[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


                  ENHANCING ACCESS TO CARE AT HOME IN 
                  RURAL AND UNDERSERVED COMMUNITIES

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

                                HEARING

                               BEFORE THE

                      COMMITTEE ON WAYS AND MEANS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 12, 2024

                               __________

                          Serial No. 118-FC21

                               __________

         Printed for the use of the Committee on Ways and Means
         
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                               __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
56-470 PDF                  WASHINGTON : 2024                    
          
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                      COMMITTEE ON WAYS AND MEANS

                    JASON SMITH, Missouri, Chairman
VERN BUCHANAN, Florida               RICHARD E. NEAL, Massachusetts
ADRIAN SMITH, Nebraska               LLOYD DOGGETT, Texas
MIKE KELLY, Pennsylvania             MIKE THOMPSON, California
DAVID SCHWEIKERT, Arizona            JOHN B. LARSON, Connecticut
DARIN LaHOOD, Illinois               EARL BLUMENAUER, Oregon
BRAD WENSTRUP, Ohio                  BILL PASCRELL, Jr., New Jersey
JODEY ARRINGTON, Texas               DANNY DAVIS, Illinois
DREW FERGUSON, Georgia               LINDA SANCHEZ, California
RON ESTES, Kansas                    TERRI SEWELL, Alabama
LLOYD SMUCKER, Pennsylvania          SUZAN DelBENE, Washington
KEVIN HERN, Oklahoma                 JUDY CHU, California
CAROL MILLER, West Virginia          GWEN MOORE, Wisconsin
GREG MURPHY, North Carolina          DAN KILDEE, Michigan
DAVID KUSTOFF, Tennessee             DON BEYER, Virginia
BRIAN FITZPATRICK, Pennsylvania      DWIGHT EVANS, Pennsylvania
GREG STEUBE, Florida                 BRAD SCHNEIDER, Illinois
CLAUDIA TENNEY, New York             JIMMY PANETTA, California
MICHELLE FISCHBACH, Minnesota        JIMMY GOMEZ, California
BLAKE MOORE, Utah
MICHELLE STEEL, California
BETH VAN DUYNE, Texas
RANDY FEENSTRA, Iowa
NICOLE MALLIOTAKIS, New York
MIKE CAREY, Ohio
                       Mark Roman, Staff Director
                 Brandon Casey, Minority Chief Counsel
                                 ------                                

                            C O N T E N T S

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                                                                   Page

                           OPENING STATEMENTS

Hon. Jason Smith, Missouri, Chairman.............................     1
Hon. Richard Neal, Massachusetts, Ranking Member.................     2
Advisory of March 12, 2024 announcing the hearing................     V

                               WITNESSES

Bell Maddux, Home Dialysis Patient and Working Mother............     4
Roy Underhill, Hospital at Home Patient..........................    10
Dr. Nathan Starr, M.D., Lead Hospitalist of Tele-Hospitalist 
  Program, Castell Home Services, Intermountain Healthcare.......    15
Chris Altchek, Founder and CEO, Cadence..........................    26
Dr. Ateev Mehrotra, Ph.D., Professor of Health Care Policy and 
  Medicine at Harvard Medical School and Hospitalist at Beth 
  Israel Deconess Medical Center.................................    37

                    MEMBER QUESTIONS FOR THE RECORD

Member Questions for the Record to and Responses from Roy 
  Underhill, Hospital at Home Patient............................   116
Member Questions for the Record to and Responses from Dr. Nathan 
  Starr, M.D., Lead Hospitalist of Tele-Hospitalist Program, 
  Castell Home Services, Intermountain Healthcare................   119
Member Questions for the Record to and Responses from Chris 
  Altchek, Founder and CEO, Cadence..............................   125
Member Questions for the Record to and Responses from Roy Dr. 
  Ateev Mehrotra, Ph.D., Professor of Health Care Policy and 
  Medicine at Harvard Medical School and Hospitalist at Beth 
  Israel Deconess Medical Center.................................   137

                   PUBLIC SUBMISSIONS FOR THE RECORD

Public Submissions...............................................   141
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 ENHANCING ACCESS TO CARE AT HOME IN RURAL AND UNDERSERVED COMMUNITIES

                              ----------                              


                        TUESDAY, MARCH 12, 2024

                          House of Representatives,
                               Committee on Ways and Means,
                                                    Washington, DC.
    The Committee met, pursuant to call, at 11:07 a.m., in Room 
1100, Longworth House Office Building, Hon. Jason T. Smith 
[Chairman of the Committee] presiding.
    Chairman SMITH. The committee will come to order.
    Today millions of Americans are able to get access to 
quality health care right in their home because of advancements 
and new flexibilities implemented by hospitals and doctors for 
the patients they treat.
    Over 3.2 million patients across America chose to receive 
infusion therapy at home. One in four adults use telehealth 
every month, and nearly fifty million Americans use some sort 
of remote-monitoring service. These technologies are helping 
providers coordinate care across different health settings, and 
bring quality care from your doctor's office and even hospital 
to your living room.
    The results show that at-home care can be better for 
patients' health and wallets. At-home dialysis has been a game-
changer for patients. Those patients have a 40 percent lower 
mortality rate, and they recover faster than those treated at a 
physical dialysis center. At-home infusion can cost up to 60 
percent less than infusion performed in a hospital or doctor's 
office.
    Not surprisingly, at-home care is massively popular with 
patients. More than 90 percent of Medicare Advantage enrollees 
using telehealth have a favorable opinion. Over 90 percent are 
satisfied with their remote patient monitoring, care, and 
assistance.
    Where someone lives, works, or raises a family should not 
be a barrier to getting top-of-the-line health care. One of our 
priorities on this committee is helping every American get 
health care in their community.
    For patients in rural and underserved communities, bringing 
health care home is a lifesaver. These communities struggle 
with access to health care, which results in worse health 
outcomes compared to wealthy, urban areas. Americans living in 
small towns often have fewer health services close by, and 
rural Americans have to drive farther to get critical care. We 
are already seeing these patients take advantage of care-at-
home options. Rural ESRD patients, for example, are 22 percent 
more likely to receive dialysis at home compared with their 
urban counterparts.
    Audio-only telehealth increases access for rural and 
underserved Americans who lack reliable Internet. In the 28 
counties I represent back in Missouri, there are plenty of 
spots that have bad Internet. You can forget about a Zoom call 
with your doctor. And I know I am not the only person on this 
committee who can say that.
    We are here to discuss the benefits of these advancements 
for our constituents, while recognizing that the Medicare 
telehealth and hospital at-home flexibilities that make at-home 
care possible are both set to expire at the end of this year.
    The consequences of these policies expiring would wreak 
havoc for patients and doctors now accustomed to providing care 
at home. Medicare patients would no longer be able to receive 
telehealth care from home, and patients receiving hospital at-
home care will have to go back to the hospital, limiting bed 
availability for other patients. Doctors and providers will yet 
again face more uncertainty and will be left scrambling to 
figure out the best way to take care of these patients.
    At the same time, we cannot accept the same tired 
approaches that have not made a meaningful difference for 
enough patients. Before today's hearing I had the chance, along 
with members of the committee, to see some of the cutting-edge 
technology that could help better address the unique needs of 
rural and underserved communities and expand access to care 
through innovation. We have to explore new approaches that have 
the potential to help make Americans healthier and allow rural 
Americans to get care when and where they need it.
    Home dialysis, infusions, and remote patient monitoring can 
be better utilized by investing in patient assistance and 
examining provider reimbursement. Additionally, meaningful 
patient and taxpayer protections should be considered to ensure 
robust access, demonstrate value, and prevent waste, fraud, and 
abuse.
    Importantly, health at home should be considered a 
supplement to quality, in-person care. Hospitals and doctors' 
offices are and will always remain critical pieces of our 
health care system that millions of patients rely on, and we 
are happy to have their support in leveraging this new 
technology.
    Still, Congress must help patients who want more control 
and flexibility over their health care, especially those with 
chronic conditions or living in rural and remote areas. I look 
forward to working with my colleagues to find ways we can 
preserve and protect health-at-home options that serve families 
and seniors across our country.
    Chairman SMITH. I am pleased to recognize the ranking 
member, Mr. Neal, for his opening statement.
    Mr. NEAL. Thank you, Mr. Chairman, and this is a good 
opportunity, I think, for a pretty good hearing to discuss a 
series of challenging issues.
    But I also want to thank the work of House Democrats, who 
have reached historic health care milestones that continue to 
improve the lives of the American people. More Americans have 
health insurance today than ever before, with 4 out of 5 people 
now being able to access high-quality care for less than $10 a 
month. The American people have trusted us when it comes to 
protecting their access to health care, and for good and 
obvious reasons. This committee is the birthplace of those 
sacred promises that were made to the American people, and Ways 
and Means Democrats will not back down from defending the 
economic, security, and peace of mind that we have given to 
workers and retirees from political threats.
    I never miss the opportunity in quiet moments here to 
reflect upon one portrait on the wall to my left, in which Mr. 
Mills, who was the chairman of the committee from Arkansas, 
embraced the idea of Medicare. Even though his enthusiasm was 
limited at the beginning, when Lyndon Johnson got done his 
enthusiasm was necessary to get the legislation over the goal 
line, always recalling that Medicare is an amendment to the 
Social Security Act. And as President Biden noted the other 
night, there will be no changes on his watch to the guarantee 
of these initiatives.
    While today's hearing is an important look at the emerging 
forms of health care, we want to make sure that there are no 
efforts that would dismantle the ACA or the health care system 
as we have improved it. Home-based health care played a key 
role in connecting Americans with medical care during COVID-19 
and the pandemic. The celebration of that famous statement from 
Dr. Fauci was yesterday. It continues to be a point of focus 
for policy-makers, and more services are being offered today at 
home.
    As we examine the current use and potential expansion of 
home care-based services, this committee must consider how 
these services impact patient outcomes, health equity, 
taxpayers, and caregivers, and implement data-driven solutions 
that promote value for beneficiaries.
    I have actually participated in home health care visits 
with advocates. What we pay for and how we pay for it will 
affect patients' costs and access to care for the foreseeable 
future. Promoting health equity in home-based services is a 
priority for our proposals to expand Medicare.
    Current infrastructure weaknesses make it impossible for 
rural and underserved communities to rely on telehealth and 
other home-based care alone. Democrats delivered a generational 
investment in our nation's infrastructure with the Bipartisan 
Infrastructure Law, and we now must continue to make sure that 
Internet access is available to all members of the American 
family that will connect rural and underserved communities with 
access to home-based health care.
    Caregivers must also be at the center of this policy 
discussion. We have more than 48 million family caregivers in 
America, too many of whom find it difficult, if not impossible, 
to coordinate health care for their loved ones. While care in 
the home can help caregivers in coordinating care, care in the 
home can also rely on already overburdened caregivers as they 
must attend to their loved ones' daily needs.
    Four years ago, as I noted, to the day, we were locked down 
in a great state of uncertainty. The following months consisted 
of heartbreak that took too many lives and stretched our health 
care system like never before, all while some ignored the 
science and put millions of lives in danger.
    When Joe Biden took office, that life returned to normal. 
We did what was needed to get done in terms of shots in the 
arms, and millions of people went back to work in record time, 
and ultimately put the health and well-being of the American 
people first. His progress and promises continue to be 
outstanding, and we certainly do not intend to go back.
    I am grateful for the witnesses for being here today. They 
are well chosen, and we look forward to hearing their 
testimony.
    Mr. NEAL. Thank you, Mr. Chairman.
    Chairman SMITH. Thank you, Mr. Neal. I will now introduce 
our witnesses.
    Bell Maddux is a home dialysis patient and a working 
mother.
    Roy Underhill is a Hospital at Home patient.
    And Dr. Nathan Starr is a medical doctor and lead 
hospitalist of Tele-Hospitalist Program for Intermountain 
Healthcare.
    Chris Altchek is founder and CEO of Cadence.
    And Dr. Ateev Mehrotra is professor of health care policy 
and medicine at Harvard Medical School at Beth Israel Deaconess 
Medical Center.
    Thank you for joining us today. Your written statements 
will be made part of the hearing record, and you each have five 
minutes to deliver remarks.
    Mrs. Maddux, you may begin.

  STATEMENT OF BELL MADDUX, HOME DIALYSIS PATIENT AND WORKING 
                             MOTHER

    Mrs. MADDUX. Hello, and thank you for inviting me to 
testify before this committee today. My name is Bell Maddux, 
and I am a home hemodialysis patient. Currently I live with my 
husband and my two children in Tobyhanna, Pennsylvania, which 
is a lovely rural area in the Pocono Mountains.
    [Slide]
    Mrs. MADDUX. I was diagnosed with kidney disease as a 
teenager, and in 2008 I was fortunate to receive a living 
kidney donation from my father. That kidney lasted me 10 years, 
and allowed me the amazing gift of becoming a mom. However, in 
2018, despite 10 years of good health, perfect labs, perfect 
blood pressure, I started experiencing signs of kidney 
rejection.
    I was standing on West Fourth Street in New York on my way 
to work, when my nephrologist called from her vacation and 
yelled through a bad connection that I needed to get to the 
emergency room immediately. From that point my health 
plummeted. I was unable to eat, and my weight went down to a 
number I hadn't seen since I was about 12 years old.
    At that time we were living in Newburgh, New York, which is 
about an hour outside of New York City. And for four months I 
struggled making my daily commute into the city to work. I 
would drive to the train station, then take the train to the 
subway. But by the time I got to my last subway transfer, I 
could only take a few steps at a time without having to rest on 
a subway support beam. Once at work I found it difficult to 
have enough strength to stay in my chair all day, and I would 
often find a back room where I could do my work laying on the 
floor.
    Dialysis had been a longstanding fear of mine, but now it 
was time to start. And before my first treatment I sat in my 
car outside of the dialysis clinic and struggled to breathe. 
But I went in and I began my life as a dialysis patient. And 
once I felt the effects of it, I realized how much I needed it 
to function in my day-to-day.
    Three days a week I sat in a chair for three hours 
straight, while the while the machine, dialysis machine, did 
seventeen percent of the work that my kidneys should have been 
doing continuously. The clinic was only five minutes away from 
my house, but my life quickly became dominated by getting to 
and doing treatment. Every Tuesday, Thursday, and Saturday I 
had to arrive at around 1:30 to prepare for a 2:00 p.m. chair 
time. And by the time I left, it was about 5:30. Saturdays with 
my family were completely gone, and things like birthday 
parties and soccer matches I just had to miss.
    I am thankful that my company allowed me to work from home 
on those two days, so I could bring my laptop with me to 
continue working during my chair time. I did want to maintain 
my 15-year career as a digital project manager, but I also 
wanted to be valuable to my team. But participating in client 
calls and team meetings became impossible with machine alarms 
constantly beeping and frustrated patients in distress. It was 
difficult. It was a difficult place to be for so many reasons.
    Many of the other patients had mobility issues and relied 
on medical transport services to bring them from their home, 
which could sometimes be 45 minutes away. One very kind man 
told me at one point that he did nothing else in his life 
except go to dialysis and then wait to go to dialysis. I didn't 
know much about home dialysis at that time, but being already 
overwhelmed with two small children and failing health, I was 
reluctant to take on any added responsibility. But clinic life 
had become too difficult.
    My doctor explained that doing more frequent treatments 
would be easier on my body, and I would get some relief from 
the physical symptoms that I had been experiencing. So I went 
to the floor nurse and I asked for an appointment with the home 
training nurse, and they all seemed excited, gave me a few 
folders and papers to read. But then I heard nothing for a few 
weeks. Follow-up calls from me and my doctor got no response. 
And finally, the scheduled appointments that I had made was 
made during the nurse's vacation.
    I was also trying to coordinate a move from New York to a 
larger home in Tobyhanna, Pennsylvania, but I was getting 
nowhere with making this transition. My doctor was equally 
frustrated, and handed me the private cell phone number of a 
home dialysis nurse at another center. My new nurse took care 
of everything, including training me how to insert the 15 gauge 
needles into my own arm, how to rotate the needle positions to 
avoid damaging my access, how to draw and process my own blood 
for labs, and how to administer my own medication.
    After the first week my energy was up, my symptoms eased, 
my diet and fluid struggles disappeared. I even got comments on 
the improvement in the pallor of my skin. So today I do my 
dialysis treatments at home and my entire day is free every 
day. After I make dinner I take 10 minutes to set up the 
machine, I lay out my supplies. Then I can do a quick bath time 
and bedtime stories with my kids, and even squeeze in a quick 
tidy-up before I take my vitals, settle in with my electric 
blanket and a movie.
    Now I can choose to do my work during treatment, or I can 
choose to do my treatment after work. When I am done I can be 
pretty wiped out still. But instead of getting behind the wheel 
of my car, I can take three steps and get in my bed. It also 
means that my free time is no longer devoted to preparing for 
or recovering from treatment. I do still travel two hours twice 
a week to my office in New York City, but now, thanks to home 
dialysis, I have the energy for the long commute and also for 
the long work day after.
    My initial perception of being on a home dialysis patient 
was not wrong. It is a lot of work. It is not without risks, 
and it is not for everyone. But the benefits are so much that I 
think every person who is on dialysis should be empowered with 
the choice and armed with the support and sufficient 
information to make the right choice for themselves.
    My younger son doesn't remember me ever being in clinic, 
but my daughter remembers wishing I did not have to go all the 
time, and they both prefer to have me at home. Having that 
choice is second only to having a working kidney. Thank you.
    [The statement of Mrs. Maddux follows:]
   [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Chairman SMITH. Thank you.
    Mr. Underhill is recognized.

      STATEMENT OF ROY UNDERHILL, HOSPITAL AT HOME PATIENT

    Mr. UNDERHILL. Good morning, Chairman Smith, Ranking Member 
Neal, and members of the committee. My name is Roy Underhill, 
and I have traveled here today from Saxapahaw, North Carolina, 
where I have lived with my wife in an old mill on Cane Creek 
for about 15 years. Our nearest neighbors are wood ducks, 
bobcats, and river otters. My primary occupation is studying 
and teaching about early American woodworking. I am honored to 
be here today with you, and thank you for inviting me to 
testify at today's hearing on enhancing health care at home in 
our rural and underserved communities.
    Now, one landmark of our old mill where I live is the dam 
and waterfall of the mill pond. Throughout 2021 I had been 
suffering with urinary blockage from prostate enlargement, and 
I assure you that the aggravation of urinary blockage is not 
enhanced by the constant sound of a waterfall by your house.
    Resorting to a urinary catheter for relief, I apparently 
induced an E.coli infection into the works. This infection 
began to spread. And on a Sunday evening, November 7, 2021, I 
began feeling waves of chills and trembling. My temperature was 
climbing, and I was sweating profusely. I became disoriented, 
verging on delirious, and my wife, Jane, managed to get me into 
the car and drove me to the emergency room over in Chapel Hill 
as fast as she could.
    Unfortunately, this was also the evening of a football game 
in Chapel Hill, and the emergency room was packed with students 
suffering from alcohol-related mishaps and malaise. It was also 
the high time of COVID, which added significantly to the crowd.
    I was eventually diagnosed with sepsis, a potentially 
deadly situation where the bacterial infection had spread 
throughout my body. They began treatment with intravenous 
antibiotics, and the doctor told me that I came close, but I 
was not going to die: information I was greatly reassured by. 
He said my course of treatment would require a hospital stay of 
at least three days. But there was an alternative, a new 
program where I could continue treatment at home, rather than 
in the hospital if I qualified.
    Well, I enthusiastically expressed my desire to pursue this 
option, and they began the questions regarding the suitability 
of my home for this new program. Once they determined that I 
qualified, they dispatched a team out to my home, where they 
began installing the technical equipment that I would need to 
stay connected to my care team at the hospital. They prepared a 
downstairs bedroom with a wireless connection to the hospital, 
a direct phone line, an emergency button, and a dedicated 
visual link. All of this was installed on the bedside tables of 
my bedroom.
    When I returned home from the hospital that afternoon, all 
this equipment was in place, and the medical staff was there to 
explain the equipment and show me how to work it. I learned how 
to pull up my schedule for each day, and how to operate all the 
equipment. I slept very well that night with my pets, and my 
books, and my own bed, with my bed clothes, my own--and the 
next day neighbors and friends were able to stop by and bring 
me chicken soup. Now, they would not have been able to visit 
had I been in the hospital.
    Twice or more a day, medical professionals dropped by on 
their rounds through the countryside to check my vitals and 
administer the continuing antibiotic treatment. I saw my 
doctors, nurses, and paramedics both in person and virtually at 
least several times a day, and received all the medical 
services I needed. At any time I could check in through the 
video link with the doctors and nurses and make sure that I was 
recovering as expected.
    I credit this Hospital at Home option with much of the 
excellent results of my treatment and recovery, as well as the 
absence of any dangerous complications that might occur from 
hospital-induced infections. The program freed up a hospital 
bed for those who might need it more, and I was happy at home 
in my own room and Jane's home cooking. The program worked 
great for me. And the thinking of my other rural neighbors, it 
is an option that I am sure could do a lot of good for a lot of 
folks. For me it was great.
    I do like old tools and techniques, but when it comes to 
health care, I am a big fan of the 21st century. I hope you can 
find a way to keep this excellent program going. Thank you for 
providing me with the opportunity to testify today, and I look 
forward to any questions you might have later on. Thank you.
    [The statement of Mr. Underhill follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Chairman SMITH. Thank you very much.
    Dr. Starr, you are now recognized.

   STATEMENT OF NATHAN STARR, M.D., LEAD HOSPITALIST OF TELE-
   HOSPITALIST PROGRAM, CASTELL HOME SERVICES, INTERMOUNTAIN 
                           HEALTHCARE

    Dr. STARR. Chairman Smith, and Ranking Member Neal, and 
members of the committee, my name is Dr. Nathan Starr, and I am 
an internal medicine physician with Intermountain Health. As 
part of my role I am medical director of home services, which 
includes our Hospital at Home and our home-based primary care 
programs. I also direct our tele-hospitalist program, which 
involves providing virtual care for patients in rural 
hospitals.
    Intermountain Health is the largest health care provider in 
the Intermountain West, covering seven states, including a 
large rural presence within our own footprint, as well as 
providing telehealth services in many rural communities outside 
of our footprint.
    Intermountain views moving care away from hospitals as 
essential to our mission of helping people live the healthiest 
lives possible. A key element of that shift is increasing the 
provision of care in the home. The directive I received from 
our CEO, Rob Allen, about our Hospital at Home program was to 
simply grow. In 2020 we stood up a Hospital at Home program as 
fast as we could in response to the pandemic.
    There are two ways that patients enter our program. They 
are admitted from the emergency department to home, or they are 
patients who are transferred home to complete their 
hospitalization following an admission.
    Taking care of patients for the last four years in their 
homes has dramatically changed how I view health care. In a 
hospital or clinic we only get a snapshot of the patient, while 
being in the home allows us to truly understand them. We have 
many patient successes within our program, and for the sake of 
time I refer you to my written testimony to see those examples, 
and I greatly appreciate the two examples that have been shared 
with us today.
    With our focus on value-based care, Intermountain plans on 
investing heavily in moving care to patients' communities and 
homes, guided by five principles.
    First, the care we give must be of equal or better quality 
than what the patient would receive at the hospital.
    Second, the patient experience must be at least as good, if 
not better.
    Third, we must show that we have cost savings that make 
this financially beneficial for the hospital, health system, 
payer, and the patient.
    Fourth, these programs must improve the working experience 
of our employees and providers, especially an opportunity with 
nurses. We can help them stay in health care and utilize their 
expertise in a way that prevents burnout and provides growth. 
For us the experience has been so positive that our health 
care--for our health care providers that we have a waiting list 
to work in our tele programs.
    Lastly, we need to ensure that we are providing needed 
care, not extra care.
    At Intermountain we have provided Hospital at Home care to 
more than 1,200 patients, have had 0 serious in-home safety 
events, have seen lower hospital readmissions, fantastic 
patient experiences, and have freed up over 4,000 physical 
patient bed days. We are just beginning to scratch the surface 
of what we can do in the home and in communities. For example, 
in addition to Hospital at Home, we provide virtual night-time 
hospitalists and 24-hour intensive care support in rural 
communities. We provide virtual tele-oncology services in rural 
communities, and my written testimony contains many more 
examples.
    Lastly, today is the grand opening of a hybrid community 
health clinic that combines telehealth and in-person services 
in Wells, Nevada, a town of 1,200 people with the closest 
health care, prior to this clinic, a round trip of 100 miles.
    On behalf of Intermountain Health and the Moving Health 
Home Alliance to which we belong, we urge you to pass the 
Expanding Care at Home Act introduced by Ways and Means 
Committee member Congressman Adrian Smith and Congresswoman 
Debbie Dingell. This legislation, H.R. 2853, will remove 
barriers that currently limit our ability to care for patients 
in the home.
    We also urge a five-year extension of the current waivers 
to the Acute Hospital Care at Home Initiative. This will allow 
the needed time to gather data to develop a permanent 
regulatory, clinical, and financial model that will make 
Hospital at Home a success for everyone. If Congress fails to 
act to extend the Hospital at Home program, we will be forced 
to roll back the program and lose the important gains we have 
made.
    What makes me so passionate and excited about moving care 
into the home is, if we do this right, then hospitals, health 
systems, communities, payers, and most importantly, patients 
will all win.
    Thank you for the opportunity to appear before you today, 
and I am happy to answer any questions.
    [The statement of Dr. Starr follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Chairman SMITH. Thank you.
    Mr. Altchek, you are now recognized.

      STATEMENT OF CHRIS ALTCHEK, FOUNDER AND CEO, CADENCE

    Mr. ALTCHEK. Thank you, Chairman Smith, Ranking Member 
Neal, and distinguished members of the committee. I am honored 
to speak with you today on a bipartisan topic: How we find 
solutions to the dramatic access challenges affecting patients 
and families living in rural and underserved communities.
    My name is Chris Altchek, founder and CEO of Cadence, one 
of the nation's leading providers of remote monitoring for 
patients living with chronic conditions. We currently monitor 
patients from home across 20 states, including nearly 12,000 
patients in rural and underserved communities. My written 
testimony details the research showing how remote monitoring 
delivers better clinical outcomes and lower costs.
    I want to start with how remote monitoring works, and why 
it matters so much to patients and their families. If you have 
ever supported a family member following a hospitalization, you 
likely struggled with confusing printed instructions and a 
laundry list of medications. If you have helped a family member 
with type 2 diabetes, you know how hard it is to titrate their 
insulin. Many of your constituents are frustrated because 
clinics are too far away, they can't get in to see their 
doctors, and when they finally get appointments they are 
rushed. The vast majority of Americans are facing these 
challenges.
    At Cadence we use technology to make it easy for patients 
to get better care. Patients are monitored by our clinical team 
from home 24/7. With easy-to-use devices, patients transmit 
their vitals, sharing blood pressure, heart rate, blood 
glucose, and weight daily. Our care team is automatically 
alerted when a patient needs intervention. For example, their 
weight increases rapidly, indicating an impending heart failure 
exacerbation; or their blood pressure is too low, indicating a 
serious infection. Cadence gets in touch proactively, quickly 
prescribes medications, orders labs, and schedules in-person 
appointments with the local physicians we work for.
    This kind of swift intervention frequently prevents health 
issues from progressing to ER visits, hospitalizations, and 
even long-term disability or death. A patient with hypertension 
in Arkansas recently transmitted a high blood pressure of 190 
early in the evening, putting them at risk for a serious event 
such as a stroke. Our clinicians immediately got in touch with 
the patient and spoke to the patient's adult child caregiver. 
We made a plan for a medication change, continued monitoring 
overnight, and avoided an ED visit. The caregiver was grateful 
to have Cadence there, providing peace of mind.
    In our country we have the ability to significantly 
mitigate the impact of chronic disease, but systemically we 
struggle to implement relatively simple interventions. Heart 
failure patients' lives could be prolonged by five years on 
average by adherence to the right medications. However, less 
than 1.5 percent of these patients are even prescribed the 
recommended doses following hospitalizations. Our system is not 
set up for success. Doctors don't have frequent enough vitals 
to make appropriate change and, even if they have the vitals, 
they don't have the time. Cadence's job is to fill in the gap.
    Another example, the management of diabetes. The wife of 
one of our patients in Alabama with type 2 recently said that 
we saved her marriage. Before, she was constantly arguing with 
her husband about monitoring his blood sugar and his watching 
his diet. Now, every time he checks his blood glucose it 
transmits automatically to his doctor and Cadence. Together, we 
keep him accountable in real time. His A1C is decreasing for 
the first time in years.
    Our written testimony shows that technology and an 
innovative care model can deliver superior outcomes at lower 
costs, especially in rural and underserved communities. Our 
data shows that remote monitoring more than pays for itself, 
with a 23 percent decrease in total cost.
    Members of this committee, you play a critical role in 
determining whether modern health care becomes broadly 
accessible. I urge you to consider two important policy 
solutions.
    First, please fix regional payment disparities that 
penalize rural communities. Reimbursement is lowest in the 
communities that need it most. Missouri remote monitoring pays 
33 percent lower than remote monitoring in San Francisco. The 
old way, adjusting Medicare payments by geography, doesn't make 
sense in a technology-enabled system. Devices, connectivity, 
staff all have the same cost, regardless of location. It is an 
important change to an unintended policy.
    Second, please ensure national payment rates stay in line 
with Medicare. Remote monitoring rates have declined up to 28 
percent since being introduced in 2018, substantially more than 
Medicare rates. I encourage policymakers to look at the data 
and decide what kind of health care future we want for our 
country.
    Thank you for your time. I appreciate your focus on these 
important issues.
    [The statement of Mr. Altchek follows:]
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    Chairman SMITH. Thank you.
    Dr. Mehrotra, you are now recognized.

 STATEMENT OF ATEEV MEHROTRA, PROFESSOR OF HEALTH CARE POLICY 
AND MEDICINE AT HARVARD MEDICAL SCHOOL AND HOSPITALIST AT BETH 
                ISRAEL DEACONESS MEDICAL CENTER

    Dr. MEHROTRA. Thank you, Chairman Smith, Ranking Member 
Neal, and other distinguished members of the committee. I am 
honored to testify before you today on a topic of such 
importance to Americans and their health.
    I conduct research on telehealth and remote patient 
monitoring because I am excited about how these technologies 
can address the complaint I often hear from my patients, and 
what I am sure you hear from your constituents, that Americans 
across this nation often have difficulty accessing care. And 
these barriers are often larger among those who live in rural 
and underserved communities. In my testimony today I will 
describe how emerging research may inform potential 
legislation.
    My first point is that telemedicine has resulted in a more 
modest change in health care delivery than initially 
envisioned. At the start of the pandemic, some contemplated 
whether the unprecedented growth in video and telephone visits 
was the beginning of a new normal, one with telemedicine visits 
as a core component of how patients receive care. The reality 
has been more of a modest change in the most clinical areas, 
and the number of telemedicine visits in the Medicare program 
continues to fall.
    In surveys, interviews, patients and physicians greatly 
value the availability of video visits and want them to remain 
an option. However, both have questioned the quality of care in 
a video visit, and specifically the inability to conduct a 
physical exam.
    The second point is telemedicine does increase spending, 
but modestly. The key impediment to permanent expansion of 
telemedicine has been the possibility that telemedicine will 
drive up spending. Telemedicine's ability to make care 
convenient and more accessible, the key to its enormous 
potential to improve health, may also be its Achilles heel.
    In my own research we find that greater telemedicine use 
does lead to more visits, and this is associated with small 
improvements in chronic disease medication adherence and fewer 
emergency department visits. However, these improvements do 
come at a cost. We estimate that greater telemedicine use is 
associated with a one to two percent increase in health care 
spending per Medicare beneficiary per year, and our results are 
generally consistent with other research, including those from 
MedPAC.
    Based on these findings, I recommend that the Congress 
permanently eliminate site location requirements and allow 
video visits for all conditions at any site. While telemedicine 
does increase spending, the increase is modest and is 
associated with some improvements in access and quality. And 
perhaps most importantly, patients and clinicians want 
telemedicine to remain an option. And given this emerging 
evidence, it is hard to justify stopping coverage.
    Invariably, areas will emerge where we see both over-use as 
well as outright fraud. But I believe these areas could be 
addressed selectively. For example, Medicare could address 
concerns of fraud by requiring in-person visits if a physician 
wants to order specific high-cost tests.
    My third point is that telemedicine visits should be paid 
less than in-person visits. Payments for care in the Medicare 
program are based on the time a clinician takes to provide the 
care and the associated space, staff, and equipment. If 
something costs less, it should be paid less. While it does 
require some overhead, telehealth visits do not require the 
same practice expenses.
    Some clinicians have objected. They argue that their 
practice expenses have remained the same because they provide 
both in-person visits and telehealth visits. I disagree. I do 
not think Medicare should cross-subsidize in-person visits with 
telehealth because it will create distortions in care. It will 
give virtual-only companies an unnecessary competitive 
advantage. It will also incentivize clinicians to give up their 
physical practice. Already we see that roughly 13 percent of 
mental health specialists have given up their physical office 
and gone virtual-only.
    And lastly, remote patient monitoring is effective, but its 
value can be improved. Remote patient monitoring, like others 
have said, is a promising clinical model that may improve the 
care for many Americans with chronic illness, and use is 
growing rapidly in the United States. And consistent with 
others, in my own research we find that among patients with 
high blood pressure it leads to greater adherence to 
medications and fewer related hospitalizations and emergency 
department visits. And another strength is that we find that it 
is more likely to be used by underserved communities.
    However, and contrary to what others have said, we find 
that remote patient monitoring increases health care spending 
in the Medicare program. There are several ways we believe we 
can improve the value of remote patient monitoring. For 
example, instead of the current policy of unlimited 
reimbursement, I believe Medicare should limit the time period, 
given that most of the benefit is in the first couple of 
months.
    Again, I thank Chairman Smith, Ranking Member Neal, and 
distinguished members of the committee for allowing me to 
appear before you today, and I look forward to your questions.
    [The statement of Dr. Mehrotra follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Chairman SMITH. I want to thank you all for your testimony. 
We will now proceed to the question-and-answer session.
    Mrs. Maddux, it looks like you have some helpers behind 
you, too. Do you want to introduce them?
    Mrs. MADDUX. Sure. My daughter is Emmy. She is 12. And my 
son is Kai. He is seven.
    [Applause.]
    Chairman SMITH. So your personal story of living with ESRD 
and experience with home dialysis speaks to the importance of 
expanding care-at-home options, particularly for kidney 
patients in rural communities who are more likely to utilize 
and benefit from home dialysis.
    What has been the impact of this option on your quality of 
life and your role as a working mother?
    And what, if any, improvements would you like to see to 
enhance the quality and convenience of care at home?
    Mrs. MADDUX. Sure, thank you for that question.
    In terms of the impact to my quality of life, I think I 
mentioned earlier that, from a physical perspective, the 
frequency of your treatments, of your dialysis treatments, have 
a direct correlation to how you feel. So I noticed immediately 
when I started doing that first week of home dialysis training 
that having the consecutive treatments, the impact on how it is 
on your heart and just how it hits your system, it is just 
easier. So I felt better, I had more energy right away.
    And then, when it comes to just the dietary restrictions 
and, like, the fluid restrictions that I was dealing with at 
that time, I felt that I was able to have more control over 
what I was eating, or when I wanted to eat, and how much I was 
able to drink because of the frequency of the treatments.
    In terms of it being at home, I have a lot of different 
appointments that I have to go to. I am listed at several--or 
almost three different transplant centers. And so that in 
itself requires a lot of follow-up doctor's visits. I spend a 
lot of time going back and forth to the doctor. The fact that I 
can have one thing where I am eliminating a trip to a specific 
office that might be two or three hours away, or a half-an-hour 
away, whatever the case may be, it makes it an opportunity for 
there to be more time that I can spend at home, taking care of 
my family, doing work, or essentially doing things that I want 
to do.
    Chairman SMITH. Thank you.
    The Hospital at Home has shown many benefits in its short 
time as a program, from reduced health care costs to better 
patient outcomes and lower hospital readmissions. Mr. 
Underhill, you have received hospital-level care both in 
facilities and now in your home through this new program. In 
your testimony you spoke of the benefits of recovering from 
your serious condition at home: better sleep, home cooking. 
Please describe the impact receiving Hospital at Home had on 
your family and friends to see you heal in your own home.
    Mr. UNDERHILL. Oh, because of the COVID being at its peak 
then they could not have visited me in the hospital at all, so 
I would have been on my own.
    And if you have tried to sleep in a hospital recently, you 
know the beeping, the constant beeping that you can't figure 
out what it is for, I didn't have that at home. I also had my 
own bed clothes instead of the disturbing garment that you are 
issued. [Laughter.]
    Mr. UNDERHILL. All around, just having my own books and 
being able to get a glass of water and make it to the 
refrigerator made such a difference.
    I also just felt safer and less a burden. Nobody wants to 
be a burden on folks. Being at home I was on my own and feeling 
better every day. So just that safety, the comfort, the comfort 
of home and the comfort of friends and family, that made a huge 
difference. And there is just nothing like it.
    Chairman SMITH. Thank you.
    Dr. Starr, there is tremendous hope and expectation for an 
ever-expanding scope of health-care-at-home services, with high 
levels of satisfaction for both patients and providers. While 
most folks are probably familiar with telehealth calls with 
their doctor, could you please share with us the full scope of 
telehealth and health-at-home services you are seeing today 
across the country?
    And additionally, can you describe how audio-only 
telehealth is utilized by the rural patients you serve?
    Dr. STARR. Yes, thank you for that question.
    So we are seeing a scope that really encompasses the entire 
patient journey, from both preventative care to care of chronic 
conditions to, really, you know, acutely ill patients in an 
intensive care unit at a small hospital that would otherwise 
need to be transferred. And being able to impact patients 
throughout that whole spectrum is really where we see so much 
value.
    We approach our telehealth programs, really, from a value 
based perspective, where our goal is to prevent the need for 
transfer, to keep patients in their communities where they will 
heal better, and the--even keep a lot of that revenue local to 
support those smaller hospitals.
    In terms of the audio-only care, there are times where what 
you need to do is get a history from a patient. Our most 
valuable diagnostic tool is still a history, like, talking to 
the patient, understanding how they feel. And that can be done 
over the phone if there are no other options, and can be a very 
significant way of collecting the information we need to help 
manage the patient.
    Chairman SMITH. Thank you. Advanced technologies are aiding 
today's health care providers in breaking through a broken 
status quo in the delivery of care to rural and underserved 
communities, improving patient outcomes and lowering health 
care costs.
    Mr. Altchek, from your perspective as an innovator in this 
field, where do you see the biggest impact, the most positive 
disruptions occurring when it comes to improving care in rural 
communities?
    And how specifically does ensuring fair reimbursement for 
services across varying geographics play a huge part in that?
    Mr. ALTCHEK. Thank you, Chairman Smith.
    Rural and underserved communities disproportionately face 
the impacts of chronic disease crisis in America, and we have 
an opportunity as a country to do a much better job of being 
much more proactive, supporting patients and keeping them out 
of the hospital to begin with.
    The technology today has advanced to a point where we can 
cover--you know, of the members of this committee, we have 13--
we have patients in 13 states, and we can do so in a way where 
84 percent of patients can share their vitals at least 16 days 
a month, which is important because a lot of these patients 
actually don't have broadband in the home. And the fact that we 
can do this is because we are leveraging cell phone carriers in 
these local regions to transmit data. And so we have been able, 
with technology advances, to broaden access in very meaningful 
ways and in ways that are likely the highest impact we can have 
in the U.S., which is turning the tide on chronic disease.
    Unfortunately, the way that Medicare reimbursement works 
for these services today is they are indexed by the geographic 
payments. And so, effectively, in rural communities you are 
paid anywhere from 20 to 30 percent less than in urban 
communities. And as Congress we have the opportunity to level 
the playing field and ensure that patients across the country 
have access to cutting-edge technology, which is only going to 
get better over the coming decade.
    Chairman SMITH. So I would assume that reimbursements in 
rural communities that were, you said in your testimony, 25 to 
30 percent less, that clearly has a huge impact on the business 
decision that providers would have, and whether they are 
focusing their efforts in a higher-reimbursed geographic 
region, correct?
    Mr. ALTCHEK. Yes, these programs typically cost Medicare 
between 5 and $600 a year, on average, per patient at the 
national payment rates. And that is for 12 months of 24/7 
monitoring, cell-connected devices that transmit data daily. In 
the grand scheme of the cost of these patients, which is 
generally 15,000 to $30,000 a year, on average, to Medicare, it 
is a small cost. But if that $500 goes down to 350, $400, it 
becomes unsustainable in rural communities. And these are 
already the communities that are struggling the most 
financially, clinically to stay afloat.
    Chairman SMITH. Thank you. I now recognize the ranking 
member, Mr. Neal, for any questions.
    Mr. NEAL. Thank you, Chairman, thanks. This was very, very 
helpful.
    You just triggered, Mr. Altchek, in my memory, an 
interesting question that has been part of the challenge that 
we have faced on the very issue that you raised. The idea, I 
think, as you have accurately described it, and we have had 
conversations that have been really good with both sides here, 
is not to ask urban areas to take a smaller slice. The answer 
is to bake a bigger pie so that people can participate, and I 
am all in on that suggestion.
    Dr. Mehrotra, your testimony today was really good, as the 
others have offered, and the research applications and the 
impacts of telehealth as you have described them tee up a 
couple of pretty good opportunities. We extended in 2022 
pandemic-era flexibilities for telehealth, hospital at home, 
remote patient monitoring with the intention of collecting more 
data to inform on patient outcomes. But it struck me that in 
your testimony you have emphasized that it is still a lack of 
data that plagues us in trying to analyze quality and equity. 
That seems like a glaring gap in our understanding.
    But what types of data do you think we need to determine 
success for patients and policy care in the home, which we all 
support?
    And, what data is sufficient to ensure patient safety?
    What types of things should we consider when thinking about 
acute care hospital-at-home programs?
    Dr. MEHROTRA. Thank you for that great question. There is--
one of themes I want to bring up here is that emerging evidence 
is there. But just as you emphasized, there is a lot to learn. 
And maybe I will hit upon a couple of places where I think 
there are really important holes.
    We recognize in a lot of research that right now these 
amazing technologies are not being used equally across the 
nation, and we have a lot of interest. And how do we make sure 
that everybody is using these technologies? How do we do so? 
What are the different kinds of innovations that we can use, 
that we can do to try to improve that?
    For example, health systems. Others are investing in 
digital navigators to help patients figure out this very 
confusing, at least at first, enterprise. Do those work or not?
    People have brought up the idea that in rural communities 
what we can do is we can have TAPs, Telehealth Access Points, 
where we can set up, I don't know, at a library, a clinic where 
people can go there. If they can't get a video connection from 
their home, they can have a telehealth visit. That is a really 
interesting idea, but we need more research on whether that is 
effective or not.
    So I wanted--that is one area that I think is really 
important is we want to make sure that these technologies that 
are used are available to all Americans. What actually works we 
don't know right now.
    Mr. NEAL. And as a follow-up, you have indicated, in your 
testimony, that poor deployment of telehealth could instead 
increase longstanding disparities already exacerbated by COVID-
19. How would you suggest that we might proceed with telehealth 
and other home-based care services that would bridge gaps and 
drive toward more equitable care, rather than exacerbating 
disparities?
    And what types of data, again, do you think success might 
look like?
    Mr. NEAL. Right. I think your question really hits upon an 
important, I sometimes see it as a misconception, the 
challenge, the idea that if we offer one of these really 
promising services, those in rural and underserved communities 
are going to be most likely to use it. I think the data is 
pretty clear that it is actually the opposite. And often those 
coming, say, from wealthier communities are more likely to use 
these technologies.
    So, the real question that you are hitting upon is, how do 
we make sure that it is equitably available to everybody? And 
so those are how do we target those communities? What kind of 
investments can be made in there? What kind of programs do we 
need to support rural hospitals, for example, in making sure 
that they have that promising technology in their emergency 
department? Those are the kinds of investments in areas that I 
think we really need to do more work in.
    Mr. NEAL. Thank you.
    Thanks, Mr. Chairman.
    Chairman SMITH. Thank you. Mr. Buchanan is recognized.
    Mr. BUCHANAN. Thank you, Mr. Chairman. I want to thank all 
of our witnesses.
    Mrs. Maddux, let me ask you. You make it sound so easy. I 
am in Florida, I represent part of the Tampa Bay area, the 
region there, and deal with a lot of seniors and the challenges 
they have. And they make a lot of progress, but you make it 
sound very manageable. You have got a beautiful family. What is 
your secret?
    Mrs. MADDUX. It is not a secret. I would definitely say 
that I am incentivized by being able to take care of my family 
and being able to be with my family.
    I agree with you. It is definitely not something that I 
think if somebody who had, you know, for example, a mobility 
issue or something that was impeding their ability to do this, 
there would be some complications. But I think in people in 
those circumstances that they are able to work with a care 
partner, if it is a spouse or a child or a friend for--or 
someone told me this morning that she is a little bit short, 
and so she can't lift boxes very--from high shelves, so she 
gets her neighbor to come and move the boxes for her.
    All of the things that I do, I promise you, I do--I have 
not spent as much time in school as some of the people here, so 
all of the things that I do, it can be done by anybody. It 
just--you just have to be willing to do it. And I think that if 
you are given the opportunity for autonomy and control over 
your health, it is possible to do--you know, take your vitals, 
take your blood pressure, you know, take your temperature----
    Mr. BUCHANAN. Let me tell you, you are a superwoman, I can 
tell you that much, to be able to manage that, because I see 
what our kids are managing with their grandkids, and it is a 
lot of work, and you don't have those challenges.
    Mr. Underhill, let me ask you, how long might you have been 
in the hospital if you had stayed at the hospital and not went 
back home?
    Mr. UNDERHILL. It would have been three days, and it 
required the administration of intravenous antibiotics over 
three days to resolve the situation.
    Mr. BUCHANAN. You think you would have been out in three 
days?
    Mr. UNDERHILL. I would have.
    Mr. BUCHANAN. Okay. Do you have any sense of the cost if 
you would have stayed there? I am just curious.
    Mr. UNDERHILL. I am afraid I do not know.
    Mr. BUCHANAN. Okay.
    Mr. UNDERHILL. No, no, I do not have the difference in the 
cost differential in that.
    Mr. BUCHANAN. Yes. Dr. Starr, let me ask you. We talk 
about, you know, telehealth. I think it is clearly the future. 
Being in Florida, many of our seniors are an hour away, half 
hour away, two hours away. But when you think about, you know, 
the mountainous regions of the country, a state like Colorado, 
you know, it is five times--it is four times bigger or three 
times bigger than Florida. How do you manage that in terms of 
where people--how is that working out in terms of people--do 
they have to move back and forth for a three-hour drive 
initially or something? Or how does that work?
    Because this is clearly a road that we are going to--I 
think we are going to end up going down in a very aggressive 
way. That is just my opinion.
    Dr. STARR. Yes, thanks for that question. It depends on the 
situation. Many of our interactions we can do fully remotely, 
and we can have a patient seen by a specialist and they can get 
the data they need remotely to take great care of the patient, 
I think equivalent care of that patient.
    Other situations, they will come in once--our tele-oncology 
is a great example. They will come to the big center to get 
their biopsy, to get the initial diagnosis. Everything is set 
up, and then we will do all of their treatment in their home 
community.
    Mr. BUCHANAN. But how far might they be away, some of your 
patients, in terms of accessing your facilities or the 
hospital?
    Dr. STARR. A hundred and fifty, two hundred miles.
    Mr. BUCHANAN. Yes, that is the thing I think a lot of 
people don't understand.
    Dr. STARR. Yes.
    Mr. BUCHANAN. Can you touch on home infusion, too, how 
you----
    Dr. STARR. Yes.
    Mr. BUCHANAN. How that works for you, and what makes sense 
and what doesn't make sense, or how we can help you with that, 
as well?
    Dr. STARR. Yes, so I appreciate that. I think home infusion 
is an area of massive opportunity, and one of those that is 
actually kind of a no-brainer for me.
    We have patients now that are Medicare patients that, under 
the current part B regulations, they go to a skilled nursing 
facility just to get IV antibiotics, or they will have to, if 
they are in a rural community, travel a great distances just to 
get an infusion. Home infusions in rural areas under Medicare 
don't exist, essentially. They are--it is incredibly rare. And, 
you know, Mr. Smith's--you know, his proposed legislation helps 
a lot with the Part B piece to provide more benefits to allow 
us to expand that.
    Mr. BUCHANAN. Thank you. Let me just close.
    Mr. Chairman, I would like to submit for the record the 
written testimony of Ms. Ashley Graves, who greatly benefitted 
from the promises of home infusion. And with that I yield back.
    Chairman SMITH. Without objection.
    [The information follows:]
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    Chairman SMITH. Mr. Doggett.
    Mr. DOGGETT. Thank you very much, Mr. Chairman, and thanks 
to each of our witnesses. I will focus on telehealth.
    I offered bipartisan legislation in the last Congress that 
was supported by 22 health-related stakeholders after chairing 
a Health Subcommittee meeting in which Dr. Mehrotra testified 
and worked with then-Ranking Member Devin Nunes to craft 
reasonable legislation that would extend telehealth for a 
couple of years, permit some data collection, and implement 
some modest guardrails that were recommended by the Medicare 
Payment Advisory Commission, or MedPAC, to prevent the looting 
of Medicare through telehealth fraud schemes. This legislation 
would have required an in-person visit within six months prior 
to ordering high-cost lab testing or durable medical equipment, 
as well as an audit of some of the outlier clinicians whose 
orders for these high-priced services and devices are largely 
made through telehealth appointments.
    The Government Accountability Office, the Health and Human 
Services Inspector General, the Justice Department, and my own 
constituents have exposed a number of fraudulent schemes 
involving telehealth and DME and lab testing. Here is what has 
been happening. Information for some patients, who were only 
seeking COVID-19 testing, were fraudulently used to build 
Medicare for cancer genetic tests and allergy tests without any 
medical necessity or the patient's knowledge. In other words, 
expensive medical equipment in no way needed by the patient was 
ordered.
    Last June, the Justice Department brought charges against 
78 providers in an elaborate telefraud scheme involving 2.5 
billion fraudulent orders for braces and other items. These 
providers were found to have used these ransacked profits to 
purchase yachts, luxury vehicles, and jewelry. This case built 
on an earlier action involving $10 billion in telefraud.
    These schemes happen regularly at both large and small 
scales. In September another health executive pled guilty to 44 
million in fraud using telehealth to order medically 
unnecessary DME, particularly back and knee braces, as well as 
genetic testing. In September, one nurse practitioner pled 
guilty to ransacking 7.8 million taxpayer dollars. Just last 
week I had an Austinite contact me because she discovered 
someone had fraudulently billed Medicare for $20,000 in DME for 
her.
    So my belief is we need more telehealth. We don't need any 
more telefraud. And prevention is so much better than 
prosecution after the damage is done and the taxpayer pays the 
bill. Unfortunately, I have been unable to get enough interest 
in the Preventing Medicare Telefraud Act that I have offered 
this year that focuses on eliminating this kind of fraud with 
reasonable measures.
    Dr. Mehrotra, let me just ask you, given the considerable 
amount of telehealth fraud which has occurred, namely this 
ordering of DME and unnecessary lab tests, would you agree that 
we need guardrails to protect taxpayer dollars at the same time 
as we extend telehealth?
    Dr. MEHROTRA. Thank you so much for that question. I think 
it is a critical issue that you are raising. We will have 
issues of overuse and this outright fraud, which is abhorrent 
and using taxpayer dollars. And so we do need such guardrails.
    I think the one guardrail that you propose, which is that 
for selective tests that are being overused such as DME or 
cancer screening tests, we do--requiring in-person visit 
requirements for that is not a substantial burden on 
clinicians, and I think it would at least be one check on that 
kind of behavior. So I think those kinds of guardrails writ 
large are necessary as we continue to use telehealth.
    Mr. DOGGETT. Thank you so much. And though I know you are a 
big advocate for telehealth and the benefit it offers, 
particularly in rural areas, would you agree that Congress 
should not extend telehealth coverage under Medicare without at 
the same time instituting reasonable checks to prevent this 
kind of fraud?
    Dr. MEHROTRA. Yes, I think we do need to allow for the 
Medicare program to continue to introduce those kinds of 
guardrails, because we need to make sure we do this in the most 
cost-effective manner.
    Mr. DOGGETT. And from a clinical perspective, do you 
believe that targeted, modest guardrails, the kind I have 
outlined, would unnecessarily hamper patient access?
    Dr. MEHROTRA. Yes, I don't think that that kind of in-
person visit requirement is--it is very selective, and I don't 
think it would impact most Americans in any substantial way.
    Mr. DOGGETT. Thank you. Well, I hope we can get it 
considered further in this committee.
    Thank you very much.
    Mr. ESTES [presiding]. And now I recognize the gentleman 
from Nebraska, Mr. Smith.
    Mr. SMITH of Nebraska. Thank you, Mr. Chairman. Certainly, 
thank you to our witnesses, as well. It is truly amazing to 
hear about new technologies that have expanded the boundaries 
of access to health care.
    Every day we see new devices which allow services that 
could previously only be performed in the hospital to be 
accessed from home. Greater access to high-speed Internet and 
the development of apps which can securely connect patients to 
providers from virtually anywhere in the world make it easier 
than ever before for patients to access the care that they 
need.
    Telehealth has been a game changer for access to care in 
rural areas such as my district in Nebraska. I have been 
advocating for expanded telehealth since even long before the 
pandemic. While access to telehealth was pretty limited before 
the pandemic, during COVID many of us quickly learned to rely 
on our phones and computers for routine health care needs.
    Unfortunately, most of the flexibilities we have come to 
rely on in the years since the pandemic are set to expire at 
the end of this year. I am pleased that this committee has 
already advanced legislation I introduced with Representative 
Steel to permanently extend first-dollar HDHP coverage for 
telehealth, but more action needs to be taken on critical 
geographic and originating site flexibilities and audio-only 
options for those without access to high-speed Internet.
    Even though telehealth has made it easier than ever for 
patients to connect with their providers, it is innovation in 
medical devices that has most dramatically expanded the ability 
of patients to safely receive care in their homes, as you have 
pointed out. For example, innovations in home dialysis 
technology have made it a more accessible option than ever 
before as new innovations make operations easier than ever, 
such as the Tablo device which can operate with just normal tap 
water, an electrical outlet, and a drain.
    But lack of adequate Medicare coverage can often create 
roadblocks to adoption of new technologies that expand safe 
home access to care. That is why I introduced the Home Dialysis 
Risk Prevention Act, which would reduce the risk hemodialysis 
patients face of serious complications from venous needle 
dislodgement. This legislation would ensure adequate Medicare 
reimbursement for the sensors and alarms that can detect when 
the blood return needle slips loose, putting a patient at risk 
of serious blood loss or even death.
    In other cases we have the technology available to safely 
perform services like home infusion, but have to painstakingly 
legislate individual conditions into lists of ``medical and 
other health services'' in order to have Medicare cover them. 
In this case, Medicare is already explicitly allowed to cover 
home infusion of intravenous immunoglobulin for primary 
immunodeficiency diseases, but would require an act of 
Congress. My legislation, the Medicare IVIG Access Enhancement 
Act, to allow for the same technology to administer the same 
treatment for patients with CIDP or MMN.
    Rather than having to legislate every single new indication 
or new device, we really need to look at broader reforms 
Medicare coverage for home-based care. That is why this 
Congress I introduced the Expanding Care in the Home Act to 
jumpstart the conversation on how Medicare needs to approach a 
whole spectrum of home-based care, including home infusion, 
home dialysis, and in-home primary care labs or diagnostics. I 
hope today's conversation leads to further legislative action 
on removing outdated regulatory and statutory barriers to 
accessing these new and revolutionary technologies for greater 
access to care in our homes.
    Dr. Mehrotra, from your perspective I was wondering, as a 
physician and a professor, what areas of care in the home under 
discussion today do you believe are most impacted by outdated 
regulations?
    Dr. MEHROTRA. I think the one exciting thing is there--a 
number of these technologies--I think home dialysis would be a 
great example of where we need to expand the use of home 
dialysis across the nation would be one where the regulations, 
I think, are quite problematic.
    I think remote patient monitoring would be another example 
of where I am excited about the potential, but I think there 
are important changes to the regulations that can be 
implemented to really increase their use.
    Chronic disease is one of the greatest drivers of health 
care spending in the United States, and morbidity, and anything 
we can do to improve chronic disease care is really important.
    Mr. SMITH of Nebraska. Mr. Altchek, would you like to 
reflect on that a bit? Do you see any particular area where 
there is more difficulty to enter or to give patients more 
options?
    Mr. ALTCHEK. Yes, I think, building on Dr. Mehrotra's 
point, in chronic disease management we just need to do a much 
better job as a country. We have a, as you know, rapidly aging 
population, the majority of which have one or two chronic 
diseases. We don't have enough clinicians to take care of these 
patients. We need to adopt technology and more modern services 
as fast as possible to deal with the issues that are coming our 
way.
    Mr. SMITH of Nebraska. Right, very well.
    Thank you, I yield back.
    Mr. ESTES. Thank you. I now recognize Mr. Thompson.
    Mr. THOMPSON. Thank you, Mr. Chairman. And to all the 
witnesses, thank you very much for being here.
    I have been working on telemedicine, telehealth, seemingly 
forever. I am a big believer, and I think that we can save 
money, time, and lives so long as we do it correctly.
    As some of our witnesses mentioned, many of the telehealth 
options available to seniors on Medicare today are slated to 
expire at the end of 2024, and I would like to focus my 
questions on how this committee and how Congress should be 
approaching that deadline.
    So Dr. Mehrotra, I thought you did an excellent job in your 
testimony describing the balance we need to strike on 
telehealth. To use your term, we need to prioritize high-value 
cases and protect against low-value utilization. I also share 
your observation that we can't really take away telehealth, 
that the genie is already out of the bottle and it is working, 
especially in the field of mental and behavioral health.
    So, as we think about the upcoming December 2024 deadline, 
can you talk a bit more about the steps we can take to make 
telemedicine permanent and give patients and providers 
certainty while avoiding low-value utilization?
    Dr. MEHROTRA. Thank you for the question, and I think that 
there are a number--in terms of improving the value of these 
kinds of technologies, it--a lot of it really focuses on 
ensuring that the patients who are going to benefit most from 
that technology are going to be the ones who receive it. I 
talked about how I felt, that remote patient monitoring was a 
great example of how we can improve chronic illness management. 
But a lot of the patients who are receiving remote patient 
monitoring today are doing just fine with their chronic 
illness. We need to focus our money, our resources, our time on 
those patients who are doing poorly. And so how do we implement 
regulations to encourage that kind of targeting would be one 
example.
    You also raised the issue of mental health treatment, and I 
think an important regulation that we should be thinking about 
is the current--as of January of next year we will be 
implementing an in-person visit requirement before a patient 
can receive mental health treatment via telemedicine. And that 
is an example of where I think that kind of regulation may 
impair Americans from getting the mental health treatment that 
they need, and is another thing we should be considering.
    Mr. THOMPSON. Thank you very much.
    Dr. Starr, you mentioned that you have an emergency 
medicine telehealth program. I think you said over 90 percent 
of the patients at the clinic ultimately do not need to go to 
the ER, even though they think they do. And each ER visit costs 
over $1,400, on average. That is exactly the kind of thing I am 
focused on. As I said earlier, I want to reduce unnecessary 
care, not expand it, and it seems that your telehealth ER 
program does just that.
    Can you tell me a bit more about how that works when the ER 
doc visits a patient virtually, and the patient thinks they 
need to go to the hospital? Do you find that your providers are 
able to accurately assess whether the ER visit is needed?
    And what are some of the examples of conditions or symptoms 
that might make a patient think they need to go to the ER?
    Dr. STARR. Yes, so this program is done in conjunction with 
InstaCares, both our virtual InstaCare and physical InstaCares. 
So patients who present to be seen--and we are expanding to 
primary care doctors, as well--they will prevent [sic] for a 
complaint--for example, chest pain. And currently, a lot of 
those patients are immediately sent to the ER. Instead of that 
happening, they will have a virtual visit with an ER physician 
who can see them, review what information we have, and then 
decide, if they were going to go to the ER, what workup would 
we give them, and then can we do that outside of the ER.
    For example, if they need a CAT scan to look for a blood 
clot, we would arrange for a rapid outpatient CAT scan, and 
they would go get it done. And we would follow up on the 
results.
    Mr. THOMPSON. And does that fall under the category you 
mentioned earlier about preventive care? Is that a type of--is 
that an example, that----
    Dr. STARR. A type of preventive care. Additionally, you 
know, like we have been talking about with diabetes and a lot 
of our chronic conditions, early identification and management 
of those, as well.
    Mr. THOMPSON. Thank you all very much.
    I yield back.
    Mr. ESTES. Thank you, and I now recognize Mr. Kelly for 
five minutes.
    Mr. KELLY. Thank you, Mr. Chairman, and it is a good 
hearing.
    First of all, I think one of the things that we fail to--
and Mr. Schweikert will be here, I am sure he is, because he 
has got a whole idea about disruption and what it actually 
means in our industry.
    So whenever I was looking, trying to figure out so how much 
of our economy is health care, and we say somewhere between 17 
and 20 percent, but then we rank eleventh worldwide in 
innovation, which is what Mr. Schweikert talks about all the 
time.
    I am a type 2 diabetic. And also, in the district I 
represent there are great distances between hospitals and 
patients. And what we are doing in a lot of the veterans' 
places, they have a place where they can go in and sit down. It 
is private, and they can go online and get information.
    So for all of you--now, I have got you, Mrs. Maddux, what 
you are able to do is incredible.
    Mr. Underhill, I got to tell you, getting care on a 
Saturday afternoon in the fall is very much the same in South 
Bend, Indiana as it is in Chapel Hill, especially if there is a 
Notre Dame home game.
    So, look, all of you are involved in this, and I really 
would defer to the doctors on this panel. I relate everything 
to the business model. I am an automobile dealer, and one of 
the biggest drivers for people that are manufacturers is 
warranty costs. And we found a new way of doing diagnosis, 
where the cars can tell you what is wrong with them, as opposed 
to a technician trying to interpret what it is that the owner 
of the vehicle is telling them, as opposed to the vehicle 
telling them what is wrong with it.
    For those of you in that business, and it is a business, 
and we have got to address it as a business because it is going 
off the charts in what it is we are able to do--and listen, I 
think telehealth is an incredible, incredible issue. I mean, 
for us to be able to sit at home and get the help we need, I 
think that is fantastic. For each of you that are in that 
business model--not so much the patients, because you rely on 
it for your health, right, and your health well-being. But for 
those of you who provide it, what role does the government 
play?
    And I know it is--everybody always talks about the fraud, 
and the abuse, and everything else. I get that. That is in 
every single business across the country, not just in health 
care. What is it that you would suggest that we can do to make 
sure that every single dollar we invest is actually going to 
the care and the health of our taxpayers?
    So--and you are all experts in this, because you work with 
it every day. Can you give us a little more of an idea? So what 
is it that we should be concentrating on? Spending more money 
is not the answer. Getting a return on the spending is the 
answer. So what could we do?
    Dr. Starr, you can start, and Mr. Altchek, and then Dr. 
Mehrotra. I want to hear from you all because you do it every 
single day.
    Dr. STARR. Yes, I--for Intermountain Health, our answer to 
that is to continue to move towards value-based care, where--
moving away from fee-for-service, everything billed fee-for-
service, towards getting paid to keep people healthy. And if we 
do that, then that is where everyone can benefit, you know, 
reducing costs and improving our margins as a health care 
system by reducing medical utilization that is unnecessary.
    Mr. ALTCHEK. We completely agree that sensible guardrails 
make sense as remote monitoring and telehealth expand. In our 
space, there are three things that guarantee a better outcome 
for patients and, again, guarantee a better outcome for 
Medicare.
    One is that on the other side of the remote monitoring 
there is a 24/7 care team that can actually respond to the data 
and make clinical decisions, whether that is ordering labs or 
ordering medication. So we encourage people who do deploy 
remote monitoring to have that 24/7 coverage.
    Second is integration into the electronic health records of 
the local physicians. We think it is really important, if we 
are going to do a better job of chronic disease management, 
managing patients over time, we need to be sharing the data 
back and forth with the local physicians.
    And then the third point is reporting on outcomes and 
metrics. You know, we believe, if we are going to be spending 
Medicare money, we should be responsible for reporting the 
outcomes to make sure the government can decide whether that is 
well spent.
    Dr. MEHROTRA. I think the key issue that I want to 
emphasize is, like you, I am just so excited about these 
innovations, and it is exhilarating as a physician to take care 
of patients in a better way. But the issue that kind of is at 
hand here is true throughout health care, and maybe other 
industries also, where we introduce a new technology and we get 
excited about the benefits, but we also have to address overuse 
also.
    I will give an example of cardiac catheterization, a 
device, a procedure that is lifesaving. I imagine many of you 
in this room have had that lifesaving procedure. But the data 
shows that we grossly overuse cardiac catheterization. So it is 
this balancing act: How do we make sure that the patients who 
will benefit most from that technology get it, but also 
ensuring, so that we use our tax dollars effectively, that we 
don't overuse it and give it to--deploy it with patients who 
are not going to benefit?
    Mr. KELLY. Yes, so I want to thank you all for your 
testimony. I have got to tell you, just because I do this every 
day in my life. One of the things that are really important 
when you have a private sector business and when it comes to 
warranty work, the people who pay that bill are the people who 
are in every month looking to make sure--this is called 
oversight--that you are doing the right thing at the right time 
for the right reasons, and not just building for the sake of 
building to get revenue.
    So thank you so much for all being here. And Mr. Underhill, 
Mrs. Maddux, good luck with your health as you go into the 
future. And thank you so much for being here today.
    Mr. ESTES. Thank you. I recognize the gentleman from 
Oregon, Mr. Blumenauer.
    Mr. BLUMENAUER. Thank you, Mr. Chairman. This has been, 
really, a fascinating hearing. A number of us have been working 
on these.
    I appreciate, Mrs. Maddux, you talk about waiting to be 
waiting, and I also appreciate the fact that you have got your 
reinforcements here. We have membership in the Congressional 
Bike Caucus pins for them in a moment.
    I do appreciate being able to focus on this. I must say I 
have some concerns about what happens with the application of 
private equity as we move forward with some of this. And it is 
just another area, if we are not careful, I think we can get 
run over. But this, I think, is really appropriate.
    I am looking forward, with Dr. Wenstrup, to introducing 
legislation to extend the deadline, not the end of the year, 
but maybe even more than a year extension, a longer extension 
to be able to deal with the impact of the care at home. This is 
a very powerful model. I think it is timely, and I would like 
to continue working with the good doctor as we are moving out 
the door, concluding our legislative careers. But I think this 
would be a fitting area to be able to make some impact.
    I do appreciate the notion about home dialysis. I think it 
is a very powerful tool. We are working with Mrs. Miller to be 
able to extend opportunities with home dialysis, to be able to, 
in terms of allowing Medicare reimbursement for in-home 
assistance, the professionals who can do the training, and we 
want to do this right. Not everybody is as adept as Mrs. 
Maddux. People need that help. And providing additional 
education, being able to get ahead of the curve to promote in a 
very thoughtful way how we can realize this very powerful tool.
    I like the notion that it gives a context for the patient 
that you don't get in a hospital setting. This will, I think, 
give a window into the conditions of the patients, their 
families, and their attitude. And these are areas that I am 
really fascinated about our potential. I look forward to both 
of these areas.
    These are not partisan, and these are things that the 
committee has done some work, has built a record of interest 
and accomplishment, and I think we ought to be able to utilize 
that to be able to move simple, common-sense legislative 
proposals that don't have to be unduly complex, and they don't 
need to be expensive at all. Done right, and I appreciate your 
admonition, it will end up saving money and improving outcomes. 
I look forward to working with the committee, with Dr. 
Wenstrup, and with Mrs. Miller on progress yet this Congress.
    Thank you, and I yield back.
    Mr. ESTES. Thank you. I now recognize for five minutes Mr. 
Wenstrup, Dr. Wenstrup.
    Mr. WENSTRUP. Thank you, Mr. Chairman, and thank you all 
for being here today.
    I have lived the life of many of you and your experiences 
as patients and as providers, and it is true we have 
opportunities to do a lot here. Mr. Blumenauer and I have 
worked together on many things. Ms. Sewell and I have worked 
together on rural issues. There is a lot we can do.
    But today has been kind of hitting home to me and bringing 
back a lot of memories. Mrs. Maddux, you know, I had a patient 
with end stage renal disease, and I treated him, you know, at 
least monthly. He had neuropathy, he had chronic ulcerations 
that we would heal. And you are always at risk, right? And one 
day he came in and he said, ``I have to quit seeing you.''
    And I said, ``Why is that?''
    He said, ``Because the bus schedule changed, and I can't 
get to you and to dialysis.'' Think if he had home dialysis, 
right? I changed my schedule so that he could still see me, by 
the way, we worked it out.
    But understanding the challenges are there and the 
advantages of some of these things that actually allow people 
to get the care that they need and get it in a timely fashion, 
you know, and--but here is somebody I know, and I know him 
well. And so if he were to call today or later in my practice, 
even, I would say, ``Well, you know, take a picture of it, take 
a picture of what is going on. Let me see if I need to send you 
to the emergency room or have you come right into the office. 
Or maybe we can wait another week.'' But I know the patient.
    And so, when it comes to telehealth, one of the things that 
is important to me is that as often as we possibly can--and 
COVID was different--you know, we need to have a relationship 
where we really do know each other in person. At least at some 
point we have to have done that.
    You know, I had a patient one time--and let's talk about 
home infusions. I had a patient that--at one time Medicaid 
didn't allow home IV antibiotic therapy, so you had to treat a 
patient--I had a guy in for six weeks, he has no pain 
whatsoever, but he has got a bone infection. He has got 
neuropathy. So six weeks he sits in the hospital, getting IV 
antibiotic treatment. Well, he drove the staff nuts and they 
drove him nuts. You know, he felt fine. If we had been able to 
do that at home, which later we did, I mean, I celebrated when 
we started to have this type of an option.
    But you have got to have the appropriate workup, you know. 
So we are talking about guardrails. You can't just say, ``He 
gave me a call, it sounded like osteomyelitis, I am going to 
prescribe six weeks of antibiotic treatment at home.'' So you 
have to have some in-person clinical evaluation, all these 
types of things. I think that is important, you know, as we are 
talking about how we are going to proceed forward with these 
things that can be a great advantage.
    You know, for a lot of surgeries, elective surgeries, we 
are doing things pre-operatively now to try and make sure we 
get the best outcomes so people can live the healthiest lives 
possible that you said, Dr. Starr. So I really appreciate all 
these comments.
    If someone is smoking, we say, ``Look, this is an elective 
procedure. You stop smoking, you got a better chance of 
healing.'' You know, ``You lose weight, you got a better chance 
of healing,'' all these things. And then post-op, you go home 
with a pulse oximeter, we are getting your blood pressure, we 
are getting your temperature. Some people don't know they have 
an infection, but you can tell by what they can report back to 
you every day. These are great things, and you nip things in 
the bud.
    But I do think back, you know, when we are on call, you are 
taking care of your patients. If they called, you weren't 
billing for it, we just did it. And we decide we have come on 
in, go to the emergency room, and then we start to be able to 
do photos, but these are patients that you know. So I worry 
about some--not tremendously, because I don't think there is 
that many bad actors out in there, you know, but there is 
always some--you know, you can't just set up a business, you 
know, call me, and I will start ordering tests and do all these 
things, and I have never seen you. So we have to have some 
guardrails and parameters, I think, to work, because it would 
be best practices, anyway.
    But I think common sense comes into play on a lot of these 
things. You know, most doctors, they are concerned about their 
reputation, they are concerned about the outcomes. They really 
don't care--I don't care what Washington thinks. I am concerned 
what my patients thought, and what my community thought, and my 
colleagues thought about how we were taking care of people.
    So I don't really have a question because you are covering 
down on it so well today. But where we could have help is 
continue to give us input on what you think for guardrails and 
best practices, and how we establish this.
    But look, patients are less anxious and heal better when 
they can be at home. And the more you can get them in that 
environment that they are comfortable with, the better off the 
patient care can be, and the better results you are going to 
get. So hang with us, help us drive on, and let's work together 
through this. So no questions because you have already answered 
them.
    Thank you, I yield back.
    Mr. ESTES. Thank you. I now recognize Mr. Pascrell for five 
minutes.
    Mr. PASCRELL. Thank you, Mr. Chairman. Mr. Chairman, it 
struck me that during this conversation with excellent 
witnesses, all of them, that health is so personal. But it is a 
good reflection of how we can come together in the Congress of 
the United States, believe it or not. I think it is so 
important that we learn from each other on this. We are 
fortunate to have some doctors on the panel, but so many health 
matters.
    I mean, it is an example for sustenance, transportation to 
work. Think about these issues. You know, I am from an urban 
setting all my life. The first time I went to Montana, I was 
lost. [Laughter.]
    Mr. PASCRELL. Lost. Environmental matters. We seldom listen 
to each other because you are in another place and you have 
different problems. But health is a perfect example that we can 
move together and accomplish a lot. This is a pretty bipartisan 
issue today, and witnesses kept it that way, which is great.
    It is truly revealing like the pandemic was revealing. We 
learned a lot about ourselves. We have yet to learn everything 
from the pandemic, the consequences in our children. We learned 
America's health care system has deficiencies, yawning 
deficiencies that must be addressed.
    But the lack of quality and compassionate care is not a 
problem for rural Americans alone. That problem exists right in 
the heart of the most congested cities in America. So, we need 
to pay attention to each other, and we can't ignore it. There 
is no reason where you live determines whether you can get 
health care. I think we have crossed that barrier pretty well.
    And no, I have never heard any Democrat or Republican 
solutions that solve all the problems; I don't think you will 
find. When we work together on these issues we control the 
outcome, I think.
    Americans in urban communities like my own face the same 
endemic challenges, facilities face staffing shortages. I mean, 
places are closing, equities taking them over. They can't 
exist. They can't afford to. Don't tell me that is just the 
problem in the middle of southeast Alabama. It is a problem 
right in the midst of where all the money is supposed to be, in 
New York City.
    Retention struggles persist. I just went to a doctor 
earlier this morning. The person that that doctor hired to do 
his medical work in the office was just fired. The equity 
company took over the outfit that he works for. She was fired 
because she was not necessary, 66 years old, single mom. Where 
the hell is she going to get a job at 66 years of age? Don't 
tell me that is just a problem in southeast Alabama or 
Paterson, New Jersey.
    We need more data comparing health outcomes between 
treatment settings and payment models for the services like we 
have been hearing from our guests today. Home dialysis, which 
has been mentioned many times, must be fair to providers while 
not encouraging over-utilization.
    And Dr. Mehrotra and Dr. Starr, can either of you share 
with us some of the challenges of telemedicine visits, and how 
we can find solutions to those barriers?
    Dr. STARR. Thank you. I think the main challenge does come 
down to you are not there, and you can't do a physical exam. So 
there are evolving technologies that allow us to listen to 
heart and lungs and other things that definitely will help. But 
that physical exam piece is what we are missing. I think 
everything else in terms of history and evaluating the patient 
you can get via tele.
    Dr. MEHROTRA. I would just emphasize that point, that the 
American people like the value of these telehealth visits, but 
the concern is that the physical exam is missing, and the 
physicians agree. And so how do we bring the physical exam to 
the home is really, I think, the next frontier of where we are 
going to see telehealth evolve.
    Mr. PASCRELL. Let me ask you just one quick question. Is 
this pie in the sky, what I am talking about, that health can 
lead the way to bringing the parties together, because nothing 
is more personal than our health and seeing that when we work 
together, we can get solutions?
    I don't mean problem solvers and that stuff. I am talking 
about, really, down-to-earth issues day-to-day. Is that pie in 
the sky to you, Doc?
    Dr. MEHROTRA. I think that the issues that you are 
describing--and I would echo what you are saying, which is that 
the issue of getting access to timely medical care is a problem 
that so many Americans face, no matter where they live. And I 
think it is--I am so glad that we are having this hearing on 
this particular topic.
    Mr. PASCRELL. Mr. Chairman, thank you.
    Mr. ESTES. Thank you. Now I recognize Dr. Ferguson for five 
minutes.
    Mr. FERGUSON. Thank you, Mr. Chairman, and thanks to each 
of you for being here.
    You know, one of the challenges and the--you know, my good 
friend from New Jersey and I go back and forth a lot on this 
dais. And, you know, clearly, private equity in health care is 
an issue. There are things that are happening there that I have 
concerns about, as well. One of the biggest challenges, though, 
as someone that has operated a small practice in rural 
America--and I think that any of the providers up here will 
tell you the same thing--the cost of doing business because of 
the regulatory burden is just absolutely through the roof.
    You couple that with decreasing payments for Medicare, you 
know, Medicaid not keeping up, and then just the unbelievable 
battles that private practices face every day with third-party 
payers, it is a model that is not working, and it is driving 
people out of private practice.
    So, you know, I hope that as we have a discussion about 
private practice, I hope that we will look not just at punitive 
measures that may, that my friends on the other side of the 
aisle may look at from a private equity standpoint, but let's 
figure out the things that are driving people out of private 
practice, and it is the regulatory burden, it is the lack of 
payments, it is the, you know, it is--really, you know, many 
times we feel like David going up against Goliath. The only 
problem is we don't have any rocks in our pocket to sling at 
them a lot of times.
    Dr. Starr, first to you, can you talk about how, you know, 
we are having this discussion about the, you know, about the 
physical exam. What is the link, I mean, what is the part of 
this where, on remote home health, that we have got a nurse, or 
a nurse practitioner, LPN coming in to do a piece of that, how 
does all of that fit with the payment model piece?
    Because we talk about telehealth, which in some cases it 
is--in most cases it is actually a great added benefit. But how 
do you weave in the payment piece of this for the actual 
person, not the physician, but maybe the nurse that is coming 
out to the rural area to check on the patient?
    What is the--you see the dilemma we have got?
    Dr. STARR. Yes.
    Mr. FERGUSON. I think we are talking about either doing 
telehealth or in-office visit, but there is a very real 
component of someone you know, of a health care provider coming 
to the house. How does that fit?
    Dr. STARR. Yes, and currently I think that is one of the 
big holes that exists. You know, there, the billed amount for 
telehealth, you know, has been mentioned, you know, ideally can 
be lower because we don't have the overhead, unless that 
overhead exists because we need to have someone go into the 
home.
    And so for our Hospital at Home, you know, all of that is 
rolled into the payment for hospital home, and we do have 
providers, you know, caregivers, whether it is community 
paramedics or nurses, in the home to do the physical 
assessment. And then we can do everything else virtually. So it 
is a model that can be really successful, but there is not a 
great answer yet to how to do that.
    Mr. FERGUSON. Do you think it would be--and I think at some 
point you are going to have to segment out the various payment 
pieces. In offices a certain amount, telehealth a certain 
amount, then you have got the expense--I mean, look, having 
somebody drive 50 miles or 100 miles from a central location 
out to do something, an injection in a rural community, I mean, 
that costs exponentially more than the in-office visit.
    Dr. STARR. Yes.
    Mr. FERGUSON. So I think there is going to have to be some 
sort--I don't think bundling is the way to go, because I don't 
think you gain the efficiencies. I think you are going to have 
to segment out those various costs.
    Dr. STARR. Well, and that is where the regulations you 
mentioned really come into play. For example, currently with 
Medicare, to do a home infusion a nurse has to start and stop 
the infusion.
    Mr. FERGUSON. Yes.
    Dr. STARR. There are--yes.
    Mr. FERGUSON. Let me get my time back here.
    Dr. Mehrotra, one thing that I am going to disagree with 
you on is the fact that you think that telehealth in an office 
should be paid differently than, you know, than an in-office 
visit. You know, you have got an impressive resume, but you 
have never owned a solo practice in a rural area. I think there 
is a disconnect from what you see theoretically to what is in 
practice.
    That overhead still exists, that building still exists. 
Those--you know, the staff still exists, the electric bill 
still exists. All of those things are there. I don't think that 
simply replacing--saying we are just going to go to telehealth 
and we are going to pay it less, I don't think that that is 
going to work, and I think it is going to exacerbate the 
problem of people being willing to go into private practice and 
practice in rural areas or, to my friend from New Jersey's 
comment, even in some underserved urban areas.
    So with that, I would just say I think you need to do a 
little bit of a reality check on what it costs to actually 
operate a practice in a rural area.
    And with that, Mr. Chairman, I yield back.
    Mr. ESTES. Thank you. And now we will go two to one with 
majority to minority. And with that I will recognize myself for 
five minutes.
    Thank you to our witnesses for being here today to talk 
about your personal experiences and helping us talk through 
this issue. My colleagues have raised some really important 
issues and questions about how we improve and expand care at 
home for Americans, and especially in rural and underserved 
communities. And I want to focus on how telehealth fits into 
this effort.
    All of us here likely are familiar with the importance of 
broad access to telehealth services, the COVID-19 pandemic, if 
there was any silver linings out of that, it was that it 
underscored how important these services were. Some of you here 
may have taken advantage of telehealth during the pandemic and 
discovered just how convenient it is, and not only in a time of 
crisis. In Kansas, especially, telehealth bridges the gap 
between those who live in rural areas and who may not have easy 
access to certain specialties.
    Allowing for greater accessibility to telehealth gives 
Americans living in rural areas increased access to quality and 
specialty health care. While telehealth is invaluable in rural 
areas, it benefits all Americans. Seniors and vulnerable 
populations benefit from the ability to meet with their doctor 
from the comfort of their own home. Busy parents and 
professionals will be glad to conveniently meet with their 
provider via telehealth, recouping precious hours that would 
have been spent commuting or in an office waiting room. In 
fact, nearly one in four adults report having utilized 
telehealth in the past month.
    Now that this technology has been available for some time, 
we have sufficient data to show how effective and beneficial 
telehealth can be: 91 percent of the patients utilizing 
telehealth report having a favorable experience, and 78 percent 
are likely to complete a medical appointment by a telehealth 
again in the future.
    There is a long way to go to ensure Kansans and all 
Americans have consistent, reliable access to telehealth 
services. To cite just one challenge, at the end of this year 
the expanded Medicare telehealth flexibility waivers will 
expire, restricting telehealth access for large segments of the 
population.
    Dr. Starr, I think many of us would agree that the 
acceptance and growth of telehealth has made a significant 
impact on our constituents' access to care, especially in rural 
areas. I have long been a supporter of telehealth and view it 
as a wonderful tool. However, in my district we have been 
experiencing significant provider shortages not just for 
primary care, but specialty care, as well. What suggestions do 
you have that maybe we can continue to expand and see 
telehealth as a tool, but not necessarily as a final solution 
to actual providers in rural areas?
    Dr. STARR. Yes, thanks for that question.
    One of the issues we run into is the licensing and 
credentialing piece for telehealth providers, particularly 
across states. There are opportunities, you know, to expand 
your pool of options if we could more easily be credentialed 
and licensed across states to see patients. And currently that 
is a very expensive and time-consuming process that limits 
things greatly.
    Mr. ESTES. Well, thank you. And, you know, while we have 
previously focused on the need for flexibility for patients, I 
believe that we should also focus on ensuring that providers 
view telehealth as a valuable tool. And as mentioned before, 
part of that conversation should be viewed about proper 
reimbursements and what they should be for telehealth services.
    Dr. Mehrotra, from your experience after initial startup 
and for material costs for technologies, what are other factors 
to be considered when looking at reimbursement rates?
    And I wanted to follow up a little bit on Dr. Ferguson's 
comments and pick your brain a little bit more.
    Dr. MEHROTRA. Yes, I think Dr. Ferguson and you both raised 
a really important issue, which is the regulatory burden. And 
just to put a point on this is that, if you do a surgery, it 
makes a lot of sense, you submit the bill. But when you are 
doing an individual, I don't know, a text message on a phone, 
or a quick phone call, or something on a portal, it doesn't 
make sense to have, you know, an individual bill for each 
encounter.
    So the real growth of telehealth and the really promising 
technologies we have discussed today also have brought to a 
head of, like, how do we pay for this in a different way?
    And I think one of the things I am excited about is--and we 
should just continue to expand upon--is trying to pay for these 
kinds of services with, say, for remote patient monitoring as a 
monthly bundled payment so you get--here is a certain amount of 
money, you figure out what is the most appropriate way to care 
for patients. We are seeing this for opioid use disorder, where 
we pay a--you know, a payment per month.
    And I think the reason I am excited about those is that, 
one, it can support the technology, decrease the regulatory 
burden on individual clinicians for submitting all these little 
bills, and also allow clinicians and patients to figure out 
what makes sense for them under this circumstance, as opposed 
to right--you know, having some payment rule for that.
    So I think this telehealth growth and payment reform sort 
of go hand in hand.
    Mr. ESTES. Yes, yes, and that is good because, I mean, we 
talk a lot about the fee for service and the restrictions that 
are on that, and paying to not be sick as opposed to paying to 
be healthy and staying that way.
    So thank you all for your time and effort in talking 
through this.
    So I will yield back, and now I will recognize for five 
minutes the gentlewoman from Alabama, Ms. Sewell.
    Ms. SEWELL. Thank you. I want to thank all of our witnesses 
here today.
    I represent Alabama's 7th congressional district. It is 
actually my home district. I grew up in this district, in the 
rural part. It includes Birmingham, historic civil rights 
cities like Birmingham, and Montgomery, and Tuscaloosa. Roll 
Tide. [Laughter.]
    Ms. SEWELL. But it also includes nine counties of the rural 
Black Belt. So, I was really excited that we are having this 
hearing today. My district is both urban and rural, and I can 
tell you that home health and the ability and expanding 
services that one can receive at home really is important for a 
big swath of our population. It is not the sole solution.
    But I can tell you that my father was a nine-time stroke 
survivor, and lived for a decade at home. And everything from 
the rehabilitation to his breathing treatments that he had to 
have, all of those were done at home. And I believe my dad's 
life expectancy was extended because we have extended services 
that are available at home.
    So my question to you, Mrs. Maddux, is, if you had an 
opportunity to have the President of the United States right 
here in front of you, what would make your life easier? What do 
you want us to know that would make your life, as a home 
dialysis patient, better on the health care side?
    And I can tell you that your lovely children, who were 
behind you, are proof positive that this type of treatment has 
worked well for you and your family.
    Mrs. MADDUX. Yes, thank you for your question. I definitely 
agree with that. Having the home dialysis option is what allows 
me to be a better mom. That is full stop there.
    But in terms of ways to improve it, we talked a lot about 
innovation several times here. And for me, I have seen a lack 
of innovation across home dialysis to begin with. You know, 
everything is being automated these days and simplified. But 
the process to conduct my treatments at home is----
    Ms. SEWELL. Very personal.
    Mrs. MADDUX. It is very personal, and it is involved. There 
are a lot of steps, there are a lot of things to do.
    But then I have also found that the equipment and machines 
that I have to use, personally, my dialysis machine has been 
replaced probably four or five times. It is a very scary thing 
when you have to do your treatment and your machine doesn't 
work.
    Ms. SEWELL. Exactly.
    Mrs. MADDUX. And----
    Ms. SEWELL. I know I have limited time. I wanted to just 
acknowledge that access is not just the medicine or therapy. 
Also, access is having the equipment that you need. In fact, 
one of my constituents in Birmingham, he owns a small home 
help, medical device equipment company, and their company 
provides home oxygen and hospital beds and other health care 
necessities for patients to receive treatment in the comfort of 
their home. And we know that at-home would be lost without 
having these DME providers outside of the hospital setting.
    And so, I think it is important that we, as a committee, 
will make sure that home infusion drugs and biologics covered 
through the Part D Durable Medical Equipment benefit must 
support an extension of the 75/25 blend rate that allows small 
businesses like the one that I just described in Birmingham to 
exist.
    I think that we have to really burrow down into health 
equity and what that means, and it is an access issue. But in 
this great country of ours I believe that health care shouldn't 
be a luxury, but it should be a right of every American. In 
order to do that we have to bring costs down. It is not just 
the cost of the actual medicine or the doctors, it is also the 
equipment and being able to provide it.
    On telehealth I want to just say that it is not just 
telehealth. Audio-only may be necessary in certain areas that 
don't have broadband, and I am excited to work with this 
Administration on the $100 million that is going to every state 
to deal with broadband. My plea is that we start at the places 
that need the first mile, not the middle mile, not the last 
mile, but the first mile. And until we do that, I think we have 
to have innovative ways of making sure that we provide health 
care, and that includes at home. Thank you.
    Mr. ESTES. Thank you. And now I recognize Mr. Smucker for 
five minutes.
    Mr. SMUCKER. Thank you, Mr. Chairman, for holding this 
hearing. I want to thank the witnesses, as well, for traveling 
to be with us here today.
    You know, it is exciting to hear some of the things that 
are happening in the medical field. We are going to see, I 
think, big changes in the way that care is delivered. Patients 
will be experiencing better care over the next years and 
decades, and better care in rural and underserved communities, 
as well. So it is really exciting. You know, we are talking 
telehealth, remote patient monitoring, home dialysis, home 
infusion. These all have sort of reached in some way the 
mainstream. They are cost-effective ways to deliver quality 
care to patients right in the comfort of their home.
    It reminds me. I have served in the state senate in 
Pennsylvania prior to serving here, and we were talking a lot 
at that time about changing the system to allow folks to age in 
their homes. And what we found was there were a lot of 
regulations, there were funding reimbursement methods that 
prevented quick movement in allowing people to age in their 
homes as they wanted to do. We found there were better 
outcomes. It is what elderly folks wanted, and actually, it 
turned out to be less cost, as well. So it is was like it was 
win-win-win, but it was very hard to move to that because of 
regulations that were in place and so on.
    And so, Mrs. Maddux, you mentioned the lack of innovation. 
I don't know that I will even have a question here, but you 
mentioned the lack of innovation in the dialysis space. And I 
wonder at times whether, you know, that is--if it is a funding, 
if it is the regulations that are in place, and I think the 
answer is probably yes.
    And so what we ought to be thinking about is how we can 
sort of unleash that innovation, and encourage and incentivize 
that innovation, and I think we will find we will get a lot of 
data. And if I do get time for a question, maybe, Dr. Starr, I 
will ask you. I would be interested in what data that we have 
available now about the improvement in the quality of care 
under some of these home health care things.
    But before I do that, because I may run out of time, I do--
I want to talk just briefly about a bill that I have introduced 
with Mr. Doggett, another member of the committee, called the 
Medicare Home Health Accessibility Act, which is related to 
some of the things that we are talking about today. This bill 
would establish occupational therapy as a qualified Medicare 
home health benefit. Currently, a Medicare beneficiary can't 
receive OT services in their home unless there is also nursing, 
physical therapy, or speech services at the same time. And this 
bill would change that.
    So again, one of these regulations that I think is 
preventing better care--so this would ensure that seniors with 
conditions like low vision, dementia, diabetes, and other 
conditions, instead of having to travel, would be able to 
receive that care that helps them safely manage activities of 
daily living and thrive in their homes.
    And studies have indicated that OT services like this will 
create savings for the Medicare system by preventing falls and 
other accidents that too often lead to emergency room visits 
and maybe even hospitalizations.
    So again, with this bill we want to ensure that the care 
that patients experience in an acute care setting is also 
available to them right at home, which is what many of you are 
doing, as well.
    And so, I appreciate the work of Mr. Doggett. We have 
cosponsored this bill together, and hope that we can see that 
passed.
    But so, Dr. Starr, I don't have a lot of time left, but I 
do--can you build a little bit on what I mentioned, and 
describe what we are seeing in terms of patient outcomes across 
the board?
    Are they equivalent at this point?
    And I know we are early on in some of these things, but are 
they better? Are the outcomes better when patients receive 
services like hospital at home or other treatments in their own 
homes, rather than in a facility?
    Dr. STARR. Yes, thanks for that question.
    So the data is still young, but what is emerging is that it 
is at least as good, leaning towards better in many of the 
outcomes. I think many programs have shown a decrease in 
readmission, 30-day readmission to being treated at home. There 
is definitely, you know, a reduction in infections like 
nosocomial infections, because you are not around those 
dangerous bacteria.
    I think one of the really encouraging things is we also 
have seen it is not dangerous to be treated with hospital at 
home.
    Mr. SMUCKER. Right.
    Dr. STARR. We are not seeing bad outcomes for patients 
being treated, and it is a safe model in that sense.
    Mr. SMUCKER. Sure. And I think, as we go along on this, we 
will get more and more studies. So that would be good to hear.
    We certainly know--I think, Mr. Underhill, you talked about 
it, Mrs. Maddux--the difference that has made in your lives to 
be able to receive care in the home. So I appreciate both of 
you, all of you for sharing your stories and being here with us 
today. Thank you.
    Mr. ESTES. Thank you, and now I recognize Mr. Fitzpatrick 
for five minutes.
    Mr. FITZPATRICK. Thank you, Mr. Chairman, for holding this 
timely hearing on enhancing access to care at home. I would 
like to use my five minutes, Mr. Chairman, to share a story 
about one of my constituents, Joe Fiandra. Joe is a Warrington, 
Pennsylvania resident and a proud Army veteran. Joe was 
diagnosed with a debilitating disease called amyloidosis. He 
unfortunately passed away in June of 2022.
    And Mr. Chairman, I would like to enter into the record the 
testimony of Joe's wife, Helen, which explains Joe's situation 
and the importance of expanding access to those receiving home 
infusions.
    Mr. ESTES. Without objection, so ordered.
    [The information follows:]
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    Mr. FITZPATRICK. Thank you, Mr. Chairman.
    After his diagnosis, Joe began the necessary infusions 
every three weeks. To get to the infusion center, Joe and his 
wife drove 2 hours in order to get to their appointment by 8:00 
in the morning. His infusion process took a total of about six 
hours. The pandemic allowed Joe to get his infusions done at 
home with a visiting nurse. However, once this funding was cut 
off, Joe was informed that he would have to pay about $9,000 
every 3 weeks if he wanted to continue to receive his infusions 
at home. This was not feasible for their family, and they ended 
up having to drive to a different state to get infusions.
    Unfortunately, Joe's situation is being lived out by many 
Americans, which is why I introduced the Joe Fiandra Access to 
Home Infusions Act of 2023, in honor of Joe, to codify a 
proposed rule that would expand access to home infusion 
treatments to ensure that these lifesaving treatments are 
covered under Medicare benefits.
    Dr. Starr, can you speak to your expansive home infusion 
program, and explain the critical importance of home infusion 
therapy for individuals like my constituent, Joe?
    Dr. STARR. Yes, thank you. It is a vital program that 
provides care on an average of 1,500 patients per day in the 
State of Utah that are managed by our home infusion, receiving 
everything from IV antibiotics to IV fluids, immunologics, 
biologics, chemotherapy, electrolyte replacement, and 
nutrition, and we have massive opportunity to expand that if we 
can remove some of the limitations that you mentioned in your 
bill.
    Additionally, just taking advantage of the existing 
technologies, where many of our current home infusion patients 
we actually teach to manage their own infusions, and we provide 
them with the medications and the equipment to do so safely, 
with backup from nursing if needed.
    Mr. FITZPATRICK. Thank you, sir.
    And Mr. Chairman, this bill is bipartisan. It is open for 
cosponsors. I hope that both my Republican and Democrat 
colleagues on this committee will join me in helping millions 
of Americans get access to the home care they need.
    I yield back.
    Chairman SMITH. Thank you. Now I recognize Ms. Chu for five 
minutes.
    Ms. CHU. Dr. Mehrotra, thank you for your testimony as both 
a professor of health care policy and as a physician.
    I am the only psychologist in Congress, and I am especially 
interested in the impact that telehealth can have on expanding 
access to mental health services.
    I am also concerned that, if deployed poorly, greater use 
of telehealth may increase health disparities.
    So, Dr. Mehrotra, in your written testimony, you noted that 
13 percent of mental health specialists have closed their in-
person clinics and now only see patients via telemedicine. You 
also mentioned that many of the new direct-to-consumer 
telehealth companies are growing rapidly using venture capital 
funding.
    While telehealth-only providers may improve access through 
innovative models, does this trend have the potential to limit 
access to mental health care for underserved populations?
    And, what are the guardrails you think are necessary for 
direct-to-consumer telehealth services when it comes to 
delivering mental and behavioral health care?
    Dr. MEHROTRA. Yes, I think I really appreciate you bringing 
up this issue of the rapid growth of these virtual-only 
companies for, you know, maybe--the biggest presence is in 
mental health treatment, but across the health care spectrum we 
are seeing these companies.
    And I think that they both have both real positives, 
potentially increasing access to care and getting into rural 
and underserved communities, but I also share your concerns 
that we could have issues where we could exacerbate 
disparities.
    And also, you didn't say it, but I think it is also we all 
know that there are concerns about the quality of care that 
some of these companies could provide, as well as prescribing 
behavior that we think is inappropriate.
    I think there is--a key issue here is that right now we 
have very little data. This is a real data gap in terms of 
understanding what the impact of these companies are. And I 
think we need to, as they are starting very quickly to enter 
the Medicare program, ensure that we are actually monitoring 
these companies effectively so that they are not leading to 
these negative consequences that you raise.
    So I really appreciate the question. We need more research 
on these companies.
    Ms. CHU. Thank you for that. Dr. Mehrotra, I wanted to talk 
about other issues for underserved populations. For instance, 
limited English proficiency. Right now, that, of course, 
remains a significant barrier for access to health care for 
more than 25 million limited-English-proficient Americans.
    As we discuss the need for expanded telehealth, I need to 
make sure that those who are limited English proficient are not 
left behind. So, can you discuss the ways that telehealth can 
help expand access to care for those who face language barriers 
in the health care system?
    Have we seen examples of telehealth successfully serving 
these communities in recent years?
    And conversely, can you discuss any risks or challenges 
that expanding telehealth services could pose to this 
population?
    Dr. MEHROTRA. Yes, I think that--I appreciate you raising 
this issue of limited proficiency because, for many patients, 
going--one of the real advantages of--potential advantages of 
telehealth is to facilitate interpreter services. If you speak 
a specific dialect, you may go to the clinic and not have 
someone who actually speaks that dialect and allow--telehealth 
can facilitate that, because you can have a interpreter who is 
very far away who could join a three-way call. So I think that 
is one of the real positives that we could see.
    But I also do have concerns that in the--what we find in 
the data is that we--sometimes clinicians make assumptions, and 
I am probably guilty of that also, where I assume that a 
patient can't do a video call and I have to do it via a phone 
call and so forth, or--and so I think we also need to be 
focused on the provider community to ensure that all patients, 
including those with limited English proficiency, are offered 
the video visits, and we don't make assumptions that they can't 
do it.
    Ms. CHU. Dr. Mehrotra, you also discussed the digital 
divide in many low-income communities of color. How about the 
disparities in telehealth utilization and the issue of Internet 
access and insurance coverage?
    What guardrails would you suggest Congress look at to help 
ensure that vulnerable communities are not left behind in the 
expansion of telehealth?
    Dr. MEHROTRA. Yes, I think that this is a really important 
point that, as I said before, we cannot make the assumption 
that if we offer this to everybody, those underserved 
communities are going to use it more. If anything, we are going 
to see it less. So what are we--what investments do we make 
among--and I think it goes two ways. One is obviously focused 
on the clinicians themselves, ensuring they are offering those 
visits, and they have the resources and the ability to invest 
in telehealth.
    But I also recognize that this is not just health care. 
There is a little aspect of the digital divide is not limited 
there, and is--I often wonder a lot about which is the lane of 
health care providers. Should they be addressing these issues, 
or do we need more community resources to allow for, say, 
digital navigators that can both help with health care, but 
also education, work? There is--you know, the digital divide 
goes across all of our lives, not just health care.
    Ms. CHU. Thank you, I yield back.
    Mr. ESTES. Thank you. Now I recognize Mr. Schweikert for 
five minutes.
    Mr. SCHWEIKERT. Thank you, Mr. Chairman. You look good in 
the seat.
    Mr. ESTES. Thank you.
    Mr. SCHWEIKERT. And I apologize for the crying that was 
back there. That is my 20-month-old--and yes, I have a 20-
month-old.
    Mr. Altchek, can you and I actually--will you work with me 
conceptually for a moment? I want you to say--think about the 
platform you offer today. If you actually had a supportive 
Federal Government, or one that just got the hell out of the 
way, what are you capable of?
    And part of this is I am a bit of a believer that the 
solution--and I know this is mostly about rural access, but we 
have seen data that makes it very clear for certain urban 
populations, for my tribal populations in Arizona southwest 
that using technology is capable of being a credible disruptor, 
and that we--often our rules, our inability to allow an 
algorithm to write a script, all these other things that go on, 
we have the barriers that actually keep the miracle from 
happening.
    I mean, you just had a language question. Well, the fact of 
the matter--you and I know that the adoption of certain of the 
chats--I mean, the IRS is doing it this tax cycle--can pick up 
dialects and different languages, and it is remarkably 
accurate.
    We need to move faster. So I come to you and say, all 
right, you have this platform. What does it look like five 
years from now if you could run amok and adopt technology? How 
much more--how much healthier and wealthier would our society 
be?
    Mr. ALTCHEK. Thank you, Congressman.
    And I think the important policy consideration is where 
Medicare goes, so goes the country. And so the decisions you 
make here are incredibly important.
    Mr. SCHWEIKERT. So your argument--so your first comment is 
on reimbursement.
    Mr. ALTCHEK. Yes, well, reimbursement and, I would say, 
what is possible here. There is easily 30 million Medicare 
patients who struggle from hypertension, out-of-control 
diabetes, and heart failure. And we--the data shows 
consistently that we can get patients' blood pressure under 
control in very meaningful ways, we can double the percentage 
of patients who get to that magic 130 over 80 blood pressure 
number, and we can do it for 10 million patients, likely, in 
the U.S.
    In heart failure--there are seven million patients with 
heart failure in the U.S. Number-one cause of hospitalizations 
for Medicare patients, we could likely reduce those 
hospitalizations by upwards of 20 to 30 percent, which is tens 
of billions of dollars.
    Mr. SCHWEIKERT. Thank you. Can I give you a quirky one that 
we have worked on for years, but we get ignored? Sixteen 
percent of all health care spend is those not taking their 
meds. You know, their calcium inhibitor, their statin, whatever 
it may be. You work with the prescribers. And for $0.99 there 
is a pill bottle cap that beeps at you in the morning if you 
haven't taken your calcium inhibitor, your hypertension 
medicine.
    Mr. ALTCHEK. I mean, exactly----
    Mr. SCHWEIKERT. And let's see, 16 percent of U.S. health 
care would be $600 billion a year?
    Mr. ALTCHEK. American technology has a great track record 
of making things better, cheaper, and faster. And I think we 
can accomplish a lot together.
    Mr. SCHWEIKERT. You could even do it with an app that just 
pings you in the morning.
    Mr. ALTCHEK. Text message, phone calls. There is a lot of 
opportunity.
    Mr. SCHWEIKERT. So what do we do to get platforms like 
yours to actually start to move that sort of techno magic, and 
make people--and help people be healthier?
    And at the same time, you know, you have a country that is 
collapsing financially with the growth of debt. We are 
borrowing, what, $95,000 a second, and almost every dime of the 
growth of that spending is interest and health care costs.
    Mr. ALTCHEK. Yes.
    Mr. SCHWEIKERT. What do we do to change--instead of taxing 
more, you know, we can keep taxing people and spending more 
money, but that is the financing side. We are doing almost 
nothing to change the cost of health care.
    So we have had a running discussion with many of my rural 
colleagues--I represent an urban-suburban district, saying, 
okay, so you want to spend this much money to run a piece of 
wire out to the middle of my Navajo Nation chapter house for a 
fraction of a fraction of a fraction, and tomorrow I can give 
them a satellite dish. I can set up Starlink or something of 
that nature, and instantly they have telehealth. Except they 
are not the ones who are here lobbying to run the wire, which 
we have been doing for 25 years and never seems to get there. 
Tell me how I am wrong.
    Mr. ALTCHEK. I don't think you are wrong. And I think 
hearings like the one today are important because providers 
need to know and clinicians need to know which investments they 
need to make for the long term. And if reimbursement changes 
can be made permanent, then providers will do the right thing 
and build out these technologies and deploy them at scale.
    Mr. SCHWEIKERT. Okay. Thank you.
    Mr. Chairman, with your permission, I have a number of 
articles we would like to submit for the record in the adoption 
of technology, improving access, particularly in my tribal 
communities, and crashing the price of health care, and that it 
is our own policies that are the barrier to the adoption of 
these technologies.
    And with that, I yield back.
    Mr. ESTES. Without exception, so ordered.
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    Mr. ESTES. Thank you. I now recognize for five minutes Mr. 
Hern.
    Mr. HERN. Thank you, Mr. Chairman, and thanks for having 
this hearing. It is good to see everyone. Thank you for the 
witnesses for your long time sitting in the chair. But I know 
you are talking about things you love to talk about, so that is 
awesome, as well. And are those your children back there?
    I am glad they are warm now, because it does get cold in 
here. They look great, and I am sure they are happy that their 
mom is healthy with the home dialysis that you are able to do. 
And so thanks for having them here.
    You know, it is great to hear about technologies. Being an 
engineer, it is exciting always to see how we can use 
technology as technology advances. And as my colleague, Mr. 
Schweikert, said, you know, we could do a lot if given the 
opportunity. So we have to figure out how to remove these 
impediments to really moving health care forward in the 21st 
century.
    And you know, as we do that and we take away the travel 
time--I live in a very rural state, in Oklahoma. There is a lot 
of work goes on to figure out how to make that happen. In many 
cases, first-time prescriptions that work, as opposed to trials 
that we--you know, you don't have to run down the block, but 
you don't get off the tractor to come to the doctor and you 
just say I am just going to live with the statins, you know, 
heart medicine and others.
    I have worked on many pieces of legislation to support 
this, from telehealth services, one of the first bills that 
came out during COVID. I have often said that COVID took 10 
years of future technology and utilization of technology and 
compressed it into about 18 months. And so we have to hurry up 
and catch up with our policies to make--you know, to catch up 
with technology. And so we are a little out of whack now.
    I am sure that everybody in this room, not just the 
witnesses or the people up here, everybody in this room has had 
less-than-ideal experiences in a hospital or doctor's office, 
sometimes waiting for what seems like just a rudimentary test, 
a blood pressure test, you know, a blood sugar test and saying, 
why am I waiting? And, you know, taking a half a day to make 
that happen.
    The stress of that and the bad experiences, and then when 
we hear your testimony, it really makes it plausible that we 
try to figure it out, all of us working together. And we have 
heard our colleagues on both sides of the aisle here today talk 
about how we need to work together. It is not a political 
thing, but how do we make this work so that we do protect 
some--you know, there is always bad actors in every industry. 
We want to make sure, and I know you all do, as well.
    Within my lifetime it has been amazing to see how new 
technologies have improved the way patients can get treatment. 
Last year I introduced H.R. 1458, the Access to Prescription 
Digital Therapeutics Act, to continue my commitment to 
supporting innovation in health care and to make these 
technology advancements more accessible.
    The DPTs can, you know, be used at home to treat a variety 
of issues. As with veterans and PTSD, we have seen many 
showcases here of the different technologies. I hope we can 
have--this committee can continue to support and expand new 
technologies that make patients' lives better.
    Just last week I heard from a constituent who provides care 
at the Utica Park Clinic in Tulsa who started offering remote 
patient monitoring services last year. Currently, they monitor 
over 14,000 patients from their homes from all over the State 
of Oklahoma. And I have heard firsthand how beneficial remote 
patient monitoring is from clinicians providing these services. 
This in-kind--or this kind of in-home care allows for better 
communication between patient and provider, and improves 
adherence to regular testing for things like blood pressure and 
other vitals.
    Mr. Altchek, can you tell us the vision you see for the 
future of remote patient monitoring, and how scalable you think 
these types of treatments can be?
    Mr. ALTCHEK. Thank you, Representative, and we are proud to 
work with many constituents in your district.
    I think the most exciting opportunity for remote monitoring 
in the chronic disease space is to truly be proactive about 
health care. We are incredibly reactive today, we wait until 
patients show up in the ED to treat their high blood pressure. 
And at that point it is too late.
    In your district and with your patients we have seen 
incredible outcomes. We have seen 43 percent of patients with 
type 2 diabetes getting their A1Cs to goal. And the long-term 
implications for that in the community are massive.
    And it allows patients to get care in the comfort of their 
own home. That is super convenient, and skips long trips to the 
physicians' offices.
    So thank you for the question.
    Mr. HERN. Well, I was able to stop by your demo booth. And 
if you could, just share with us what kind of savings we could 
see with these services. You shared earlier some of the things 
that--some of the successes you have had in ambulatory care and 
things of that nature. If you could share that for the record, 
that would be awesome.
    Mr. ALTCHEK. Yes, our data shows that we are able to reduce 
the total cost of care, inclusive of the additional costs for 
remote monitoring, by 23 percent, primarily driven by lower ED 
utilization, lower in-patient admissions, lower skilled nursing 
facility, and lower home health.
    So effectively, we are keeping patients independent and 
healthier at home for longer, which is ultimately our goal.
    Mr. HERN. Again, thank you.
    Again, I want to thank all of you for being here today and 
sitting and giving your testimony. But I know it is something 
that you really are sincere about seeing change, and we are 
here to work with you to make that happen. So thank you all.
    Mr. ESTES. Thank you----
    Mr. HERN. Mr. Chairman, I yield back.
    Mr. ESTES. Now I recognize Ms. DelBene for five minutes.
    Ms. DelBENE. Thank you, Mr. Chairman, and I want to thank 
all of our witnesses for being here.
    And Mrs. Maddux, thank you for sharing your story and your 
time with us today. As you noted in your testimony, hundreds of 
thousands of patients across the country are spending three to 
five hours per day, three days at an in-center dialysis clinic, 
often for years on end. And that does not include time getting 
to and from the clinic, getting your kids to school or to 
childcare, trying to keep a job and earn a paycheck, and 
trying--and juggling all the other responsibilities of being a 
parent.
    But if more patients were able to do their dialysis 
treatments at home, like you, some of these stresses could be 
relieved. Countless studies show that the quality of life for 
patients dramatically improves when given the option to receive 
treatments at home. And, home dialysis rates in the U.S. have 
increased roughly 7 to 15 percent since 2011. But, we are still 
far behind other developed countries that have achieved much 
higher rates.
    And so, Mrs. Maddux, I want to start off, how did you learn 
that home dialysis was even an option?
    Mrs. MADDUX. Thank you for your question. It was something 
that was mentioned to me in passing when I was in clinic. You 
know, a nurse or a doctor would just come by and say, ``Why 
aren't you doing this at home?'' But they weren't giving me 
much information about what was necessary for that, or what it 
entailed, and I didn't know much about it.
    My husband was also in dialysis for a short time, and he 
did dialysis at home through peritoneal dialysis. So I knew 
what that entailed. But it wasn't until the doctor that I have 
currently explained to me the benefits of doing the more 
frequent, shorter dialysis sessions, and then after a series of 
bad experiences that I had at my clinic, at that point I 
thought I needed to look into it a little bit more.
    Ms. DelBENE. What was the process like shifting from in-
clinic to at-home dialysis?
    Mrs. MADDUX. Sure. So the first clinic that I was at, 
trying to get an appointment with my dialysis--with the home 
training nurse was very difficult. They were unresponsive, and 
they gave me some papers and pamphlets, but they didn't really 
help me with that process.
    My doctor eventually directed me to a different nurse at a 
different clinic. And from there, he took care of everything. 
He helped with the training, he even came to my house and set 
up my equipment and, you know, got me going.
    So with the person that I had it became much easier. But 
also recognizing he is the only person that works at the home 
training facility that he is at, and so I know that that--with 
the logistics, administrative work, and with the health care 
part of it, it can be a lot for one person.
    Ms. DelBENE. And how long did it take, then, do you think, 
from when you first decided you were going to do it to when you 
finally were set up in home?
    Mrs. MADDUX. Once I connected with the training nurse that 
did actually train me and that I work with now, it was a couple 
of days. He arranged for me to come into the office and to his 
clinic not the next day, but the day after, and I was able to 
start my training immediately.
    Ms. DelBENE. And you feel comfortable now doing it at home?
    Mrs. MADDUX. Absolutely.
    Ms. DelBENE. That is great. We need to make sure that 
people have the resources and the information they need, and so 
that they can do that quickly, too. Thank you.
    This is a slightly different question, Dr. Mehrotra. In 
your testimony you argue that policymakers should focus on 
expanding telehealth when it would most significantly improve 
health outcomes or barriers to access. And providers that 
participate in alternative payment models, or APMs, have the 
financial incentive to target telehealth use to when it is the 
most impactful, which seems to align well with your proposed 
approach. And so, I wondered, how can telehealth policy support 
CMS's goal of having 100 percent of traditional Medicare 
beneficiaries in accountable care relationships by 2030?
    Dr. MEHROTRA. Yes, I think that is a--you raise an 
important issue, which is that if we want in a--in such an 
arrangement, the clinician has the responsibility both for the 
quality and spending of the patients. And I think that 
providing clinicians in those such arrangements as much 
flexibility as they want in terms of how to deploy--so removing 
any regulatory barriers, payment barriers for those specific 
clinicians--could be--both give them the flexibility to provide 
care as they see fit for their patients, but also potentially 
create an incentive for those clinicians to join such 
alternative contracts, because that could be another way of 
reaching CMS's goal.
    Ms. DelBENE. Thank you. I am out of time.
    I yield back, Mr. Chairman.
    Chairman SMITH [presiding]. Mr. Kustoff.
    Mr. KUSTOFF. Thank you, Mr. Chairman, for calling today's 
hearing. And thank you to the witnesses for appearing.
    If I could, to Mrs. Maddux and Mr. Underhill, I appreciate 
your testimony. First of all, your testimony about how at-home 
care has benefitted you. Mrs. Maddux, your story was really 
touching and very moving, and everything that you have related 
during the questioning that you have had. So I appreciate both 
of you very much.
    Dr. Starr, if I could with you, maybe a little bit 
different question. Can you talk about how you treat the at-
home patients now? And maybe from a diagnostic or treatment 
standpoint--but diagnostic--what you think will be improved on 
two years, three years, five years out, maybe that would be 
better in the future, or more capable, or things that you are 
looking forward to, if that makes any sense?
    Dr. STARR. Yes, for sure. A really fun question, actually, 
for me.
    So number one would be improved ability to--monitoring in 
the home, including continuous telemetry monitoring. We could 
monitor heart rate and rhythm in a much improved way.
    Second would be, you know, point-of-care laboratory testing 
in the home that could immediately give results of many more 
lab tests.
    Third, we are seeing pocket ultrasounds coming, where even 
nurses can be trained and technicians can be trained just how 
to put an ultrasound on different parts of the patient's body, 
and then those images can be read either by artificial 
intelligence, or a radiologist, and then get almost 
instantaneous, you know, results that in many ways could 
replace chest X-rays and other imaging where you could have a 
patient with a status change or new symptoms that you could 
immediately diagnose.
    And those are a couple of the ones that just immediately 
come to mind.
    Mr. KUSTOFF. In terms of the at-home lab testing, can you 
give an illustration of how you think that might work, and what 
you specifically test for?
    Dr. STARR. Yes. So--and some of this technology exists and 
is being used, but there are certain lab tests that basically 
you need a drop of blood, and it will give you results. So, you 
know, metabolic panels, electrolytes, kidney function, blood 
counts, those sort of things. And there is a lot of work to 
expand what we can do with that sort of testing.
    Mr. KUSTOFF. Okay, thank you.
    Mr. Altchek, if I could with you, maybe the same question.
    First of all, I appreciate the technology that the patients 
don't have to have broadband, they--you can do it based on 
cellular service. What are some of the things that you look 
for, from a technological standpoint, maybe 24 to 36 months out 
that aren't available today?
    Mr. ALTCHEK. Thank you for the question.
    We are getting the ability to monitor more vitals more 
frequently, which gives us better data on how to manage 
patients.
    And then the second big piece is we are able to do it in a 
way that is more passive for patients. And so I think over the 
next few years you are going to get the opportunity to 
hopefully get blood pressure from potentially a simple device 
as a watch, or blood glucose from a watch, and not have to 
prick yourself. So I think there is a lot of opportunities 
maybe not in the next 24 months, but definitely in the next 5 
years.
    And the question is, you know, how are we going to use 
those to deliver better care?
    Mr. KUSTOFF. In terms of--Dr. Starr, in terms of the 
monitoring from a physician standpoint, do you see--of course, 
we are now four years into the pandemic, four years yesterday. 
Do you see pushback from any physicians as it relates to care 
at home or telehealth?
    Dr. STARR. Not pushback. I think it is a new way of doing 
things, and that makes it challenging. Like, it feels weird to 
people to do some of this care in such a different location. 
And normalizing it is still part of the process we are 
undergoing. And it is one reason volumes still aren't as high 
as they will be.
    Mr. KUSTOFF. Mrs. Maddux, if I can with you, and I think 
you have said this, but I will just ask you in a different way. 
So you talked about having to go originally to the dialysis 
clinic three days a week, what you would miss in terms of your 
children. Now that you are able to do dialysis at home, the 
manner that you have done it, do you see any difference in 
the--pardon me for saying this--the level of care or treatment 
that you receive at home versus what you would see in the 
clinic?
    Mrs. MADDUX. I would have to say yes. At the clinic that I 
was at before, immediately before I started home dialysis, I 
was finding that there was a tremendous amount of non-patient-
care-related pressure that the staff was under there. For 
example, they were required to get the patients connected in a 
certain timeframe because they were required to have a certain 
number of patients dialyzed in a specific period of time. So 
when they would come over, they would have to rush through, you 
know, putting the needles in and taking everything. And, you 
know, I would try to make small talk, and they couldn't do that 
because they were trying to just get through their required 
timeframe that they had to finish by.
    My doctor and my dialysis nurse, I would say we are almost 
like friends at this point. And I--we touched on it earlier, 
but the holistic care that is required for knowing the entire 
patient, and not just knowing, you know, the immediate care 
needs, but knowing everything about their life that feeds into 
their care, I think it is something that is valuable and has 
been part of my experience in home hemodialysis.
    Mr. KUSTOFF. Thank you to the witnesses.
    Thank you, Mr. Chairman, I yield back.
    Chairman SMITH. Ms. Tenney.
    Ms. TENNEY. Thank you, Mr. Chairman, and thank you, Ranking 
Member, for holding this meeting. And thank you to our 
distinguished panel here.
    This is something that I think has been so necessary in my 
district in upstate New York, which spans hundreds of miles and 
across all kinds of rural communities, and it will be even 
larger next year. And I have seen so many people in my 
community who do not have adequate access to care. It is a huge 
problem. We had this issue where we finally got telehealth, at 
least, or telemedicine to the Veterans Administration through 
our VA clinics to get them some, especially because of the 
pandemic, but it was really great to have that.
    Many of these people, as I know some of my colleagues have 
cited, have a hard time getting to these facilities. It could 
be a many-hour drive. In my area we have lake effect snow. 
Almost the entire district is in the lake effect stripe of New 
York State. And, you know, it has just been a tremendous burden 
on them.
    And one of the interesting things that stumbled upon me the 
other day, and we have been pushing telehealth, and obviously, 
it was very interesting that, Dr. Altchek, you said that, you 
know, where Medicare goes, so goes the telehealth, I think, was 
what you said. Well, last year I happened to be stumbling upon 
a 200th bicentennial of the Town of Macedon in Wayne County, 
New York, a very rural area. And I walked into the library just 
to get set for the big bicentennial celebration, and they had 
in there a digital privacy booth, where patients could go and 
call up their doctor in a secured setting and look at their 
doctors, and I thought this was pretty incredible.
    So I wasn't sure exactly what it was, but it was actually a 
test put out by the University of Rochester, Wilmot Cancer 
Institute and the Community Cancer Action Council, and a group 
of about 29 stakeholders in upstate New York to try to see if 
this is something we could do to bring telemedicine to rural 
communities. And it was interesting. This was the test site, so 
I was fascinated by it. And I think they are getting great 
results.
    And again, the big question is, how do we get Medicare to 
get us there so we can get health care to so many people 
struggling in rural communities? And that is why I wanted to 
ask you, Mr. Altchek, about how do we--and I know that 
telehealth, telemedicine is the step before we get to where you 
are. How do we make that--can telehealth, telemedicine be 
valuable in pre-determining in some ways what happens when you 
get to the stage where your vision is with Cadence to get 
people to full health care? And how do we get there?
    Obviously, Medicare is going to be a big part of it, but I 
would just be curious about where your vision is, since you are 
obviously a visionary leader here.
    Mr. ALTCHEK. No, thank you for the question, 
Representative. And my wife, who is a physician, will be upset 
if I don't say I am not a doctor.
    Ms. TENNEY. Yes.
    Mr. ALTCHEK. She reminds me of that every day.
    Ms. TENNEY. No, I see doctor up there, I figured I just--
    Mr. ALTCHEK. Yes. No, no, no.
    Ms. TENNEY. I am a doctor of laws, right?
    Mr. ALTCHEK. She would be--my wife would be very upset if I 
didn't say that.
    But, you know, to answer your question, telehealth is a 
very valuable tool here. And when we think about chronic 
disease management, I think one of the things that is most 
exciting is the ability to give patients access 24/7.
    And so you talked about the lake effect in your district 
right now. On President's Day--I guess that was three weeks ago 
now, Monday--we had 300 patient red alerts, which are those 
blood pressures above 180, as I was talking about, and 300 
patients called in proactively. And the fact that now they have 
access to care 24/7 has a massive impact. A lot of those 
patients would have ended up in the emergency department if 
they could have gotten there.
    And so the opportunity here to create a better experience 
for patients is very meaningful.
    Ms. TENNEY. Well, thank you. And I want to just jump on one 
thing that just came to mind while listening to you with these 
lake effect problems.
    One really urgent problem we have is the closure of a lot 
of hospitals, and most of our rural hospitals are operating in 
the red. One of the issues that has come up is this safe 
patient staffing rule that we have in New York State, and also 
a requirement that an RN be visible. We have had numerous 
people come in and constituents say that we can't even find an 
RN for an entire county. So how is your model at Cadence 
helping us?
    Because, obviously, you are monitoring people at home. How 
do we comply with something like the safe staffing rule that is 
in New York and has also been proposed here on the Federal 
side?
    Mr. ALTCHEK. I think one of the interesting opportunities 
with this type of chronic disease management is you can help 
clinicians treat more--manage more patients safely and 
effectively. We have such a large provider shortage in the U.S. 
that we need to use technology to help providers be more 
effective, managing more patients safely, and there is a very 
large opportunity to do that.
    Ms. TENNEY. Great. Well, thank you so much. I appreciate 
the witnesses. Wonderful. I am sorry I didn't get to everybody, 
but tremendous to hear you all. Thank you.
    I yield back.
    Chairman SMITH. Mr. Kildee.
    Mr. KILDEE. Thank you, Mr. Chairman, for holding this 
really important hearing. I want to thank the witnesses, all of 
you, but in particular Mrs. Maddox and Mr. Underhill, for 
giving us the human side of this story. I really do appreciate 
it. I once worked in Newburgh, and I am a PBS fan, so Mr. 
Underhill, I don't know if it has been raised because I have 
been coming and going, but I am a fan of your work on 
television. So thank you for that.
    Last Congress, and you will hear this theme, there has been 
a lot of bipartisan work in this space, last Congress I joined 
Dr. Wenstrup, introducing the Rural Behavioral Health Access 
Act, which would have extended the pandemic-era policies that 
allowed Medicare to pay critical access hospitals for mental 
health services delivered via telehealth, even when the patient 
they are caring for is not located at the hospital.
    By giving critical access hospitals, which operate in rural 
areas with often very limited capacity, but giving them the 
flexibility for how they are paid for these services, our 
intention was to expand access to mental health services--
obviously a critical need, but particularly critical in 
underserved communities.
    Given the demonstrated need for mental health services 
across my home state of Michigan, I was really happy to see 
this notion, this bill, in a sense, advance not through 
Congress, but instead through the rulemaking process at the 
Centers for Medicaid--Medicare and Medicaid Services. Under 
their calendar year 2023, Hospital Outpatient Prospective 
Payment System Final Rule, CMS acknowledged that allowing this 
policy to expire would have created harm for patients in 
underserved communities, and chose to extend it beyond the 
pandemic.
    So Dr. Mehrotra, I wonder if you might just speak to the 
importance of this particular aspect, this particular policy 
toward increasing access to mental health services in our 
communities that have great need. Obviously, mental health is 
often overlooked as a part of the overall health picture.
    We try to make some progress in this space, and we think 
that the idea that we promoted is having some value. I would 
like to make it permanent, but I wonder if you might just 
comment on how this impacts overall health.
    Dr. MEHROTRA. No, I think that, obviously, the mental 
health needs in the communities, in particular in rural 
communities, is really an enormous problem.
    And often what we find is--one of the things I think is 
really important to emphasize is that these kinds of 
technologies bring up a new model in the sense there is often a 
lot of upfront investment that you need to--fixed costs to set 
up that technology. And sometimes the economics don't work as 
well in rural communities because you just have fewer patients.
    And I might give, not related to mental health, but another 
example which came up earlier, which is stroke care. We find 
that acute tele-stroke in rural hospitals is--that is where it 
is most effective. But we see it is the least likely to be 
used. And what we hear from chief financial officers in rural 
communities is that the economics aren't working because of 
this issue of fixed costs being so substantial.
    So we need to think a little bit about how we make those 
investments in rural communities, because we might need to pay 
more or give them that--resources to be able to implement these 
really necessary technologies.
    Mr. KILDEE. Well, I am glad you raised that, because my 
other question really has to do with what we have learned 
during the pandemic, the flexibilities that we provided, how 
that impacted underserved communities, and what other--I mean, 
obviously, the telehealth access to mental health care was one, 
but are there other sort of innovations that occurred. And I 
would offer this to any of the panelists. During the pandemic 
that we learned enough about that we ought to make sure we 
extend them, and absent some action we may not be able to do 
so? Any thoughts on that subject?
    Dr. STARR. So, you know, thinking about hospital at home, I 
think, is a really big one.
    And kind of the question was brought up a minute ago about 
nursing and nursing shortages. And one of the great things 
about hospital at home is we do a ton of virtual nursing care, 
and can utilize, you know, community paramedics in the home, 
you know, so a trained EMT who can be the nurse's hands and 
feet to take care of the patient while the nurse does their 
work remotely. And so, you know, that would be a big one that, 
again, could have a lot of broader impact.
    Mr. KILDEE. Well, thank you. I really appreciate this 
panel. Thanks for your input. This has been a very good 
hearing. I want to thank all the witnesses.
    And I forgot to mention, Mr. Underhill, you are from 
Saxapahaw. If you ever go to the Saxapahaw general store, make 
sure to say hi to my cousin Jeff, who owns and runs it. 
[Laughter.]
    Chairman SMITH. Mrs. Fischbach.
    Mrs. FISCHBACH. Thank you, Mr. Chair, and thank you all for 
being here, sincerely. And I appreciate all of the information.
    And I will just say I represent a very rural district. 
Biggest town, 50,000. My folks drive hours for medical care. 
And so I really, really appreciate the at-home and the 
telehealth. And I am just wondering--and as we talk a little 
bit about, you know, Mr. Kildee was asking a little bit about--
you mentioned community paramedics, and the--and Ms. Tenney was 
talking about the staffing shortages.
    And Mr. Underhill, you talked about that they are coming to 
visit, and I believe, Mrs. Maddux, you mentioned that they are 
coming to visit also. So I am just kind of wondering, 
practically, how is that--are you able to reach those very 
remote areas?
    And it is not like Alaska. My district isn't like, you 
know, you have to fly to get somewhere. But I am just concerned 
that when we are talking about, you know, several hours' worth 
of drives and things like that, if we can utilize it as well as 
we should be able to.
    Dr. Starr, if you want to start, any of the----
    Dr. STARR. Yes, that is a huge challenge. And what we are 
looking at doing is, again, utilizing every resource we can 
find. So if there are EMTs that are available, we will look at 
that. We partner closely with home health, and we will utilize 
home health nursing, you know, who are in that geography. And 
we even have had discussions with some of our rural hospitals 
as they have waxing and waning patient volumes, using some of 
the inpatient nurses as a way to keep them busier and not call 
them off, but have them possibly go do some of that work, as 
well.
    So it is really identifying every resource we can, and 
utilizing it as best as possible.
    Mrs. FISCHBACH. Okay. And practically, I mean, are you able 
to go in and set up--you know, Mr. Underhill talked about how 
they came in--when he was getting out of the hospital they came 
in, set up the Internet, the whole bit, and so they----
    Dr. STARR. Yes. So we actually send patients home with a 
lot of that, and then walk them through the set-up at home in 
that situation. So we give them--we test all the equipment, we 
make sure everything is working correctly, and then they will 
leave and take that home, and we will help them set it up at 
home.
    Mrs. FISCHBACH. Okay. Has--and maybe somewhere along the 
line it was mentioned, but is the issue of solid broadband--
have you run into that, I mean, where we are having issues with 
that?
    Dr. STARR. Yes, yes, for sure. And we can always--you know, 
for hospital at home, for example, we can take care of the 
patient in the hospital. We have a safe place. So we make sure, 
before we send them home, that we have the right connectivity, 
whether that is really stable WiFi or cellular coverage. 
Typically, cellular coverage for most of our areas.
    Mrs. FISCHBACH. And then to any of the members of the 
panel, what are kind of the parameters for determining if 
someone qualifies for in-home care or at-home, or how, whatever 
the hospital at home, whatever the term is?
    I mean, does it vary with every single diagnosis? Or how do 
you determine if they are able to use this?
    Dr. STARR. Yes, it really comes down to we look at the care 
the patient needs to get better, what they would get in the 
hospital, can we provide that in the home. So we have gone 
through all our diagnoses and what it takes to take care of 
those, and make sure that we can actually provide an equivalent 
level of care.
    Mrs. FISCHBACH. So you have maybe a chart that you are 
saying----
    Dr. STARR. Yes.
    Mrs. FISCHBACH. Okay.
    Dr. STARR. Really extensive.
    Mrs. FISCHBACH. And age and ability?
    Dr. STARR. And then some patients fall outside that, and 
then we will huddle as a team and decide. Can we actually take 
care of them safely? And if the answer is no, they stay in the 
hospital. If yes, we will take them home.
    Mrs. FISCHBACH. Okay. And Mrs. Maddux and Mr. Underhill, I 
know that you talked a little bit about your experience, you 
know, during your opening statements. And I am just curious. 
And I got the impression that it was positive, that both of you 
had positive experiences. Was there anything that either could 
be improved, and I guess I only have 46--I have so many 
questions, but could be improved, or that was helpful?
    I guess maybe just commenting on that. I am just kind of 
curious if you felt it was, like, something----
    Mr. UNDERHILL. I was so enthusiastic, I really didn't have 
anything to improve it. I cannot think of a thing.
    Mrs. FISCHBACH. Okay.
    Mr. UNDERHILL. It has just worked flawlessly for me.
    Mrs. FISCHBACH. Well, I appreciate that, okay.
    Mr. UNDERHILL. Yes.
    Mrs. FISCHBACH. That is very----
    Mrs. MADDUX. I mean, I would say that a potential barrier 
for some other patients or--including myself--there is a heavy 
utilization on your electric bill and water bill. Garbage 
pickup is a big thing. And I think that, for a lot of people, 
that might be a barrier because they wouldn't want to see those 
increase in costs weigh on their family. And so that would 
definitely be something that could be improved.
    Mrs. FISCHBACH. Yes, and I know I only have a couple--I am 
over time. But I suppose, when you mention that, I hadn't even 
thought of that, that that is not covered. That is something 
that is not covered. You bear those costs yourself.
    Well, thank you very much, and I really appreciate all of 
you being here. And I am looking forward to really expanding 
what we have, because it is so important to folks, like, in my 
district. But not only that, I think the health of people--I 
think Mr. Underhill said it and, Mrs. Maddux, you said it, too, 
that it is so much better to be at home. And so I appreciate 
it. So thank you all very much.
    Chairman SMITH. Thank you.
    Mr. Evans.
    Mr. EVANS. Thank you, Mr. Chairman.
    Dr.--I hope I get your name right. Name, Doctor?
    Dr. MEHROTRA. Mehrotra, yes.
    Mr. EVANS. Mehrotra. Can you describe how the impact of 
hospital closures in communities will affect the demand for 
telehealth services?
    And how can the decrease in medical workforce caused by 
hospital closures impact their ability to provide telehealth 
program options?
    Dr. MEHROTRA. Well thank you, Representative. I think you--
I wanted to emphasize, like, two sides of that coin.
    The first is, obviously, when a hospital closes in a 
community, patients are going to have to, when they get care, 
go much farther to the nearest hospital. And I think it 
really--some of the technologies we have described today can 
really facilitate those patients from getting that care that 
they need.
    The other side that I wanted to emphasize that your 
question raises, which is that--can telehealth keep rural 
hospitals from closing? Because there is the possibility that 
we bring a lot of that technology for stroke care, for mental 
health care, sepsis care, et cetera, to rural hospitals, and 
allow them to care for a broader range of patients and 
conditions, and allow them the finances and so forth to stay 
open. So I also do want to emphasize that aspect, where 
telehealth can keep rural hospitals from closing.
    Mr. EVANS. Studies have shown that increased access to 
telehealth services increased accessibility for communities of 
color. Can you please elaborate for communities explicitly why 
disparities in health equity are reduced when telehealth 
services are made available?
    Dr. MEHROTRA. Yes, I think the--what we are finding in some 
of our data and we--obviously, this has been a theme of the 
work that we have done--is that we have the concern that, when 
we introduce these new technologies, we often see that, if we 
just offer it to everybody, it can increase disparities of 
care. And that is one of the greatest concerns I have and I 
think many of the other folks, the witnesses, share.
    And so the real question is how do we target our 
investments, resources, reimbursement to those communities so 
that we don't widen disparities, but rather reduce them, which 
is what we all want?
    Mr. EVANS. Thank you, Mr. Chairman.
    Chairman SMITH. Thank you,
    Mrs. Miller.
    Mrs. MILLER. Thank you, Mr. Chairman.
    Thank you all for being here, I know it is a long day, and 
for taking the time to testify.
    My home state of West Virginia is about as rural as you can 
get, and there are so many patients that have to drive up to 
five hours to get medical care. Either they are driving to it 
themselves or their caretaker takes them just to get the care 
that they need. That is what makes home health care so 
important. And where clinically appropriate, it is an absolute 
game changer for my constituents.
    The technology available today makes it common sense to me 
that we try and make health care available to patients in their 
own home, where they are most comfortable. This not only helps 
patients access care more easily, but it also lessens the 
burden that the caretakers have of, you know, having a job 
outside of their own loved ones, you know, having to take care 
of them.
    One group of patients that I work particularly closely 
with, and are those with end stage renal disease, patients with 
ESRD typically have to dialyze at least three times a week just 
to manage their disease. In rural America, that can amount to 
hours upon hours. It can take your whole day, really, because 
you are traveling back and forth. You spend three or four hours 
doing it and, you know, it is hard, it is exhausting. That is 
why I am such an advocate for home dialysis. The ability for 
patients to dialyze at home reduces that burden of travel, and 
it allows the patients to work a full-time job if they want to, 
or go to school and still manage their own health care.
    Mrs. Maddux, I am a mother and a grandmother, and I know 
what it is like to have your hands full and your darling 
children. But I didn't have any health problems like you have, 
and the complications. And hearing your testimony and how you 
juggled being a mother, and having a full-time job, and having 
to commute three times a week just to receive your dialysis is 
extraordinary to me, because I know what it was like not having 
a problem. And I am sorry that that was your reality. I applaud 
your strength and the grace that you have shown, and how you 
have been taking care of your own health, as well as your 
family simultaneously. And I see them there, back there, 
shaking their heads.
    As a patient who dialyzed in-center and now at home, can 
you compare the experiences? Tell us what was most difficult 
about making the transition to dialyzing at home?
    Mrs. MADDUX. Being in-center, as I mentioned, there were 
many different parts of it that was very difficult. A lot of 
the patients, they were very ill, and sort of didn't want to be 
there. So the experience of going to in-center, compared to 
going at home, the impact on your emotional health and your 
mental health is indescribable. And you can't really calculate 
that.
    And I also think that having that emotional impact and that 
mental health impact does have an impact on your health, as 
well. When you feel better about what you are doing, you feel 
better. And so with being at home, I was able to see an 
improvement in my health from that standpoint.
    And then there was also the sense of autonomy and control 
that you regain of your own life. And that also has a positive 
impact on how you are feeling about things and how you feel. So 
that transition has multiple aspects of it that were an 
improvement on my life.
    Mrs. MILLER. And even your disposition, because you are not 
feeling guilty, and you are more at ease of being in control of 
something that you weren't in control of, especially with the 
little ones that you don't have to take that deep breath before 
you answer because you are cool and you are calm.
    I am working on a bill with Congressman Blumenauer that 
aims to increase access to home dialysis by providing trained, 
professional staff assistance to patients in their home. And 
the bill will ensure that all patients are given the education 
and the support that they need to utilize home dialysis, if 
they so choose.
    I am glad to hear that staff training helped you to be able 
to dialyze at home, and I am hopeful that my bill will help 
provide coverage for these services to more ESRD patients. Mrs. 
Maddux, share what your experience was like navigating Medicare 
coverage for your training and dialysis at home.
    Mrs. MADDUX. It was definitely a huge learning experience 
for me, and a lot that I had to learn on the fly and through 
trial and error. I learned that Medicare is required for people 
who are on dialysis for a period of time. So even though I 
maintained my health care coverage and my main health care--
sorry, my main insurance coverage through my employer, I was 
still required to have Medicare.
    And then I learned that I had to, you know, pay a premium 
for that coverage, even though it wasn't my choice.
    I also learned that I had to maintain that coverage in 
order to stay active on a transplant waiting list.
    So these are all things that I had to figure out as I went. 
There is a financial coordinator that is available, but she 
wasn't able to help me with filing paperwork, visiting the SSA 
office, waiting in line, being online on the telephone to just 
get all of that sorted out. So it was a difficult experience, 
but I understand why I had to do it.
    Mrs. MILLER. And it had to have been scary. It had to have 
been. And then, for you to finally reach that again, that deep 
breath of, okay, I am just going to follow through and get this 
done. I thank you for your answers and for sharing your story 
and your family.
    And I hope to introduce the Improving Access to Home 
Dialysis Act very soon to help patients access this at home, 
and, Chairman, I yield back. Thank you.
    Chairman SMITH. Mr. Panetta.
    Mr. PANETTA. Thank you, Mr. Chairman. Thank you, Mr. 
Feenstra, for letting me go real quick. But thank you, Mr. 
Chairman, for having this hearing, and thanks to all the 
witnesses.
    This hearing, for me, really highlights a number of issues 
that affect my constituents. In California's 19th congressional 
district, we face a convergence of high health care costs, 
provider scarcity, and a high rate of government insurance, all 
of which have really kind of created a perfect storm for 
providers and for patients, and pushed access out of reach for 
many people that I represent. That is why I have repeatedly, be 
it in this committee room or outside of it, raised the issue of 
costs which stretch providers that impact care, health care, in 
my district.
    Now, Mr. Altchek, in your testimony you stated that 
Medicare reimbursement or remote patient monitoring, RPM 
reimbursement, based on geography, I think you said something 
to the effect of it is antiquated, but you also said it 
disincentivizes the adoption of home health services, 
especially in rural areas where payments are lower.
    You go on to say, though, that your services have led to a 
23 percent average decrease in a cost of care. So Mr. Altchek, 
have Medicare payment limits kept pace with these savings?
    And as seniors make up a larger share of the population, 
how do you see telehealth, home health, and RPM services 
playing a role in the growth of Medicare?
    Mr. ALTCHEK. Congressman Panetta, thank you for the 
question. I think there is two important policy considerations 
on Medicare.
    The first is reimbursement rates for remote monitoring 
broadly have declined 28 percent since they were introduced in 
2018. That is compared to nine percent decrease in broader 
Medicare rates via the conversion factor. If we want a health 
care future that is modern, we need to invest in it.
    Number two, reimbursement in rural communities is 
substantially lower, 20 to 30 percent lower, than it is in 
urban communities because of the geographic differences. The 
cost to deliver the service is equal, whether it is in a rural 
community or an urban community. And we should just fix that. 
It is common sense policy.
    And then number three, to your to your point about how--
what role this plays, we have a dramatic access challenge 
today, as you mentioned, in your district. That problem is only 
getting worse, and exponentially worse, given the rapid 
increase in elderly population in the U.S. that is very 
chronically ill. So we have no choice but to embrace these 
technologies.
    Mr. PANETTA. Now, obviously, when it comes to providers, my 
constituents, like I said, are facing a shortage. And the 
failure of Medicare to keep up with the cost of care, including 
the fact that Medicare Advantage payment rates for home health 
care have dropped by nearly a third, combined with the high 
cost of living, especially in my district, and the high rate of 
government-payer patients all make it harder year after year to 
recruit and to retain a health care workforce.
    Now, when it comes to care by providers either at the 
office or by home, we need to work to ensure that Medicare is 
paying a substantial rate, but also that providers are 
maintaining standards of care. Mr. Altchek, how can CMS 
establish better measures to ensure patients continue to 
receive quality care under home health so we know that 
Medicare's investment is actually leading to better patient 
outcomes?
    Mr. ALTCHEK. Yes, it is a great question. And I think the 
opportunity here is actually not to meet the existing standard 
of care, but what we are trying to do is elevate the standard 
of care. And I think we can do a dramatically better job in the 
U.S., especially with outcomes for patients with chronic 
disease.
    The metrics that matter, you know, the good thing is that 
the CMS in the new shared savings metrics is really focused on 
a few key goals: A1C control, blood pressure control. We know 
the metrics that matter. I think all the physicians are aligned 
there. The question is, can we do a much better job of getting 
patients to control, which--the technology shows that it is 
able to do that.
    Mr. PANETTA. I hope so. I got to go vote.
    Mr. Chairman, thank you, I yield back.
    Mr. FEENSTRA [presiding]. I now recognize Representative 
Beth Van Duyne.
    Ms. VAN DUYNE. Thank you very much, Mr. Chairman.
    With over 800,000 people living with end stage renal 
disease, which requires patients to undergo dialysis to survive 
since their kidneys can no longer filter their blood and remove 
toxins on their own, the patients need to be treated for 
roughly three to five hours at a medical facility, or they can 
opt to do home analysis four to seven times per week. Every 
step possible must be taken to allow a patient to get this 
lifesaving organ quickly and safely.
    So last June I introduced the Saving Organs One Flight at a 
Time Act, which requires the TSA and FAA to issue regulations 
that would offer common-sense reforms to improve the air 
transportation of human organs. After September 11, 2001, the 
terrorist attacks in our nation, the ability for human organs 
to fly above the wings in commercial aircrafts was removed, 
causing organs to fly in the cargo hold, which has created 
confusion, delays, and even the destruction of these organs. 
And that is why I am also working to introduce a bill that 
would add the ability to automatically refer donors to organ 
procurement organizations, which should lead to the increased 
chance of a successful donation. I look forward to introducing 
this bill in the next coming weeks, and working across the 
aisle to help patients in need.
    We have had a lot of people who have asked you questions. A 
lot of them have been multiple questions. When you get all the 
way down to the end of the dais and you have got, like, 
freshman members of this committee, we are looking over our 
questions and, like, that has been asked, like, five times. So 
while I do have a number of questions that I could ask and make 
you all repeat yourselves, what I would prefer to do is at this 
point in time, what are some of the points that you feel, like, 
haven't been made that you would like to respond to that you 
perhaps didn't have an opportunity to respond to?
    Mrs. Maddux, I am going to ask you to go ahead and go 
first.
    Mrs. MADDUX. Thank you so much for asking that, and also 
thank you so much for your work.
    I think that one thing that we haven't covered is trained 
staff. And a lot of the issues that we talked about with, for 
example, you know, traveling--health care provider traveling 
along distance to get to their patient. If we had more people 
and more staff who were trained in these modalities, I think 
that that would solve a lot of those issues. With the home 
dialysis training facility that I am working from, there is 
only one person who is doing the training and all the 
administrative work.
    But I think that outside of, you know, innovations and 
technology, and outside of the other areas that we have 
discussed today, one thing that we haven't touched on is just 
training and having more prepared and well-trained staff to 
facilitate these different modalities.
    Ms. VAN DUYNE. Excellent. Mr. Underhill.
    Mr. UNDERHILL. I was asked earlier the cost of this 
treatment relative to cost in the hospital, and I have--as a 
patient, of course, I have no idea. So the lack of 
transparency, lack of ability to get that information is a 
concern to me.
    Ms. VAN DUYNE. All right. Dr. Starr.
    Dr. STARR. Thanks for that question.
    The point that came to mind was one that was briefly 
mentioned before, and that is the ability of these telehealth 
and hospital-at-home programs to keep care and revenue for that 
care locally within some of these facilities and hospitals that 
are struggling so much financially.
    You know, every patient that we keep locally is revenue 
that can then support the overall facility and benefit every 
member of that community.
    Ms. VAN DUYNE. Excellent. Thank you.
    Mr. ALTCHEK. Very quickly, I believe American health care 
is desperately in need of more innovation. And I can't 
underestimate--or understate the role that policymakers have in 
enabling that to happen. Obviously, this is a bipartisan issue, 
but the support from Congress makes a meaningful difference in 
these technologies becoming a reality.
    Ms. VAN DUYNE. Anything in particular, though?
    Mr. ALTCHEK. Medicare reimbursement sets the tone for 
Medicaid, for commercial. And so making sure Medicare 
reimbursement is aligned with where--with your vision for where 
health care should go is where we need to focus.
    Ms. VAN DUYNE. Other than just, though, adding additional 
dollars, which is typically what, when folks come to our 
office, that is what they ask for, is there anything?
    Mr. ALTCHEK. I think the big one is actually not adding 
additional dollars, it is making sure the geographic adjustment 
factor for Medicare takes into consideration the fact that 
technology costs the same, whether it is in a rural community 
or an urban community. And I think we need to fix that going 
forward to make sure that we level the playing field between 
these communities.
    Ms. VAN DUYNE. Excellent. Thank you.
    Dr. MEHROTRA. I want to build off one point that Dr. Starr 
made before, which is about licensure.
    I don't know--Mrs. Maddux is--you are currently listed at 
three transplant centers, you said. And for patients in your 
position to go to clinicians who are in different states is 
very, very difficult right now because of the licensure rules. 
And so this is a major barrier to care for patients who want to 
get the care, the specialty care that they need, because the 
clinician in the other state can't care for them in their home 
state. So any reforms in that area would be critical.
    Ms. VAN DUYNE. Thank you very much.
    And I yield back.
    Mr. FEENSTRA. Thank you. Now I recognize myself. I want to 
thank the panel for all that you have said and what you are 
working on.
    I want to thank Mrs. Maddux for your comments. Truly 
inspiring, especially when you have children. I have children, 
too. And the challenges, you know, just being a mom, and then 
also dealing with your health.
    And same thing with Mr. Underhill. Thanks for your comments 
and your thoughts and what we can do better. And that is what I 
want to address.
    So I am from rural Iowa. I have 36 counties. And this is 
probably the number one issue right now, is rural access to 
care. And I see this on an ongoing basis, from EMS to maternal 
health care to just finding a doctor, a clinic to take care of 
patients. And so this is really outside-the-box thinking. And I 
think of Dr. Starr, Mr. Altchek, what you are talking about, is 
normalizing this type of care when it comes to telehealth, when 
it comes to hospital at home, when it comes to dialysis at 
home.
    But the problem is, when you really step it down to rural, 
all right, there is a disconnect, right? Because I do hear 
about it. I hear from our hospitals, ``If we could do more of 
X,'' what you are just doing. So Mr. Starr, Mr. Altchek, what 
are solutions to getting it to that next level?
    I get it. Medicare and Medicaid are big problems, but it 
just seems like there is still a disconnect to creating the 
solution of what we want to normalize this care. What are your 
thoughts on that?
    Dr. STARR. Yes, part of it is just time. It is still so 
new. Like somebody mentioned, you know, we had 10 years of 
innovation in 18 months during the pandemic. And I think 
everyone is still catching up to that, and recognizing that 
this--it is pretty revolutionary, what we are trying to do with 
care compared to what has been done the last 50 years. So part 
of it is getting comfortable with it.
    But part of it is also having health systems and, you know, 
overall, as a society, recognize that, you know, some of this 
care is needed, it is transformative. The return on investment 
is going to be there, but it is not going to be for 20 years.
    Mr. FEENSTRA. That is right, and it is innovative. But the 
return on investment--but that is what we have got to look at, 
the return on investment.
    Mr. Altchek.
    Mr. ALTCHEK. I would just say that the thing that we found 
to be successful is engaging local primary care doctors. We 
work with 800 local primary care doctors in rural and 
underserved communities. They want to do what is best for the 
patients. When given the technology they adopt it. The issue is 
how do we get the technology in their hands with a business 
model that they can support. But if we do that, the demand is 
there, as you mentioned, and you see in your district.
    Mr. FEENSTRA. Yes. Well, thank you for that. I have to go 
vote, but I would like to--I will yield back, but I would like 
to thank the witnesses for appearing here today.
    VOICE. Just recess, because Mr. Smith is coming back.
    Mr. FEENSTRA. Okay, I guess we are going to recess, then. 
So the committee will take a brief recess, and we will be back 
shortly.
    [Recess.]
    Chairman SMITH [presiding]. The committee will come to 
order. Thank you all. We had to do something called voting on 
the House floor, and we worked that through.
    We will go to Dr. Murphy.
    Mr. MURPHY. Thank you guys for your patience today. This is 
our world, and it is insane. Why did I leave medicine, right? 
Why did I leave medicine to join this insanity? Well, it is 
because our country and medicine are a mess. So anyway, thank 
you all for coming. I had a specific question I wanted to ask.
    First, what happened to our lady on the left? Did she 
leave? I will ask her when she comes back.
    I want to ask, I guess, Dr.--pardon me, Mehrotra? There we 
go. Thank you, sorry. I was reading your testimony here, and I 
actually had asked Dr. Ferguson, if I was not here, to do this. 
I wanted to follow up on some of the studies and some of the 
statements that you made in your testimony. I ran a surgical 
practice for many years until I literally had to resign just to 
join Congress, and I was the one who was there at Saturday 
night at 2:00, counting the paper clips to make sure that we 
saved as much money to make payroll. Our payer mix is 74 
percent government, Medicare and Medicaid, no insurance. And so 
literally, to survive we had to make sure that payments were 
done and we saved money where we could.
    I was reading in here, when you were talking about 
telemedicine, which--telemedicine is critical for our practice, 
because I see patients two hours north, two hours south, and 
sometimes five hours out east. It was absolutely a lifesaver. 
And I mean literally a lifesaver during the pandemic to be able 
to do this.
    I fully believe that we should not step down in any of 
this, because in rural America, we--first of all, everybody 
doesn't have gas money to get out to see physicians, and it is 
absolutely critical. I don't believe the doc on the clock kind 
of thing, on the video thing spitting out weight loss medicines 
is good medicine, I believe it is absolutely poor medicine.
    But I want to go back to one of the things you said. I know 
maybe Dr. Ferguson brought it up, that you recommended payment 
for telehealth visits to be less than in-person. Let me tell 
you what that would do to a practice, to a private practice. It 
would absolutely decimate it because patients want it, and I 
believe it is an absolute wonderful thing. If I am seeing a 
patient back who has had a prostatectomy and they are coming 
back for a PSA visit, that is absolutely a wonderful thing to 
do to save them, you know, it could be two hours on one end, 
two hours back.
    But there is capital. There is an investment in a building, 
there is an investment in your nursing staff, in your 
malpractice, and everything. None of that goes away. And you 
have also invested 30--I invested now 35 years of my life in 
medicine with not only academia, but expertise in the field.
    To say to Medicare, to say to insurance companies that that 
value of the knowledge that I deliver is less just because I am 
on a screen, rather than talking to somebody in person is 
wrong. It is absolutely flawed because those expenses still go. 
And if we want to be able to--in this world of a shortage of 
physicians, which is not getting any better--recent studies 
show that 63 percent of medical students do not plan on 
practicing clinical medicine. Our medical schools are doing an 
absolute failing job in delivering people into a workforce that 
is now terribly short. But then to then push people into 
further debt so that they close their private practices and 
either retire or go into hospital employment, which I know for 
a fact is less quality medicine, is absolutely wrong.
    So I just have to say that. I don't care what studies show, 
because these studies were done outside of any real-world 
medicine. But this is factually inaccurate. Okay? I just, I 
have to say that. I speak from the real world. I take care of 
people that don't look like I do. And the expenses that--how 
many times I did not take a paycheck because we couldn't answer 
the expenses, or couldn't come up with the expenses.
    Now, with the United Healthcare debacle, this is 
literally--while they get to keep their money, and they are 
making money on their money, this is absolutely wrong. So I 
just have to bring that out. We can't practice medicine, and 
CMS is doing this. It also absolutely countermands the whole 
great gift we have of telemedicine. I would not do it if you 
are going to lose money on it. Why would you do that? Why would 
you do that? You want to put something through.
    I just want to say, Mr. Underhill, I am glad that 
experience worked out well for you. I am a little wary. Are we 
only talking about literally IV antibiotics and vital sign 
monitoring when people go home? Because you are surely not 
going to give patient-instructed narcotics or any type of 
cardiac medication. Are you guys talking about doing anything 
else?
    Dr. STARR. Yes, so pretty--we can do a pretty broad range 
of therapies safely. Narcotics are a huge issue, and we don't 
do any IV narcotics. We do some limited oral, but IV diuresis, 
you know, a variety of infectious treatments, IV fluids, you 
know, symptom control, you know, nausea and so forth we can all 
do.
    Mr. MURPHY. Yes, you know, I think of people coming in with 
a catheter who are in retention and having post-obstructive 
diuresis. If they can literally just drink, they are in a good 
spot to be at home.
    I am a big fan of this. It just has to be, we have to know 
the conditions into which we are delivering our patients, and 
have to understand that renumeration models are going to be 
critical. This cannot cost the system more than what it is 
costing now, because we are on a pathway to, you know, a desert 
with our money right now.
    So I thank you all for doing this. It is way too late and 
it is past its time. But now with the technology that we have, 
it is going to be a lifesaver, and it is going to hopefully 
cost [sic] a lot of people money.
    So thank you, Mr. Chairman, I will yield back.
    Chairman SMITH. Thank you.
    Mr. Moore.
    Mr. MOORE of Utah. Thank you, Mr. Chairman. Thanks for 
holding this important hearing today to hear from patients, 
providers, and stakeholders on innovative ways to bring care to 
patients at their home. This is particularly important as 
Congress considers the expiring Medicare telehealth 
flexibilities and the hospital-at-home waiver this year.
    I am excited to welcome Dr. Nathan Starr from Intermountain 
Health today to speak to their work in expanding patients' 
access to care in particularly rural and underserved areas. 
Intermountain is a Utah-based health care system, and yet 
another illustration of how Utah leads the nation in finding 
innovative and outcomes-based solutions to our various 
communities' challenges.
    My team and I have heard from several folks back home, 
ranging from the Rural Health Association of Utah to primary 
and specialty care providers, about how telehealth 
flexibilities and the hospital-at-home waiver are enhancing 
their ability to provide care to patients from Saint George to 
Logan, and everywhere in between. And this is an important 
discussion today because, you know, as miserable as the 
pandemic was, and confusing as it was for people like--you look 
in the business community, and folks were able to find certain 
avenues and lanes to play in that they could be more flexible 
and, you know, we got through it. And I think we need to make 
sure that health care is doing the same. We came up with 
opportunities.
    Dr. Starr, you and I have spoken. I have got four young 
kids. My wife is very busy, especially with me being gone so 
much. Finding these telehealth opportunities for ailments or 
conditions that could be solved if she has the flexibility to 
do this, I mean, there is real work that can be done here.
    To my colleague from North Carolina, doing it right, doing 
it safe is key, and I know that Intermountain and many of the 
others are focused on that.
    Dr. Starr, Intermountain has several telehealth programs 
aimed at expanding access to specialty care in rural areas of 
the state and throughout the Intermountain West region. Can you 
discuss what those programs look like for patients, as well as 
how you balance in-person versus virtual care?
    Dr. STARR. Yes, thanks for that question. The feedback we 
have gotten from patients has been really positive. And having 
done a lot of virtual care myself, it is really fun to be able 
to tell a patient, ``If we brought you up to our quaternary 
center in Salt Lake City, I would take care of you. And I am 
telling you we can do the exact same things we would do here 
down there. You are going to get the exact same care,'' and 
that is incredibly reassuring.
    The other thing we see all the time is many of these 
patients who live in rural areas don't want to leave. We have 
heard many times, ``I would rather die than go up there and 
have to deal with all that.'' And so the fact that we can care 
for them where they are in place is hugely powerful and 
impactful.
    Mr. MOORE of Utah. And would you say that it encourages 
folks to be more involved in their health care if it is more 
easily accessible?
    Dr. STARR. Oh, definitely.
    Mr. MOORE of Utah. Right, and we all talk about the 
performance of preventative health care, right? And getting out 
ahead of issues before they become catastrophic, or before you 
are in an ER. And, you know, I view this as an opportunity to 
continue to double down or double our efforts to encourage 
patients to change, right? You know, providers can do 
everything they can, but patients and--we have to change, the 
society has to change, and we have to be more willing to. And 
if that barrier is safe and lower for us to get that care, it 
is key.
    You know, we have talked also, on the flip side of the 
coin, is the workforce shortages in health care, especially in 
rural and underserved areas. How can telehealth or remote 
patient monitoring expand the capacity for rural facilities to 
serve more patients?
    Dr. STARR. Yes, we have seen some great examples of that, 
some of it mentioned, you know, with remote patient monitoring 
allowing a provider to see more patients.
    Additionally, we have done a lot of work with nursing and 
providing not only, you know, tele-support for physicians and 
patients, but actually having a nurse program where 
inexperienced nurses can reach out and get support if they are 
not sure how to manage a patient--again, trying to make them as 
comfortable as possible and improve their job as much as we 
can.
    Mr. MOORE of Utah. Mr. Altchek, anything to add to that?
    Mr. ALTCHEK. I think your emphasis on preventative medicine 
is key, and what we have found is when patients actually start 
checking their vitals regularly and knowing that there is a 
nurse on the other side seeing the results, they take a lot 
more personal accountability for their care. So I think you are 
exactly right. This is not only a technology opportunity, but 
it is an opportunity to get patients more invested in their own 
health, which will have dramatic impact.
    Mr. MOORE of Utah. Members of this committee are obviously 
very interested in ensuring taxpayers' dollars are utilized 
properly. You know, we are the stewards of Medicare's program 
finances, make sure that health care services improve patient 
outcomes.
    Dr. Starr, just lastly, as we wrap up, can you talk about 
how Intermountain measures the value and quality of telehealth 
or other at-home services?
    How does this differ from inperson care for similar 
services?
    Dr. STARR. Yes, the way we measure it is really we don't 
look at revenue we bring in at all. It is all about cost 
savings, which makes it challenging. Our telehealth program 
runs in the red significantly if you just look at net operating 
income. But when we look at that value we create and the costs 
that we save in terms of transfers, keeping patients in their 
community, improved outcomes, the value is there.
    Mr. MOORE of Utah. Excellent. Thank you all. Thank you to 
the patients, providers, everyone. I appreciate your thoughtful 
testimony today. And know that we are all partners here to try 
to get costs to a point where they are not so difficult for our 
constituents, and find solutions like this. I know you all are 
very much working on it.
    Chairman, thank you.
    Chairman SMITH. Thank you. I would like to thank our 
witnesses for appearing before us today, and also point out 
that Mrs. Maddux, our witness, had to actually leave early to 
do her dialysis. So that is how important this hearing is all 
about.
    But please be advised that members have two weeks to submit 
written questions to be answered later in writing. Those 
questions and your answers will be made part of the formal 
hearing record.
    With that, the committee stands adjourned.
    [Whereupon, at 2:24 p.m., the committee was adjourned.]
      

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