Transcripts For CSPAN3 Hearing Examines Health Care For People With Chronic Illnesses 20170517

850 formally submitted comments. In december of 2015, the working Group Released a comprehensive document. In october of last year we issued a legislative discussion draft. Soon after that we finalized four of our policy proposals in its 2017 medicare physician fee schedule rule, and twon provisions from our discussion draft where included in the 21st century cures act which president obama signed into law this past december. In other words, sefrlt working groups policies have already been enacted and were working to get rest signed into law fully implemented. Toward that end, we introduce the latest version of the chronic care act, the bill that encompasses the working groups proposals in april. The legislation currently has 17 bipartisan cosponsors and has been endorsed by numerous organizations in the Healthcare Community. Today, is the latest step in our in our efforts. The next step will come later this week, as weve noticed a markup for thursday morning. I want to thank my colleague Ranking Member senator widen for his work on this matter. His passion for improving care for those with chronic conditions has been a driving force behind this effort. And of course i want to thank senators isakson and warner whofz worked tirelessly to lead our working group. Through their ef forts the committee has not only learned about the Patients Living with chronic conditions but also identify new policies to improve care coordination, increase value and lower costs in the Medicare Program without adding to the deficit. Todays hearing will provide us with an opportunity to examine these policies more extensively so we can better understand how they will help patients and enable providers to improve care and produce better outcomes. The bill includes a number of policies that would improve care for the chronically ill through increased use of telehealth by giving Medicare Advantaged plans and certainly Accountable Care organizations enhanced flexibility to target Telehealth Services to medicare patients with chronic conditions. Senator schatz and wicker have been instruments in this particular effort and im pleased to have them here with us to talk about how the chronic care act advances their policy goals. Now, i would be remiss if i did not also recognize the finance Committee Members po who have joined senators schatz and senator wickers efforts to promote the increased use of Telehealth Services. In that regard we appreciate the leadership of senator thun, cardin, and womaner aern on the matters. I want to thank the fine institutions in utah for their help, specifically on the quote telestroke, unquote, policy. Specifically i want to recognize dr. Jenny ma jess sick and dr. Nicholas johnson at the university of utah as well as dr. Kevin call with intermountain healthcare. I appreciate their willingness to share their kpers and expertise using technology to properly diagnosis individuals presenting stroke symptoms and i look forward to hearing more on this particular aspect of telehealth here today. Of course our bill goes beyond telehealth making improvements for beneficiaries, including fee for service, Accountable Care organizations, and Medicare Advantage. We have a panel of recognized experts here before us today to discuss all of these issues and i want to welcome each of our distinguished witnesses. Obviously im well aware that there are some contentious debates going on in the healthcare space these days, and there there is no shortage of political and partisan points that people would like to make in a venue like this. However, for todays hearing i sincerely hope that we can maintain the bipartisan spirit that has driven our efforts on the chronic care act. Toward that end, i respectfully ask that members of the committee focus their questions on the policy areas specifically addressed in the bill. With that, im going to turn the time over to senator wyden for any opening remarks he would like to make. Thank you very much, mr. Chairman. I want to thank you, your staff, senator warner, senator eyesic son. This san extraordinary hearing and ill touch on why, but it could not have happened if you hadnt been willing to initiate a committeewide process. So. Thank you, senator. To begin i want to thank you. Thank you. For all of the efforts to make this morning possible. Colleagues, ive looked forward to today for many years. Thats because the finance committee is now beginning to tackle the premier challenge of American Health policy. Specifically, by updating the guarantee of medicare to better serve seniors with chronic illness. When i was codirector, medicare had just two parts, arks a and b. If you broke your ankle and had you surgery in the hospital, with you were covered by part a. If you got a really bad case of the flu, and you went to the doctor, you were treated by the doctor in their office and that was part b. That is not medicare today. Today, medicare is cancer, its diabetes, its Heart Disease, its strokes, and its other chronic conditions. Seniors who have two or more of these chronic conditions now account for more than 90 of all medicare spending. And today older people get their care in a variety of different ways. Theres still fee for service and theres also Medicare Advantage, Accountable Care organizations, and a host of innovations being tested across the country. Because medicare is a guarantee, a promise of defying benefits, its pastime to update this promise so as to deliver to patients with chronic conditions the best possible care in the most efficient manner. So as the chairman touched on, the legislation today begins this transformation. Older people will get more care at home, less in institutions. There will be expanded use of lifesaving technology, thats why its so good to see senator schatz and senator wicker here to talk specifics. There will be a stronger focus on primary car and expanded use of nonphysician providers. Now, in my view, still to come is ensuring that each senior with multiple chronic conditions has an advocate to guide them through what can be a teeth gnashing experience of trying to navigate American Healthcare. Two final points. One, picking up on the debate about the Affordable Care act, i would just say, colleagues, this is the way to do it right. Doors were open here, not closed. There was bipartisan cooperation, not partisan reconciliation. The public was asked to shape the bill, not taken for granted. And finally, i want to thank our partners, chairman hatch and i, senator warren and senator eyes sack son coordinating this effort. The chairman has made mention of the fact that many colleagues both on and off the finance committee have really helped to produce what our witnesses are going to call this morning a model for how to take on tough challenges. Its been an honor for me to be part of this bipartisan effort on and off the committee. And like you, mr. Chairman, im very pleased that our colleagues senator schatz and wicker are here with us today. Thank you, senator. Were pleased to welcome senator smats and wicker to our hearing today. As i mentioned in my opening statement, these two senators have done a lot of work on telemedicine and telehealth issues. We appreciate your support and your input today and we look forward to hearing your remarks on these important issues and your perspectives on this topic. Senator wicker will provide his statement first and followed by senator schatz. Senator wicker, if you would, please proceed with your remarks and well take senator shoots schatzs next. Thank you mr. Chairman, my distinguished colleagues its a pleasure to be here. Thank you for allowing me to share with you what we already know in my home state of mississippi, telehealth works. Im glad to be here to discuss the promises of telehealth and to celebrate the progress your committee is making with the chronic care act, which i have enthusiastically cosponsored. I would like to command the leadership of the Senate Finance committee for their years of work to address the cost and quality of chronic care in america. Today is the testimony to your efforts. Im pleased to be here today with my friend senator brian schatz. He and i lead the commerce subcommittee on communication, technology, innovation and the internet. In the commerce committee, we have worked tirelessly to provide innovation by removing barriers to connectivity and expanding access to rural broad band. In fact, it was during a 2015 hearing of our subcommittee on the potential of telemedicine when senator schatz and i decided to join forces to reform how medicare reimburses hell telehealth. We were fortunate to get a team and if was the secretary for health act, a widely supported legislative proposal for telehealth. Connect for health s 1016 is a pro duskt hard work and determination. It is designed tacoma prove quality of care and cut costs. I thank the committee for including telehealth provisions inspired by our connect bill in the bill we are discussing today. In so doing, youre recognizing the promise of telehealth. I became interested in this topic because my home state of mississippi has led the nation in maximizing technology to improve patients health. The university of Mississippi Medical Center . Jackson has been a leader in telehealth for over a decade. The team there has managed to increase access to quality care and cut costs by using Services Like remote patient monitoring, and teleemergency reaching some of our states most rural, vulnerable and costly patients. Mississippi say very rural state and, in fact, we have some of the toughest Health Problems too. We have the fewest providers per capita, and the highest rates of Heart Disease and type ii diabetes. These Health Disparities and barriers to access are what drove university of Mississippi Medical Center to experiment and innovate with telehealth. One of the many mississippi telehealth Success Stories is the diabetes telehealth network. A Remote Patient Monitoring Program that provides rural mississippi patients who have uncontrolled diabetes with routine access to a provider through a medical tablet. This Partnership Began following 200 chronically ill patients in the underserved mississippi delta. The technology allowed providers to monitor and care for the patients remotely on a daily basis following their vital signs and intervening when things didnt look good. Throughout the course of the first year, zero of the 100 patients were admitted to the hospital. Think about that. No emergency room visits for any of these previously chronically ill patients. This is an excellent care that can improve patientss life. In fact telehealth can save money also. The Mississippi Department of medicaid found that if this remote Monitoring Program were extended to just 20 of mississippis diabetic medicaid population, the state would save 189 million per year. So mississippi medicaid, like Medicaid Programs in virtually every state, is expanding access to and coverage for telehealth and remote patient monitoring. However, medicare is behind the curve limiting access for millions of seniors. Emergency the incredible impact that this technology could have if medicare would allow its most vulnerable beneficiaries to use Something Like remotepatient monitoring. Im confident that the success we have seen in mississippi can be replicated for patients across the United States. Upon enactment of the chronic care act and ultimately enactment of connect for health. We are still looking for cosponsors, mr. Chairman, and we will not stop until access to quality care through telehealth is realized for medicare patients. The chronic care act is a step in the right direction. We have more work to do in this space and i look forward to continuing to work with each of you. Thank you, sir. Thank you. I think im a cosponsor if not put me down, okay. Senator schatz, well thank you now and then were going to turn to senator warren who has played a significant role in this. Thank you, chairman hatch, Ranking Member wyden, distinguished colleagues, members of the finance committee for holding this important hearing on bipartisan legislation. Im happy to cosponsor the chronic care act a bill that can help improve outcomes and disease management for people on medicare who have chronic illnesses. Right now progress and modern technology has not translated into progress across the Healthcare System. That impedes the Health Systems ability to provide highquality care, improve access to care, and to lower costs. And so its time to bring medicare into the 21st century by taking full advantage of telehealth and remote pashlt monitoring. When were talking about telehealth, were talking about using technology provide Clinical Services to patients remotely. Telehealth more broadly can also include nonclinical Services Like provider training. One type of telehealth relies on live video or audio or visual technology, its like using a secure version of skype or face time so that a patient can connect with his or her healthcare provider. When these substitute for a traditional inperson visit they can save er kperngsz, they save travel time and fut put patients back to work more quickly. They can also use store and for technology, another type of tej health which is exactly ha it sounds like. Providesers can take an imagine or other clinical picture, store it and send it to a specialist anywhere on the plan. He theres also remote patient monitoring. If a highrisk patient with a chronic disease needs to have her Blood Pressure or blood sugar monitored, she is use a device at home to collect and sthaend data remotely and continuously. This improves the outcomes for the patients with chronic conditions and it saves money too. The vet vans administration, the department of defense, and the private sector are all taking advantage of telehealth and remote patient monitoring and improving access to care, improving quality of care, and saving money. The problem is, that medicare is not. Its limited by an old law, section 1834 m of the Social Security act which put which puts restrictions on the use of telehealth. The law says that patients must be located in certain originating sites in order to use telehealth. They cant be seen at home and can only be located in certain rural areas. Only certain types of physicians and practitioners can use telehealth under medicare, physical therapists or Occupational Therapists for example cannot, and remote patient monitoring is hardly covered at all. And thats why senators wicker and i along with senators cochran, cardin, thune and 13 other members of the state and three dozen members of the house and everybody is invited to cosponsor the connect for health act after the past two years. Our bill would lift restrictions on telehealth and improve coverage of remote pashlt monitoring. I know the Chronic Care Working Group has worked in a similar bipartisan fashion to find ways to advance legislation. There are four provisions in both the chronic care act and the connect for health act that would help patients to lower costs. These include lifting 1834 m reinstructions that hold back patients of who had acute strokes and need dialysis. People enrolled medicare. While these are an important first step, we still have further gore. We look forward to working with this committee to continue to advance the important provision dollars in the connect for health act including improving coverage of remote patient monitoring, lifting 1834m restrigss and giving the skekt of human Health Responsibility of 4ri69ing these costs if quality measures are met. Thank you to all the members here for the privilege of speaking before you today, and especially thank you to my partner on this legislation, senator wicker. Well thank you both very much. Were very appreciative that you would come and appear before the committee and give us your excellent remarks. Well turn to senator warner now for whatever hed like to say. Im proud to you one of the original cosponsors and i think its great to see that you both wore purple ties today, think that color coordination gives it a little certain extra. So did the chairman. So did the chairman. Its a trip let. I should be mention toad, i think. This shows when theres a will theres a way to get to things. This chronic care topic is obviously extraordinarily critical and i want to particularly thank the chairman and the Ranking Member for asking senator isakson and i to work with both ever you on this group. I know senator isakson is not here this morning yet but as in so many projects ive worked with him hes been a great partner, as have you senator chairman and wyden. I echo what senator schatz and wicker said in terms of telehealth being a critical part of how we deal with chronic care and how we get medicare right. The truth is, as our population ages and americans survive account illnesses, to an extent previously unimaginable, we need to make meaningful reforms to our Health Programs so we can move healthcare into the 20 u. N. St century to keep prourmszs and the ensure high quality care. All hoe though the rate anyone crease may be slowing, our aging population and uncertainty around 8 ford able care act means that our public Health Systems will continue to face serious financial challenges. I know this area particularly has been a topic for senator wyden for some time and hes repeatedly pointed out the fact that if an individual has more than six illnesses in terms of chronic disease, while that is only 14 of the medicare population, that accounts for about half of the medicare spending and as people continue to age those numbers are only going to go up. So that means tackling systemic reform, how we treat patients with chronic conditions, how we pay for quality and how we measure value are key challenges in what we need to get right. This Chronic Care Working Group which weve been part of and again working with colleagues like senator wicker and schatz, think weve got a good product and i thank the chairman, the Ranking Member hopefully were going to be able to move on this even if we cant agree on other areas in the healthcare field because the truth is our Current System fails to adequately care for patients with chronic conditions and unfortunately while our Healthcare System does a great job of paying for individual procedures, surgery, chemotherapy, hip replaceents, et cetera, it doesnt provide a good job for paying Healthcare Providers to coordinate care and to treat patients in a way that takes into account how these progressing conditions really do affect the lives of patients and their families. This Chronic Care Working Group received over 530 comments, submitted by Healthcare Community and subsequently meeting with our staffs met we 80 individual stake holder groups. Weve put together a series of proposals that would, i believe, modern eyes our Healthcare System including these changes would expand the Telehealth Services available to home dial lis patients. Ive got a daughter with diabetes i know how important it is to get that monitoring done at home. Provide greater availability of Telehealth Services to help ensure individuals presenting with strokes symptoms receive the best course of treatment. So some of the telehealth components of your legislation. Improve the design of Medicare Advantage to provide targeted highvalue services for individuals who need it most. Another provision of what were proposing would provide better Care Planning services, provided by directing gao to submit a report to congress to inform the development of a payment code for comprehensive care plaining. This is an issue that ive been working on since my tenure in the senate, goes back to my time as governor, my mom had alzheimer for ten years, didnt speak for niechb those ten years, trying to get that right and trying to make sure that we no longer remain the distinction of being the only industrial nation in the world that hasnt had an adult conversation about that part of life is something that i think would take a step in this conic Care Working Group to getting done. Although not perfect, these initiatives move the medicare systems towards better coordination, quality, costeffectiveness and make steps towards moving medicare into the 21st century. And i want to thank on behalf of senator isakson both the chair and Ranking Member for letting us work with you on this and i think weve the good a good product. Thank you. Thank you. We appreciate all the work and we certainly appreciate all of you at the witness table. Thanks for being here. Today, we have the opportunity to hear from four other witnesses that will help inform ourpath frd on chronic care. I want to welcome these four witnesses and thank them for their willingness to testify today. We will first hear from Katherine Hayes the director of Foreign Policy t at the policy center. Prior to joining bpc she was a Research Professor at George Washington skoofl Public Health and health services. Prior to joining gw, ms. Hayes served as Vice President of Health Policy for jennings policy strategies, inc. , and worked as a Health Policy adviser for two large catholic Health Systems and cardinal glennen, childrens hospital. Ms. Hayes was also served as Health Policy advisor to members of the senate and house of representatives in both political parties, served as a Program Consultant to the state of missouri, medicaid agency, and has edge and education policy adviser for the state of texas in the office of state, federal relations. Ms. Maize hayes received a bachelor of arts degree in International Studies from the university of North Carolina at chapel hill and a juris doctorate from the American University western college of law. Following her remarks well hear from dr. L. H. Schwamm professor of neurology at Harvard Medical School and executiveman of neurology at hospital where he is the chief of the stroke division. He also serves as director of the Partners National Telestroke Network as well as medical director for mgh telehealth and as a cochair of the innovation counsel and partners healthcare. He has authored over 250 peerreviewed articles and has chaired or cochaired many of the Current Practice guidelines for stroke and telehealthenabled care and delivery. Dr. Schwamm graduate from the Harvard Medical School in 1990 waund completed his neurologic training and fellowships in neurocritical care and vascular neurology at the massachusetts General Hospital. Hes testifying here today on behalf of the American Heart Association and the american stroke association. Third, we will hear testimony from john g. Lovelace, the president of upmcu, a Medicare Assistance Program and mel medicare participants in 40 counts counties in pennsylvania pelt also served as president of Government Programs and individual advantage for the new pmc Services Divisions as well as the chief Program Officer and Community Care Behavioral Health organization and Behavioral Health managed Care Organization that is part of the upmc Insurance Services division. Mr. Lovelace also served as board chair for the association of Community Affiliated plans. Mr. Lovelace received graduate degrees in rehabilitation counseling from the State University of new york at buffalo, and Information Services from the university of pittsburgh. Finally, we will hear from steven rosenthal. Mr. Rosenthal is the senior Vice President of Population Health management for monte fee orys inbah greated Delivery System as well as president dy yet care llc. Hes also an associate in the department of epidemiology and associate of medicine at the Albert Einstein college of medicine. Previously mr. Rosenthal spent a number of years practicing as a clinical auddiologist. He holds a mastors degree in sns science from Brooklyn College as well as a masters of Business Administration in finance and management. Information systems from pace university. Now, i ask you all to limit your Opening Statements to no more than five minutes each if you can, and mr. Hayes please proceed with your opening remarks. Chairman hatch, Ranking Member wyden, and other members of the committee, im honored to be here today. I cant tell you how many hours i logged sitting behind you in the staff seats when i worked for john chafe if i from rhode island back in the day. Today, bpcs healthcare project is led by former Senate Majority leaders bill frsk and tom dash he will had the our process for deputy developing pro policy is similar to the process that the working group took as it begin to put together this chronic care bill. And we are very impress pd with the way this has worked out, i commend the members of the committee for this open and transparent process and really thank you very much for the opportunity to have been able to contribute our views to the process. The committees work in drafting the legislation really highlights the need of caring for chronically ill individuals. Weve long known that patients with multiple chronic conditions have higher medicare spending and for decades policymakers have worked to address how costs, the needs of highcost medicare patients. Patients with multiple chronic conditions, four or more chronic conditions, as you know, incur average annual medicare costs that are five times higher than those with four or fewer chronic conditions. They have hospital readmission rates that are twice as high and four times as many Emergency Department visits. Increasingly, Research Shows that nonmedical social services and supports not covered under traditional medicare fee for service can reduce hospitalization, Emergency Department visits, and other expense of acute care episodes when supports are targeted to frail and chronically ill individuals. Examples of these Services Include nonemergency transportation to medical appointments, Home Delivery of lowsodium or lowsugar meals for patients with Heart Disease or with diabetes or other chronic conditions. Pilot programs tested in the community demonstrate that these type of services and supports have resulted in as high as 27 reduction in medical costs and significant reductions in avoidable hospitalizations. The Medicare Advantage program has a number of barriers in current statute and regulation to the provision of these services. And the recommendations that the committee has put forward goes a long way toward addressing those concerns. In fact, many of the recommendations that the Bipartisan Policy Center has put forward are very similar to the work that the Chronic Care Working Group has put forward. In medicare, there is a requirement called the uniform benefit requirement that requires all Medicare Advantage plans to offer the same benefits to all enrollees. Research has shown that for that the benefits of targeting services to certain highcost beneficiaries and with the plans that we have spoken to they said they would very much liking to provide a lot of these services, but theres not clarification in the law that they can do these things such as providing home delivered meals. In fact, there are limitations and regulations that allow them do that. For dual eling ablgibles, your allowing for coverage of services that are not primarily health relatded. Bpc has supported all of these. In fact, we took a look at the cost of these services. We looked at four services had the inhome delivered meals, nonemergency transportation and targeted Case Management services and found that within both the existing Medicare Advantage program but also in other plans such as Accountable Care organizations or patientcentered medical homes, the cost of these services could be as little as five dollars a month and when spread across the balance of Medicare Beneficiaries. In conclusion, id like to thank the committee for proposing these policy changes that are recommended in the chronic care act, but equally important, again, is the transparent and bipartisan nature of the prov says. Through these policy changes, many frail and chronically ill medicare patients could benefit from improved care coordination, access to care in the home and communitybased setting and the availability of nonmedicare covered supports. Thank you. Dr. Schwamm. Chairman hatch Ranking Member and other members of the committee, thank you for allowing me the opportunity to testify today about the chronic care act. We commend you for your bipartisan work to strengthen and improve the Health Outcomes for Medicare Beneficiaries living with chronic conditions. Your legislation would help people meet their healthcare needs as well as create incentives for the provisions of coordinated care for high cost beneficiaries. The american haft association is pleased to offer our full support for this important legislation. In addition to be a longtime volunteer for the American Heart Association im also a member of the American Academy of neurology and weve worked closely with the aan to improve telestroke as youve hear described today. We applaud to you are including this provision in the chongic care act. It takes an enormous stole on our families and nation its the number five killer and serious long term of zabltd and dementia. As the baby boomers age, its important that we reduce the risk of this disease. By improving access toss telestroke care, we can ease this burden. In the treatment of shoek stoke, we often say time is brain. Thats because every minute that a stroke goes untreated 2 million brain cells are dying along with 14 billion connections that go between them and they dont grow back. The clot busting drug tpa and mechanical clot retrieval devices are highly most common treatment and significantly reduce stroke disability, but they must be administered as quick lizza possible after symptoms start. Patients who get this 90 minutes from the time of their stroke are three times more likely to recover with little or nor disability. And pash whoebts get a clot device within 150 minutes, 90 of them will recover with little or no disability in the say gamechanging treatment in the field of stroke. Ive seen firsthand countless examples. Miraculous difference these treatments can make for patients, but unfortunately aye mong medicare patients the National Average tpa treatment rate is only about 2. 5 . Theres several reasons why tpa rates have remained low, including a shortage of stroke experts, as well as patients arriving at the hospital too late. The good news, however, is that telestroke has been proven to increase the percentage of stroke patients who get tpa and get it faster. One recent study of four urban hospitals in illinois with low treatment rates found that their use of tpa increased two to six fold after telestroke was implemented. Rapid and accurate diagnosis of stroke is a critical first step to ensure that patients get the best care. Even in urban settings they may experience delays in streemt. When a patient presents as a hospital that does not have a stroke expert, they can use the telestroke to get instant access to stroke expertise. Despite the proven benefits, medicares coverage of it is outdated. The current policy restricts coverage for Telehealth Services only to originating sites in very rural areas. I might add for example that 80 of people who live in utah and oregon liveout u outside this designation. The most significant step congress could take would be allow medicare to reimbus for telestroke evaluations regardless of patient location. In addition to improve arc says to evidencebased care, we believe the greater use of telestroke will result in cost savings to medicare and medicaid by reducing chronic disability and the need nor expensive longterm care. I believe this change is long over due and im heart end by the number of people that have endorsed telestroke in the in addition to 170 bipartisan cosponsors in the last congress, organizations such as the aarp, the American Hospital association, and the American Medical Association have aul also expressed their firm support for lifting medicares coverage restrictions on telestroke. In conclusion, telestroke is supported by a wealth of evidence and say common sense, costeffective step the committee can take to reduts burden of stroke as a conic disease. Im convinced that expanding the use of telestroke will greatly improve the kwauflt care that stroke patients receive, increase the utilization of stroke treatments, reduce strokerelated disability for Many Americans and save the Healthcare System money. We greatly appreciate the thought and deliberations that went into the development of the chronic care act and for the opportunity ton express our strong support at todays hearing. I urge the Senate Finance committee to act quickly on this legislation and send it to the full senate and then the house for approval. Thank you very much for the opportunity to testify. Thank you, sir. Mr. Lovelace. Good morning, chairman hatch, Ranking Member wyden and members of the committee. Thank you very much for the opportunity to be here this morning and to talk to you about the work of upmc and the work thats affected by the chronic cair act. Ive had ray remarkable opportunity over the past 20 years to learn about services in medicare, medicare, special needs plans, Childrens Health insurance, Behavioral Health and the marketplace operations. Being able to expand that operation with where i work with 50 nine other Medicaid Health plans to create other opportunities to include care and coverage for the most vulnerable citizens. We believe this bill would accelerate the pace of innovation and quality of services for all people certainly throughout medicare and other coverage options. As part of ann ta greated Delivery System, we worked very closely r with world Class Providers to provide other beneficiaries and other plan members to access to affordable innovative plan products. Our model finances aligns financial incentives between payer promote and to provide Higher Quality outcomes at lower cost. It gives us unik incite into care modalities and payment mow dats. With more than 3 million covered lives, we offer a wide range of services. Since our creation in 2003, special needs plans have fasd uncertainty in the form of contrary authorization. They are specifically designed to serve the most frail. Medicare complex and Medicare Beneficiaries by ensure that each plan member receives an accessed care plan and tail lorz services than she or he would otherwise have. While congress has recognized the value of these plans as part of medicare, they need to integrate efforts for these beneficiaries. They cover 23,000 dual beneficiaries were we are the second large e69 fourstar dual plan in the country and were positioned to begin in january of the coordination with medicaid Longterm Services in supports rolling out through pennsylvania through 2018 and 2019. We urge the support of the initiative to make this permanent and were in support of the conditions which are laid out under which that might happen. Weve also had the opportunity to work through the initiation of valuebased insurance designs in medicare. Pennsylvania is one in seven states in which this is covered. This offers the opportunity to do as catherine has suggested, to create essential incentives for people with chronic disease to participate more actively in their healthcare. Our particular program focuses on people with diabetes, congestive Heart Failure and depression and it allows people to engage in concentric programs to engage in Health Coaching and wellness supports to improve their care. The opportunity i think we hope to see and the bill expanded in the come are here and well have an opportunity to to prove its value as we move forward into 20 twnt. Another challenge to independence is the chronic of illness is the access to care. While weve made Great Strides in delivering high quality care, there are Many Services that are not delivered facetoface or in a patients community. They providing toque technology for Remote Services that youve heard this morning. While speed and convenience are one success of this also is the promise to develop healthy, active patients, but also reach people in rural areas and elderly Patients Living in areas where transportation maybe costly and burdensome. We analyze data from a number of initiatives we support including telemedicaid, teledermatology and so forth as well as online sink contracttist tus access to primary care physicians facetoface under the skype methodology. Our evaluations of these to date have indicated theres not ann contract mental cost to this rather it replaces Services People would otherwise get in the Doctors Office, Emergency Care centers and emergency centers. The act includes coverage that expand the telehealth advantage. This provides flex ability to better meet the needs of the patients. Were happy to answer any questions after were done and thank you for the opportunity to speak. Well, thank you for taking time to be with us and help us to understand this even better. Well now turn to mr. Rosenthal and well take your testimony at this time. Thank you, mr. Chairman and Ranking Member wyden and mebds of the committee. I appreciate this opportunity to discuss solutions to one of the most vexing problems facing the nations Health Systems, how to effectively and efficiently care for the growing numbers of american who suffer from chronic conditions. I commend the committee for its unrelenting focus on this topic. Monitor Health System is a premier academic Health System and University Hospital for the Albert Einstein college of medicine. We serve 3. 1 Million People living in a new york city region and the hudson valley, a combination urban, rural, and suburban communities. Approximately 80 of the patients discharged from our hospitals are enrolled in medicare, medicaid or both programsed on are uninsured. We have deep roots in treating chronic disease dating back to our founding in eight 1884 by jewish fill lan tro pists for pash webts chronic illness. Today were one of the largest groups in the country. As one of the nations original 32 pioneer acos, we have achieved overall savings for medicare of over 70 million out of a total cost of care of 2. 2 billion over five years. Were now participating in the next generation aco program well 55,000 beneficiaries and were optimistic we can continue to achieve savings for medicare and reinvest those savings in our Delivery System. When we apply to become a pioneer aco, we were a fourhospital system serving primarily bronch county, one of the nations poorest and most disproportionately diseased burden counties. Today the Network Includes 13 hospitals, three federally qualified health centers, and more than 3,800 primary care and specialty physicians, almost 30 of whom are in practice in the communities they serve. Yet its our decadeslong experience providing care for the 1. 4 million residents of the bronx, 75 of whom receive their Healthcare Service throughs medicare and medicaid. This gives us the experience to successfully manage the care of beneficiaries that are attributed to our aco. If you have any doubts about the importance of this concentration, consider this. In our experience, 5 of the 400,000 individuals covered by the value based contracts account for 65 of the total cost of care, and thats largely because of chronic conditions. Id like to just briefly discuss several provisions in the chronic care act which build upon provisions included in the next generation aco program and offer you our support for them. In our experience, perspective attribution is one of if not the most important crit cam component twoside risk models. While retro spective assignment of patients may be appropriate in onesided models, in twoside models we can quickly identify bishlz r beneficiaries with a history of high cost and high utilization as well as those with the potential for coming high cost and high utilizers. Perspective attribution allows an aco to deploy resources with a sufficient period of time to have an impact on the beneficiarys care. And or remain attributed to the aco to the end. Measurement period. Your proezal to expand the ability of acos to employ Telehealth Solutions that weve been discussing is an Excellent Way to provide Patient Access to services to best manage their chronic disease. To serve our urban and rural areas faced with challenges of getting to office appointments, Telehealth Technology can be a successful alternative to being there. In addition, this tool can provide specialty consults for primary care physicians in more rural locations and locally as for an alternative for Mental Health services where variable contact can be an important part of care. I would also ask the committee to consider an expansion of the definition of telehealth to include audio only. And those modalities that allow communication between providers, care managers and patients in a seamless fashion, especially in lowincome communities that may not have access to Video Conferencing incentives to their patients is visionary. While there may be a cost for developing the infrastructure to administer the benefit, it would not only benefit the patient directly, but also the provider. By improving his or her quality scores, the aco itself, increasing its potential for shared savings and the Medicare Program by lowering the total cost of care to the system. Incentives could encourage patients to remain in an aco Network Without limiting their choices. On behalf of the Health System, i thank you for your efforts to advance Accountable Care with proposals that i believe have the potential to improve quality and lower costs. I look forward to working with you to achieve our shared goal of a better Health System for all americans. Thank you. Thank you. And thanks to all four of you. Youve added a lot to this discussion. Well turn to senator wyden first. Thanks for making this a bipartisan effort. Let me begin to see if you can paint a picture for what its like for somebody 70 years old trying to navigate this byzantine maze of doctors, visits, multiple prescriptions and test after test after test. Seems to me, and im reflecting on my days when i was codirector of the great panthers, this is a labyrinth that can be challenging if youre, say, in your 30s and youre fairly healthy. I think it would be helpful if the four of you, real experts in this, could really paint a picture for what its like if youre a senior who has multiple chronic conditions, cancer say, Heart Disease, you know, diabetes. And what happens if youre basically out there on your own. In other words, if youre in a good Medicare Advantage plan, youll be able obviously to have some help, Accountable Care organization, ms. Hayes talked about a Patient Centers health care plan. But the reality is for lots of seniors, theyre really out there on their own. Dr. Skhwamm, youre an authority on this. Paint the picture for what its like for somebody who is 75 years old to get up in the morning and wonder how in the heck are they going to be able to juggle all of this stuff during the day. [ inaudible ] i think we got to get your mike working. Very important question and observation. Ill answer that in two ways. One is when the patient gets comes into the emergency room with a stroke, so many times theyre an older patient, 65 , 70 of all of the strokes that we see are in Medicare Beneficiaries, on multiple medications, havent been taking their medicines, didnt have the money or didnt understand the prescription or something got changed, they didnt make it to their last doctors visit. So often we see a failure of prevention. 25 of strokes happen to people who have already had a stroke. The issue is not knowledge and the issue is not a desire to improve their health. The real issue is the challenges of navigating this incredibly complex system. And i think from the perspective of then what its like to be someone in this community, the average length of stay in the hospital now after a stroke in the United States is four days. So in four days you come into the hospital, you have a new disability, you cant speak well or you cant move your arm or you cant walk. You get given 100 pieces of paper. 55 things get explained to you. Youre discharged from the hospital and unfortunately for most of our patients, its up to them to figure out how to pull a Team Together of advocates and providers and make sure they follow through on all of the instructions that we provide. What im struck by again, im trying to reflect on the days when and i ran the Legal Aid Office for the elderly. We handled trying to help patients in these cases. I gather that in the example that youre talking about where somebody isnt part of a coordinated care plan, arent part of an ma plan, Medicare Advantage, an Accountable Care organization, even when you discharge them from the hospital, i gather in a lot of instances if you ask the patient who you might even send records to, who could you make a followup call to so that somebody who is knowledgeable in the health field would actually be able to pick up where the hospital left off that in many instances. If a person isnt in some kind of coordinated care program, things break down almost at that moment after the hospital visit, is that right . Very much so. And its not that providers are doing something wrong. Everyone is doing their best. But when yes youve just had a stroke or your mom has had a stroke, youre not in the right frame of mind to absorb a lot of information. One of the things we find at my hospital, we make a phone call to every patient who is discharged home from the hospital within the first few days to make sure theyre taking the right medication. We frequently find that they have a cabinet full of medicines at home and they dont know whether to take the old ones or the new ones. They really dont understand what happened to them. I cant agree with you more of the need for a better way to investigate this complex Health Care System to prevent what we all know is coming down the road, which is another Major Medical illness or event if we dont get things sorted out properly. My colleagues all have questions. But i appreciate particularly your point about the role of the providers. Thats what has been at the heart of this bipartisan effort. Nobody thinks providers are getting up in the morning and saying, gee, i really want to be rotten today to people with chronic conditions. Quite the opposite. I think they share the frustration about the lack of who to turn to, particularly if you arent part of Medicare Advantage plan or one of these others. So youve been very helpful. Ill have some questions for the rest of you on the second round. But i want it understood, particularly the last point i made and the chairman has been kind enough, we meet every wednesday and we talk about it, to have it understood that for the future, for the long term i want somebody to be the point person, the point person for coordinating care for the people who are now essentially out there trying to make their way through this byzantine some on their own. We can do better than that. We are better than that as a country. So yall have been great. Thank you, mr. Chairman. Thank you. Senator roberts. Well, thank you very much, mr. Chairman. And senator wyden, i couldnt agree with your comments more. [ inaudible ] am i okay . Yeah, youre okay. Im authorized . Sworn in. Let me ask the panel this. Medication is a routine and the most prevalent means by which we prevent and control chronic disease. Thats right. But we read stats all the time im sorry. And time again that show a large number of individuals with these chronic illnesses do not take their medications as prescribed. Including in the chronic care edge las vegas theres a provision that directs the Accountability Office to study the extent of the medicare prescription use drug programs that synchronize so they may receive multiple prescriptions on the same day to promote medicationed medication adherence. As a long term champion with the work that i have done with senator harper whos taken the lead in this, and i thank him for that, strengthening medication adherence strategies, i want to make sure were targeting this to the patients that will benefit the most. Do you have any recommendation, any person on the panel for us to consider within this chronic care package and further legislation that will help us ensure were targeting the right patients to improve adherence . Dr. Skhwamm, do you want to take a shot at that . The first part of the visit is we go over the medication list to make sure its accurate in our Health System. And i would say that more than half of my patients are on at least one and a half pages of medicines. And we go through each one. And half the time they cant tell me what the medicine is for. They recognize the name and tell me they take one or two pills of it. We know for every additional medicine that the patient is prescribed, their ad americahers down. If the patients use a pill dispenser, filling up the pills on monday for the whole week, they increase their likelihood for adherence. It seems crazy that we dont invest money to make sure that the therapies that we know are proven effective when taken routinely get taken routinely. I would encourage the committee to target the patients that there the conditions for which we have the best evidence that these medications reduce the risk of rehospitalization, stroke and Heart Disease and Heart Failure, work to strengthen the program to encourage us to mange suke sure medication adherence is happening. One of the things that we do, because its very difficult for physician to reach out to large numbers of their patients, we use a number of farm ds. And they two out and help patients. Many of them a have as many as eight to ten prescriptions with the goal of trying to appropriately outline a plan using these pharmacists who work directly with the physicians to best manage the medications the patients are on. Because it enhances the compliance ultimately and avoid understand necessary medical consequences. Weve added that. Dr. Lovelace, you indicated you have a comment. Thank you. We do have a similar extenders, pharmacists and nurses to interact with the patients and physicians around complicated regimes. And the questions to ask people in this complicated processing, do you understand why youre taking this, can you afford to take it and does it make you feel bad. And if the answer is no i dont understand, yes, it makes me feel bad, then people dont do it. The option is to get a direct interaction with the patient around the experience of the drugs. Many people they have medications prescribed by seven doctors that only the patient knows the whole regime, not the prescribers. The pharmacist has an opportunity to pull it all together. What about over the counter . Seniors watch tv a lot. And you see all of these ads that say very positive things about the medication theyre trying to sell. Maybe thats not putting it accura accurately. Or promote. And then they always list everything that could happen to you at the bottom. But i think probably a lot of seniors go in and buy these products adding to their prescriptions. The mix of that im not too sure works very well. Would you comment on that and how we could get our arms around that one . Well im not sure i can tell you how to get your arms around it but i think there is a misperception that things you can buy over the counter are not drugs and medications. And i counsel my patients frequently that they need to tell me everything they take on a regular basis, including things they buy in the health food store, nontraditional medications. Many times patients may be taking things that interfere with the effectiveness of the treatments were trying to get them to take. And as i mentioned before, its the number of things you take every day that lead to you not taking them regularly. That includes overthecounter medicines as well. And we know that over time we discover there are harmful effects for many of the things that we presume to be benign or only have beneficial effects. I think this poly pharmacy is used to describe this mixture of medications. And the idea of reconciling those medicines and looking for interactions between them is incredibly important. You practice in an integrated Health System, the software you use to prescribe medicines will often alert you to dangerous interactions between med sicine you may not have been aware of. Anything we can do to strengthen the support at the time of prescribing and at the time of visits to help providers and physicians understand the dangerous interactions is important. Thank you for that. My time has expired. I want to thank senator harper for working with me. And im working with him on this legislation. Thank you. Senator. Thank you very much, mr. Chairman. I want to echo senator roberts concerns on what is happening on medications and i appreciate very much what all of you are doing. And mr. Chairman, i thank you for the hearing today. Im a proud cosponsor, and senator wyden of your passion on this, the chronic care act. Its two years of work of hundreds of stakeholders. This is a very important model of how we should be Going Forward frankly. When we did the last major Health Reform that is now under such great political debate, we had 100 meetings in the senate, and hearings between the finance and the health committee. So i would hope that were going to be focusing on improving quality, lowering costs, lowers premiums, creating more quality. And i would very much hope and im very sincere in this that whatever product comes forward in the senate before it comes to the floor that we have an opportunity to have a hearing on impact. Because this is really important. Onefifth of the Gross Domestic Product affects every single american. The other thing that i would say, because its so important as were looking at this discussion which is very positive, thoughtful in the right discussion, that for seniors, people with multiple chronic conditions, people in Nursing Homes and so on, the bill that came over from the house is exactly in the opposite direction. 880 billion being cut from medicaid. And in michigan three out of five seniors in Nursing Homes and half of the people with disabilities are covered by medicaid. Im underscoring this, why its so important that we have input. Because this bill, the chronic care act is very positive. And what has come to us from the house is very, very negative. And would undercut everything that were talking about. I want to specifically talk about the value based insurance designed today. Not something that everyone in the public really would be thinking of in terms of an improvement in the system. But i probably have to say this is a michigan export in 2005 dr. Mark started the Michigan Center for value based insurance design. Theyve done terrific work in evaluating inveinovative health plan benefit designs to improve care and lower costs. And senator thune and i have worked on this as well as many others. And this bill would take this from a pilot in seven states as you know to the opportunity for every state to use this. So first mr. Lovelace, i know you mentioned that your health plan is participating in the model. And i wonder if you could talk a little more about that, the types of plan designs that youve incorporated. Have you used it in other commercial plans . And have you seen any results so far and what would those results be. Id be happy to. We have about 8,000 enroll lees at Medicare Advantage who are eligible to participate who have the combination of conditions that are targeted. And weve had a lot of opportunity to have the consultation with the doctor and his staff in what he knows and how it informs our program. Hes supportive of our work in this area. It would be fair to say at month number four that we do not have any results yet. The people that the plan we have designed basically is a series of six 25 incentives which we have to pay in checks. As People Choose to achieve certain goals. The drill basically is the first incentive is do you agree to talk to a health coach. Do you agree to participate in the process. Second step is set goals for yourself. Theyre whatever you want them to be. They could be diabetic related, could be something else. The next step is that you along steps along the goals and you work on the steps. You dont have to achieve them, you dont have to lose weight if thats your goal, you dont have to have an a 1 c under 9 if thats your goal but you have to make an effort to work on it. Most people who have been offered a chance has been enthused act it. Its a lot of time to spend on the time with Health Coaches and people medicare recipients on the whole like to talk on the phone to people. They like some help because theyre bewildered by the whole system. And anybody who has a glimmer of how to get through this in one piece is helpful. Its an engaging experience. Were pleased by the uptake and we look forward to evaluating this. We have incentive in the program around health and wellness issues, including setting goals around weight loss and Blood Pressure control, a different kind of financial payoff to people. We have about 65,000 employees. You eliminate your deductible by engaging in thhealthy behaviors. Its significant you save 1,000 a year in your deducti e deductible. It catches peoples attention. 500 did not. Weve experimented to see what the level is that people Pay Attention and it seems to be 1,000. Turns out health care is complicated. Who knew . I didnt know. Did anyone im out of time. I didnt know if anyone has a quick comment. You have. Im out of time. Ill leave it there. Thank you, senator. Senator harper, youre up. Thanks mr. Chairman. To one and all welcome. Thank you for trying to help us and help us better assist the folks that we represent. My mom died a number of years ago. She had dementia for the last years of her life. So did her mother and grandmother. She lived down in florida near clear water. And my sister and i would take turns going down seeing her about every other month. Wed take turns. One of the things that may mom had what looks like a fishing tackle box. It had no fishing tackle in it but a lot of medicines. She would take one before breakfast and throughout the day and night and she reached a point in her life where she couldnt do it on her own. My dad was deceased. We hired people to come be with her part of the day and eventually 24 207 help her. One of the things that we found out, she had seven doctors and they were prescribing a total of 15 different medicines. The doctors never talked to each other. We were convinced that some of the medicines were just fine for her conditions and some were probably not. And so one of the things that senator roberts and i with the help of our staff is to figure out better ways to do that. And im sure there are. But yall have talked about this already. Talk to us about best practices. I dont care who goes first. But just practice to deal with situations like that. I know theyre common place. Somebody has nifigured this out. Give us a better idea of what the best practices are. Ms. Hayes would you go first, just briefly. Sure. I think some of the best examples have been done through duals special needs plans. There are a couple of staltes that are more gartd think iforw. One im familiar with is massachusetts, theyre doing the coaching that the eligibles need to get their drugs at the right time. And most importantly, they have someone that they know they can call at the plan. They have a phone number and the name of a person that they can call when they need help, or their caregiver can, in the case of your mother, shes not able to do it. All right, thanks. Dr. Schwamm. The concept of the patient Medical Center home, the era of marcus wellby. Someone in the Doctors Office knew you, knew your circumstances with. There was a Community Around you that would tell you need help if youre struggling. We live in a very Different Society now. But we need to figure out ways to coordinate the care so that somebody owns that person and owns the issues around them and make sure that the specialists are coordinated. But as was said a minute ago, medicare is really complicated now. I was watching the audience when you said dr. Marcus welby, and the people under 30 did anybody know who i was talking about . We knew. Telemedicine and telemonitoring in terms of reminder to people, in terms of texts, in terms of monitoring whats in the pill box. There is a lot of technology to support the efforts of caregivers and physicians. They certainly dont replace them but can coordinate them. Thank you. You raise an important aspect, the benefits of a clinically integrated system using technology. And with some care coordinating capabilities within that. What we do is through the depth and breadth of our clinically integrated system, incorporate that information with our medical records so that all of the physicians know what everyone else is doing and the information about medications and the like or incorporated within that system. And then we take responsibility for those individuals and have a care coordinating process within our operations so there is someone trying to be accountable for those individuals that have those complicated health issues. All right. Thanks very much. One of the issues i focused on, my staff and i focused a great deal on, some of our colleagues is the issue of obesity. And were not getting any slimmer. And theres, i think reasonably, were going in the wrong direction. So many bad things flow from being i was in a hospital in dover, delaware not too long ago and went into one of the operating rooms. They had a hoist and i said, what is this for and they said this is for people that are really heavy. I said like how heavy. One person 700 pounds, 800 pounds. Unbelievable stuff. But in terms of getting us on the right track to do a better job of reversing this trend, epidemic toward obesity, give me one piece of advice for what we should be doing at this level to help win this war. And dr. Rosenthal, you want to go first in. It begins at a very young age. I think ad lolescent obesity begins to bring individuals to the complicated illnesses that obesity can lead to. It begins in the school, the school Health Systems. Were active in the school Health Systems. We have one of the Largest Networks of schoolbased health care, educating our Young Children today on eating habits, exercise and if we can begin at the early ages, i think we can begin to stem the tide on obesity. Thanks. Mr. Lovelace . I would certainly agree with that. It is its not that we dont know what to do. We know we shouldnt smoke, we know we shouldnt be 700 pounds, we know we shouldnt eat cheeseburgers for breakfast but people do it any way u. Ingraining early what Healthy Eating and exercise is so its an expectation. Not something you to learn to do. A contributor to stroke and stroke rates are in the rise in younger americans now shockingly and depressingly. Avoiding a sedin tear lifestyle is critical and making affordableable thel thy fo affordable healthy choices. One diet soda a die triples your risk of dementia. We are what we eat and we need to be focused on healthy food. Katherine. Education on what to eat and the importance of physical activity is absolutely important. But there are a lot of confusing messages out there in marketing. My mother has Heart Disease and diabetes. And because hes not able to go up the stairs and use the kitchen in our home, she lives with us, she was buying prepackaged meals that were convenient. Theres so much salt in them that she ended up in the hospital last week because she had too much sodium and started having Health Problems again. I would agree making Healthy Foods available and education. My time is up, senator. Senator thune. Thank you, mr. Chairman. I want to thank you and senator wyden for holding this important hearing. Im pleased with the progress we heave made with the bipartisan chronic care act. I look forward to working with you and members of the committee to promote care coordination. And i also want to again recognize the senators who were here earlier and the rest of the connect for Health Working group for teaming up to increase access to telehealth technologies. The inclusion of a number of connect for health act provithss in the Chronic Health care act is a step forward improving access to timely and Effective Health care. Dr. Skhwamm thank you for being here. Early this year i introduced the f. A. S. T. Act which seek to break down existing barriers related to telestroke technology. Parts of south dakota fall into a Health Professional shortage area and may meet the geographic requirements that exist under the krurcurrent law you mentionn your testimony that some urban regions do not have access to neurologists to make timely diagnoses. Could you talk about how geographic and originating site restrictions on Telehealth Technology have limthed access to effective but time sensitive treatments for stroke victims both in rourl and urban areas . I think it would surprise people on the committee to know that 90 of the strokes in the states every year are occurring outside of the coverage area. The area that medicare has designated coverage for is a small swath of the United States and its not densely populated. The places that need this treatment are not far from where you and i live. When i first started doing this work about 15 years ago, hospitals 15 or 20 miles away from the mass General Hospital in boston were not treating with tpa because they didnt have the availability of a stroke expert. Its very straightforward to provide the necessary information that you need at the bedside to make a diagnosis of stroke, review the brain scan, examine the patient, talk with the family and make a decision with the bedside physician with the technology that we have. The main barrier is creating an environment where people feel there is no option. This is a standard of care and every hospital needs to be able to provide this evaluation. We wouldnt accept the idea that you come in the hospital with a heart attack and be told we dont have a heart expert available, well have to send you to another hospital an hour away. And if you dont get treatment when you arrive there because its too late, im sorry. We have to have that same attitude towards stroke. And this opening up of the geographic restriction will encourage many more hospitals to be able to initiate these service which are broadly available in the u. S. And europe. You in your testimony you also noted the potential savings that could be found by investing in telestroke technologies instead of treating the lasting effects of stroke after the episode occurs. What are some of the issues faced by stroke survivors that do not receive timely care versus those who do as well as the cost associated with those conditions. Well you know, there are huge hidden costs of stroke on our society. Im sure many of the members have had has Family Member who has had a stroke. Patients become disabled, often cant return to live at home or if they do often need close to 24hour care. Loved ones have to give up working or reduce their work in order to be available and help take care of their loved ones. If people need chronic care and residential care, they go through all of their savings first and end up on medicare and in the nursing home with frequent admissions to the hospital for bedsores, pneumonia, urine infections, recurrent strokes. Its a debilitating disease and it happens in an instant. Your life changes in an instant. The math is simple in that we know that telescope increases the use of tpa. Every treatment with tpa saves money because it avoids Long Term Disability. A study back in the late 90s estimated 4,000 per treated patient of savings because of the reduced burden of this. And if you multiply that together with 500,000 Medicare Beneficiaries who would be eligible for consultation if the restrictions were removed, you can see that the savings are going to accrue. Now whether they accrue to medica medicares budget, the state budget or to other payers, someone smarter than me will have to figure that out. Its a good way to find a low cost treatment that we know is effective and we would encourage the hospital to do anyway if they had a stroke expert on hand. The cost is trivial. What were talking about is spending more money giving tpa to reduce Long Term Disability which is the highest level of evidence recommendation of every major professional society. Mr. Chairman, i just mention i want to associate myself i understand that the senator already talked about value based insurance based model which is a legislation that we worked on. So i would think shes covered that base already. Thank you. Thank you, senator. Thank you, mr. Chairman. I want to thank you and senator wyden for bringing this hearing forward. This is how we should be conducting our business on a bipartisan basis. I thank you and i think its going to lead to some good results and passage of legislation. I want to follow up on senator thunes point on telehealth. My state, a rural part, very rural part of maryland at the va facility where they dont have the type of specialists that you would have in most communities. So ophthalmology is performed through telehealth and it ears working very very well. On the dealing with the stroke victims, we have three policemapolicemarograms works in maryland today, we have a program work in hagerstown which is also working well in conjunction with major center. So we have programs in our state that are performing extremely well. Also incorporated in the bill is the deal with dialysis patients. With a stroke victim saving the cost by reducing the disability is time intervention is critically important. But a dialysis patient, it becomes a matter of cost and getting to a center and trying to have some degree of normalcy in life. And to be able to do your teleexam so that a person can get care in their home can save a great deal for a family and make a person much more mobile. So my question to you, this bill moves us forward in telehealth but be a little visionary. Where do you see telehealth going . What can we look forward to doing . What obstacles are in the way . And what concerns do we have as we move more towards a teleHealth System so people can get more timely and more cost efficient care . Dr. Skhwamm if you want to start. Im curious as to where you see us going and what we need to change in order to accommodate this type of health care. One of my favorite topics. Thank you for the question. Just briefly to comment on the dialysis question. Anything we can do for access increase the services. We spend a huge amount of money on balance transport for dialysis patients to and from dialysis is a hidden cost that could be reduced by using telehealth in these circumstances. My hope and vision ten years from now, 15 years from now we wont be calling it telehealth. Well be calling it health care. Theres no reason that the falsefalse dichotomy of inperson is going to exist. We dont call it mobile banking and think of it as a separate enterprise and have separate costs. Anything you can do that way saves everybody money, makes it more convenient and desirable. I really think we have to examine the health care encounter. And theres more than one type. Deconstruct it into its individual parts and reassemble them in a way thats Patient Center centered, not doctor or hospital centered. If we do that right well figure out how to provide better care sooner and well be able to implement upstream befores thes manifest themselves. We have to Fund Research to find what hewere doing is evidence based. We must be driven this way in the way that we are in medical care in general. We also dont want to create a new Digital Divide where we disinfranchise a new class of Vulnerable People because they dont have access to the technology in the same way. These are important parts of weaving telehealth into health care. If i could build it a minute, you heard earlier, the Health Care System is really designed for the convenience of Health Care Providers with not for the convenience of users. This is a move, this customization of health care to make services for accessible, more convenient and timely is a Movement Toward a more consumer friendly model to enable people to manage their care with improved access to quality standards. And i athink telehealth has the ability for more consistency in monitoring. I would sb interested if you believe in the reimbursement structures, there are certain areas particularly unfriendly towards advancing technology. I think the restrictions on state licensure and some of the regulations around billing and as to whether the doctor is licensed in the location where the patient is living, it would make a lot more sense to have physicians licensed in the state where theyre rendering care. Its cray za that a patient who lives in New Hampshire sees me in boston, has a crisis and needs my held. That under the law i shouldnt provide any medical advise to them if they call me from their home in New Hampshire. Theres a lot of opportunity there to rethink what it means to be licensed to Practice Medicine for telehealth. Thank you, mr. Chairman. Did you want to respond . I was just going to add to what dr. Schwamm said. I think in the future technology will be evolving so quickly it be become a component of our everyday life. Making sure that we understand the impact of the tools on the Health Outcomes becomes important. So i think the opportunities are enormous and i appreciate the committees vision on that. Senator bennettme. Thank you, mr. Chairman and thank you and the Ranking Member for holding this important hearing and for your leadership over many years on chronic care issues. I also want to thank senators isaacson and warner for convening the working care group. A lot of good work has been done there and i think some Thoughtful Solutions for how to improve care for the sickest are coming to the floor now. Over 70 of health care spend in the u. S. Is linked to care of those with more than one chronic condition. And weve got improved care with those with diabetes, parkinsons. These are our loved ones managing complicated instructions and may need a caregiver to help with daily tasks. Mr. Lovelace, the independents would help improve the care of patients in the comfort of their home and reduce costs. I would like to thank the senators for their leadership on this bill which would make the independent at home a national and permanent program. The independence at home model takes it possible for Health Officials to provide access to care 24 hours a day, 7 days a week to beneficiaries with multiple chronic conditions. The home payment model saved 3,000 per participating beneficiary. They need expansion of the act. If were to go further and make this a national program, programs at upmc and those in my home state of colorado, do you think be able to serve even more chronically ill patients with Higher Quality and better Cost Effective care. Absolutely. We are fans of independence at home as a model. We have a version not quite exactly the same that we employ in our health plan with roving care managers with Nurse Practitioners who visit people on a regular bay missis. Consistently managing chronic conditions as they begin to get worse instead of waiting on the emergency room. Were supportive of the expansion of that. Have you been able to measure cost savings in your own operation as a result . We dont do independence at home as its laid out in the bill. But in terms of our own efforts it reduces significant reductions in unplanned care, improvements in adherence to medications, people go in and organize your pill box. On the whole it saves a lot of unplanned money it costs money to do and its a break even for us. Doctor, did you have something to add . Zbli was reflecting on your comment about parkinsons disease. If you go to a typical neurology clinic in the country, youll be seen once every six months for 30 minutes. Id argue for being seen for five minutes a day for six month to adjust your medications would be time and money better spent and would save that poor family, you know, 60 to 70 hours of travel and recovery and the debilitating nature of the disease makes ambulation difficult. So there are better ways to spend even the dollars that were spending now. And thats actually a fascinating very practical point. Why arent we seeing somebody what are the to doing it the way you describe. The first is you dont get paid. The system doesnt get paid, the doctor doesnt get paid. The patient spends a lot of money taking the day off from work, having a loved one come with them, driving, parking, waiting in the waiting room for one, two hours, not being able to see someone at night or a time thats convenient for them. Its really doctorcentered care or helicoptercentered care. Telemedicine, what were seeing now is theres so much demand for this that were seeing Urgent Care Solutions pop up in the cracks of our existing Health Care System. Once the flood gates are open and we are reimbursement you can see better creativity at meeting the needs of the patients. Thank you for that. Chronic care is taking important steps to increase care coordination for those with multiple drchronic conditions. It would allow Medicare Advantage plans to offer Supplemental Benefits designed for chronically ill beneficiari beneficiaries. Medicare advantage plans make sense for many seniors as they align with their hospital, doctor and Prescription Drug benefits. Thats why i worked on the medicare plus act to enroll the top 15 of highest cost Medicare Beneficiaries in a Medicare Advantage plan or an Accountable Care organization rather than a fee for service plan, a plan or aco can work with their doctors or hospital to coordinate better their services and medications. What do you think we should keep in mind to anybody on the panel as we continue to work on our proposal and other proposals here to better coordinate care for the sickest and highest cost patients . What are some of the unintended consequences we should try to avoid. I think you guys have today done us a lot of good by pointing out that not enough of the Health Care System seems to be patient sen tr centered. Its focused on the people delivering the care. But this is about the patient not having to fight the system to get the care they need when they need to care so that in the end its cheaper. I wonder if any of you have a met that observation about what we ought to keep in mind. I think the most important thing we have to understand wh when we move forward value based purchasing and other measures is what is the outcome of interest. If were looking at quality, quality from whose perspective. Is it patient reported outcomes, the things that matter most to patients . Is it things that are easy to measure we because we can measure them. So much work needs to be done to build the patient measure to are medically meaningful to have costs tied to them so we can monitor what were doing. Anybody else . Im sorry, mr. Chairman. I realize im out of time. Thats okay. Anybody else want to comment . Just a brief comment. One of the greatest failures for health care is blaming the patient for failure to compliance. And its much more driven by people not being able to comply with whats instructed or not understanding or have the wherewithal. Thinking of the mco persian of what the partnership is, people who use services need tore engaged more actively rather than passively. We assume people will participate and oftentimes they would if they could but they cant. I have to say as chairman of this committee, this has been one of the best panels weve ever had. I havent asked any questions. I used to be a medical Liability Defense lawyer. So ive dealt with has number of these problems. You folks are really covered this about as well as ive heard it covered before. I want to commend you for it. Senator wyden has a question he would like to ask. Thank you very much, mr. Chairman and i very much share your view with respect to this panel. I think this is the finance committee at its best. I mean this is tackling i think its a panel at its best, myself. Sorry. I was giving you the credit for bringing them. All right. Let me ask about one other issue that we have talked a lot about in oregon. You touched on it i think just sort of collaterally, ms. Hayes, and that is that a big part of our challenge here is that a lot of these patients with multiple chronic conditions face challenges that probably dont fit into the quote medical box, but clearly have ramifications for their health. I think someone mentioned access to transportation, certainly the inability to get access to Good Nutrition affects diabetes. In our part of the world people always talk about the fact that you may have a patient with a heart problem and its very hot and humid and they cant get access to an air conditioner. And maybe a really cheap air conditioner would save enormous sums in terms of the person having to be hospitalized. And in effect, these are conditions that might not be quote technically medical, but just proportionally hurt patients with multiple chronic conditions. So i think ms. Hayes you were the one, you know, who touched on it. I think i would like to hear you just kind of describe, as we wrap up, what you think the role is for services that dont fit the classic box of being medical but have enormous ramifications for a persons health. Obviously m. A. , the Medicare Advantage program has tried to incorporate some of that. But as we wrap up, what the chairman has correctly said has really been an exceptional panel. Were counting on all of you to stay with us as we try to move this across the finish line. I think sometimes as i have talked to people, people have said, excuse me, ron, youre going to pass a major medicare bill, you know, in this kind of climate . And i said weve put a lot of work into this. Weve got a good Cross Section of the senate represented on this committee. Were going to be calling on you for your help to get this across the finish line. Just wrap up if you would for me, ms. Hayes, your sense of what we ought to be doing for the long term as it relates to treatment for these services that dont probably fit the classic box. You know, people always say to me in health, the cost find coverage. That sounds like its pretty good for the provider but it probably isnt so great for the patient. What would you do for the patients in the area that were talking about, the classic being the air conditioner for somebody who has a heart problem and could be helped with modest costs . I think one of the most important components of this legislation is that youre allowing plans or allowing reimbursement models that are working under a bench mark or capation system to cover anything thats reasonably related to improving or maintaining health and functional status so long as its part of a care plan developed by care team. And this allows providers to sit down with patients, with Family Members, with their caregivers and really talk to them about what they need. And basing their care plan on what they need rather than what the Medicare Program covers. And you know, someone has suggested to me, actually one of my staff at one point said to me, are you telling me that you would allow medicare to cover a Dog Walking Service . And i said, well, you know, if a plan working under a capitated system determines that its better to bring in a dog walker for grandma on a day when there are six inches of snow on the ground to avoid a hip fracture, maybe we should consider that so long as its within that payment model. And its to the benefit of the plan to provide these services. Why dont we do this. I know senator warner has got additional comments. Could you furnish us for the record two or three of the models that you think have been particularly good at picking up on this area that im talking about, the services that dont technically fit what would be called the medical condition . Could you furnish that for the record . Yes. Senator warner, youll be the last one. Thank you, mr. Chairman. I appreciate that and recognize sometimes when a member comes in after a long hearing, i wont try to take my whole five minutes. But i want to at least that would be great. I want to start by thanking you and the Ranking Member and also for the wisdom of appointing Johnny Isaacson to serve on this effort as well. I think echoing what senator wyden said, we got a great product here. It may not be the whole enchilada but its an area where we can find common ground. Thats right. And i would commend both of you and commit anything i can do to assist in getting it other the finish line. Not only the value of this product but the value of showing that even in these challenging times this committee on this challenging subject can move a product, count me 100 in in any way i can help. Thank you, senator warner, we appreciate that. Ms. Hayes, two questions. One, two parts of the bill that i particularly like, having been a former governor and can probably get comments to everybody, ill just go to ms. Hayes on this. The challenge with dual eligibles and the challenge of folks that float between medicare and medicaid and the amount of time it takes to qualify, requalify for one program after another, you know, we do have an appeals process, a streamline appeals process for grievances in this legislation. To my mind thats a great step forward. Do you want to make a comment on that . Sure. That has been one of the major challenges in the demonstrations because of the differences in medicare and medicaid laws. And i think that will move forward. One of the promising things is the concept of a threeway contract. The state can sit down with cms and a plan and negotiate a contract to provide services with uniform requirements between the medicare and Medicaid Program so you dont have patients working with two its bad enough to be 78 years old and have medicare. But to be 78 years old, have medicare and medicaid when the Program Rules dont align right. That goes back we had those issues back when i was governor. Final point i want to raise. Senator isakson and i shes been a great partner again have championed a long time the Care Planning act and this whole question about not limiting by any means anyones choices but expanding choices and trying to urge family to sit down with their caregivers, with their religious figures, with medical personnel and really kind of think through the part of life that were going to go through. Increasingly, you know, weve got a lot of folks with lots of chronic illnesses that have cognitive impairments. And one of the things that our bill does is introduce a gao study to identify barriers to Care Planning that would take place particularly for folks who have these chronic illnesses and chronic impairments. Do as i say, not what i did. I was relatively wellinformed individual, a governor of virginia but we didnt sit down and have those conversations with my mom before it was too late for her to participate. I think this is again an important step forward. I appreciate the chair and the Ranking Members support of this provision. Quit comment on that and then ill sign off. Sure. I think the way youve structured it, structured reimbursement would allow a team to sit down or a care team to sit count and talk to the Family Member. My mother was just discharged from the hospital and they asked if she had a care plan. They gave her one going in and going out. And she was not educated on this and she was afraid and didnt understand what they wanted her to do. But telling her mom, you know, i have a care plan, an advanced care plan, this is really something thats important and it benefits not only the patients but their families who have to make such terrible decisions. And i simply close out by saying again, mr. Chairman and Ranking Member, we ought to prove the cynics wrong and get this legislation passed. Thank you for your great work. Thank you. And we appreciate your support. We really appreciate the four of you. Youve been wonderful witnesses. What we consider to be a very very bipartisan discussion. And we intend to get this bill through. And i think youve made our lives a little better in getting it through, because of the excellent testimony youve brought here today. I want to personally thank each and every one of you. I havent asked any questions because i wanted everybody else to have the opportunity to. But ive listened carefully and all i can say is youve done a great job and youve represented an awful lot of wonderful people in ways that they havent been represented before. So were grateful to have you here and with that were going to recess until further notice. Cspan ewashington journal live every day with news and policy issues that impact you. Wednesday morning, South Carolina republican congressman joe wilson shares fallout. And Sheila Jackson lee discusses the latest on the firing of james comey and the future of the fbi. And amtrak president and ceo Charles Mormon and association of american railroads president edward hamburger discuss the state of the rail system during infrastructure week. Join the discussion. Agriculture secretary sonny perdue testifies on the impact of agriculture on the u. S. Economy here on cspan. You can also follow live on www. Cspan. Org and our free cspan radio app. Thursday, treasury secretary stevemy mnuchin testifies about International Fiscal policy. Hell testify. Our live coverage begins at 10 00 a. M. Eastern here on cspan3. Saturday on book tv live all day coverage of the maryland book festival. Starting starting 10 00 a. M. Eastern, at 10 30, melvin goodman, author of whistle blower at the cia. Sharon wineberger discussing her book, the untold story of darpa, the Pentagon Agency that changed the world. At 1 15 eastern, Craig Shirley on reagan rising the decisive years. At 2 15 p. M. , sydney blumenthal author of the political life of abraham lincoln. And at 3 15, Sally Mott Freeman on the jersey brothers, a missing naval officer in the pacific and his familys quest to bring him home. Watc live all day coverage starting saturday at 10 00 a. M. Eastern on cspan2s book tv. The democratic policy and Communications Committee and a group of Senate Democrats hosted a meeting on the Republican Health care replacement bill. Witnesses included the Pennsylvania Insurance Department commissioner and those affected by chronic illnesses. This is just over two hours. Good afternoon. Well call our hearing to order. We know we have many more colleagues that are coming to join us. But we will get started in the interest of time. First thank our wonderful guests, our witnesses who have come here today to share their stories. As we look at the panel, i have to say it looks like the great lake states. I did not plan this on purpose, but we have indiana, michigan, pennsylvania, wisconsin. We are glad to have the great lakes represented here today. We thank everyone for tuning in to the livestream. For engaging with us. If youd like to share and we hope you will share your story