Kaiser Family Foundation, approximately
20% of Medicare beneficiaries in fee-for-service have no type of supplemental cov-
erage, which makes paying out-of-pocket costs more challenging. Coinsurance often
stands in the way of patients seeking and receiving the care they need, particularly
for Medicare patients with limited resources.
Remote monitoring, such as our hypertension program, typically involves a monthly
‘‘charge’’ to cover the costs of having the data reviewed by the health-care team and
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additional involvement by the physician should any adjustments to treatment or the
care plan need to be made. We know from our clinical experience that for many
beneficiaries the cost of the monthly out-of-pocket fee caused them to decline the
opportunity to enroll in a digital medicine program. Yet, over the past 14 months,
with the copayments waived, we have noted a significant increase in enrollment and
participation among patients who need these programs, which in turn will help im-
prove their health and reduce costs over time. Permanently waiving the copayment
requirement for these non-face-to-face services will meaningfully improve access and
much better enable Ochsner to more effectively and comprehensively care for pa-
tients, especially for patients in rural and underserved areas where significant dis-
parities in care remain and must be addressed.
Other Waiver Related Policy Recommendations
In addition to the telehealth waivers enumerated above, HHS and CMS have pro-
vided additional waivers during the PHE that have strengthened our ability to con-
tinue to provide health-care services and outpatient treatment during the pandemic.
Based on our experience with these waivers, we recommend that Congress and CMS
work together to address the following:
1. Cross jurisdictional licensure in the event of a PHE: In the event of a
PHE, there should be automatic allowance of CMS physician or non-physician
practitioner licensing requirements when the following four conditions are met:
(1) must be enrolled as such in the Medicare program; (2) must possess a valid
license to practice in the state, which relates to his or her Medicare enrollment;
(3) is furnishing services—whether in person or via telehealth—in a state in
which the emergency is occurring in order to contribute to relief efforts in his
or her professional capacity; and (4) is not affirmatively excluded from practice
in the state or any other state that is part of the emergency area. This change
would have no effect on state licensure requirements.
2. Modify EMTALA: The 1135 emergency waiver authority has allowed the Sec-
retary to waive enforcement of EMTALA. In response to the current PHE the
Secretary allowed hospitals to redirect patients who present at the emergency
department to an alternative screening site and to transfer individuals with an
unstable emergency medical condition. To use these waivers, many health sys-
tems relied on technology to screen patients upon emergency department ar-
rival. Outside of a PHE, such screening tools would not typically meet the med-
ical screening requirements under EMTALA.
While EMTALA is necessary to ensure that all patients have access to emer-
gency medical care, we urge Congress to revise the statute to allow for
new types of medical screenings. Specifically, many health systems hope
to employ pre-screenings that use technology that can help divert non-
emergent cases to other settings. The current medical screening requirements
are so extensive that patients remain in the full queue of emergency depart-
ment patients before it is determined that they could be diverted to another
setting of care. More often than not, the patient is treated in the hospital after
long wait times rather than being directed to nearby outpatient departments
or physician practices, where the patient could have received appropriate care
in a timelier manner and at lower cost to the patient and health-care system.
We envision appropriate guardrails could be put in place by requiring hospitals
to have their pre-screening approaches approved by CMS and requiring addi-
tional data submissions on patient diversion.
Other Policy and Payment Recommendations
1. Expand covered remote monitoring services to allow for beneficiary
participation and Medicare coverage and reimbursement for more
than one program, which will increase access, ease patient day-to-day
care, and improve health outcomes: Federal health programs should per-
mit patients to participate in as many remote monitoring programs as their
health needs dictate. A significant number of patients have more than one
chronic condition (e.g., hypertension and diabetes) that would benefit from re-
mote monitoring. Currently, Medicare only provides payment for one remote
monitoring program/initiative, generally resulting in the provider receiving re-
imbursement for the program to which the patient consents first. Ochsner
treats patients who would benefit from being enrolled in both our HTNDM and
DDM programs because they have both hypertension and diabetes. For exam-
ple, in Louisiana among Medicare beneficiaries aged 65 and older 65.63% have
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225
hypertension and 27.99% have diabetes.3 Hypertension is twice as common
among people with diabetes as those without it and an estimated two-thirds
of people with diabetes have elevated blood pressure and/or are treated for hy-
pertension.4 Among the population we treat at Ochsner, an estimated 75% of
patients with diabetes also have hypertension. Many chronic care Medicare
beneficiaries have multiple comorbid conditions. CMS data for Louisiana show
that 28.63% of Medicare beneficiaries in the state have 2–3 chronic conditions
and annual Medicare per capita spending for this group of patients is $5,999.5
As such, the Medicare program and patients could benefit from allowing pro-
viders to offer a variety of remote monitoring services at the same time for all
applicable documented diagnoses. Federal health programs should permit pro-
viders to bill for all remote monitoring services applicable to a patient’s diag-
noses to foster increased patient access to more coordinated and more com-
prehensive care, ultimately, resulting in improved patient health outcomes at
a lower total cost-of-care.
2. Provide digital medicine and telehealth tools/devices to Medicare pa-
tients at no cost to increase patient uptake of these services: Patients
often need technology or tools to support their health and well-being and allow
for better care management by their provider team. As explained above,
Ochsner’s successful digital medicine programs require the use of connected
smart devices that communicate with the care team. Patients must purchase
these devices—in some cases entirely out-of-pocket and in other cases with
some cost-sharing and some coverage. Unfortunately, as noted above, out-of-
pocket expenses often preclude patients from accessing to the care, services,
and tools they need to stay healthy and prevent catastrophic episodes of care.
In our experience, approximately 10% of patients decline to participate in our
digital medicine programs when they learn they have to pay for the device out-
of-pocket. Therefore, Congress should expand Medicare payment policy to in-
clude full coverage of digital medicine devices (e.g., Bluetooth-enabled blood
pressure cuff, Bluetooth-enabled digital scale, Bluetooth-enabled digital
glucometer) and telehealth devices (e.g., Tyto Anywhere Care kit) and do so
without any cost-sharing requirements. The overwhelming response to the Con-
gressionally established COVID–19 Telehealth Program at the FCC has dem-
onstrated the need for a funding mechanism for these devices. Ochsner has
seen firsthand the willingness of patients to participate in these beneficial pro-
grams when they have affordable access to them. Expanding access to these
important patient engagement and support tools will help providers leverage
the full value and improved patient health outcomes that digital medicine and
telehealth care can offer.
3. Ensure patient access to TeleStroke services by establishing separate
Medicare payment for providers giving both TeleStroke consult and
same day inpatient care to Medicare beneficiaries experiencing acute
stroke: Ochsner commends the Congress for expanding Medicare beneficiary
access to TeleStroke services as part of the Bipartisan Budget Act (BBA) of
2018. To foster further Medicare beneficiary access to TeleStroke services, Con-
gress should permit Medicare to make two separate payments to a single pro-
vider for both a TeleStroke consult and the work of a subsequent stroke admis-
sion on the same day if the admitting hospital both provides the initial Tele-
Stroke consult and later admits the patient after transfer due to the acuity
level of the patient’s stroke.
4. Expand Medicare beneficiary access to non-stroke telehealth services
for acute neurological conditions: Patients in rural and underserved com-
munities typically have significantly less access to treatment for acute neuro-
logical diseases. To build on the important expansion of TeleStroke care,
Ochsner requests that Medicare provide unrestricted telehealth coverage for
other non-stroke acute neurological conditions that typically require consulta-
3 https://portal.cms.gov/wps/portal/unauthportal/unauthmicrostrategyreportslink?evt=20480
01&src=mstrWeb.2048001&documentID=69E5BACC452E9CC0D72D6DA872A90AF6&visMode=
0¤tViewMedia=1&Server=E48V126P&Project=OIPDA-BI_Prod&Port=0&connmode=8&ru
=1&share=1&hiddensections=header,path,dockTop,dockLeft,footer.
4 https://www.hopkinsmedicine.org/health/conditions-and-diseases/diabetes/diabetes-and-
high-blood-pressure.
5 https://portal.cms.gov/wps/portal/unauthportal/unauthmicrostrategyreportslink?evt=20480
01&src=mstrWeb.2048001&documentID=69E5BACC452E9CC0D72D6DA872A90AF6&visMode=
0¤tViewMedia=1&Server=E48V126P&Project=OIPDA-BI_Prod&Port=0&connmode=8&ru
=1&share=1&hiddensections=header,path,dockTop,dockLeft,footer.
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226
tions with emergency departments to achieve optimal patient health outcomes.
These include diagnostic questions of numbness, weakness, vertigo, confusion,
headache, tremors and seizures, leading to treatment of complications of spinal
cord injury, nerve compression, brain tumors, Multiple Sclerosis (MS), Parkin-
son’s disease, Alzheimer’s disease, epilepsy, Amyotrophic Lateral Sclerosis
(ALS), and many other conditions. Similar to the request for TeleStroke above,
Congress should allow Medicare to make two separate payments to a single
provider for both a non-stroke telehealth consult of an acute neurological condi-
tion and the work of a subsequent inpatient admission on the same day related
to that condition if the admitting hospital provides both the initial telehealth
consult and later admits the patient after transfer due to the acuity level of
his or her neurological condition. Patient access to acute neurological tele-
health services should not be limited by geographic or originating site require-
ments in the original Medicare telehealth statute.
5. Expand access to intensive care unit (ICU) telehealth: In many cases, pa-
tients in rural and underserved areas have to travel significant distances to re-
ceive emergency care. Through Ochsner’s innovative telehealth offerings, we
can give telehealth ICU consults that save meaningful time to treatment in
many instances where immediate access to care can result in the likelihood of
significantly better patient health outcomes. Congress should provide unre-
stricted Medicare coverage for telehealth ICU consults (i.e., no originating or
geographic site limitations) so that all beneficiaries can access the emergent
care they need as quickly as possible.
6. Provide payment to providers who are offering additional levels of re-
mote monitoring for patients through programs such as TeleStork. Of-
ferings like TeleStork provide an additional level of specialized monitoring and
clinical support to providers who are caring for maternity patients who may
be at higher-risk for poor maternal and fetal outcomes. Because the care is not
delivered directly to the patient there is no reimbursement provided for the
service, yet in our experience it is cost-effective and cost-saving.
Conclusion
The federal waivers outlined above have allowed Ochsner’s telehealth and virtual
care programs to operate at their full potential, and in doing so, have demonstrated
that telehealth and virtual care are high quality, efficient, and effective ways to
treat patients safely both inside and outside of the clinic and hospital settings.
Ochsner urges the permanent extension of these critically important waivers; mak-
ing these changes permanent will allow us to continue providing care to patients
that may otherwise go unserved.
Further, we thank you for considering our additional recommendations for ways to
modify federal coverage and reimbursement policy to facilitate the provision of vir-
tual care and patient monitoring in a cost effective and convenient manner and in
a way that also reduces patients’ unnecessary exposure to infectious disease, such
as COVID–19. We believe that by strengthening our nation’s telehealth, virtual
care, and digital medicine infrastructure we will be able to maintain the access to
care gains made over the past year and support hospitals and providers in con-
tinuing to provide care throughout the PHE and otherwise.
We thank you for your consideration of our recommendations and stand ready to
serve as a resource. Sincerely,
Will Crump
Director of Public Health Policy
PARTNERSHIP FOR EMPLOYER-SPONSORED COVERAGE
1212 New York Avenue, Suite 1100
Washington, DC 20005
The Partnership for Employer-Sponsored Coverage (P4ESC) appreciates the Senate
Finance Committee holding this hearing to discuss options for continuing health-
care delivery and policy flexibilities implored during the COVID–19 pandemic.
P4ESC believes that the time is ripe to modernize laws to increase access to tele-
health services as patients, health providers, and coverage plan sponsors adapted
to remote working and social distancing measures by utilizing this care delivery
method and benefit offered by many employers.
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227
As an advocacy alliance of employment-based organizations and trade associations
representing businesses of all sizes and millions of Americans who rely on employer-
sponsored health coverage every day, P4ESC is working to ensure that employer-
sponsored coverage is strengthened and remains a viable, affordable option for dec-
ades to come.
P4ESC appreciates the COVID-related policies adopted over the last year to help
employees and businesses, including expanding telemedicine availability to employ-
ees. Congress should build on this policy to provide employers with the ability to
enhance employee coverage permanently. P4ESC is eager to work on bipartisan leg-
islation to expand employee access to telemedicine, including enabling employers to
offer a telehealth service plan to all employees regardless of their enrollment in the
employer’s medical coverage.
P4ESC supports: (1) treating telehealth services as an excepted benefit which would
enable employers to offer this type of coverage to part-time and variable workforces,
and other employees not enrolled in the employers’ medical plan; (2) reforming li-
censure requirements to enable services to be offered across state lines; (3) estab-
lishing a national set of standards for telemedicine services to address state-based
requirements that have not kept pace with technology, practice site and remote
working advances, including eliminating originating site and prior provider relation-
ship requirements; and (4) clarifying that CARES Act telemedicine provisions are
effective for plan years on or after January 1, 2019 (employer plan years vary be-
tween non-calendar and calendar year basis).
According to the Society for Human Resource Management’s (SHRM) Navigating
COVID–19: Impact of the Pandemic on Mental Health,1 ‘‘the COVID–19 pandemic
has put unprecedented strain on workers’ mental health the research finds that a
majority of employees are experiencing symptoms of depression, but very few are
receiving care.’’ Findings include:
• Two out of three employees report experiencing symptoms of depression some-
times amid widespread lockdowns
• More than two in five employees feel burned out, drained, or exhausted by work
• 37 percent of employees have not done anything to cope with depression-related
symptoms and only 7 percent have reached out to a mental health professional
The pandemic has offered employees the ability to receive mental and behavioral
health services via telemedicine, and we strongly support making this access perma-
nent. As noted in testimony before the House Education and Labor Committee hear-
ing 2 on April 15, 2021, James Gelfand of the ERISA Industry Committee (ERIC)
stated ‘‘[w]hen COVID–19 caused many employers to shift to remote work or re-
duced employee presence onsite, many worksite clinics went virtual, offering mental
and behavioral health via telehealth. Some clinics expanded eligibility to other em-
ployees in the same state, who may not be based at the same site. This helped cre-
ate continuity for employees undergoing care, and a new access point for many oth-
ers.’’
Further, in an op-ed published in The Hill 3 on May 28, 2020, SHRM’s Emily M.
Dickens, Chief of Staff, Head of Government Affairs and Corporate Secretary, wrote
‘‘[g]reater access to telemedicine, including telepsychiatry, will provide the resources
for employees to navigate all health-care options and privately seek the help that
they need. The convenience of this offering will benefit employers and their employ-
ees because such services can be received at home and after work hours during a
time when personal and professional schedules are anything but definite for so
many workers.’’
In the employer benefits space, telehealth services come in different forms, such as:
the ability for employees to be treated by a health provider or practice, with whom
they already have a relationship, in a telemedicine setting instead of through a tra-
ditional in-office visit; and access to a telehealth service vendor which is included
in a benefits package offering, similar to a dental or vision plan, that is separate
from the medical plan but provides the ability to be connected to a physician or
health professional for a consultation.
1 https://www.shrm.org/hr-today/trends-and-forecasting/research-and-surveys/documents/
shrm%20cv19%20mental%20health%20research%20presentation%20v1.pdf.
2 04–15–21 ERIC Testimony—E&L Mental Health Hearing [Final].pdf.
3 https://thehill.com/opinion/healthcare/500017-assist-mental-health-of-workers-by-increas-
ing-access-to-telemedicine.
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In the later example, the separate telehealth vendor program can legally be pro-
vided to full-time employees enrolled in the employer medical plan but not to other
groups of the workforce. Part-time and seasonal employees, and full-time employees
who declined the employer medical plan cannot access the telehealth vendor pro-
gram because this type of stand-alone benefit would violate the coverage rules under
the Affordable Care Act’s (ACA) employer mandate. P4ESC supports legislation to
enable employers to offer these excepted benefit telehealth service plans to all em-
ployees, regardless of their eligibility for or enrollment in an employer’s medical
plan. Offering this type of telehealth service to employees is not at all meant to cir-
cumvent an employer’s responsibility to offer a medical plan to full-time employees
under the ACA’s employer mandate.
Additionally, as the Committee considers ways to improve access to telehealth serv-
ices, P4ESC urges you to also consider network access and availability of behavioral
and mental health providers. Employers and employees face challenges in finding
available and affordable behavioral and mental health-care providers. Some behav-
ioral and mental health providers—particularly those in rural areas—decline to par-
ticipate in health insurance networks. In the case of most self-insured plans under
the Employee Retirement Income Security Act of 1974 (ERISA), employers rent in-
surance carriers’ provider networks. The decision to join a network lies with the pro-
vider, subject to network standards.
Because so many behavioral and mental health providers choose not to go in-
network, employees can often face large out-of-network bills for care sought. It is
important to stress that efforts to evaluate the availability of behavioral and mental
health providers in health insurance networks must also consider whether these
providers make themselves available and affordable to employees. Coverage require-
ments and civil monetary penalties on employers and insurance carriers are coun-
terproductive, particularly regarding access and affordability, unless there is a coun-
tervailing requirement enforced by equal penalties for providers to participate in
one or more networks.
The Partnership for Employer-Sponsored Coverage welcomes the opportunity to pro-
vide input and speak in further detail. Benefits offerings and coverage plans in the
employer-sponsored system are as diverse as employers themselves. There is no one-
size-fits-all employer plan, and the functionality of a business is centered around a
productive, thriving, and healthy workforce. As a coalition representing businesses
of all sizes, we have the unique ability to provide operational input across the full
spectrum of the employer system—from the smallest family business to the largest
corporation.
American Health Policy Institute
American Hotel and Lodging Association
American Rental Association
Associated Builders and Contractors, Inc.
Associated General Contractors of America
Auto Care Association
Business Group on Health
The Council of Insurance Agents and Brokers
The ERISA Industry Committee (ERIC)
FMI—The Food Industry Association
HR Policy Association
National Association of Health Underwriters
National Association of Wholesaler-Distributors
NFIB—National Federation of Independent Business
National Restaurant Association
National Retail Federation
Retail Industry Leaders Association
Society for Human Resource Management
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229
PREMIER INC.
444 North Capitol Street, NW, Suite 625
Washington, DC 20001
T 202–393–0860
F 202–393–6499
https://www.premierinc.com/
The Premier health-care alliance appreciates the opportunity to submit a statement
for the record on the Senate Finance Committee hearing titled ‘‘COVID–19 Health
Care Flexibilities: Perspectives, Experiences, and Lessons Learned’’ on May 19,
2021. We applaud the leadership of Chairman Wyden and Ranking Member Crapo
and members of the Committee for holding this hearing to evaluate the lessons
learned during the pandemic and what the important flexibilities that have played
in safely expanding access to care during the pandemic and options to extend tele-
health capabilities into the future.
Many of the waivers and temporary regulatory changes granted during this period
have significantly improved health-care providers’ ability to combat the epidemic.
These actions have also highlighted key opportunities to modernize health-care de-
livery by removing outdated regulations. Premier’s hope is that by identifying tem-
porary policies that proved successful in improving and innovating health care for
Americans during this challenging time, we can pinpoint changes that should be
made permanent or implemented on a broader scale beyond the pandemic.
Safely Treating Patients through Telehealth
Premier greatly appreciates Congress acting to broadly expand permitted uses of
telemedicine and telehealth during the public health emergency in the Coronavirus
Preparedness and Response Supplemental Appropriations Act and the Coronavirus
Aid, Relief, and Economic Security (CARES) Act. These provisions have allowed
beneficiaries beyond just those in rural areas to receive telehealth services in their
home from an expanded set of providers, including through audio-only communica-
tions, and provided payments to match in-office rate for clinicians who typically pro-
vide care in an office. As such, telehealth has provided a lifeline during the pan-
demic for individuals in all geographic areas who still need access to health care
when traditional care delivery approaches are interrupted.
Premier data for more than 30,000 ambulatory providers nationwide shows that the
use of virtual visits in the outpatient space have averaged 14.2 percent since the
pandemic (an increase of nearly 30X compared to pre-pandemic) with a 31 percent
better no-show rate than in-person visits. With this concentrated experience over
the past year, providers have learned how to best deploy telehealth and patients are
overwhelmingly reporting high satisfaction with their virtual care visits. As a result,
it is now seen as a valuable and potentially cost-effective addition to health-care de-
livery.
As health systems and providers continue to support their communities and navi-
gate a new normal after the pandemic, they are concerned that a retreat to prior
rules will limit provider care delivery innovation for Medicare beneficiaries. A per-
manent expansion of telehealth policies will require appropriate guardrails. Recog-
nizing more time is needed to determine the best approaches for permanent tele-
health expansion in fee-for-service, Premier urges Congress to permanently ex-
tend to all alternative payment models (APMs) the telehealth coverage and
payment policies that were operationalized under the public health emer-
gency. Providers in APMs are incented to use telehealth only when it is most ap-
propriate as they are responsible for the cost of care and improving quality. A sur-
vey 1 conducted by Premier found that providers participating in accountable care
organizations (ACOs) drew heavily on their population health capabilities to manage
COVID–19 cases and keep people staying at home healthy, including by quickly
ramping up the use of telehealth.
We believe Congress should immediately start with allowing greater flexibility
around the types of technology that can be used, adopting additional services, and
exploring additional telehealth flexibilities through Center for Medicare and Med-
icaid Innovation (CMMI) models and other Medicare APMs. While telehealth waiv-
ers are available for APMs, they are far more limited than the waivers provided
during the public health emergency. The greatest flexibility should be awarded in
models in which providers bear downside risk, such as in global budgets and
1 https://www.premierinc.com/newsroom/press-releases/premier-inc-survey-clinically-inte-
grated-networks-in-alternative-payment-models-expanded-value-based-care-capabilities-to-man-
age-covid-19-surge.
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230
capitated payments. Providing greater telehealth flexibility in models will be a tre-
mendous incentive for providers to transition from fee-for-service to value and total-
cost-of-care and other risk-based models.
As Congress considers how to make expanded telehealth a permanent part of our
health-care system, we also encourage lawmakers to explore increasing telehealth
access across all of Medicare fee-for-service and Medicare Advantage by granting
Centers for Medicare & Medicaid (CMS) greater authority to set regulation on al-
lowable health services and payment for telehealth services.
With appropriate guardrails, Congress should also take action to:
• Provide temporary state licensing reciprocity for telehealth during the pandemic
by passing the Temporary Reciprocity to Ensure Access to Treatment (TREAT)
Act (S. 168/H.R. 708).2,3
• Ensure audio-only telehealth continues to be an effective source of health care
for all seniors during the course of the COVID–19 public health emergency by
passing the Ensuring Parity in MA for Audio Only-Telehealth Act (S. 150).4
This bill would count diagnoses obtained from audio-only telehealth services for
risk adjustment purposes under the Medicare Advantage program to ensure
that health costs are adequately covered while providing the information care
teams need to manage patient care.
Ensuring Continued Movement to Value-Based Care
The pandemic has required greater care coordination across the traditional health-
care silos as providers work to manage infected patients in the most effective set-
tings. According to a Premier survey,1 leading health systems and providers oper-
ating in value models were able to rapidly implement strategies to respond to
COVID–19, expanding care management, call centers and remote/home monitoring
and other capabilities to respond to COVID–19. Moreover, if we had made more
progress in value-based care prior to COVID–19, with more entities in global budg-
ets or capitation, we could have avoided the financial challenges many providers
faced. We urge Congress to support a continued emphasis on movement to value by:
• Incenting providers to move to downside risk arrangements by extending the
Advanced APM bonus by five years and giving CMS the authority to set the
thresholds to qualify for the bonus;
• Fixing a perverse flaw in the Medicare Shared Savings Program that penalizes
organizations in certain communities that are achieving savings for the Medi-
care program by including their ACO population in their spending benchmark
calculation; and
• Removing risk adjustment caps from value models so that the complexity of pa-
tients is recognized in the benchmark.
Conclusion
In closing, the COVID–19 public health emergency has illuminated the need to
allow more flexibility in Medicare payment and delivery system models so that pro-
viders can tailor care to the specific needs of beneficiaries and their communities.
This is especially true for providers serving rural and underserved communities.
Congress and the Administration can build on the limited flexibilities for telehealth
and APMs granted during the public health emergency and make other key changes
to open doors to providers who are seeking to better serve their Medicare popu-
lations through accountable delivery system models that focus on care coordination,
improved outcomes and value.
The Premier health-care alliance appreciates the opportunity to submit a statement
for the record on the Senate Finance Committee hearing on COVID–19 health-care
flexibilities. Premier is available as a resource and looks forward to working with
Congress as it considers policy options to continue to address this very important
issue.
If you have any questions regarding our comments or need more information, please
contact Blair Childs, Senior Vice President of Public Affairs, at blair—childs@
premierinc.com.
2 https://www.congress.gov/bill/117th-congress/senate-bill/168.
3 https://www.congress.gov/bill/117th-congress/house-bill/708.
4 https://www.congress.gov/bill/117th-congress/senate-bill/150.
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PSYCHIATRIC MEDICAL CARE, LLC
8 Cadillac Drive, #230
Brentwood, TN 37027
May 19, 2021
Dear Chairman Wyden and Ranking Member Crapo:
Psychiatric Medical Care (PMC) appreciates the opportunity to submit a statement
for the record to the Senate Finance Committee on ‘‘COVID–19 Health Care Flexi-
bilities: Perspectives, Experiences, and Lessons Learned.’’ PMC applauds the mem-
bers of the Finance Committee for their rapid action to expand access to telehealth
services during the COVID–19 pandemic and strongly believes this expansion of
health-care access should be maintained to address other health issues, such as
America’s ongoing behavioral health needs.
Founded in 2003 and headquartered in Nashville, TN, PMC is a leading behavioral
health-care management company. Focused on addressing the needs of rural and
underserved communities, PMC manages inpatient behavioral health units, inten-
sive outpatient programs, and telehealth services in more than 25 states. The com-
pany’s services provide evaluation and treatment for patients suffering from depres-
sion, anxiety, mood disorders, memory problems, post-traumatic stress disorder, and
other behavioral health problems.
Critical Access Hospitals (CAHs) have provided outpatient hospital services via tele-
communications technology during the COVID–19 pandemic by leveraging the Cen-
ter for Medicare and Medicaid Services (CMS) waiver of the provider-based regula-
tions described in ‘‘Hospitals: CMS Flexibilities to Fight COVID–19.’’1 CMS clarified
that hospitals could use this flexibility to designate a patient’s home as provider-
based and treat services rendered to such a patient in their home via telecommuni-
cations technology as if they were being performed in-person.2 This flexibility to le-
verage virtual care to its full potential has proven crucial to meeting surging behav-
ioral health needs during the COVID–19 pandemic. However, even after the COVID–
19 public health emergency comes to an end, America’s behavioral health crisis will
continue.
Unfortunately, public health experts expect that the opioid crisis public health
emergency, which has been exacerbated by the COVID–19 pandemic and further
compounded the country’s behavioral health challenges, will also continue. Indeed,
in the months since COVID–19 brought the nation to a standstill, more than 40
states have recorded increases in opioid-related deaths.3 Additionally, approximately
20 percent of the rural population experiences mental illness 4 and are dispro-
portionally impacted by the opioid epidemic (SUD often co-occurring with mental ill-
ness).5 Approximately 48,000 people die by suicide every year—the 10th leading
cause of death in the United States.6 These suicide rates were 40 percent higher
in rural areas than in large urban areas (and are increasing at a faster rate).7
These challenges are particularly acute for Medicare beneficiaries. Approximately 33
percent of widowers become depressed—and while elderly adults represent only 13
percent of the population, they represent approximately 20 percent of all suicide
deaths.8, 9 At the same time, approximately 68 percent of elderly adults have little
awareness about how to recognize and be treated for depression.10
1 https://www.cms.gov/files/document/covid-hospitals.pdf.
2 85 Fed. Reg. 27750, 27563 (May 8, 2020).
3 https://www.ama-assn.org/system/files/2020-10/issue-brief-increases-in-opioid-related-over-
dose.pdf.
4 Rural Health Reform Policy Research Center (2014). The 2014 update of the rural-urban
chartbook, available on Gateway at https://www.ruralhealthresearch.org/publications/940.
5 Keyes KM, Cerdá M, Brady JE, Havens JR, Galea S. Understanding the rural-urban dif-
ferences in nonmedical prescription opioid use and abuse in the United States. Am J Public
Health. 2014;104(2):e52–e59.
6 National Vital Statistics System—Mortality Data (2018) via CDC, www.cdc.gov/nchs/
fastats/suicide.htm.
7 National Advisory Committee on Rural Health and Human Services, Policy Brief and Rec-
ommendations, ‘‘Understanding the Impact of Suicide in Rural America,’’ December 2017.
8 National Institute of Mental Health, The Many Dimensions of Depression in Women: Women
at Risk (1999).
9 National Institute of Mental Health, Older Adults: Depression and Suicide Fact Sheet (1999).
10 Depression in Older Adults: More Facts, Mental Health America (n.d.). Retrieved from
http://www.mentalhealthamerica.net/conditions/depression-older-adults-more-facts.
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In addition to maintaining access to critical services, the ability of CAHs to furnish
outpatient behavioral therapy via telehealth has also improved continuity of care by
easing some of the transportation barriers intrinsic to rural settings, which are in-
variably exacerbated during the winter months even in the absence of COVID–19.
In other words, CAHs serve communities defined by barriers in accessing medical
care, and CMS’ flexibilities have enabled CAHs to not only maintain access to out-
patient behavioral therapy during the COVID–19 period of health emergency, but
these flexibilities have also driven CAHs to identify and implement more efficient
and clinically appropriate delivery of care models that leverage telecommunications
technology.
These rural behavioral health challenges are both a moral and economic imperative
for communities across the nation. These are exactly the issues that Congress in-
tended CAHs to address as providers of essential services in rural communities, and
the telecommunications flexibilities granted during the COVID–19 pandemic that
enable these facilities to meet these challenges should continue.
Why CAHs Are Different
As you know, CAHs receive their designation because they are viewed as critical
health-care hubs within their rural areas and communities. This designation ex-
cludes CAHs from the outpatient prospective payment system (OPPS) for outpatient
services unless they elect otherwise, because Congress understood that payment
under the OPPS would generally not be adequate. Under the standard payment
methodology for CAHs, a CAH receives payment for outpatient services under a rea-
sonable (‘‘fair market’’) cost-based methodology. More specifically, many CAHs as an
institution receive payment for outpatient hospital services they furnish to patients
and then pay the medical staff according to their own internal policies.
However, the telehealth statute is currently structured to provide fee schedule pay-
ment to ‘‘physicians’’ and ‘‘practitioners,’’ not reasonable cost payment to institutions
like CAHs. Specifically, with respect to telehealth services under section 1834(m) of
the Medicare statute, section 1834(m)(2) requires that the payment for telehealth
services be made ‘‘to a physician or practitioner located at the distant site . . .’’.
Further, the terms ‘‘physician’’ and ‘‘practitioner’’ are defined in statute and may not
generally include the state-licensed health-care professionals that CAHs rely on, by
virtue of their rural location and scarce labor market, to provide outpatient behav-
ioral therapy to their patients.
Unless Congress preserves CAH’s existing reasonable cost payment methodology
under which they receive payment for behavioral health services furnished via tele-
communications technology during the PHE, CAHs will be unable to provide these
services after the end of the PHE because Medicare cannot pay CAHs as an institu-
tion for ‘‘telehealth’’ services under a reasonable cost methodology. For a CAH to be
able to furnish behavioral health services via ‘‘telehealth,’’ it would need to affirma-
tively elect to bill under the OPPS for all outpatient services, which undermines the
reimbursement flexibility Congress intended to provide to CAHs in the first place.
Even then, the CAH would not be paid reasonable costs, and instead the ‘‘physician’’
or ‘‘practitioner’’ would be paid by Medicare the Medicare fee schedule amount for
their professional services. Moreover, as discussed above, CAHs rely on state-
licensed providers to furnish behavioral health services, and many of these pro-
viders may not be eligible to bill as ‘‘physicians’’ or ‘‘practitioners’’ under the Medi-
care program. These limitations would leave many Medicare beneficiaries in rural
communities served by CAHs without mental health services, and would represent
a significant decrease in our national capacity to address rural mental health needs.
Recommendation
Psychiatric Medical Care requests that the Senate Finance Committee take action
to ensure that this important strengthening and expansion of rural behavioral
health capability is preserved at the end of the public health emergency.
• Our preferred action in response to this problem would be a change to section
1834(g)(1) of the Social Security Act.i This approach would retain the standard
billing structure that CAHs use and understand, while allowing the Centers for
Medicare and Medicaid Services the flexibility to continue the delivery of virtual
care by these facilities under that provision (rather than 1834(m)). CMS would
retain its authority to make evidence-based decisions as to the services covered
under this recommendation.
• Psychiatric Medical Care would also support a two-year extension of CMS’s
Hospital Without Walls flexibilities that are currently allowing the delivery of
these telehealth services by CAHs, so that the Finance Committee can better
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understand the importance of these services—particularly with respect to the
delivery of behavioral therapy services to seniors in rural areas.
Finally, it is important to understand that while Congress passed legislation allow-
ing the Medicare program to cover the provision of mental health services offered
in the patient’s home through telehealth in December 2020, that legislation did not
make permanent the flexibilities afforded under the ‘‘provider-based’’ waivers that
currently allow CAHs to bill telehealth services as if they were furnished in-person
during the PHE. Without this flexibility, many CAHs will have significantly reduced
capacity to provide behavioral health services through telehealth after the PHE ex-
pires.
We strongly encourage the members of the Finance Committee to Act to preserve
these services for rural seniors. We look forward to continuing to work with you to
expand access to health care for Americans.
Sincerely,
J.R. Greene, FACHE
i Legislative Text for Consideration
(a) EXPANDING TELEHEALTH FOR CRITICAL ACCESS HOSPITALS. Section
1834(g)(1) of the Social Security Act (42U.S.C. 1395m) is amended to read as fol-
lows:
‘‘(1) IN GENERAL.—The amount of payment for outpatient critical access
hospital services of a critical access hospital is equal to 101 percent of the
reasonable costs of the hospital in providing such services, unless the hos-
pital makes the election under paragraph (2).
‘‘(A) SPECIAL PAYMENT RULE FOR TELEHEALTH SERVICES.
‘‘(i) IN GENERAL. Notwithstanding subsection (m) critical access
hospitals may receive payment under this paragraph for outpatient
critical access hospital services that are furnished via telecommuni-
cations technology, which may include the use of audio or visual
equipment permitting two-way, real-time interactive communication
between the patient and health-care professional at the critical access
hospital.
‘‘(ii) INITIATION OF OUTPATIENT CRITICAL ACCESS HOSPITAL
SERVICES VIA TELECOMMUNICATIONS TECHNOLOGY. Serv-
ices described in clause (i) may also be initiated via telecommuni-
cations technology as long as such services complement a plan of care
that includes in-person care at some point, as may be appropriate.’’
(b) EFFECTIVE DATE. The amendments made by this section shall apply to cov-
ered outpatient critical access hospital services furnished on or after January 1,
2022.
TECHNET
805 15th Street, NW, Suite 708
Washington, DC 20005
Telephone 202–650–5100
Fax 202–650–5118
www.technet.org
May 19, 2021
U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510
RE: ‘‘COVID–19 Health Care Flexibilities: Perspectives, Experiences, and
Lessons Learned’’
Chairman Wyden and Ranking Member Crapo:
Thank you for the opportunity to submit a statement for the record regarding the
Senate Committee on Finance Hearing titled ‘‘COVID–19 Health Care Flexibilities:
Perspectives, Experiences, and Lessons Learned.’’ We appreciate the efforts you are
making to prioritize greater access to health-care services through telehealth as the
nation recovers from the devastating COVID–19 pandemic, and we wanted to share
with you TechNet’s federal policy principles on telehealth.
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TechNet is the national, bipartisan network of technology CEOs and senior execu-
tives that promotes the growth of the innovation economy by advocating a targeted
policy agenda at the federal and 50-state level. Our diverse membership includes
dynamic American businesses ranging from startups to the most iconic companies
on the planet and represents over three and a half million employees and countless
customers in the fields of telehealth, information technology, e-commerce, the shar-
ing and gig economies, advanced energy, cybersecurity, venture capital, and finance.
Telehealth has fundamentally altered how patients experience care. New commu-
nication technologies allow health-care professionals to provide patients with med-
ical care and services in convenient, affordable, and accessible ways. TechNet sup-
ports efforts that affirmatively enable the use of technology neutral, innovative sys-
tems to treat patients remotely and ensure the physician-patient relationship can
be maintained and strengthened. The COVID–19 pandemic has demonstrated how
critically important this is, as an increasing number of patients need to access safe,
timely, and effective care. For example, the number of patients reporting at least
one telehealth visit has increased by 57 percent since the start of the pandemic
(Doximity).
With the onset of the pandemic, Congress provided the authority for Centers for
Medicare and Medicaid Services (CMS) to lift the antiquated restrictions that condi-
tioned eligibility for telehealth services on the location of a patient and the site of
care. CMS also significantly expanded telehealth by approving more than 80 serv-
ices eligible for reimbursement under traditional Medicare while allowing Medicare
Advantage plans to use telehealth for the purposes of risk adjustment. These are
only a few of the regulatory flexibilities Congress authorized to increase and en-
hance virtual care, and we believe that many of these temporary measures should
be made permanent. Telehealth should be supported as a tool to practice medicine
and ensure patients have access to affordable health-care options despite their prox-
imity to health-care facilities or personal barriers restricting accessibility.
We look forward to working with you on this and other critical issues facing our
nation. Please don’t hesitate to reach out if we can be a resource on these important
issues or if you have any questions. I can be reached at cholshouser@technet.org or
(202) 372–7000.
Best regards,
Carl Holshouser
Senior Vice President
TELADOC HEALTH, INC.
2 Manhattanville Rd.
Purchase, NY 10577
June 2, 2021
The Honorable Ron Wyden The Honorable Mike Crapo
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20515 Washington, DC 20515
RE: Teladoc Health Statement on the U.S. Senate Committee on Finance
Hearing, ‘‘COVID–19 Health Care Flexibilities: Perspectives, Experiences,
and Lessons Learned’’
Dear Chairman Wyden and Ranking Member Crapo,
Teladoc Health welcomes the opportunity to submit a statement for the record for
the May 19, 2021, U.S. Senate Committee on Finance hearing, ‘‘COVID–19 Health
Care Flexibilities: Perspectives, Experiences, and Lessons Learned.’’ We appreciate
your interest in leveraging telehealth and virtual care services to improve outcomes,
expand access, address disparities, and reduce health-care costs for all Americans.
Founded in 2002, Teladoc Health is the world’s only integrated virtual care system
for delivering, enabling and empowering whole-person health—from wellness and
prevention to acute care to complex health-care needs. The integrated services from
Teladoc Health include telehealth, expert medical services, AI and analytics, and li-
censable platform services. With more than 2,400 employees, the organization deliv-
ers care in 175 countries and in more than 40 languages, partnering with employ-
ers, hospitals and health systems, and more than 50 health plans in the U.S. to
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transform care delivery. Teladoc Health serves more than 40 percent of Fortune 500
employers, as well as thousands of small businesses, labor unions, and public-sector
employers, which offer our virtual care services to their employees.
More than 70 million Americans access high-quality health-care support through
Teladoc Health and our providers. In 2020, Teladoc Health Medical Group clinicians
and therapists delivered more than 10.6 million unique virtual visits. Our hospital
and health system clients completed more than 3.5 million patient visits using our
technology platform. Additionally, more than 600,000 members use Livongo solu-
tions to manage a range of chronic conditions. Our behavioral health solution saw
an increase in use by over 500 percent in 2020.
While clinicians have used telehealth and virtual care services for decades, many
Americans were unable to access virtual care due to overly restrictive and outdated
policies at the state and federal level. In many cases, these barriers disproportion-
ately impacted urban and underserved communities that rely on Medicare and Med-
icaid.
Yet, during the COVID–19 pandemic, telehealth proved to be a lifeline—providing
Americans with access to critical health-care services while keeping vulnerable pa-
tients out of clinics and hospitals. Now, across the United States, at unprecedented
levels, clinicians are leveraging virtual services to extend access to mental health,
chronic condition management, primary and specialty care, and other critical serv-
ices for patients who otherwise would not be able to see a physician in person. In
terms of our services, Teladoc Health expects total patient visits to be between 12.5
million and 13.5 million for 2021 and we expect similar patient volume growth for
our hospital and health system clients as they move to virtualize more aspects of
care delivery post pandemic.
From a policy perspective, increased use of telehealth services was augmented by
several key policy changes that Congress helped enable through the Families First
Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic
Security (CARES) Act and which the Centers for Medicare and Medicaid Services
further encouraged by waiving restrictions on exactly how, where, and who can ac-
cess and deliver virtual care services.
Prior to the pandemic, only 13,000 Medicare beneficiaries accessed a telehealth serv-
ice per week. Leveraging emergency flexibilities, providers delivered care to more
than nine million beneficiaries via telehealth from March through June 2020. This
alone underscores the critical role that virtual care can play in providing expanded,
high-quality, convenient, and cost-effective access to many in-demand health-care
services.
Without additional legislative changes, many of the temporary flexibilities imple-
mented during the current public health emergency will expire, and patients, in-
cluding beneficiaries enrolled in traditional fee-for-service Medicare, will continue to
face substantial, outdated barriers to obtaining critical virtual care services.
Concerns With Respect to In-Person Requirements
for Medicare Telehealth Services
As you and your colleagues consider the path forward for telehealth, we urge you
to consider the unintended consequences of relying on in-person requirements as a
policy tool. Given the bipartisan objectives of the Committee with respect to Medi-
care, we believe that restricting telehealth coverage for seniors using mandated
prior in-person visits is not a viable strategy and would control costs in much the
same manner as the existing statutory restrictions—by arbitrarily restricting access
to care for America’s seniors. Restrictions on telehealth that mandate a prior in-
person relationship are clinically unnecessary, exacerbate health inequities, and
would conflict with existing safeguards at the state level that would add to the ex-
isting regulatory morass that providers must navigate when delivering care vir-
tually.
Health Equity and Racial Disparities
• As of 2019, 23% of Americans report not having a relationship with a doctor
or health-care provider.1
1 KFF. ‘‘Adults Who Report Not Having a Personal Doctor/Health Care Provider by Race/
Ethnicity,’’ October 13, 2020. https://www.kff.org/other/state-indicator/percent-of-adults-report-
ing-not-having-a-personal-doctor-by-raceethnicity/.
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» 23% of Black and 39% Hispanic Americans do not have a pre-existing rela-
tionship with a health-care provider.
» In Oregon, 42% of Hispanic Americans do not have a pre-existing relation-
ship with a health-care provider.
» Nearly 30% of all Idahoans do not have a pre-existing relationship with a
health-care provider.
States Regulate the Practice of Medicine and Have Implemented Robust Safeguards
The use of technology does not alter the ethical, professional, and legal require-
ments around the provision of appropriate medical care by clinicians. The role of
Medicare is to regulate and establish payment and coverage for Medicare physician
and non-physician provider services, not to regulate the practice of medicine or nurs-
ing, which has long been the prerogative of the states.
Over the past decade all 50 states and DC have passed legislation to remove re-
quirements for prior in-person consultations to establish a valid physician-patient
relationship, so long as the standard of care is upheld. Today, not a single state in
the U.S. mandates a prior in-person consult to establish a relationship. The evidence
has been clear for some time that in-person requirements were, and remain, unnec-
essary and have no clinical basis of support. In fact, in 2014, the Federation of State
Medical Boards (FSMB), the association of state regulators that oversee standards
of medical care, issued guidance and model policy to state medical boards on regu-
lating telehealth, that included safeguards to ensure providers are required to meet
the appropriate standards of care when delivering care using technology.2
Patient Choice and Continuity of Care
In the past, some state medical associations have expressed concern that telehealth
would allow other providers to ‘‘come between a patient and their doctor.’’ In re-
sponse, nearly all states have incorporated requirements into their telehealth stat-
utes to ensure continuity of care by requiring that patients’ medical records from
telehealth consults be shared with each patient’s primary care provider (with pa-
tient consent) or be readily and easily accessible to a patient to provide to their pri-
mary care provider or specialist.
The solution to enhancing continuity of care is to redouble efforts toward patient-
centered health data interoperability rather than mandate that a patient sees a pro-
vider in person. The 21st Century Cures Act, the ONC Cures Act Final Rule, and
the CMS Interoperability and Patient Access rule have accelerated the ability for
a patient to access their personal health information and as implementation pro-
ceeds, will facilitate nationwide access to health records for patients, health-care
providers, and payers.
Patients should have the choice to see any provider. Survey data from the pandemic
shows that more than 70 percent of patients using telehealth saw their own doctor.
The remaining 30 percent represent the millions of Americans who did not have a
pre-existing relationship with a provider due to widespread Primary Care and Men-
tal Health workforce shortages but were able to use telehealth to establish a rela-
tionship and receive care from a provider licensed in their state.
We cannot ignore the importance of providing all Americans, regardless of whether
they have a medical provider with whom they have an established relationship, the
opportunity to access health care. For years Congress has urged patients and con-
sumers to make smart decisions about their health-care spending. Telehealth is sim-
ply a modality and is a safe and economical way to access quality health care with
the patient in the driver’s seat.
Antitrust Issues
The U.S. Federal Trade Commission (FTC) and the US Department of Justice have
conducted numerous investigations into anti-competitive behavior from state med-
ical societies and state medical boards that have used regulatory requirements for
a prior in-person visit to restrict access and limit patient choice.
In fact, FTC staff recently submitted comments to CMS and addressed in-person re-
quirements for Medicare telehealth services, noting the impact on competition, inno-
vation, choice, and price:
As discussed in a number of FTC staff advocacy comments, in-person exam-
ination requirements prevent licensed health-care providers from providing
2 https://www.fsmb.org/siteassets/advocacy/policies/fsmb_telemedicine_policy.pdf.
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telehealth care that they otherwise would deem appropriate. Such restric-
tions potentially reduce competition, innovation, consumer choice, and the
supply and quality of care, and may also increase price. Accordingly, FTC
staff advocacy comments have opposed proposed laws and regulations that
prohibit the use of telehealth for initial, as well as subsequent evaluations.
Rather, FTC advocacy has favored flexible provisions that allow the li-
censed practitioner in the best position to weigh access, health, and safety
considerations to decide whether to use telehealth. Such policies, which
allow the patient-practitioner relationship to be established by telehealth
and typically hold the practitioner to an in person standard of care, are
supported by several physicians’ organizations.
Program Integrity
Antifraud enforcement and investigations of waste and abuse in federal health pro-
grams must be a priority. However, Congress must not allow program integrity con-
cerns to inappropriately limit Medicare beneficiaries’ access to needed care. Arbi-
trarily restricting telehealth coverage for seniors, including mandated prior in-
person visits, is not a viable program integrity strategy.
In fact, in a recent statement, Principal Deputy Inspector General Christi A. Grimm
stated unequivocally that bad actors using telecommunication services to perpetrate
‘‘telefraud’’ should not be conflated with the legitimate practice of telemedicine or
imply that telehealth services are at greater risk of abuse than in-person services
under Medicare.
Inspector General Grimm’s statement is consistent with an HHS–OIG 2018 audit
that found that the limited number of improper telehealth payments were the result
of deficiencies in Medicare claims forms or the result of providers who inadvertently
billed for telehealth delivered to beneficiaries outside of the 1834(m) geographic site
restrictions.
Comprehensive anti-fraud statutes exist at both the federal and state level. HHS
OIG and CMS have extensive program integrity policies and procedures in place to
leverage existing authorities to address all fraud, waste, and abuse, including im-
proper payments. However, Congress must ensure HHS and CMS have the nec-
essary tools to combat bad actors and provide robust funding for critical antifraud
programs.
Bipartisan consensus exists across a range of telehealth and digital health issues.
We have presented recommendations in the appended white paper intended to pro-
vide a framework for how best to advance telehealth and virtual care both in prepa-
ration for future public health emergencies and on a permanent basis to ensure ex-
panded access to quality care in the U.S. As detailed there, and noted previously
in this letter, these changes can, and should, be made without unnecessarily lim-
iting patient access to clinically appropriate care.
Thank you for the opportunity to provide a statement for the record. If you have
any questions or would like to further discuss our recommendations, please do not
hesitate to contact me.
Sincerely,
Claudia Duck Tucker
Senior Vice President
Government Affairs and Public Policy
Expanding Access to Care Through Proven, Quality, and
Cost-Effective Digital Health Technology
Federal Policy Recommendations
January 2021
Overview
Health-care providers have long used telehealth and remote technology to provide
timely access to needed health services, enhance the patient experience, improve
health outcomes and reduce costs. During the COVID–19 pandemic, telehealth has
proven to be a lifeline—providing Americans with access to critical health-care serv-
ices while keeping vulnerable patients out of clinics and hospitals. Now, across the
United States, clinicians are leveraging virtual services and platforms to extend ac-
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238
cess to mental health, primary and specialty care, and other critical services for pa-
tients who otherwise would not be able to see a physician in person. More Ameri-
cans than ever have engaged with a provider through synchronous real-time video
or asynchronous technologies to access lifesaving prescriptions, receive follow-up
care after an in-person procedure, or avoid high-cost ER and urgent care clinics for
minor conditions.1 Providers in underserved communities are deploying telehealth
solutions to ‘‘beam’’ in specialists from across the country to rapidly respond and
treat critical stroke patients, augment and support ICU’s and NICU’s, and use re-
mote technologies to monitor long-term care patients and help patients overcome
chronic diseases.
These rapid advances in virtual care were made possible, in part,
because federal policymakers advanced a number of legislative and
regulatory changes to enhance patient access during the COVID–19
public health emergency.
For example, Congress provided the Department of Health and Human Services
(HHS) authority to waive Medicare’s longstanding geographic and originating site
restrictions on telehealth.2 HHS and the Centers for Medicare and Medicaid Serv-
ices (CMS) also leveraged emergency authority to waive many of the in-person re-
quirements for services across Medicare programs while allowing Medicare Advan-
tage plans to add new virtual care benefits and use telehealth for risk adjustment
purposes.3, 4 Congress also allowed high-deductible health plans (HDHP) with a
health savings account (HSA) to cover telehealth services prior to a patient reaching
their deductible.5
These and other temporary COVID–19 policy changes have, overnight, opened the
door to virtual care services that were previously unavailable to many patients in
the U.S. In response, Teladoc has worked alongside our clients and partners—health
systems, health plans, and employers—to help meet new demand as Americans
have embraced virtual care on an unprecedented scale.
As of 2020, more than 70 million Americans have paid access to high-quality health-
care support through Teladoc Health clinicians and therapists. In 2020, Teladoc
Health Medical Group clinicians and therapists delivered more than 10.6 million
unique visits. Our hospital and health system clients completed more than 3.5 mil-
lion patient sessions using our technology platform. Additionally, as of Q3 2020,
more than 540,000 members use Livongo solutions for chronic conditions. Overall,
Teladoc Health has seen utilization of services stabilize at a level that is 40% higher
than before the COVID–19 pandemic with total visits expected to exceed 10 million
for 2020.
In terms of Medicare, prior to the pandemic, only 13,000 beneficiaries accessed a
telehealth service per week. Leveraging emergency flexibilities, providers delivered
care to more than 9 million beneficiaries via telehealth from March through June
2020. This alone underscores the critical role that virtual care can play in providing
expanded, high-quality, convenient, and cost-effective access to many in-demand
health-care services.6
This experience has made clear that there is no clinical basis for
the long-standing restrictions that have prevented Medicare bene-
ficiaries from accessing services via telehealth from their homes,
and it is time for Congress to finally take action to permanently ex-
tend access to virtual care.
As policymakers look to the future, it is important to note that telehealth is not a
separate care delivery system. From a patient and provider perspective, telehealth
is a tool to deliver health-care services by a licensed health-care professional to a
1 ‘‘Synchronous’’ means an exchange of information regarding a patient occurring in real time.
‘‘Asynchronous’’ means an exchange of information regarding a patient that does not occur in
real time, including the secure collection and transmission of a patient’s medical information,
clinical data, clinical images, laboratory results, or a self-reported medical history, https://
www.americantelemed.org/wp-content/uploads/2020/10/ATA-_Medical-Practice-10-5-20.pdf.
2 Section 3703, H.R. 748, CARES Act.
3 https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emer-
gencies/coronavirus-waivers.
4 Centers for Medicare and Medicaid Services. Applicability of diagnoses from telehealth serv-
ices for risk adjustment. April 10, 2020, https://www.cms.gov/files/document/applicability-di-
agnoses-telehealth-services-risk-adjustment-4102020.pdf.
5 Section 3701, H.R. 748, CARES Act.
6 Early Impact of CMS Expansion of Medicare Telehealth During COVID–19, Health Affairs
Blog, July 15, 2020, https://www.healthaffairs.org/do/10.1377/hblog20200715.454789/full/.
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patient at a different location. Since health care and the practice of medicine are
primarily regulated at the state level, state legislatures and professional boards de-
termine how and when clinicians can deliver care remotely. This provides federal
policymakers with the opportunity to leverage federal health programs to incentivize
and promote access to virtual care.
As Congress and the Administration work to expand access to care, efforts to har-
monize federal and state requirements must be a priority to prevent fracturing an
already complex patchwork regulatory landscape that has long hindered the uptake
and adoption of virtual care. For example, in all 50 states, state law allows physi-
cians to establish a relationship with a patient virtually.7 However, in recent years
some legislative proposals to expand Medicare telehealth services would require a
patient to see a provider in-person before they are eligible for telehealth benefits.
Not only are such in-person requirements clinically unnecessary, but they are also
out of step with a decade of telehealth reform at the state level and would exacer-
bate the patchwork regulatory environment that hinders patients’ access to virtual
care.
In short, the challenges and shortcomings revealed by the pandemic have exposed
a fragile and inflexible U.S. health-care delivery system. Without additional legisla-
tive changes at the state and federal level, many of the temporary flexibilities imple-
mented during the current public health emergency will expire, and patients, in-
cluding beneficiaries enrolled in traditional fee-for-service Medicare, will continue to
face substantial, outdated barriers to obtaining critical virtual care services.
As Congress and the Biden Administration take stock of recent tem-
porary COVID–19 policy changes and consider the important role
that virtual care has played in improving care delivery during the
pandemic in the U.S., efforts should focus on:
1. Determining if the authorities put in place by Congress and the Adminis-
tration are sufficient for future public health emergencies, including pan-
demics.
2. Identifying and permanently extending certain flexibilities and authorities
made available during the public health emergency.
As policymakers work to answer these questions, we encourage continued engage-
ment with stakeholders to ensure that post-pandemic policies reflect the preferences
of patients and the realities of those on the front lines of care delivery. Bipartisan
consensus exists across a range of telehealth and digital health issues. The rec-
ommendations proposed in this document are intended to provide a framework for
how best to advance telehealth and virtual care both in preparation for future public
health emergencies and, perhaps most importantly, on a permanent basis to ensure
expanded access to quality care in the U.S.
7 https://www.ama-assn.org/system/files/2018-10/ama-chart-telemedicine-patient-physician-
relationship.pdf.
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Teladoc Health is empowering all people everywhere to live healthier lives by trans-
forming the health-care experience. Recognized as the world leader in whole-person
virtual care, Teladoc Health leverages clinical expertise, advanced technology and
actionable data insights to meet the evolving needs of consumers and health-care
professionals.
For more information, please visit teladochealth.com or follow @TeladocHealth on
Twitter.
Enhance Health-care Access, Convenience, and Outcomes
Virtual care technology can serve as a powerful equalizer by eliminating the bar-
riers of time, distance, and geography and empowering patients to overcome the
challenges and limitations of accessing in-person health care. Post pandemic, federal
health programs must ensure that patients can access high-quality telehealth serv-
ices anywhere, including the home. For a wide range of health-care services, pro-
viders utilizing telehealth have demonstrated the ability to provide the same level
of care as in-office visits and shown that, in both rural and urban underserved
areas, telehealth serves as the only means by which patients can quickly and con-
veniently access quality care.
Before the waiver authority granted through the Families First Coronavirus Re-
sponse Act (FFCRA) and expanded under the Coronavirus Aid, Relief, and Economic
Security (CARES) Act, traditional Medicare allowed seniors and individuals with
disabilities covered under the program to receive telehealth services only when lo-
cated in certain rural areas of the country and at an eligible ‘‘originating site’’—usu-
ally a clinic or hospital. This regulatory imbalance between in-person care and tele-
health prevented the health-care system from leveraging the agility and convenience
of virtual care with no clinical basis of support. These unnecessary and outdated re-
strictions were waived during the COVID–19 pandemic but will require action from
Congress to be eliminated permanently.
Recommendation 1.1: Congress must reform 1834(m) of the Social Security Act
and permanently eliminate the geographic and originating site requirements to
enable Medicare beneficiaries to access telehealth services outside of federally des-
ignated rural areas and, importantly, from home.8
8 Social Security Act, Pub. L. No. 104–321. Codified at 42 U.S.C. § 1320b–5.
51921.005.eps
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Recommendation 1.2: Under current authority, CMS should permanently allow
Medicare Advantage organizations to use telehealth, including both real-time
interactive video and audio, for the purposes of risk adjustment.
Recommendation 1.3: Section 1135 of the Social Security Act provides HHS
with authority to waive many of the requirements that could potentially limit the
provision of virtual care during a national emergency, including EMTALA, Physi-
cian Self-Referral, HIPAA, and requirements that a provider be licensed in the
state of the patient as a condition of participation in federal health programs.
Under FFCRA and the CARES Act, Congress gave HHS additional authority to
waive restrictions on telehealth during the COVID–19 pandemic. However, the
waiver authority is limited to the COVID–19 PHE determination. Congress should
ensure HHS and CMS can act quickly during future pandemics and natural disas-
ters by granting permanent waiver authority for all public health emergencies
under Section 1135 of the Social Security Act.
Incentivize 21st Century Virtual Care
Federal health programs should incentivize the expansion of virtual care and reim-
burse providers for all forms of telehealth. In addition, patients and payers should
have more flexibility to use account-based plans and innovative coverage arrange-
ments to help finance care. Private payers should compensate health-care providers
for delivering virtual care; however, a provider and health plan should have the
ability and flexibility to agree to reimbursement rates based on market conditions.
Recommendation 2.1: Congress should permanently allow pre-deductible cov-
erage for telehealth and other remote care services for high-deductible health
plans (HDHPs) paired with a health savings account (HSA).
Recommendation 2.2: CMS has historically taken a conservative approach to
expanding telehealth services under traditional Medicare FFS. In response to
COVID–19, CMS broadly expanded the list of eligible telehealth services available
to beneficiaries for the duration of the PHE. COVID–19 has demonstrated that
providers are able to responsibly deliver care remotely, and CMS should seek to
broadly expand the list of eligible Medicare telehealth services that are dem-
onstrated to be safe, effective, and clinically appropriate. For services that CMS
needs additional evidence before initiating permanent coverage, the agency should
create an additional pathway that would cover telehealth services on a temporary
basis and allow providers to develop the evidence that the agency believes nec-
essary for adding a service on a permanent basis.
Recommendation 2.3: Under Medicare FFS, there are two payment rates for
many physicians’ services based on the site of service: the facility rate; and the
non-facility, or office, rate. For telehealth services, Medicare has historically reim-
bursed the billing provider at the facility rate since the costs (i.e., staff and equip-
ment) for the telehealth service were borne by the originating site where the pa-
tient is located, not by the provider at the distant site. This payment methodology
has worked for delivery models where networked, affiliated hospitals and prac-
tices share costs. However, when the home is made an eligible originating site,
payment rates must adequately compensate providers so as not to incentivize and
favor in-person visits over virtual.
Recommendation 2.4: While reforming Medicare FFS to allow for telehealth
must remain a priority, the power of telehealth to address costs and improve out-
comes is best leveraged within risk-bearing payment arrangements. As CMS con-
tinues to pilot and expand value-based care models, expanding flexibility to use
virtual care must be a cornerstone of key payment reform initiatives moving for-
ward.
Recommendation 2.5: Congress should ensure Medicare enables virtual chronic
condition prevention and management, including virtual-only providers in the Di-
abetes Prevention and the Diabetes Self-Management and Training Programs.
Recommendation 2.6: Congress should designate standalone telehealth as an
ERISA excepted benefit to ensure that virtual services can be offered as a supple-
ment to employees and dependents who are eligible for traditional group health
coverage and to employees—and their dependents—who are ineligible for em-
ployer group health coverage.
Ensure Patient Choice and Provider Autonomy
The paradigm for health care has shifted in response to the rapid growth and ubiq-
uity of digital technology. Prior to COVID–19, patients’ expectations for how care
is delivered had already significantly changed, and the pandemic further accelerated
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these trends. Given the speed and proliferation of digital health, patients should be
afforded the ability to choose the technology by which they want to interact and en-
gage with their health-care provider. To expand patient choice, health-care services
accessed and delivered remotely should not be held to a different standard than
services provided in-person. The form of communication, or modality, should be de-
termined by clinicians, in consultation with their patients, provided that it is suffi-
cient to evaluate and diagnose the condition and meet the standard of care.
As the COVID–19 pandemic has demonstrated, Americans that do not have access
to high speed Internet or broadband have challenges in accessing a provider through
real-time video, and have come to rely on telephone and interactive audio visits to
access care. A clinically appropriate telehealth encounter—when it includes in-
formed consent, affirmative identification of patient and treating provider, a patient
evaluation and diagnosis in accordance with the standard of care, and an appro-
priate treatment plan—should not be limited by arbitrary legislative or regulatory
restrictions. Policymakers should pursue a technology neutral approach and allow
health-care providers to determine what technology is best to treat patients. Tele-
health should not have clinicallyunsubstantiated barriers to technologies if it is safe,
effective, appropriate, and complies with HIPAA and all related state privacy re-
quirements.
Recommendations 3.1: As Congress seeks to address the outdated geographic
restrictions in traditional Medicare FFS, it should avoid imposing requirements
for a prior in-person visit or limits on the type of technology that may be used
for a telehealth encounter.
Recommendations 3.2: Congress should not limit Medicare beneficiaries’ access
to telephone-based communications, which has proven safe and effective across a
range of use cases during the COVID–19 pandemic.
Recommendations 3.3: Congress and CMS should expand support for asyn-
chronous telehealth technologies, including remote patient monitoring, to ensure
beneficiaries are not limited to accessing virtual care via real-time video.
Recommendations 3.4: To address the ongoing substance abuse crisis, Congress
must ensure that DEA finalizes the telemedicine special registration rule which
would allow DEA-registered practitioners to prescribe controlled substances, such
as certain kinds of medication-assisted treatment, without an in-person medical
evaluation. The DEA has temporarily waived requirements during the COVID–19
PHE; however, the agency will need to promulgate and finalize the rule to ensure
providers can continue to treat and prescribe controlled substances to patients
post-pandemic.
Address Digital Literacy and Expand Telehealth Access to Underserved
Communities
Underserved rural and urban communities, tribal nations, racial and ethnic minori-
ties, and vulnerable patient populations all have higher prevalence of chronic condi-
tions and should have equitable access to telehealth and digital health services. The
pandemic has revealed that connectivity is a critical health-care resource and a pre-
requisite for expanding access to high-quality care. A patient should not be denied
access to virtual care because they live in a community that lacks sufficient broad-
band access, cannot afford the appropriate technology, or are not comfortable using
a computer or device. Underserved patient populations deserve the same savings,
convenience, and access to care as patients elsewhere. Health disparities must be
accounted for in federal health programs, and virtual care reform efforts should be
coupled with targeted federal investment to help bridge the digital divide and help
ensure autonomy and access for all seniors and caregivers that want to use it.
Recommendation 4.1: To address racial, ethnic, and income-based disparities
while ensuring Americans in both rural and urban communities are not left be-
hind, Congress must advance a national strategy toconnect all Americans via
broadband and 5G, with robust investments targeted toward underserved areas
of the US.
Recommendation 4.2: Building on the investments made in recent COVID–19
relief legislation, Congress should continue to invest in telehealth and remote care
infrastructure for health systems that serve vulnerable patient populations, Fed-
erally Qualified Health Centers (FQHC), Rural Health Clinics (RHC) and Commu-
nity Behavioral Health Centers (CCBHC), expand existing HRSA telehealth grant
and technical assistance programs, and task HHS with developing a national
strategy to support community health workers (CHW) to identify and work with
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high-risk patients who need help with understanding how to use technology to en-
sure all Americans can access virtual care.
Recommendation 4.3: HHS and CMS should work with stakeholders to develop
education and training resources that account for age, socio-economic, geographic,
cultural and linguistic differences in how beneficiaries interact with technology
and ensure seniors and Medicaid beneficiaries can fully leverage digital health
technologies.
Recommendation 4.4: Congress and the Administration should revisit cost-
sharing requirements for digital health. Monthly recurring copays for remote pa-
tient monitoring and other virtual care solutions can serve as a deterrent to those
living with chronic and complex conditions that may benefit most from ongoing
care management solutions.
Ensure Patient Privacy and Address Cybersecurity Risks
The protection of patient privacy and personal data are critical to the expansion of
virtual care. Balanced federal health data privacy and cybersecurity policy are nec-
essary to support innovation; however, telehealth and digital health technologies
must be required to mitigate cybersecurity risks and protect patients’ privacy and
personal health data. Coordinated disclosure, information sharing, patient and pro-
vider education, and the development of consensus standards must remain the cor-
nerstone of cybersecurity policy for regulated devices, mobile applications, and re-
lated health-care products to ensure that risks to patients and providers are miti-
gated.
Recommendation 5.1: Post-pandemic, the HHS Office of Civil Rights (OCR)
should swiftly end the current COVID–19 PHE HIPAA enforcement discretion
policy and ensure virtual care and telehealth encounters are conducted via secure
HIPAA-compliant platforms designed to protect PHI. Patients should be assured
that health-care providers are complying with HIPAA’s privacy, security, and
breach notification requirements when receiving care virtually.
Recommendation 5.2: While the Federal Trade Commission (FTC) has some au-
thority to regulate organizations that are not considered covered entities under
HIPAA, the FTC’s authority is limited to practices that are ‘‘unfair or deceptive.’’
To better protect patients and consumers and address the patchwork privacy
framework for health data in the U.S., Congress should establish a Commission
to study and issue recommendations for the protection of individual privacy that
balances the need to preserve innovation, with clear rules of the road for the ap-
propriate use of health information by mobile application and platform developers.
Recommendation 5.3: The Food and Drug Administration (FDA), HHS, and
other health-care regulators already have broad authority to strengthen the cyber-
security requirements for regulated devices and products that could potentially be
exploited by bad actors. Federal agencies must prioritize the recognition, pro-
motion, and direct participation in the development of private sector consensus
standards to ensure manufacturers and developers have a consistent framework
for implementing cybersecurity safeguards. Given today’s dynamic threat land-
scape, Congress and relevant agencies should also facilitate collaboration with
health-care delivery organizations, medical device manufacturers, independent se-
curity experts, and academia through public-private partnerships to ensure that
these stakeholders are able to quickly address and resolve emerging cybersecurity
threats to patients and providers.
Expand Patient Health Data Portability and Ensure Interoperability of
Digital Health Technology
The COVID–19 pandemic has demonstrated the importance of patients and pro-
viders having access to health-care data when and where they need it. Over the past
decade, progress has been made to incentivize the adoption of technologies that are
capable of exchanging electronic health information; however, data remains siloed
and inaccessible across much of the health-care system. Congress and the Adminis-
tration must remain committed to advancing a patient-centered interoperable
health-care system that empowers patients and enables providers to deliver safe
and efficient care.
Recommendation 6.1: CMS and ONC should remain committed to implementing
the 21st Century Cures Act, including robust enforcement of the CMS Interoper-
ability and Patient Access Final Regulation and the ONC Interoperability and In-
formation Blocking Final Regulation—both of which will advance the uptake of
patient access application programming interfaces (APIs) and facilitate greater
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provider-to-provider and payer-to-payer data exchange. COVID–19 has placed an
unprecedented burden on the nation’s health-care system, and the agencies should
extend implementation deadlines in line with the COVID–19 PHE.
Protect Patients and Taxpayers
The economic benefits of robust antifraud and abuse enforcement under existing fed-
eral law are much larger than monetary settlements when accounting for deterrence
effects, including long-lasting changes in physician behavior and wasteful medical
procedures.9 Antifraud enforcement and investigations of waste and abuse in federal
health programs must be a priority. However, Congress must be cautious about let-
ting program integrity concerns dictate virtual care policy in traditional Medicare
FFS. Arbitrarily restricting telehealth coverage for seniors, including mandated
prior in-person visits, is not a viable program integrity strategy for Medicare. Such
a strategy would cause Medicare Advantage and private health plans members to
receive more robust telehealth benefits and could exacerbate health-care disparities.
As virtual care is expanded, the federal agencies tasked with protecting federal
health programs—and ultimately beneficiaries and taxpayers—must be appro-
priately equipped to maximize and leverage currently available technologies and
strategies to audit claims and enhance fraud investigations.
HHS OIG and CMS must continue to invest in innovative strategies,
appropriate private sector best practices, and leverage artificial in-
telligence and predictive analytics rather than rely on policies that
would restrict access to virtual care.
Recommendation 7.1: HHS OIG and CMS have extensive program integrity
policies and procedures in place to address fraud, waste, abuse, and improper pay-
ments. Congress should ensure HHS and CMS have the necessary tools to combat
bad actors and provide robust funding for critical antifraud programs. Teladoc
Health believes that the existing public-private partnership codified under Sec.
124, Public-Private Partnership for Health Care Waste, Fraud, and Abuse Detec-
tion, H.R. 133, Consolidated Appropriations Act, 2021 can significantly advance
efforts to mitigate and prevent telehealth from being utilized as an avenue for
fraud and abuse. We recommend strengthening the public private partnership by
ensuring experts with experience in virtual care are included and represented on
the executive board.
Recommendation 7.2: States should maintain responsibility for regulating the
practice of medicine to ensure the full resources of the state are available for the
protection of any patients that receive services that fall short of the standard of
care. Federal policy should support and incentivize the adoption of interstate li-
censure compacts and other related licensure portability policies to ensure that
clinicians can treat patients safely across state lines.
Infuse Innovation into Federal Health-care Programs
More than seven million federal employees have access to Teladoc Health solutions
through their Federal Employees Health Benefit Program. There is great potential
to empower those in federal service through contracting opportunities with entities
like the Department of Veterans Affairs, the Department of Defense and the Indian
Health Service. Supporting and caring for federal health beneficiaries with chronic
conditions is a complex process that draws on many clinical and financial resources
from across the federal government. From devices and supplies to care management,
nutrition, clinic visits, and specialist consults, the points of contact for a beneficiary,
and the associated agency cost/payment flows, are numerous.
Modern digital disease management solutions offer the potential to make things
easier and meet federal health beneficiaries where and when they need support the
most. Connected data can be combined with intelligent support and empathetic
coaching that is available all day every day. Unfortunately, most federal bene-
ficiaries with chronic conditions have little access to management tools such as this.
Depending on their disability status, federal beneficiaries receive various levels of
care from appointments to medications and testing. Across Medicare/Medicaid, VA,
and IHS, beneficiaries are now receiving video visits via telehealth, as well as a
small number receiving home-based remote monitoring. This piecemeal approach
does not allow for scale or comprehensive cost analysis and is complicated for both
beneficiary and federal agency alike.
9 Howard, David H, and Ian McCarthy. ‘‘Deterrence Effects of Antifraud and Abuse Enforce-
ment in Healthcare.’’ Working Paper. Working Paper Series. National Bureau of Economic Re-
search, October 2020, https://www.nber.org/papers/w27900.
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Recommendation 8.1: Congress must continue to invest and ensure that federal
health-care program beneficiaries through the Office of Personnel Management
(OPM), the Department of Veterans Affairs (VA), the Department of Defense
(DoD) and the Indian Health Services (IHS) have access to telehealth and other
innovative virtual care offerings to manage their health and wellness.
Recommendation 8.2: As hospital systems, health plans, and employers, are
seizing on modern virtual care methods to support their patients and beneficiaries
with chronic conditions, VA, DOD, and IHS should create pathways to pursue Al-
ternative Payment Models (APMs) for chronic conditions and diabetes manage-
ment.
Æ
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