where marsha blackburn is running to replace bob corker in the senate as he retires. we will have live coverage of streaming online at c-span.org starting at 8:00 p.m. eastern. tomorrow the release of the annual state of cities report focusing on the priorities and issues as he says across the country. coverage at 9:00 a.m. eastern on c-span2. >> a senate finance committee hearing on some challenges facing world hospitals with industry analysts and healthcare providers talking about incentives for doctors and potential changes to medicare payments. this is chaired by the utah senator, orrin hatch. [inaudible conversations] [inaudible conversations]

>> the hearing will come to order. i would like to welcome everyone to today's hearing. the topic today is a rural healthcare, which is a critical issue for virtually every member of this committee and so many others. as long considered a special mission to create the same rural payment opportunities that many of our nation's urban counterparts enjoy. representing western state i understand the challenges a rural hospital and providers face to deliver high-quality medical care to families in environments with more limited resources. in the senate, rural healthcare policy both a long history of collaboration and cooperation on both sides of the aisle. take for example back in 2003, when we passed the medicare

modernization act including a comprehensive healthcare package tailored specifically with rural communities, hospitals and providers in mind. the mma finally put rural providers on a level playing field with their neighbors in the larger communities. the law also put into place commonsense medicare payment provisions to help isolate underserved areas of the country and provide access to medical care as close to home as possible however, the vast majority of rural health payment policies enacted in the mma were permanent, someone will-- were only temporary and in the years following to bury provisions have become known as the medicare extenders. as many of us know the problem with extenders is the annual debate over necessary funding often takes priority over

developing a more robust strategic plan for the future. although, some partisan and bipartisan healthcare policies have altered medicare payments, many rural healthcare providers still face significant obstacles attempting to successfully participate in medicare delivery system reforms and payment arrangements. while these changes continue to emphasize new ways to pay providers, medicare's existing strategies to preserve access to health care in rural areas don't rely on special reimbursement programs that either supplement inpatient hospital payment rates or provide hospital payments. these special payment structures may work just fine in a certain parts of the country, but even with a wide range up special medicare rural payment programs

some smaller communities are home to hospitals tha find it hard to achieve financial stability. the reasons, as we will learn from the expert witnesses on the panel today, are complex and multifaceted. for example, when compared to their urban counterparts on average the 4 million medicare beneficiaries living in rural areas-- rural land frontier areas are less affluent, suffer from more chronic conditions, face higher mortality rates to make matters worse, small rural hospitals continue to be more heavily dependent on medicare inpatient payments as part of their total revenues. at the same time we are seeing a steady nationwide shift away from inpatient care to providers

offering more outpatient services, it seems to me. many rural hospitals serve as a central hub of community service and development, but some struggle to keep their facilities operating in the black in order to meet local demand for a full range of inpatient outpatient and rehabilitation services. resolving these issues is no easy task. clearly, for some communities medicare's special rule payments structure-- structures i guess i should say may stifle innovations that could pave the way for more sustainable rural healthcare delivery systems. one consistent theme that we will hear from our witnesses today is the need for flexibility. they are not asking congress for one-size-fits-all federal policy

they want the flexibility to design innovative ideas that are tailored to meet the specific needs of the communities they serve. they need the federal government to support data driven states and local innovation that have the promise to achieve in increasing access to basic medical care, lowering costs and improving patient outcomes. the federal government cannot tackle this challenge alone. while i was pleased to see cms release its rural health strategy earlier this month, i believe this administration led by hhs a secretary still needs to improve the nation across the agencies within the department to help prioritize new rural payment models while reducing regulatory burdens on rural and frontier providers.

state and local officials must be aggressive in their efforts to design transformative policies and programs that meet their unique rural healthcare needs and the federal government really needs to listen to we should listen to what these folks had to say and how we can -- what some of the solutions really are. in my view, states should be the breeding ground to test new ideas. however, it's not sustainable for every small town to have a full-service hospital with every type of specialty provider at its disposal. that is why it's so important for rural communities to work together, share resources and develop networks. of the federal government must continue to recognize the important differences between urban and rural healthcare service delivery and respond with targeted fiscal responsible

solutions. by pooling our knowledge and financial resources we can work together to develop targeted payment policies and ensure appropriate access while also protecting medicare beneficiaries and american taxpayers. i'm looking forward to hearing some of those innovative ideas from our witnesses here today. before i turn to my ranking member, i want to bring one of four night into the attention of the committee. the medicare payment advisory commission, otherwise known as medpac has a submitted a statement for the record. outlining the commission's latest recommendation aimed at ensuring access to emergency development services for medicare. beneficiaries living in rural communities. i encourage all members to review the statement and asked

that it be made part of the official hearing record. with that, let me turn to my partner on this committee senator wyden for his opening statement. >> thank you very much mr. chairman. i want to stay out of the gate that i think it is very doable to produce a bipartisan product here. we did that with respect to chronic care work we did that with respect to 10 years for chip. we did it, by the way, in the rural area related to medical extenders where we were talking about literally life-and-death matters. i want to make sure we understand that we think it is very doable to come up with a bipartisan product. each year i hold open to all-- townhall meetings in every county in there and meet with many leaders from the healthcare field. they tell me there are a few potential healthcare calamities that have them frayed for what

is going on the pipe. first, many in rural communities feel that there is a wrecking ball headed their way because the trump administration and half of congress have spent the last 15 months trying to pull out all the stops to make enormous cuts to medicaid. the president's budget, which is a public document, indicates that another could become. the fact is medicaid is a lifeline for rural hospitals and patients and those who have been on the front lines will tell you -- those that have been out there for decades that if you want to turn rural america into a zone where hospitals shut down and peoples can't get the healthcare they need the fastest way to do it is by cutting medicaid.

second, people in rural areas today feel their local hospitals are already teetering on the brink of closing their doors and if the local hospital goes under , that means no more emergency departments available in a crisis. now, this isn't a far off theoretical problem. back when getting routine healthcare more often meant spending multiple nights in a hospital inpatient bed, rural hospitals were much more secure. they could afford then to maintain the emergency department, but that service may be on the ropes now because rural hospitals are under such huge financial pressure. offering a variety of inpatient services and keeping that emergency room open is extraordinarily expensive and at the same time more and more americans are turning to outpatient settings for chronic care rehab and routine

surgeries. in 2010, 83 rural hospitals close to their doors and hundreds more are in dire straits-- excuse me, rural services have been closed since 2010, 83 rural hospitals. bottom line, when you live in a big city like portland, chicago or los angeles you take it for granted that there will always be an emergency departments nearby, but rural americans feared their hospital will be the next to close or left wondering what's going to happen if their son or daughter breaks a leg in a high school basketball game. i heard exactly that kind of concern just a couple of weeks ago in rural oregon. wherewith the family go if an older one-- older loved one suffered a stroke? when they get to a hospital in time if dad suffers a heart attack?

keeping these hospital emergency departments open is a key challenge when it comes to rural healthcare work in my view to step one when you work to prevent rural america for turning into that sacrifice zone ere people can't g the care they need. i will just close by this point, i have already indicated and i think we can produce a bipartisan product here. i mean, a looks like we spent at $3.5 trillion last year and healthcare. for that amount of money, you could practically send every family of four in america a check for $40000 and say here, get healthcare. it ought to be possible to guarantee that rural americans are not on the outside looking in. thank you, mr. chairman. looking forward to working with our colleagues in getting that bipartisan product. >> thank you.

lets me just set the record straight that make rural hospital started long but for medicaid expansion and prior to the trump administration, of course. rather than touting medicaid expansion or blaming trump, i hope we can set politics aside and evaluate whether medicare and medicaid are yielding an appropriate federal response to states and communities. that is, after all, the purposes of this bipartisan harry. we cannot just spend more money and medicaid and expect to solve every problem, so i look forward to continue discussion with our expert witnesses about what more can be done to assure federal dollars are being spent judiciously and wisely to help out rural hospitals and providers. we need to do that. i would like to extend a warm welcome to each of our five witnesses today. i want to thank you all for coming. today we will briefly introduce each of you in the order you

have set to tet-- you are set to testify. first, we would hear from doctor george h pink, humana distinguished professor in the department of health policy and management at the gilling's school of global public health, deputy director of north carolina rural health research program and a senior research fellow at cecil g ships center for health services. university of north carolina capitol hill. prior to receiving his phd in corporate finance doctor pincus spent 10 years in health services management planning and consulting. he held a bachelors degree from the university of calgary, masters degree in health administration from the university of alberta and a phd in finance from the university of toronto. our second witness, doctor

mueller will be introduced by my good friend and fellow committee member senator grassley. senator grassley, if you would like to proceed right now with your introduction. >> before i do that, since rural hospitals have been brought up i would like to point out to my colleagues and particularly senator wyden because he brought it up, i have a bill that goes by the accurate name reach an epic about the half of the senate is cosponsoring and you may even be a cosponsor. i hope people look at that because it's an alternative to the possible closing of several hospitals. ..

he directs the acronym for the center for rural health policy analysis at the university of iowa. doctor mueller has published more than 200 scholarly articles and receive national recognition for his role healthcare research. welcome. >> next to speak will be connie martin and she will introduce our friend and colleague, senator bennett. >> thank you, mr. chairman. thank you so much for holding this hearing. rural communities have long been struggling with the scarcity of

healthcare providers and facilities. this is exacerbated the challenge of responding to the opioid epidemic which has hit rural americans particularly hard. i'm pleased to introduce my fellow colorado, the chief executive officer at an independent health system in colorado. she's working to help serve the core needs of colorado in the valley for more than 30 years. prior to being named ceo in 2013 she served as the health chief operating officer and completed advanced leadership training and environmental leading at the university of colorado and that healthcare executive program at the ucla anderson school of business but you graduate from the university of arkansas at monticello and she also played a pivotal role in the community and a member of the county economic development corporation. i look forward to hearing her testimony. thank you, mr. chairman. >> thank you senator bennett.

our fourth witness will be this susan thompson was also from iowa and there will also be introduced by senator grassley. take it away. >> its privilege to introduce you to the committee and she is a senior vice president of integration and optimization for unity. she is also the ceo of unity point accountable care, a nurse by training and she's a first i went to be named to the medicare payment advisory commission and as you said, mr. chairman, no one has medpac for short but she's a professional achievement and expertise will speak for themselves however i'd like to say that a part of her legacy is sitting behind her today. i will talk about her family that is involved in rural healthcare as well. nate thompson is her son and he is the ceo of story county

medical center in a beta, iowa and ashley thompson is the daughter-in-law and needs wife, ashley, is government relations specialist for unity point. doctor caitlin thompson is her daughter and doctor thompson is a psychiatrist working with the mental health center in fort dodge, iowa and chad is sue's son-in-law and doctor thompson's husband. chad is a director of physician billing operation for unity point in planning so it seems that your family is as much involved in rural healthcare as you are. welcome to the committee. >> thank you, senator. thank you for providing that kind introduction. a final witness will be doctor murphy who will be introduced by a good friend and colleague senator casey. >> thank you, mr. chairman. a privilege to introduce doctor

murphy. doctor murphy is chief innovation officer at the health system and i know her from our hometown and she has a long record of service in healthcare and served our state as secretary of health and president and ceo of the moses taylor healthcare system which is box for my home and her education is substantial. doctor of philosophy in business administration from temples business school and my mother and my daughter and my sisters would want me to mention marywood. a bachelor of arts from the university of scranton in a nursing diploma. whether it's nursing itself which was her calling as well as a real commitment to the reform in the healthcare delivery system in so many ways karen has brought a passion and a degree

of excellence to these issues that is unmatched. welcome. >> thank you senator casey for running off our introduction. we also like to thank the witnesses for being here today and in the testimony and in advance and the flexibility members will be moving in and out of today's hearing since we have other markups going on right now. i have two or three markups going on right now. firstly i have to lead the markup and with that out of the way we will begin with your opening remarks. >> chairman hatch, ranking member wyden and members of the committee, thank you very much for the opportunity to testify today on behalf of my colleagues at the north carolina rural

health research program and the global health school of public health at the university of north carolina at chapel hill. we research problems in healthcare, rural healthcare delivery and are funded primarily by the federal office of rural health policy i am here to discuss what we know about rural closures and i will start with an all too common story. i need it is insolvent and will close all services in june. the closer we leave residents in the rural city of 70000 people without an emergency room at the nearest hospital is in [inaudible] health in 40 miles away. it will be the second hospital

in the valley to close in the past six months. another medical center and 125 rural hospitals he closed and from 2010. why is this happening? many reasons but long-term is a factor. years of losing money results in bad debt that can be covered, older facilities and technology. why do they lose money? small rural hospitals are older, better, thicker and more underinsured. they staff emergency rooms often in communities with small populations and low patient volumes. combine this with reimbursement reduction and nationa professiol shortages in many challenges you can see why after being a

professor to rojas billy executive. what happened after closure and some convert the type of healthcare facility but more than one have no longer provide any healthcare services. they are parking lots and empty buildings and apartments in patients travel an average of one half miles to the next closest hospital and many troubled 5 miles or more for the world to come up for an disabled cannot afford and do not have access to such transportation and use the systems that can be real barriers to obtaining care. is most affected have investigated communities of certified rural hospitals at high risk of financial distress because they may be the next facility to close. these communities have a significant higher percentage that are black unemployed and lacking a high school education and support being obese and

having fair to for health. in other words portable people. the hospitals conserve these committees and their services they are to be close vulnerable people will be at increased ri risk. what can be done we can try to improve we have by exploring ways to better target medicare payment several huskies and foreclosure would have the greatest adverse consequence on the communities. probably we should develop something new and at meetings around the country the most common frustration i have is the lack of a model to place a distressed or closed hospital. we have acute care inpatient hospital emergency rooms on one end and prepare care clinics on the other end. we need something in between. there is no shortage of innovative ideas and eight to ten new models have been proposed by various organizations and the profound challenges facing fighters that

serve communities are not going away and we need to step up the pace of innovation with faster evaluation of new models and development of a medicare policy and regulation that will allow and sustain them. thank you again for the opportunity to discuss these issues with you today. particularly because during the past 35 years some of the most innovative and effective developments in rural health policy have emerged from the senate finance committee and -- >> thank you so much. we appreciate your expertise. we will turn to you now. >> chairman hatch ranking member wyden, members of the finance committee thank you for this chance to share my perspective on key issues and were health in policy considerations. while some things have changed in the 30 years i have been conducting rural health research

and policy analysis the underlying dynamics remain much the same. we have new tools both in healthcare delivery in the public policy to help us continue our request to establish a high performance health system in rural america. we've had annterting ride in policy debates over that time including weathering the aftermath of creating perspective hospital payment in the 1990s and considering healthcare reform in those years and major changes in medicare payments and benefits and changes through the patient protection and a verbal care act and now a renewed and welcome discussion of what we should be doing to best serve the need of rural residents. i benefited from exchanges with this committee and others throughout and is starting with the conversation that senator roberts and i had which we now chair the house committee on agriculture in 1993 and we provided analysis of reform proposals including the house

and react at assessing their impacts on rural considerations. senator roberts may remember and looks like he does sharing appreciation with the straightforward analysis that we provide which help give me the confidence to continue bringing the best forward and of course then representative roberts might not like the thumbs up thumbs down table of our conclusions to my local newspaper provided display during the hearing. the health panel launched in 1992 to bring rural dimensions front and center in policy discussions. we provide analysis during development in implementation of major national policies including a balanced budget act of 1997 the mma that senator hatch referred to in 2003 and [inaudible] in 2010. we provide feedback during policy formation and followed up with analysis of real impact in the policies including calling attention to unintended consequences of the bba in 1997

and before that term was ubiquitous as it is now. i've come to appreciate the nexis of what we did in the research community with the concerns and needs of our colleagues developing healthcare services. as president of the national health association in 96 i represented the needs of rural providers and policy discussions. one of my funded projects in the early 1990s was working with providers in nebraska and iowa to develop a template for provider sponsored medicaid plus choice plan. much might research now involves visits to rural health visits to understand indications of medicare and other policies in what they do. [inaudible] in collaboration with others considers a host of topics that interest the committee including medicare advantage, rural aco's, rural pharmacy, indications of changes in healthcare delivery in organization and deliver system reform initiatives and the evolution of the marketplace and health insurance coverage in the

role of telehealth. my written testimony includes specific research findings on some of those topics along with policy considerations. i like to share important questions to consider for the future of the program and other benefits other than savings related to changes in delivery models that help achieve the triple aim of patients experience better health and lower cost. should there continue to be different tracks and should variations of advanced payment perhaps as grants continue to be available and finally, what is the next generation of payment reform that builds from the experience of aco's and perhaps global budgeting that will hear about later. i now offer the panel rural

considerations for policy and designed to encourage deliver system corporate one, organized to create integrated care. two, build where system capacity to support and a great care and a three facilitate rural participation and value -based payments. for a line medicare and assessment policies with medicaid and commercial payers and five develop rural appropriate payment systems. in general policies should be sensitive to the role practice environment including population density, distance and the need for infrastructure investment. new models can build on the strengths of the rural system in primary care. thank you for the opportunity and i look forward to your questions. >> thank you. we appreciate your testimony today. >> thank you for the opportunity today to share our help to start. i'm the ceo of a small healthcare system located in the san luis valley which is a rural agriculture based community and southern colorado. we serve the six counties in an area roughly the size of massachusetts and other safety net for nearly 50000 residents. two of our counties are the poorest in colorado. nearly 70% of our patients are

covered by medicare or medicaid and with less than 20% having commercial insurance. with this challenging payer mix we are constant struggle to remain financially viable. they are repetitive of this committee's commitment to rural communities and we are for that meaningful health is on the way. our system is comprised of over 49 beds and 17 bed critical access hospital. we operate two of which provider base and this past year we provided a 500 hospital visits and 58000 out patient services and over 65000 clinic visits. we are a level three trauma center and the only facility that delivers babies and provide surgery or has any type of specialty care for hundred miles in any direction. we serve veterans, farmworkers, college students, tourists, and her own friends and family.

we are resilient and crated team apopka providers. we are the largest employer in the region the staff of over 800. many of them have lived in the community their entire life and the families for generations. as for me i moved to the valley in 1985 and i began my gear career and an entry-level it position back when the personal computer was new technology. i have worked my way into the current ceo role. our staff struggles with the co of meeting regulatory requirements which are often different and sometimes conflicting across payers. our system must report on dozens of measures for the medicare quality and pay-for-performance graham however are private insurers asked us to report yet more sometime on the same topic but using a different

definition. this complex and confusing data reporting takes time away from what really matters which is delivering on our healthcare mission. recruiting and retaining qualified workforce is another challenge for rural providers. we been fortunate to form partnerships with local and state schools that help develop and maintain our workforce. specifically we have multiple grow your own programs from paramedic training to hosting medical students internship and mentoring those who are pursuing the healthcare and ba. we collaborate with the local community health center to post a rural residency training track program and we are set to have the first positions complete this training in june of 2019. we do have our work for success stories to celebrate, as well. to family medicine physicians in our system who returned to their childhood home to care for friends and neighbors. we have a position came during college to serve as a volunteer

at a local shelter and today he's a surgeon in our organization. rural communities pride themselves on hard work and taking care of their own however, federal payments and delivery models must recognize the unique circumstances of providing care in a rural community. they must be updated to meet the reality and challenges of how healthcare delivered today and into the future. ten years ago the critical hospital that is part of our system approach us for help. nearing closure and in dire financial condition we entered into a partnership to provide management services and financial support and in 2013 this critical access hospital really merged into the system that is today san luis valley health. this type of rate implanted a hospital closure but such partnerships are not available to many rural hospitals. we see the result of hospital closures across the country and today 12 rural hospitals in

colorado are operating in the red. i'm here today to ask for support and consideration for new financial models to consider our needs and including the creation of a 247 rural emergency medical designation such as the has been recommended and senator grassley has championed. i ask you to provide appropriate resources flexibility and ongoing dialogue with those of us in rural america to stand ready to innovate, or card and meet the current cllenges o caring for our friends a ighbors. in a country as great as ours where you should live and where you live should not determine if you have. thank you for your remarks. >> thank you so much. return to you now. >> thank you and good morning. thank you for this great opportunity to address the committee on several of the challenges facing healthcare in rural america. and offer up ideas for potential

solutions. i would be remiss if i did not take this opportunity to publicly thank our senator from iowa, senator grassley he is made access to quality healthcare and a relentless priority. thank you for what you do for iowa and our country. this walking a unity i was a ceo of a small -- it's a 49 bed hospital including a group of physician clinics and care services that the year have held the designation of eight to bed pcs hospital and is in the hospital and health clinic and most recently ate dinner as a participates in the rural devastation program. trinity has a formal management agreements with five critical access hospitals in close for relationships with metropolitan markets including des moines. possibly the most unique experience trinity has participated in today has been a medicare accountable care organization or aco.

classified as a pioneer a seo trinity took responsibility for improving the quality and lowering the total cost of care for approximately 10000 medicare beneficiaries attracted to them in this rural northwest iowa community. they did this successfully and continue to do so is the next generation aco. it is through this work the challenge facing rural health communities and hospitals and providers have become so be clear to us. the first challenge to highlight is the dichotomy and incentives that exist between those cooperate under total cost of care programs like aco's, medicare advantage plans and bundle rams and the rural counterparts operate under these for service cosby and while the former looks to keep methods -- i'm sorry, while the former looks to keep members healthy and out of the hospital the

latter is rewarded when hospital beds are full of medicare patients. if the two groups worked in isolation of each other this might work but they do not. they are intrinsically woven together. the beneficiaries attributed to the trini pioneer aco mov in and out of the rural facilities in the region and whe regding value -based payment models for rural groups would ask where do we fit in and to date the answer the question has been you don't. the policy approach has been to exempt them from value -based policy altogether and we submit this up is not working and needs to change. rural healthcare can fit in to value -based models so you wonder is unity health advocating at cost -based be deconstructed into that we answer no. we are requesting it be renovated. this brings me to my second challenge i must highlight and that challenge is the greatest.

access to care services in rural areas. bringing quality care to rural americans comes at a cost and the cost is distinct from the actual provision of the medical service. these additional unique costs relate to the time and distance to major service centers and lack of competence of community services and healthcare workforce dead zones. we propose the renovation of healthcare delivery in rural areas include a value -based component tied to quality medical outcomes and expenditures and a separate and distinct payment structure is developed for the production of cost -based reimbursement that pays for the cost associated with access in rural areas. while i went has money goes into greater detail of how such a system could be structured i offer you a full dues and just one don't the assignment the

system. the dues. do encouraged the cms innovation center to develop pilots that test medicare advantage programs designed to work in rural markets like iowa we see great potential for medicare advantage to bring the benefits of population health methods to rural areas. do design aco benchmarks to accommodate the additional cost of bringing access to rural markets. do support bills like the reach act that allows rural hospitals to transition designations designed to meet modern means. to continue to allow telehealth practice to extend the reach of our inputs and providers. with the utmost respect just one don't. don't embrace a policy that allows freestanding ambulatory surgeon centers to establish residence in rural markets and cherry patients by procedure. it further strains the viability of community hospitals.

i challenge you to find one for profit freestanding afc that has an emergency room. in closing healthcare entities are the backbone of many of our rural communities and we need our rural healthcare delivery system to be viable and we need them to make the transition to rural healthcare access centers and we know they can become. thank you for this opportunity to share these views. >> thank you. ms. murphy, we turn to you. >> chairman hatch, ranking member wyden and members of the committee. thank you for inviting me to testify today about rural hospitals. in addition to my clinical background which party heard i spent two years at sea mmi before assuming my role working on the state invasion models initiative and today i like to

share the development of an innovative payment and delivery model that was developed when i served as secretary of health in pennsylvania i began my tenure as secretary of health assessing the status of the healthcare delivery system in you and i was struck by the financial instability of the rural hospital i found that in the research i found the situation in sylvania was being replicated across the country. selena has the third largest rural population in the united states. sixty-seven of our 106 and hospitals in pennsylvania are in rural communities. more than 58% of those hospitals in rural areas are mounting financial pressure resulting in negative operating margins. we began to look for a solution. after having worked on the [inaudible] care model and seeing the oppressive results we decided to design a similar model for rural hospitals in pennsylvania we worked collaboratively with the mmi and is designing the model and i'd like to knowledge senator casey and his office support as we designed this model. the design. was launched in january the

17th and the objective of the model are to provide after improving health and healthcare delivery in rural communities the model changes the way to spinning hospitals will be reimbursed and the model replaces the current service systems the multiplayer global budget based on the hospital distort that revenue. like maryland the permit model in pennsylvania is designed to include all pairs. however it was necessary to develop a new methodology since maryland has the authority to establish hospital rates in it is not. the model moves rural hospitals from focusing on inpatient care centers to a greater focus on outpatient center healthcare services with an emphasis on appellation health and care management. it replaces the current concurrency for service systems with little emphasis on quality and safety which will instruct

incentives to improve quality and safety and eliminate subscale service lines. rural hospitals are encouraged to move from traditional care models directly on site to innovative care models that are enabled by technologies such as telehealth and videoconferencing in remote modeling. rural hospitals will invest in a coordination such as reaching out to patients who frequently use the emergency room services and connecting them with a provider. it also includes population health and preventative healthcare services such as chronic disease prevention programs and behavioral health initiatives including those targeting substance abuse disorder with the expansion of medical homes to medication treatment programs. participating hospitals will have the ability to invest in social services that address community issues that lead to detrimental health outcomes. based on the global budget dissipating hospitals are expected to develop a transformation plan that could outline an innovative approach

to improving health and healthcare delivery for the communities they serve. they are encouraged to work with community agencies such as united way agencies on aging, drug and alcohol sentiments to develop services based on their community needs. provide dissipating hospitals transmission support was to create a rural health redesign center. cms has entered agreement with pennsylvania to provide $25 million over five years to support the rural health design center. this provide a way to deploy capabilities to support up spinning hospitals. selena is planning to engage six hospitals in the initial peormance year gradually expanding 230 hospitals in the mania. we are participating in the initial phase and doctor david feinberg or, the ceo, has been a strong supporter of the initiative since its inception as a builds the vision for building healthcare delivery system to focus on improving health and value creation for

each community we serve. we are looking forward to working with the state on this important initiative. the financial challenges of rural hospitals today are the result of a changing healthcare industry. may not be able to offer the same services that they did in the past but it is possible they could be leveraged to improve the health of those residing in rural communities. next week i will be speaking on the global edge it at johns hopkins university in 26 states have registered to participate .-period-paragraph it is the opportunity to engage additional states and the ensuing rural health model. in permitting across diverse states would give us the opportunity to evolve this innovative payment and delivery model. thank you for your interest in 80 rural hospitals. i do believe rural communities deserve access to healthcare and we must continue to work to keep identifying innovative approaches that are properly straggled. >> thank you so much.

it's been interesting today. let me start with you, ms. martin. in her testimony referenced times when the hospital systems have been on the verge of financial crisis in the past. how did you leverage resources and streamline service delivery so that or operation lines to state financially viable and can talk about what you think an appropriate medicare margin should be for small and nonprofit rural hospitals like yours? >> thank you, senator. i think it's interesting when you talk about margins for rural hospitals. any margin would be helpful to so many rural hospitals. i think for my system located in the rural part of colorado if we can be in a margin area of three or 5% we consider that a very successful year and so i think different areas have different needs with and so much depends on your info structure and what you need to replace as far as

equipment and facilities goes. i think for our system and my perspective that is the margins that we are trying to achieve and sometimes we're on 1% or in the negative and i think what we did initially over the past few years as our two systems the critical access hospital and are still coming to the hospital and we use the economy of scale. we have one ceo for that rural system of care and one finance department and we share a lot of services between our two organizations and that makes it cost-effective to run the different departments. we have a person who is an expert in laboratory or in imaging and they have help a larger organization we can divide across a couple of communities. we are frugal. we are thoughtful about what we buy and will provide services

that are community does not need because we don't have that luxury and we need to match our services to the needs of our community. we have built our primary care base over the past three years and that has made a substantial difference keeping our care close to home and we've added special services that are the highest need for our patients and community. for instance, we added oncology services in the past three years and started out with the model we brought a specialist a day or two a month and built that where we could have a full-time provider and part of our challenge is one single specialist in a rural community and you have to have the connections to have coverage in support for that individual. those are been some of our strategy and we are not a lucrative health system at all. >> thank you. let me go to you, doctor murphy. let me say that there's a lot of excitement around the

pennsylvania rural health model and hold click great promise. i am so pleased to see this working with states to design a rural healthcare payment strategies and is there any concern under any new multiplayer global budget and payment that rural hospitals might lose incentives to providing healthcare services and secondly how do you think yours rural hospitals will have improved health outcomes if they already know bigger need for seizure budget. >> thank you, senator. i think the challenge is which is why i recommend that cmi might look to expand the test and it is a test to determine if we can sexually transform rural hospitals in a way that makes efficient in's population and

delivery services. there is a monitorg component within the global budget methodology. the model is being evaluated from day one that will determine the appropriateness of the services and the inability for unintended consequences to occur. that is built-in within the test of the model. but i think the goal here and the differences there's a transformation plan that goes along with the global budget with monitoring metrics throughout the life of the budget so the hospital is going to be very tightly monitored as we go through implementing the global budget. i can assure you that certainly medicare would be concerned about that as would be all the other commercial payers. i believe the model is robust in the way that it will measure

those unintended consequences. >> thank you. let me turn to senator wyden. >> thank you very much mr. chairman. it's been a terrific panel. next week when i have opened everybody's town meetings in oregon i will remember what you said, ms. martin, that where you live should not determine if you live i looked around the room and practically the whole place got whiplash when you said that because that sums up the challenge. let me give you my sense of where we are in terms of the bipartisan possibilities going forward. we had the bipartisan budget act and got five years additional funding for several programs for rural communities. medicare depends on hospital and increasing payment for low-volume hospitals and as i touched on earlier the ambulance

add-ons. that at least gives us some measure of predictability for the next five years but it seems to me that we have got some heavy lifting to do in the next five years. i think we understand this calamity does not arrive on us in 15 minutes. will not solve it in 15 minutes. what i'd like to do for purposes of going forward in a bipartisan way here is we move under the efforts of colleagues on both sides is i'd like to go down the road and have each of you give me what would be your top priority for medicare, as related to longer-term stability for rural fighters and particularly for rural seniors in our country because we know

that you have a disproportionate number of seniors in rural communities. right down the row, top priorities for medicare for this long-term stability that we have a chance to work on because we got at least a little thick ability for the next five years. let's go right down the road. >> thank you, senator. we talked to people and committees for rural hospitals have closed and almost always the first thing we're is the disappearance of the emergency department. i would say my top priority is maintaining access to emergency care. >> good. mr. mueller. >> i would say mine would be building that integrated system that i talked about that would include non- hospital-based services particularly both postacute care after a hospitalization and care for the elderly with chronic conditions which was a part addressed by

the care act and we need to move forward with some of the innovations that are coming on that. >> good. ms. martin. >> fox ability to develop a model in each rural community that meets our needs so that they can keep emergency care and can keep services. >> what would -- good thing. what would be your top priority for flexibility because we are all interested in that. >> it would be to allow critical access hospitals to develop to move and merge into different model which would limit their need to have inpatient beds and the emergency and have outpatient care and keep the financial healthy in that model. >> ms. thompson. >> top priority would be recognition of the difficulty in acquiring and retaining providers to rural communities. >> if you wave your want what could we pursue because that's enormously important. >> rural healthcare and rural

communities create an environment that is unique in this country and the community cares for each other and i think the opportunity that are before us that have been demonstrated in our models create not only hospitals in sufficient but in all health care across the continuum and this kind of environment is motivating and inspiring and quite frankly we could create a platform for transforming and i want to give ms. murphy the chance to wrap up around. the chairman is gracious about this but let's keep the record open for you all to give us as many concrete ideas for getting more fighters to rural america because this is important. we try this and that and look, we all understand that year after year we are faced with this question of whether there will be anybody to keep the

lights on and in other words we got buildings and light you have to people who can run them with mr. murphy, your one priority for medicare to be useless. we got five years to chart for longer-term. >> expand the test for global budgets to different states. >> very good. >> mr. chairman, only seven seconds over. >> senator robert. >> thank you, mr. chairman. i'm very grateful that we are holding this hearing on rural healthcare in is long overdue. the congress tries to focus on the unique needs as espoused by all the witnesses and people in rural areas and the healthcare challenges faced by these constituents. i have a pledge of a serving as a cochair of the senate rural healthcare congress along with the ever enthusiastic and helpful cochairman senator

heitkamp of north dakota. with similar problems or challenges, we don't have problems but challenges. we want said that rural residents deserve the same kind of healthcare there is no reason why rural communities should be left behind as other areas advance or healthcare systems. thank you so much for reminding everybody that i was here in 1993 as you were and it indicates that this is been a long-term battle and i can remember clear back but it was not 882 asked what hew and secretary joe [inaudible] and remember thee there was a pid cam out that before any rural hospital could receive a medicare reimbursement the doctors had to review all of the patient came in and the procedures in the team of three doctors had to do this every four hours. that was ludicrous and i don't

know who came up that but then i decided it would be a good thing to be for that because maybe one of the doctors would say if in fact they were inspecting the hospital but it's been a long-term effort and i want to focus, by the way, we have 86 critical access hospitals in kansas and i hope that when we renovate, i think, we should renovate we should not illuminate we are on first base or second base trying to put on and i don't want to get stuff by all of a sudden say no to the critical access or moving to something without knowing what we were doing. i want to concentrate on the workforce situation and i'd like you to comment on that. recruiting is one of the biggest challenges we have and our position for assistance practitioners may be only primary care provider available

we have to drive quite a few miles to get to that hospital like you have in alamosa. in wyoming they have to travel a couple hundred miles maybe to do that. let's go down the panel and say the one thing that i'm interested in is the federal comments between the provider and the patient and i'm talking about the 96 hour rule but the face-to-face regulations and things that just don't takes a terrible amount of time and expense of you focus on that what suggestion could you make? >> senator, i would defer my chin to my colleagues with much more expertise on that. >> that will be fine. >> to suggestions.

one is looking at medicare conditions and what is required for supervision and anything that you alluded to from the [inaudible] years still exist today. second whatever we can do to open up more of the use of telehealth services to support the local rural healthcare professionals and we've got some of that is a mentioned earlier in the climate correct. >> you mentioned telemedicine and not trying to interrupt ms. martin but there were three there were three unique places where telemedicine was to start out and this is back in the 80s and one was in new mexico and another was an island and a third one is in kansas between garden city they were selected and we were about to announce that and all of a sudden they called up and said we found a doctor. after all that hard work i was

very upset that they had found the doctor and sure enough the doctor came and they were not like your doctors in the two that came back six months the doctor was gone and in the meantime we lost the opportunity for telemedicine. we now have it back but it's very typical. you got to doctors that came back because they believed in their community and wanted to live in the community where they can raise the family and all the good things that have been referred to by ms. thompson but on the better side what would you pick? >> i think i would be aligning quality measure so that is the measure value in rural committees there measures that are relevant about what they provide and we report so many different measures to agencies and they are not meaningful always in moving ahead of our quality. for instance, some of the things we report on the volume that we do is so small that one single fallout appears to make us look

like we have a lesser quality than maybe our urban counterparts and that is simply not true. i think that is a very important point and the paint with meaning for you to know that the evolution of meaning for you is approving the use of technology in healthcare industry but the pace at which the change is happening and the expense it keeps to keep us up by worry about those measures worried about the doctors and their patients. >> wisconsin. >> consistent with my concerns around access for providers. i would strongly recommend continuing to expand the use of telemedicine. >> doctor murphy. >> i think that the relaxation of medicare and allowing rural hospitals to execute more innovative strategy and

recruiting position so we have some rural slip private that and i secondly think that relaxation or the acceleration of the ability of the medicare program to waive certain requirements for rural hospitals and overall management. >> i thank you for your testimony. senator. >> thank you. i appreciate this hearing is being held and i appreciate the great talent that we are put together to do it. i will yield. >> noted. >> senator cantwell you were next. >> mr. chairman. >> if i could, i think in order of who is here it would the senator and the next and then senator cassidy and then senator cantwell of the senators were here.

>> thank you. again i appreciate the talent and the fact that we are having this may come from the least probably did state in the nati nation. our biggest city is 60000 and all of our towns are 40 miles apart and we only have 19 towns where the population exceeds the elevation and i have one county that is the size of delaware and you get be a first-class city when you have 2500 people and they just did and it's 2500 for the whole county. we just try to get a hospital open their which usually means having a physician assistant. this is a critical hearing for us and i begin my question with ms. thompson. the weight medicare pays rural hospitals including critical access and so communities like

we have in wyoming it is closely related to inpatient services and the medical providers have started to shift toward providing more and more services on an outpatient basis and is the inpatient metric still the most appropriate measure for hospital cost? >> that is a great point of not certain it is. when we began our work in the pioneer aco in the entire question around utilization of inpatient services was very much in hand because that is what drives the predominance and what calculated [inaudible] and in the contract with federal government in the aco we essentially made a promise that we were going to reduce that total cost of care while approving quality to the medicare beneficiaries. as a result, a lot of focus work in investment in reducing spent we reduced inpatient utilization

and a lot of the services you have outpatient and what i think is more important in terms of the take away for this hearing is not that we reduced the spend or that we improve the quality. both are quite important in both predominant components of the agreement in terms of the aco. what we learned and what i believe is so important as we rethink policy around rural healthcare is how strong and how absolutely woven together a rural community is an commitment to caring for its patience and in that lies the secret sauce in terms of how we rethink not just payment for hospitals or how we think about inpatient or payment for physicians or payment for homecare which is typically how we think about policy development but rather how do we

look at an organized system of care of a defined community whether a rural hospital with six counties that are serving and create an account ability and motivate a community to want to come together whether a global payment model or in some model that gets us out of this silent way of thinking about how we organize payment structure in rural america and in that way of thinking i believe we will transform not only how we pay for care but how care is delivered and how we re-create an entirely new filter system. that to me will be the most important -- >> i'm running out of time. >> i'm sorry. >> figure much. thank you. doctor murphy, medicare used to allow states to declare whether to designate hospitals as cruel assess and i understand we've prevented state -based designations because of the concerns that they were over utilized that allows hospitals

to earn that state -based designation to keep it. in cases where the critical access designation may have been over utilized how do hospitals compare to the cms definition of critical access hospital? >> i think the definition of critical access hospitals and their impacts on whether a hospital is probably outdated to even think about it because the hospital and the problems suffered by rural hospitals today is because the healthcare industry has changed and critical access hospitals receiving whether they are designated or not still have all rural hospitals have the same problem and they have little resources to deliver any type of substantial inpatient care and they are devoting all the resources to inpatient care for a very small number of patients. whether at the critical access designation was definitely a

plus for hospitals decades ago but what were faced with today is any type of assistance to hospitals that exist in the service environment whether excuse me, regardless of where it is tied and it will lead to the same place sitting here two years from now if we don't take a look at innovative model. >> thank you. i have more questions but if we have a second round i will do those otherwise estimate them and i appreciate all the expertise that we have here in my time has expired. >> senator cantwell. >> i'm sorry, isn't senator cassidy next? >> i know it's been hard to follow. i believe in order of appearance senator cassidy is next and then senator cantwell and hopefully we can get out of these colleagues and in the next few minutes. >> what would i do without you? [laughter] >> as the jewish people would say, only.

[laughter] >> senator cassidy, i'm sorry. i never overlook you, sir. >> as my daughter would say, omg. thank you very much. folks, i'm a physician and i worked in a hospital for the uninsured and often interfaced with my colleagues who are in emergency room with understaffed critical access hospital but so understaffed that frankly they had to send their patients to the hospital where i worked. a lot of what i will say now reflects that perspective. let me first go here. i'm interested in the medicare wage index. hospitals at the higher cost structure get more and if you will the more get more. it seems as if under current law you are based upon your geographic area rural hospitals in my state cannot compete with

the urban hospital because of medicare policy which tells them urban hospital we will give you more. if you are a nurse you will offer -- you tend to go where you go more. the current policy does not have a floor or ceiling in place for an adjustment in which the cost of wages is comparable when reimbursing providers and so, as i just said, urban hospitals get more rural less. i guess i can ask many of you this question. doctor, does the lack of a medicare wage index frankly give up perverse incentive for the urban hospitals to keep increasing wages and to make it harder for a rural hospital in louisiana or iowa or tennessee to compete and be able to keep that nurse who lives close to home home. >> senator, we have done research on the various rural

designations that congress has created and there are some of these designations where the wage index plays a k role. for example, one study we completed last year we found that many of the sole community hospitals in the country it's an important payment designation but they are located in states which have lower wages and therefore hospitals that are eligible for that designation in fact there's no advantage to taking it. they take the payment instead of sole community. i believe it is an issue that we have not studied it beyond that however. >> i will say that senator isaacson has a bill which i cosponsor to put a floor on the medical where wage index would help rural hospitals substantially. secondly, i will stay with you doctor pink, over the last decade has been a lot of consolidation in hospital

systems just for folks to see obamacare passed in oh nine that is the point whether or not it was associated we don't know but we wanted to show others as well but in zero nine we see the number of consolidation episodes is increased about doubling year-to-year and we know that that increases cost and there's good data showing that a price monopoly 12% higher than those markets with four or more rivals and i could give more evidence that. doctor pink, given that these mergers coincide with rural hospital closures, i don't know the answer to this, i'm asking you, has consolidation by lack of systems reduced competition

or increased prices and give resulted in hospital closures? ... >> how come not? >> the cost based reimbursement model that is at place with critical access to hospitals simply reduces any opportunity because they are reimbursed based upon their costs associated with the medicare patients they are caring for so they don't have an opportunity to see the savings associated with that. >> the consolidation which may keep the doors open but none of

the extensions, the punitive benefits extended to others. let me move on. i have nine seconds left. we've heard about the rise of free standing in er's in places like texas and colorado, you is have mentioned when these facilities close, people want an emergency room nearby. proponents argue the facilities are providing increased access to er care in rural areas, not financially feasible to have an entire acute care hospitals. the opponents argue that they are cherry picking and although i'm told they'd take anybody who comes, and that the physician owned facility, the fact that the physicians owned it is an issue. currently the facilities are not reimbursed by medicare or medicaid patients. you worked in colorado. they are allowed, if we're to allow these facilities to be reimbursed by medicare and medicaid, would this be a good thing for your rural area? increasing access to rural -- to

rural er care, if you will? or not? >> i don't believe that it would be a good thing in a rural area. the free standing that have originated in colorado are all exclusively in the urban areas. they are not in the rural markets. and i believe in a rural market the idea of an emergency department conversion from a critical access hospital is that you keep care located close to a community where -- >> let me stop you first a second. it is impractical if someby has a head injury, you are not going to have a neurosurgeon in a rural hospital. and quite likely not have a general surgeon just because a general surgeon cannot -- my wife is a general surgeon. you cannot -- she cannot maintain her practice because there's not enough volume. i thought the paradigm is if you stabilize the patient, do as much as you can, transport quickly, would that not work in colorado? >> i guess what i'm referring to is the free standing emergency

departments that have been created in the front range market. in our rural community, and the hospital that i work in, we do have general surgery and some of the critical access hospitals that neighbor us, they do a lot of stabilization and transferring. that's what we do in the rural facilities. i think keeping an emergency department in a rural facility is very positive and something that we need to do collectively. my statement was simply that the free standing emergency departments that have started on the front range have not -- >> you have to wrap it up because i'm way over. okay. i'm sorry. i didn't mean to interrupt. i'm 2 1/2 minutes over. i apologize. thank you very much for your answer. thank you, all. >> not to beat a parliamentary horse to death, but senator, if you would like to be a member of the always powerful senate agculture committee, we

recognize people on abipartisan basis, going back and forth, as opposed to the schedule espoused by my distinguished friend from oregon, the time of arrival so for the third time i'm delighted to recognize you. >> just for senator cantwell. >> thank you, mr. chairman. i would love to be at this moment, to that committee, i appreciate your leadership and all you are doing to express we need trade and not tariffs. >> without objection. >> thank you. i thank the witnesses and thank both my colleagues for this important hearing. obviously i wasn't here when you gave your statement, ms. martin, but the statement by you about where you should live should not determine -- resonates in a lot of my state. the access to healthcare through the medicaid expansion was big in rural communities in my

state. we're at large 600,000 people in our state got expanded coverage. but we have counties like douglas and other counties where, again, so that the chairman knows where our apple and cherry and pear industry is located, they have seen an uninsured rate drop more than 60%, thanks to that medicaid expansion. so i just wanted to ask about the importance of making sure that we keep that expansion and making the importance of not letting any kind of cap or reduction under this discussion that we had, cbo was saying that the previous proposals on block granting and changing medicaid might cut as much as quarter out of medicaid over the next two decades. is that problematic, ms. martin for rural? >> i think certainly the aca expansion made a very positive

difference in the community where my service area is, and i think in colorado overall we had an uninsured rate of nearly 20%, and that's been reduced in my community down to low single digits. so the coverage for patients allows patients to get access to care. it's improved the financial bottom line of certainly our organization. i spoke earlier that 70% of our population is medicare and medicaid. so our relationship with government payers is critical to our survival. >> did you say 70? >> 70. >> and ours is up there as well, over 50. i don't know what the latest numbers are. >> yep. >> but i don't think people quite understand that that's the challenge we face. i mean, we love our rural economy. and we love our rural communities. they are a great place for people who are aging to retire and live, and it's more affordable, but that means it is a different mix of the population as it relates to how you build a healthcare delivery

system. so the medicaid expansion is so critical to that. i also wanted to ask about medicine becau that i another deliverym sys that i think for us we have this project echo, the university of washington working with -- you have heard it probably in your state as well but it's allowed medical professionals from seattle to consult with people over in other areas, some of our clinics to talk about decisions for really high complex patients for hepatitis-c and substance use disorders. so how do we -- what do we do about that as it relates to the payment system? because i don't think fee for services is any kind of friend to that cost-saving technology and that cost-saving collaboration that's existing? >> i think in our community, we're modestly beginning the use

of telehealth and part of our challenge is that we don't have the resources for a lot of the start-up equipment and some of the payment constraints don't allow us to be able to provide the service. i think one of the best things we could do is to invest in the start-up exexpense -- expense particularly for rural hospitals and allow the services to be reimbursed on a fair basis. we currently do telehealth now in our community for infectious disease, genetic counselling and we're trying to build that for oncology coverage and for cardiology coverage. and it would save the system money. when a person goes into our emergency department, and we have one cardiologist in the community, when that person is not there, we have to -- if the condition of the patient warrants, we have to transfer them to another area to be evaluated by a cardiologist. they often times get transferred, are evaluated and then they are dismissed from the hospital. if we could have cardiology

services available 24/7, we would save the expense of an air ambulance or a ground transport for a patient with a cardiology problem. >> and there's no reason you can't with telemedicine; right? with that kind of technology? >> yes, that's true. >> it is just getting it recognized into the system in some way. >> and paid for. >> right, well that's what i meant. recognized into the system. that's why the challenge that just a fee for service model -- for anybody -- well, actually i don't have any time left, but the doctor shortage issue for rural communities continues. and we just need to fight that, and so, you know, we have counties in our state that have very, you know, like 4,000 people and no access. so we've got to do better. thank you. >> senator? >> thank you very much. my first question for the witness is how many counties are there in america? all right. let the record show they have no

idea. [laughter] >> the answer is 3,007. delaware has three counties. the southern most county, the third largest county in america. we don't have many of them, but we make them big. [laughter] >> we raise more chickens in my county in america. we raised more soybean than any county in america. i think we raise more lima beans than any county in america. we have more five star beaches i think than any county in america, all in one county. we have a lot of rural areas. a lot of people who live in rural areas -- despite all of that, we have a lot of people live along the coast. but the rest of the county is largely agriculture, and we have some hospitals, rural hospitals. we have community based outpatient clinics. we have a va clinic that's actually quite good.

but we have a lot of people who don't have access to healthcare because they are so spread out in a big county. i want to talk a little bit with all of you now that we have gotten it out of the way, i want to talk with you about the costs that flow from tobacco use. actually costing all of us. in this country, we're spending an extra 200 billion dollars each year because of our addiction to tobacco products. we're spending 150 to 200 billion dollars a year because of obesity from one end of the country to the other, including in our county. our rural communities are also more overweight and more obese. i want to ask what tools -- here's my second question of the day, what tools, what resources, what delivery system reforms could we be using to reduce the

disparity in rural communities when it comes to tobacco use and obesity? >> -- >> and i want to start with dr. murphy. >> thank you, senator. >> i was told you are really good on this question >> thank you. what we have talked about earlier was a new way to pay for rural health. i don't even say rural hospitals. but a new way to reimburse rural hospitals. it is a multipayer global budget system that allows hospitals to focus on the problems that you just talked about and invest -- instead of investing in sub scale services, invest in tobacco cessation programs, invest in substance use disorder treatments, invest in the clinical -- the health status outcomes that we're looking for and to end this disparity or to gradually decrease this disparity between rural health outcomes and those of their

urban counterparts. so that is the beauty of this model. it allows for the investment in care coordination. it allows communities to really take those chronic disease problems and reallocate the dollars that they were receiving from sub clinical care services, that they had to provide because that's the only way they got paid. it now allows them to address this population health more. >> let me ask the other four witnesses. if any of you agree with what she has just said, would you raise your right hand? all right. if any of you have something you would like to add to what dr. murphy said, go ahead. ms. martin? >> i would like to add that an investment in primary care providers because i think that is the relationship that impacts patients' behaviors -- behaviors and on going quality of life, and in so many communities it is the importance of primary care provider that impacts these

behaviors. >> anybody else would like to add? how do you pronounce your name? >> keith mueller. i would add to the investment in public health infrastructure. you can come at that in two ways, one encouraging collaboration between the clinical sector and the public health sector which the aco model does and two direct investment into public health agencies. >> one last quick question, what are your recommendations for how we can increase the supply of mental health workers and improve access to mental health treatment in rural and underserved areas? we start all the way on my left, please. would it be dr. pink? >> yes, sir. >> please? >> i would defer to my colleagues. i have not got expertise in that area. >> all right, thank you. >> one comment would be to integrate our support for behavioral and mental health services with primary care. >> okay.

thank you. ms. martin? >> i think it is investing in the education and programs where as community hospitals we can educate and train workforce of our own. we have extreme shortage in the number of qualified professionals in that area. >> thank you. ms. thompson? >> yes, i believe it is to further study the integrated health home model is that at play with our medicaid population and i think there's a great deal to learn there and a great deal of excitement to create in young folks that we can get into high schools and educate and motivate them about the opportunities in mental health. >> okay. dr. murphy, do you want to add anything to this? >> i would just say leveraging the technology so that we can access rural areas can access the more urban sevencenters -- centers. >> where are you from dr. murphy? >>i'm the chief innovation

officer. >> unity point health in des moines, iowa. >> family health in colorado >> university of iowa. >> university of north carolina chapel hill. >> okay. well, you've come -- some of you have come from a long ways. we thank you. we thank you for the work you do. it is really important for our country. for the people of our country. thank you very much. >> senator? >> thank you, chairman roberts. and thanks to the panel. i was here earlier to hear your testimony. i really appreciate it. some of the insights about the special challenges we face in the rural areas. i come from ohio. we have a lot of big urban hospitals and we have a lot of small rural hospitals. sadly some of them are closing down or consolidating and i would tell you in my state one of the issues that is particularly difficult to deal with in our rural areas is the opioid epidemic. and i would think if you did, you know, per capita analysis of the opioid epidemic in my state,

you would probably find in the rural areas, the problem is even more acute than it is in some of our suburban and urban areas although it is in every zip code. but the difference is really not so much the per capita impact, but the services that are provided. and one of the issues as you know is we have more and more children who are being born with neonatal syndrome meaning they have to taken through withdrawal themselves. we have some great programs taking moms who are addicted, weaning them off of their addiction and hoping to ensure these babies are born without the neonatal syndrome. it is overwhelming. i'm sure the same is true with you. one of the things i'm hearing about from our children's hospitals is that sometimes they can take care of the babies shortly after their birth, but then these babies go home and there's not the ability to continue to monitor, particularly in our rural areas, and so i guess what i'm asking you today is -- and this -- i

know doctor you mentioned the opioid epidemic. i think you were the one who talked about that. but to the hospital ceos, maybe you could help me a little on this. what services do your hospitals offer to support the longer term recovery needs of these growing number of children who have this neonatal syndrome and for their moms and families? in particular if you work with kids with nas how do you work to ensure the families receive the support they need? >> in our community we have seen an increase in this issue. just last year about 11% of the babies that we delivered had this syndrome that you speak of, and we've done a lot of training with our staff to have them have the skill set to help the babies, you know, for the first few weeks of life, and we sometimes keep them for that period of time. when they move out into the homes, often times unfortunately they are going into foster homes because if the mother was a

user, unfortunately, they are placed in foster families. so we have pediatricians who try to work with these families and development and we have like a grassroots community organization that involves the schools, early childhood development, some of our primary care providers and together we're trying to sort of leverage and learn resources. it is a challenge because there's not a lot of information about that. we hear from our schoolteachers particularly of elementary schools that they don't feel equipped to deal with the challenges that some of these young children bring to the classroom. and so i think just additional resources around education and training so that our workforce would know better how to help these children would make a huge difference. >> any others? >> senator, we are just beginning to develop a program for moms who have substance abuse and then their children subsequently born with neonatal

syndrome. the vision for the program is that we would intervene when the mother begins medication, treatment prenatally, we would what we say wrap our arms around the mother and the baby with services, such as, behavioral health services, addiction medicine counselling, pediatric services and other social services that would enhance the likelihood of the mom staying in recovery after the baby is born. so the idea behind it is that we would test -- we would offer these services for a period of up to two years and determine what tests, evaluate the model and determine what interventions really help that mom stay in recovery. and go on to live a productive life. >> well, thank you. we did pass legislation here called the comprehensive addiction recovery act which has a separate title for pregnant moms, post partum moms and these

kids with nas. we have passed a budget which increased the funding for it. we're looking for good pilot programs throughout the country. i think ms. martin is right, dr. murphy is right, if we n spend some money up front to avoid some of the longer term problems and figure out what works, you mentioned information and the right kind of therapies to be able to help these babies as well as their moms take advantage of this. many of these moms are facing their addiction because of their pregnancy. in other words they don't want their kids to be born with this syndrome so they are willing to go into treatment where maybe previously they were not. dr. murphy is right, how do you then once the baby is born to keep them usually it is a weaning off of the opioid -- how do you then keep them in that treatment program and longer term recovery and use that family relationship to help kindle some better prospects for longer term recovery. so anyway we look forward to

working with you all in that. i think in the rural hospitals, in the rural setting we have a particular challenge. and i appreciate you being here today. we look forward to following up. i have another question. i will offer that as a question for the record. senator bennett and i have some legislation that we would like to get your views on. thank you. >> thank you, senator. you are up next. >> thank you, mr. chairman. must be high noon. thank you for holding this hearing. we have in my home state of south dakota lots of challenges in accessing healthcare services in rural areas. we have providers who work diligently coming up with creative solutions but there are still barriers and complications they face on a daily basis. part of it has to do with traveling long distance and having limited transportation options, big hurdles for people to overcome. and the tracking providers of course rural areas is another challenge we face too often we lose south dakotans if they attend school and train in other

states. we have got a unique issue in south dakota as well with our tribal communities making sure that they have access to quality healthcare services due to the pervasive problems that health services facility throughout the great plains region continue to have. i look forward to working with my colleagues on this committee and trying to advance solutions that will address many of these challenges. dr. mueller, in your written testimony, you mentioned that a center has completed multiple studies on how telehealth can serve as a tool to expand access to care in rural settings. i couldn't agree more. i understand you have a current project that's looking at initiatives in south dakota which range from emergency department eicu, e-pharmacy, e-behavioral health and more. i have seen some of this technology first-hand. i know they are working hard to innovate -- i should say for this committee's benefit, could you discuss what you have learned so far about that model and how it's helped increase

access in our state of south dakota? >> well, thank you, senator for the question. i will focus primarily on what we've learned about the use of telehealth in the emergency rooms because that has impressed us the most. what that has done especially since i mentioned earlier cms coitions of participation, the condition of particition was changed a number of years ago to allow meeting the necessity for a non-call physician through the use of telehealth. that's made a tremendous difference across south dakota and other facilities that are supported. because you can have advanced practice primary care provider not a physician in the er that can quickly access a board-certified physician. more important even than that is the finding that the use of that kind of telehealth actually helps in recruitment and retention of primary care providers. and this goes to a broader point that the more we can do to

support the professional activity of those healthcare professionals and the local environment, the greater the likelihood they will come there because that's how they want to practice with the support of board-certified physicians and the greater likelihood they will stay because they are getting that kind of consulting support. the other quick example is in the case of pharmaceutical services. inside the hospital, in particular, which is how the e-health reaches out you can meet the requirements for review of medication as it's being prescribed in the hospital much more efficiently and effectively through the use of telehealth. >> we've -- perhaps as you know -- put forward multiple policies that were signed into law this year that will reduce barriers to the use of technology in medicare and promote telehealth and medicare advantage and accountable care organizations and other areas, including in treating stroke

patients and these are significant advancements, but i'm wondering if there are other areas where technology can transform delivery of care in rural states. i mean, what should we be looking for in terms of technology opportunities in medicare and medicaid from your perspective and if ms. thompson if you would care to comment on that as well. but we're making some headway. what else should we be doing? >> i think we should try to learn as rapidly as we can from you mentioned the use of telehealth in aco's and medicare advantage plans so that we can transfer that knowledge into the basic medicare system and affect reimbursement policy as was mentioned earlier this morning as one of the barers to the expansion of telehealth. >> ms. thompson? >> i would simply add i think there's a great opportunity to attract the new generation of physician providers or providers in general to rural health. these young people have grown up with technology.

it's very familiar to them and frank frankly it gives them a lifestyle that is something that's very attractive and i think would help us answer the needs of recruiting to the rural areas. >> mr. chairman, i have another question i can submit for the record having to deal with ehr's and how that impacts service delivery in rural areas as well. my time has expired. i will submit that for the record. thank you. >> we thank you, senator. suddenly we have four more. [laughter] >> just magically appeared here. [laughter] >> senator warner? >> thank you, senator roberts. one of the issues that -- and i think ms. martin was raised in your testimony, but i'm

increasingly seeing kind of isolated areas where there may be two competing hospital systems and they leave an isolated island in between where the two systems -- and you may have rural communities with a single doc and in my state the county of king george where the doc has been practicing 35 years, done a great job is about to leave. and because it falls in between two competing healthcare systems, nobody has wanted to take this region, and should he retire, and frankly his system is being sold, we have a community that could frankly go without any kind of coverage at all. this problem of isolated areas where there's not a larger system to provide the back office coverage, even if the rural area has relatively high affluence, this one particular

community king george has relatively high affluence, how are we going to get a that? is the any systemic thing we can do, whether it be a slight increase in terms of medicaid reimbursements or other reimbursements to make these islands more attractive on a longer term basis? >> i don't experience that quite as much in my region of colorado because geographically we're defined by a mountain range. so certainly anything within our valley we are covering and taking care of. we see that more in the eastern plains of colorado where you will have a community with the retirement of physician or closure of hospital, you have a gap in coverage. i really hope that the statewide leadership can make a difference in that in pushing people there. i do think that for the age of physicians going and starting practices on their own, if it hasn't came to an end, it's slowly coming to an end. and i think it is going to be working with existing rural healthcare systems so that they have the financial means to do a

start up and a practice. i think payment for physicians makes a difference with that and i think certainly medicaid reimbursement makes a difference with that in rural communities because when you have 70% medicare or medicaid like you do in my community, you can't make a private model business work. >> this notion of an individual doc going has to have some kind of back office operation to support him or her. do you have other ideas? i know back in the 90s a foundation had a huge kind of focus on this issue of that underserved communities and gp practices opening up, but as you said the ability to open up a practice on your own right now without some additional support from overall system is really hard. is there any way -- has anyone thought about beyond what the government could do in terms of reimbursement levels or loan

forgiveness, incentives to healthcare systems to make sure you don't leave these isolated islands not havg coverage? >> i guess my thought on that would be that i think rural systems do really look at that geography and make a difference. the idea of even the j-1 visa program, things that will help small hospitals like ourselves be able to get providers that would go to these communities through long-term incentives, that's what comes to mind for me. i think the idea of critical access hospital or a rural hospital like the one we have in alimosa being able to get paid under a different reimbursement model in those communities gives you the resources to take on those communities that don't have providers. i think it's a real challenge, and i wish i had a better answer. >> yeah. anybody else want to add on this? i do think the notion of a higher reimbursement level but then do you create almost an

incentive for some systems to kind of drop providers so they could then qualify for increased reimbursement? it's a conundrum. i would be happy to hear from anybody else on the panel. this would be my only question. when you have the hospital systems, who want to make a profit, and they're not willing to stretch for these isolated islands and with the retirement of many docs and the inability for a new doc to go into these communities, real problem, real issue, can't set it up on their own. we have to find a way to crack this code. thank you, mr. chairman. >> senator? >> thank you, mr. chairman. i thank the panel. i first want to just encourage comments on several of my colleagues on telemedicine particularly for rural healthcare i think it is an area we can do much better. i'm proud to join some of my

colleagues in legislation that would allow for medicare reimbursements for telemedicine broader than it is today. if i were to talk about what we do in maryland, we are the only state in the country that has an all payer rate structure for hospital reimbursement. and we went to the next plateau a couple years ago and just approved this month, the final aspects of this demonstration that allows our hospitals basically to be judged on the overall reduction of the growth rate of healthcare costs, rather than just the hospital element of it. so we have an all payer rate structure in our hospitals. but coordinated with reducing the overall costs of that patient's healthcare beyond the hospital care. so there's incentives to keep people healthy. and by way of example, the western maryland regional medical center which is in a rural part of our state, offers care coordinators, navigators

and local practices, uses telemonitoring for blood pressure, weight, glucose, works on the social needs of the patients and that could be incorporated into the all payer rate structure which means all of the third party payers are helping to reimburse for that because you can't get discounts at maryland hospitals, so it works to allow rural areas to have full access to the continuum of services. so my point is this model, this is now being implemented in our state, how do we take this type of a model in the rest of the country that is still in the reimbursements that to me work against rural america, how do we take the model of what we're doing in maryland and use this to develop more access to care and reducing the growth rate of healthcare costs in rural

america? >> senator, thank you for that question. so i had the opportunity when i worked at cmmi to work on the maryland model and share your enthusiasm with the model. and in pennsylvania, there's actually a pennsylvania health initiative that is looking to do what you just articulated so taking the maryland model in a state that is not an all payer rate setting state and develop a different methodology, but similar in the way that it includes all payers and has also the metrics of total cost to care involved in the model, but really using it as a way maryland did for the tpr hospitals back in 2010, and trying to -- but with eight more years of knowledge on how do we

transform and how do we focus on population health. so we concur that it's a great model. i had previously testified that on your state next week the johns hopkins university school of public health is conducting a summit for states to attend on global budgeting and it is my understanding we have over 26 states that are interested in pursuing this. >> yes. >> i would just say that in colorado we're beginning to explore this model as well. we're very much in the beginning stages of it. but the conversations around global budgets and ways to keep our community healthy and control costs is at the forefront of our mind too. >> i just simply want to applaud the recognition that the current payment structure, the current payment systems for rural america, while all

well-intentioned and all designed at a certain point in time to help save rural healthcare, at this point in time are now setting rural healthcare back and not being able to move into population health and the alternative payment models and i just want to applaud the work. >> thank you. my concern is i think the payment structure does not allow for this to occur, so you have to find very creative ways in order to do it. we should be looking at some mechanisms that allow you to use a reimbursement structure modification that brings down the overall cost of healthcare in your community. so that the hospitals are not the driving force for utilization rather that they are part of the overall coordinated integrated care. thank you, mr. chairman. >> senator? >> thank you very much, mr. chairman. i want for the record want to

thank the chairman and ranking member, they actually moved up the hearing this morning because we anticipated that a number of us would be in the mark-up. we did so well yesterday, we finished it last night. so i still appreciated the consideration. i want to talk a little bit this morning -- first, i want to say for the record this is a crisis in our country, the cost of healthcare in rural communities. and we are doing nothing in the united states congress to address it at this moment. we know the premiums on the exchanges are going up because of various things that have occurred. and i think i can get everybody to agree that when we have more uninsured and underinsured, we have more rural hospitals in stress and insurance premiums go up for those of us who buy it. correct? correct? all five witnesses agree. so every time the uninsured number goes up, it costs everybody who is paying,

including taxpayers and including everyone who buys insurance. so the idea of keeping the uninsured number down is all about saving money in the healthcare system and making everyone responsible for their own healthcare bills. so it's just ironic to me that we're going to go back to the days where uninsured numbers are climbing and we're doing nothing right now to address it. there is a lot of bills out there that would help. i'm hoping that the leader mcconnell will see fit to allow some of the bipartisan bills that have been negotiated to the floor so we can actually provide some relief. my issue i want to talk about, there was a really good state audit done in my state by the auditor nicole galloway about a rural hospital and what was discovered was there was a small rural hospital that transferred operational ownership to a lease agreement november of 16 and all

of a sudden there was this giant increase in laboratory billings. and what happened is the vast majority of these billings were for lab activity for individuals who are not even patient ts of that hospital. -- who are not even patients of that hospital. billings began immediately after the management agreement despite the fact the hospital in unionville, missouri, had not even begun processing tests. the hospital partners, which is the company that took over this small rural hospital, also placed on the hospital payroll 33 out of state to perform laboratory services throughout the country. it appears the hospital partners reduced it to a shell organization for purposes of lab billing. this morning i'm directing a letter to the inspector general at hhs to investigate this. evidently this same group was involved in the northern district of georgia, sued on a

pass-through billing scheme at another regional hospital. the missouri audit findings note that a large private insurance company has identified up to 4.3 million in payments for fraudulent claims to putnam in he cent months -- in recent months. my question to you that are working in rural systems and researching rural hospitals, is this a trend? are these companies coming around and buying up these hospitals to front for shady billings on lab work? have you seen this anywhere else? no. you have not. okay. well, this letter is going to -- to hhs today, and i think there's some -- in all likelihood i'm betting there's some criminal activity somewhere and i think maybe there should be some kind of cap on payments to labs outside of the state,

particularly if the billings are coming from a rural hospital. i know you all talked about the lack of doctors in rural communities. i had the university hospital in columbia, missouri, say they were taking in more rural patients than they should. rural patients were bypassing their local hospitals and going to the university hospital, mainly because that's where their doctors were. can any of you address maybe ms. martin you can address the real problem especially we have with ob gyn's being able to be in rural areas and any ideas you may have on how we can incentivize doctors to stay in these rural communities, go to these rural communities and stay in these rural communities? >> i think the workforce issues are very much challenges in rural areas. i think we've spoke today about the loan repayment programs, the conrad 30 j-1 visa programs, i think they are very important to rural communities.

but i also think it's about easing some of the regulatory burden on physicians who work in small areas because they just want to be physicians. they want to take care of patients. and when they can work to the top of their license and to the top of their skill, they're more satisfied in a rural community. and i think that we talked about telehealth a bit today because when physicians know that they can be covered when they're off and they're out or they don't feel the burden of a 24/7 responsibility, i think that's a more satisfying opportunity f them as well. we know with ob gyn's we're very fortunate in the community that i'm in that we have three that work there, and we work with a lot with nurse mid wives to do first line coverage for call for regular deliveries to give them a little bit of relief so that their call time and their quality of life balance is different maybe than what they would experience without those, and so it's the use and the complement of those events

practice nurses that helps to keep the ob's in our community. >> thank you. thank you, mr. chairman. >> senator brown? >> thank you, mr. chairman. my state of ohio struggles with some of the highest rates of eventual mortality and maternal mortality in the country, shamely it is because we have not invested in public health for decades. it is more complicated than that in 08 and 14, women died from pregnancy related causes. more than a thousand babies died before their first birthday. obviously these losses, these tragedies weren't felt equally across all communities. african-american communities in our cities suffered disproportionately to the greatest extent. we also know that in terms of maternal infant mortality, places like small towns in ohio

generally dealt with this. this hearing is about rural hospitals and rural healthcare, so i will stick to that. i'm concerned, though, that not in a conspiracy sort of way, but this committee has done nothing that i can see on infant mortality generally when the problems are equally acute, maybe even more so in urban areas among low income people of color especially. there is a national effort troubles that work requirements seem to be the new far right wing rage in this community, work requirements for food stamp beneficiaries even if they are getting treatment for opioids even if they are incapable of working they are also now looking to do work requirements for medicaid and they are doing it in a way that will absolve

the rural white communities on hi unemplment for these work requirements but will have these work requirements in inner city black families increasingly because they are really smart and figured out how to do it legally apparently but immorally if i could say that, but because this hearing is about rural health, i will stick to a couple questions about that. ms. murphy, if i could start with you, what do we do -- partly taking off on senator mccaskill's question, what do we do to support rural communities in proving outcomes for moms and babies? ms. martin said something about that. i would like to hear your thoughts particularly maintaining access to obstetric services. >> i think we have to be realistic with maintaining obstetrical services in rural communities. i think ms. martin gave an example where there's adequate coverage, three physicians there, that in case of an

emergency, could certainly cover for one another. it's a very high intensity -- ob gyn has a high intensity schedule so you need the numbers that ms. martin talked about to be able to effectively and safely render obstetrical care. i think in areas where they are fortunate enough to have the physician services in a high quality manner, i think we should do that. i think we should work through other providers such as nurse mid wives, certified nurse practitioners, physician assistants to be able to perhaps offer some of the obstetrical care many the rural community when -- in the rural community when it is not possible to deliver there. so a mom doesn't have to drive 35 miles for their monthly appointment. i think it is a very difficult

service to staff in rural communities unless you have the kind of -- the number of physicians that ms. martin talked about. >> thank you. a few weeks ago i hosted a conference with someone in our office to host a conference for ceos from ohio, smaller hospitals, we have incredible from the big children's hospitals we have to some of the best hospitals in the country in ohio, but rural hospitals are not often part of the conversation. and they rarely come to washington and so we hosted a number of them. one of the questions that came up of course was the challenge faced when attracting and retaining a strong workforce. i'm sorry i have been at another hearing today from ms. martin's comments and dr. murphy's comments, i appreciate that. before i yield back, mr. chairman, i wanted to thank too senator widen has been helpful on this medicaid work requirement which is i know we're working on some things together. i wanted to thank him. i wanted to close with this, just a comment, senator roberts,

i want to thank senators grassley and casey for their work on a bipartisan bill we introduced together -- introduced, allow pharmacists to bill for services. they are obviously central to a lot of this too. they can work then with rural hospitals to help improve access to basic healthcare services like immunizations and chronic disease management in their communities, about a dozen members of this committee if i could just name them. they are also cosponsors of this legislation. i'm hopeful -- i know the chairman is not here. i'm hopeful that chairman hatch and ranking member widen will commit to working with senator grassley and me on this bill and other creative initiatives to help all of you deal with the challenges you have in workforce. thank you all so much. thanks, senator roberts. >> senator widen? >> thank you very much, before he leaves, i want to tell

senator brown i'm anxious to work with him on the agenda he's outlined because as usual he's going to bat for folks who don't have clout and don't have power, i want to thank him for his comments. we have been at it for almost 2 1/2 hours. you have been terrific. but what i'm struck by is i don't think we have mentioned over the course of 2 1/2 hours what is really the backbone of rural healthcare, literally from sea to shining sea, and that is rural health clinics. i'm heading home. we have 83 of them in my home state. i know ms. martin, you have got a significant number of them. mr. mueller, you have got expertise on this. in my home state, these rural clinics are literally the backbone of healthcare. they are where seniors go and people go for preventive screenings and primary care

services and everything that helps them to stay healthy and out of the hospital. so what i would like to do since we're getting ready to wrap up is go right down the row again since we got this little window here to try to look at what's important going forward. i don't think it gets much more important than these rural health clinics so why don't we start with you, mr. mueller. one item on their wish list for the rural health clinics going forward. mr. mueller? >> optimizing the use of nonphysician professionals by federal policy on conditions of participation and supervision requirements. >> i missed your colleague, mr. pink, maybe i need to wear my glasses. mr. pink? >> the suggestion made by dr. mueller i would strongly endorse. >> okay. ms. martin >> the issue with co location and co mingling rules that

prevent the true integration of the healthcare provider. >> i think that's so important. chairman roberts, the co chairs of this really important rural health caucus along with our colleagues who talk to me about this constantly. hardly a week goes by when it's not brought up. mr. chairman, this whole dwe question of commingling rules that ms. martin is talking about. this just looks like a bureaucratic la la land to me trying to sort all this out. i will talk with chairman roberts about it. yes, ma'am? >> strengthening the support to the advanced registered nurse practitioners and pa's and extenders that are many times working in isolated areas to give them the support, the education, the retraining and the access to consultation. >> giving them a bigger role? i got to tell you, we had it in our healthy americans act, our bipartisan bill with 8 democrats and 8 republicans, you ought to be able to practice up to the top of your license, and

particularly in these rural areas. mr. chairman, that's another one. why you wouldn't let people practice up to the top of their license in a rural area. i mean, that's just common sense. that has nothing to do with democrats and republicans. yes, ma'am? >> [inaudible]. >> well, you all have been terrific. you know, we have been at it for close to 2 1/2 hours. and i think, you know, to me, you know, without rural healthcare, you cannot sustain rural life. this is not rocket science -- rocket science. there are a couple of pieces to the puzzle that are part of this. we are trying to for example expand broad band. one of the striking aspects about this is i think we started a revolution in medicare with our chronic care bill, because what we're doing is moving from acute care which back when i was director, was a program, you

broke your ankle, that's not medicare anymore. today medicare is cancer, diabetes, heart disease, strokes, that kind of thing. we had a terrific group of members led by two senators come and make the case for telemedicine. really really important in rural areas, but what we've seen in central oregon and the like, if they don't have broad band, they can't tap all the opportunities for telemedicine. there are a lot of pieces to this puzzle. but you've given us a lot of suggestions. i want also to say i'm especially looking forward to the suggestions for the record with respect to how to get more providers in rural healthcare because you can have the facilities, don't have the providers, that's that. so mr. chairman, been a really good really important hearg. people know i have very very strong feelings, which i will not express again, which will please the chairman, about how

damaging these medicaid cuts would be. we can get a bipartisan package here. this is doable. a bipartisan product in a crucial kind of area. looking forward to working with all of you and with chairman hatch and all of my colleagues on both sides of the aisle. wasn't a bad question in the house today. we've got a lot of work to do. looking forward to working with you, senator roberts. >> thank you, senator widen. thank you all for your attendance and your participation today. this was in fact an important and very helpful conversation. all of us look forward to working with each of you on a bipartisan way, both sides of the aisle as we continue to work on a path forward to improve our rural healthcare for all of us who are privileged to represent rural and small town america.

dr. mueller, 1993 that you testified before me, i guess. now here it is 2018, so i look forward to hearing you -- hearing you in 2033 when hopefully we have these things settled. i ask my members to submit questions for the record to do so by the close of business on friday june 8th. with that this hearing is adjourned. thank you very much. >> can i ask you a question? [inaudible]. >> the hearing has adjourned. >> [inaudible].

>>. >> at noon eastern on c-span2, the cato institute looks at war powers and how congress can

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