tv Rural Health Care CSPAN May 24, 2018 8:00pm-10:18pm EDT
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the model is being evaluated from day one. it 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. i think the goal here, the difference is there is a transformation plan that goes along with the global budget with monitoring metrics throughout the life of the global budget. the hospital is going to be very tightly monitored as we go through and lamenting the global budget. i can assure you that certainly
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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 for those unintended consequences. >> thank you. let me turn to senator ron wyden. >> it has been a terrific panel. next week when i have opened -- have open town meetings in joseph oregon, i'm going to remember what you said ms. martin that where you live should not determine if you live. i can just tell you i looked around the room and practically the whole place got whiplash when you said that because that really sort of sums up the challenge. let me give you where we are in terms of the bipartisan possibilities going forward. we have the bipartisan budget
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act. we have five years additional funding for several important programs or rural communities. expending the medicare -dependent hospital program, increasing payment for low- volume hospitals. as i touched on earlier, the ambulance at on. that at least gives us some measure of predictability for the next five years. it seems to me we have really got some heavy lifting to do in the next five years. i think we understand this calamity did not arrive on us in 15 minutes. we will not solve it in 15 minutes. what i would like to do for purposes of going forward in a bar partisan -- in a bipartisan way, we move under the efforts of colleagues on both sides, i would like to go down the row and have each of you give me what would be your top priority
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for medicare as it related to longer-term stability for rural providers and particularly for rural seniors in our country. we know that we have a disproportionate number of seniors in rural communities. write down the row, top priorities for medicare for this long-term stability that we have a chance to work on because we have at least a little predictability for the next five years. let's go right down the road. >> thank you senator. we have talked to people in communities where rural hospitals have closed and almost always the first thing we hear is the disappearance of the emergency department. the emergency room. i would say my top priority is maintaining access to emergency care. >> mine would be building that integrated system that i talked
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about that would include non- hospital-based services particularly both postacute care after hospitalization, and care for the elderly with chronic conditions which was in part addressed by the chronic care act. we need to move forward with some of the innovations that are coming out of that. >> good. ms. martin. >> the flexibility to develop a model in each rural community that meets our needs so they can keep emergency care and can keep services. >> what would be your top priority for flexibility? we are all interested in that. >> i think it would be to allow critical access hospitals to merge two different model which would limit their need to have inpatient beds and be able to have emergency departments and to outpatient care and keep the financials healthy in that model. >> miss thompson. top priority would be recognition of the difficulty in rare tiring -- in retaining
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providers in rural communities. >> what would we pursue? that is enormously important. what would you do by provider policy? >> rural healthcare create an environment that is unique in this country. the community cares for each other. the opportunities that are before us that have been demonstrated in some of our aco models create not only an integration of hospitals and physicians, but in all components of healthcare across the continuum. this kind of an environment is motivating. it is inspiring and could create a platform for transforming health care for the country. >> i want to give ms. murphy the chance to wrap up this round. i would like to keep the record open for you all to give us as many concrete ideas for getting more providers to rural america. this is enormously important.
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we have tried this and that and we all understand that year after year we are faced with this question of whether there's going to be and want to keep the lights on. in other words we have buildings and lights but you have to have people who can run them. ms. murphy your priority for medicare as we use this. where we have five years to push hard. >> expand the test for global budgets to different states. >> very good. only seven seconds over. >> senator roberts. >> thank you mr. chairman. i am very great for that we are holding this hearing. -- grateful that we are holding this hearing. it is well overdue. we try to focus on the unique needs as espoused by the witnesses of people in rural areas. the healthcare challenges faced by these constituents. i am the
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cochair of the senate rural healthcare caucus along with the ever enthusiastic and helpful cochairman heidi high camp of north dakota. we have very similar problems. challenges, we don't have problems. we have long said that rural residents deserve the same quality healthcare as urban counterparts. there is no reason why rural communities should be left behind as other areas continue to advance their healthcare systems. doctor mueller thank you for reminding everyone that i was here in 1993 as you were. it indicates that this has really been a long-term battle. i can remember claire back when it was not h2 s. -- clear back when it was not h2 s. all of a sudden there was a rag that came out that said before any rural hospital could receive medicare reimbursement, three
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doctors had to review all of the patient that came in and the procedures and the team of three doctors had to do this every 24 hours. that was ludicrous. i don't know who came up with that. then i decided it would be a good thing before that because one of the doctors would stay if in fact they were inspecting the hospital. it has been a long-term effort. i want to focus -- by the way we have 86 critical access hospitals in kansas. i hope that when we renovate, i think ms. thompson said we should renovate and not eliminate. we are on first or second base trying to hold on. i don't want to get picked off by all of a sudden saying no to the critical access or moving to some other thing without knowing where we are going. i want to concentrate on the work for situation tonight. you all comment on that.
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recruiting, read training -- retraining staff is one of the biggest challenges we have. our nurse practitioners may be the only primary care provider available. we have to drive quite a few miles to get to the hospital like you have in alamosa. ms. martin 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 really interested in is the federal regulations that come in between the provider and the patient. i am talking about the 96 hour rule, i am talking about the face-to-face regulations. the things that just take a terrible amount of time and expense. if you could focus on that, what suggestion could you make? >> i would defer that question
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to my colleagues who have much more expertise on that than i do. if that would be all right. >> that would be fine. >> to suggestions. one would be looking at medicare precipitation and what is required for supervision. what you alluded to still exists today. and second whatever we can do to open up the use of telehealth services to support the local rural healthcare professionals. we have some of that in the chronic care act. >> you mentioned telemedicine. there were three unique places where telemedicine was to start out. this is back in the 80s. one was in new mexico on an indian reservation. the other was an island in maine and the third one was somewhere in kansas between garden city and dodge. they were selected.
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we are about to announce that and all of a sudden they called up and said don't announce that. we found a doctor. after all that hard work, i was very upset that they had found a doctor. sure enough the doctor came and they were not like the two that came back. in six months was gone. in the meantime we lost the opportunity for telemedicine. now we have it back. it is very typical. you have two doctors that came back because they believed in their community and they wanted to live in the community where they could raise their family and all the good things that have been referred to by ms. thompson. on the federal wreck side which one would you pick -- federal rag side which one would you pick? >> as we measure value in rural communities they are with measures that are relevant to who we are and what we provide. right now we report so many measures to so many agencies.
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they are not meaningful always in moving us ahead with our quality. for instance some of the things we report on, the volume we do is so small that one single fallout appears to make us look like we have a lesser quality then maybe our urban counterparts and that is simply not true. that is a very important point. the point of meaning for use, the revelation of meaningful use has improved the use of technology in the healthcare industry but the pace the changes happening and the expense it takes rural facilities to keep up, i worry about those measures getting between the doctors and the patient. >> consistent with my concerns around access or providers. i would strongly recommend continuing to expand the use of telemedicine. >> doctor murphy? >> i think the relaxation of
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medicare regulations in terms of rowling -- allowing rural hospitals to execute more innovative strategies in recruiting physicians. we have some rural that prohibit that. secondly i think the relaxation or the acceleration of the ability of the medicare program to waive certain requirements for rural hospitals under overall management. >> thank you for your testimony. senator nc. -- senator mike enzi. i appreciate the talent that has been put together to do this. >> i will yield. senator nc said he would yield. >> if i could, i think the
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order of who is here, it would be senator mike enzi next, then senator cassidy and then senator cantwell of the senators who are here. >> i appreciate that. senator mike enzi why don't you proceed. i appreciate the talent -- >> i appreciate the talent and the fact that we are having this. our biggest city 60,000 where i come from. our towns are at least 40 miles apart. we only have 19 towns where the population exceeds the elevation. i have one county that is the size of delaware and you are first class city when you had 2500 people, and they just did. it is 2500 for the whole county. we just try to keep the hospital open their which usually means having a physicians assistant. this is a
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critical hearing for us. i will begin my question with ms. thompson. the way medicare pays rural hospitals including critical access, like we have in wyoming, it is closely related to inpatient services. the medical providers have started to shift to providing more and more services on an outpatient basis. is the inpatient metric still the most -- >> i am not certain it is. when we began our work in the primary ceo the entire question around utilization of inpatient services much at hand because that is what drives the predominance of spend and what calculated the pm p.m. and in the contract with the federal government in the hco, we essentially promise that we were going to reduce the total
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cost of care while reducing quality care beneficiaries. as a result of a lot of and investment in reducing spends, we have reduced inpatient utilization and they moved to outpatient. what i think is more important in terms of the take away for this hearing is not that we reduce the spend or that we improve the quality. both quite important and both are dominant 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 patients and in that lies some secret spot and how we rethink
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not just payment for hospitals or how we think about in patients or payment for positions, or payments for home care. that is typically how we think about policy develop it. but rather how do we look at an organized system of care of a defined community whether it is a rural hospital, the six counties they are serving and create accountability and motivate the community to want to come together whether in a global payment model or in some model that gets us out of this way of thinking about how we organize payment structure in rural america. 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 entirely new healthcare systems. that to me is the most important. >> i'm running out of time. >> sorry. >> thank you very much for doctor murphy. medicare used to allow states whether it would designate
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hospitals as critical access. i understand we have prohibited state-based designations because concerns that it was over utilized. but if the hospital has already learned that state -- earned that state bait designation -- state-based designation to keep it. how did the hospitals compare to the cms definition of a critical access hospital? >> i think the definition of critical access and their impact on whether a hospital is critical access or noncritical access is outdated. the problems suffered by rural hospitals today are really because the healthcare industry has changed. critical access hospitals receiving, whether they are designated or not, they all have the same problem. they have little resources to deliver any type of substantial
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inpatient care. they are devoting all their resources to inpatient care for a very small number of patients. whether the critical access designation was a plus for hospitals two decades ago, i think what we are faced with today is any type of assistance to hospitals that exists in the fee-for-service environment, whether -- regardless of where it is tied it will lead us to the same place sitting here two years from now if we don't take a look at an innovative payment model. >> thank you. i have some more questions but if we have a second round i will do those. otherwise i will submit. i appreciate all the expertise we have here. my time is expired. >> senator cantwell. >> colleagues i know it has been hard to follow.
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i believe order. senator cassidy is next and then senator cantwell. hopefully we can get both of these colleagues in in the next few minutes. >> what would i do without you? >> is the jewish people would say, only. >> senator cassidy i am sorry. >> i never overlook you, sir. >> is my daughter would say, omg. thank you very much. >> i am a physician and i have worked in a hospital for the underinsured and work with my colleagues that are in the emergency room in the understaffed critical access hospital. they think they have to send all their patients to the hospital where i work. a lot of what i will say now reflect that perspective. >> let me first go here. i am interested in the medicare wage index. in which hospitals with a higher cost structure get more.
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if you will, the more get more. now it seems as if under current law based upon your geographic area, were hospitals in my state cannot compete with the urban hospital because of medicare policy which tells the urban hospital we are going to give you more. obviously if you are a nurse and you have to decide where to work, you tend to go where you would earn more. the cost of current policy does not have a floor or ceiling considered when reimbursing providers. as i said urban hospitals get more rural rest. i can ask many of you this question. but doctor pink, does the lack of the floor with the medicare wage index frankly give a perverse incentive for the urban hospitals to keep increasing wages to make it harder for louisiana iowa or
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tennessee to compete who lives -- to keep the nurse who is close to home home? >> senator we have done some research on the various rural designations that congress has created. there are some of these designations where the wage index does play a key role. for example one study we completed last year we found that many of the community hospitals in the country, it is an important payment designation but they are located in states which have lower wages and therefore the hospitals that are eligible for that designation, in fact there is no advantage to taking it. they take the pps payment instead of soul community. i believe it is an issue. we have not studied it beyond community hospitals. >> senator isaacson has a bill which i cosponsored to put a
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floor under the medicare wage index. we do think this would help rural hospitals substantially. secondly and i will stay with you doctor pink, over the last decade there has been a lot of consolidation and hospital systems just for folks to see. obama care passed in 09 and inflection point whether it is causal or associated we don't know. but we wanted to show others the fee as well. subsequent to 09
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>> they don't have an opportunity to see the savings. >> the consolidation may keep the doors open but the benefits don't extend to others. >> let me move on. i have nine seconds. >> ms. martin we have heard about the rise of freestanding ers. several of you have mentioned when these facilities close, the folks primary complaint is i want to have an emergency room nearby. proponents argue that the facilities are providing increased access to er care in rural areas that are not financially feasible to have an entire acute care hospital. the opponents argue that they are cherry picking. although i am told they take anyone who comes. the physician owned facility, the fact that the physician
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owns it is a -- an issue. they are not reimbursed by medicare or medicaid patients. ms. martin you work in colorado. if we were to allow these facilities to be reimbursed by medicare and medicaid, would this be a good thing for your rural area? an increase access to rural er care or not? >> i don't believe it would be a good thing in a rural area. the freestanding ed's that have originated in colorado are all in urban areas. they are not in rural markets. i believe in a rural market, i believe that the conversion is that you keep care located close . >> it's practical that someone has a head injury you are not going to have a neurosurgeon in a rural hospital. you might not have a general surgeon. >> a general surgeon cannot
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maintain their practice because there is not enough volume or because your payer makes it so poor. i thought the paradigm is that the you stabilize the patient and do as much as you can but then transport quickly. does that not work in colorado? >> what i am referring to is the freestanding emergency departments that have been created in the front range market. in our rural community in the hospital i work in, we do have general surgery. some of the critical access hospitals that neighbor us do a lot of stabilization and transferring. that is what we do in the rural facility. i think that keeping an emergency department in a rural facility is positive and something that we need to do collectively. the freestanding emergency departments that have started on the front range -- >> you have to wrap it up. i'm way over. i'm 2 1/2 minutes over. my folks have been forbearing. i apologize. thank you for your answer. thank you all.
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>> not to beat a horse to death, but senator cantwell if you would like to be a member of the always power -- powerful senate agricultural committee, we recognize people on a bipartisan basis going back and forth instead of the tlr schedule espoused by my distinguish friend from oregon. the time of arrival. so for the third time, i am delighted to recognize you. >> thank you mr. chairman. i would love to be at this moment to that committee and i appreciate your leadership and all that you are doing to express it. we need trade and not tariffs. thank you. i think the witnesses and think both of my colleagues for this important hearing. obviously i wasn't here when
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ms. martin gave her statement. the statement about where you should live should not determine if you live resonates and lots of my states. the access to healthcare through the medicaid expansion was big in rural communities in my state. 600,000 people in our state that expanded coverage. we have counties like douglas where again, so 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. 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
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that the previous proposals on changing medicaid might cut as much as a quarter out of medicaid over the next two decades. is that problematic ms. martin? >> certainly the aca expansion made a positive difference in the community where my service area is. i think in colorado overall. we had an uninsured rate of nearly 20% and that has been reduced in my community to low single digits. the coverage for patients and allowing patients to get access for care has improved the bottom line. 70% of our population is medicare and medicaid. our relationship with government payers is critical to our survival. >> did you say 70? >> 70. >> hours is up there as well. over 50. i don't think people quite
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understand that that is the challenge we face. we love our rural economy and communities. they are a great place for people who are aging to retire and live and it is more affordable. but that is a different mix of the population as it relates to how you build a healthcare delivery system. the medicaid expansion is so critical to that. i also wanted to ask about telemedicine. that is another delivery system for us. we have this project echo at the university of washington. you probably heard it in your state as well. it has allowed medical professionals from seattle to consult with people in the yakima basin. some of our clinics to talk about the decisions for highly complex patients for hepatitis c and substance use disorders.
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what do we do about that as it relates to payment system? i don't think fee-for-service is any kind of friend to that cost-saving technology and that collaboration that is existing. >> in our community we are modestly getting the use of telehealth. 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 provide the service. one of the best things we could do is to invest in the startup for rural hospitals and then allow the services to be reimbursed on a fair basis. we currently do telehealth now in our community for infectious disease, genetic counseling. we are trying to build that for oncology coverage and for -- it would save the system money. when a person goes into our emergency department and we
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have one cardiologist in the community. when that person is not there, if the condition of the patient's warrant, we have to transfer them to another area to be evaluated by a cardiologist. they often get transferred or evaluated and then they are dismissed from the hospital. if we could have cardiology services available 24 seven we would save the expense of an air ambulance or ground transport with the patient with the cardiology program. >> there's no reason you can't with telemedicine. >> that is true. >> it is getting it recognized in the system in some way. >> and paid for. >> recognized into the system. that is why the challenge that a fee-for-service model. >> i don't have any time left. the doctor shortage issue for rural communities continues. we just need to fight that. we have counties in our state
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that have 4000 people and no axis. we have to do better. thank you. -- no access. we have to do better. thank you. >> senator carver. how many counties are there in america? >> let the record show they have no idea. the answer is 3007. delaware has three counties. the southernmost county is called sussex county. it is the third largest county in america. we don't have many of them but we make them big. sussex county raises more chickens than any county in america. last time i checked we raise more soybean than any county in america and more lima beans. we have more five-star beaches than any county in america. 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 who
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live on the coast. the rest of the county is largely agriculture. we have hospitals and rural hospitals. we have outpatient clinics in the va clinic. it is actually quite good. we still have a lot of people who don't have access to healthcare because we are so spread out in a big county. i want to talk a little bit with all of you about cost that flow from tobacco use. i understand that an extra $200 billion is spent because of our addiction to tobacco products. i am told we are spending hundred and $50-$200 billion a year because of obesity. i am told that america's rural
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communities are still more likely to use tobacco products than other parts of our country. rural communities are also more overweight and more obese. i just want to ask what tools and what resources, what delivery system forms could we be using to reduce the disparity in rural communities when it comes to tobacco use and obesity? i want to start with doctor murphy. >> thank you. >> i was told you were good on this question. >> thank you. what we talked about earlier was a new way to pay for rural health. i don't want to say rural hospitals in any way to reimburse. it is a multi-payer global budget system that allows hospitals to focus on the problems that you just talked about and invest -- instead of investing in subscale services, invest in tobacco cessation
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programs. invest in substance use disorder treatments. invest in the clinical -- the healthcare outcome you're looking for and and this disparity or to gradually create this disparity between rural health outcomes and those of their urban counterparts. that is the beauty of this model. it allows for the investment and care coordination. it allows communities to really take those chronic disease problems and re-allocate the dollars that they were receiving from subclinical care services. they had to provide it because that was the only way they got paid. it now allows them to address the population help more. >> let me ask the other four witnesses. if you agree would you raise your right hand? >> if any of you have something you would like to add to what doctor murphy has said? >> ms. martin.
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>> an investment in primary care providers. i think that is the relationship that impacts patients behaviors and impacts patients ongoing quality of life. so many communities, it is the importance of the primary care provider that impacts these behaviors. >> anyone else want to add? yuma county pronounce your name? >> keith mueller. pull -- and how do you pronounce your name? >> mueller. you can come out that in two ways. encouraging collaboration healthcare in the public and private sector. an investment into public health agencies. >> one last question? what is your recommendation for how we can increase the supply of mental health workers and increase access to mental health treatment in rural and underserved area? is we will start on my left please.
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doctor mike ink doctor mike unix -- >> i have to defer to my colleagues. this martin? >> it is investing in the education where we can educate and train a work force of our own. we have an extreme portage in -- shortage of qualified professionals. >> i believe it is to further study the integrated health model that is in play with our medicaid population and i think there is a great deal to learn their and a great deal of excitement to create young folks that we can get into high schools and motivate them about opportunities and know-how. >> doctor murphy? >> i would just say leveraging
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technologies so we can access more urban centers. >> ready will come from? >> doctor murphy? >> i am the chief innovation officer. >> i have been there before >> unity point health in des moines iowa. >> sally health amoroso colorado. >> university of iowa. >> some of you have come from a long ways, we thank you. we thank you for the work you do it is very important. thank you so much. >> thank you chairman roberts. really appreciated the insights about special challenges we face in rural areas. i come from ohio. we have a big urban hospitals and rural hospitals.
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some are closing down and consolidating. i will tell you in my state one of the issues that is particularly difficult to deal with in a rural area is the opiate epidemic. i would think if you did a per capita analysis of the opioid epidemic in my state, you'd probably find in the rural areas the problem is even more acute than in some of our urban areas. the difference is really not so much the per capita impact but the services that are provided. one of the issues that we have more more children that are being born with neonatal abstinence syndrome. they have to be taken through withdrawal themselves. we have great programs taking moms who are addicted, weaning them off of their addiction and helping to ensure the babies are born without neonatal abstinence syndrome. it is overwhelming. our neonatal units, one of the
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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 the babies go home and there's not the ability to continue to monitor in rural areas. what i'm asking you today, you mentioned the opioid epidemic. to the hospital ceos, maybe you can help me on this, what services do hospitals offer to support the long-term recovery needs of these growing number of children who have this neonatal abstinence syndrome and for their mom and families. in particular if you work with kids with nas how do you ensure the families receive the support they need? >> we have seen an increase in this issue just last year. about 11% of the babies that we delivered had the syndrome that you speak of. we have done a lot of training
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with our staff to have them have the skill set to help the babies for the first two weeks of life. we sometimes keep them for that period of time. when they move out into the home, often times they are going into foster homes because if the mother was a user, unfortunately they are placed in foster families. we have pediatricians who try to work with these families and development. we have a grassroots community organization that involves the schools early childhood development, some of our primary care providers. together we are trying to leverage and learn resources. it is a challenge because there's not a lot of information about that. we hear about elementary schools that they don't feel equipped to deal with the challenges that some of these children bring to the classroom. i think just additional resources around education and training so that our workforce would know better how to help these children would make a
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huge difference. >> any others? >> we are just beginning to develop a program for substance abuse and their children born with neonatal abstinence syndrome. the vision for the program is that we would intervene when the mother begins medication for treatment prenatally. and what we would say is wrap our arms around another and the baby with services such as behavior health services, pediatric services and other social services that would enhance the likelihood of the mom staying in recovery after the baby is born. the idea behind it is that we would offer these services for. of up to two years and determine -- evaluate the model and
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determine what interventions help that mom stay in recovery and go on to a productive life. >> thank you. we did pass legislation here called the addition recovery act which has a separate title for pregnant moms, postpartum moms and these kids with nas. since that time, we passed a budget which increase the funding for that. for those who aren't aware of that. we are looking for good pilot programs around the country so apply for it. doctor murphy is right. if we can spend money up front to avoid the long-term problems and determine what works, you mentioned information and the right kind of therapies to be able to help the babies as well as their moms and take advantage of this moment. many of the moms are facing the addiction because of their pregnancy. they don't want their kids to be born with the syndrome so they're willing to go to treatment when previously they were not. i think doctor murphy is right. once the baby is born, how do you treat them?
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usually it is a suboxone treatment and weaning off the opioid. how do you get them into the treatment program and long-term recovery and use the family relationship to help kindle some better prospects for long- term recovery. we look forward to working with you all on that. in the rural setting we have a particular challenge and i appreciate you being here today. i have a question but i will offer that as a question for the reference center. i have legislation i want to get your views on. thank you. >> thank you. coop you are up next. >> inc. you mr. chairman. thank you -- thank you esther chairman. thank you for holding this chairman. -- mr. chairman. thank you for holding this. we have providers who work diligently coming up with creative solutions but there are still barriers and
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complications faced on a daily basis. there are big hurdles for people to overcome. -- too often we lose south dakota's if they train and then -- train in another state. our tribal communities have trouble getting access to healthcare communities. i look forward to working with my colleagues on this committee and trying to advance solutions that address many of the solutions. doctor mueller, in your written testimony you mentioned that the center has completed multiple studies on how telehealth can work as a tool to care in rural settings and i couldn't agree more. i understand you have a current project that is looking at health initiatives in south dakota which range from
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emergency department icu, pharmacy, behavioral health and more. i have seen some of this technology firsthand and know they are working hard to innovate. for this committee's benefit could you discuss what you have learned so far about the model and how it has helped increase access in our state of south dakota. >> thank you for the question. i will focus on what we have learned about use intel health emergency rooms. what that has done, i mentioned earlier a condition of precipitation -- participation was changed to meet the necessity of telehealth. that has made a tremendous difference across south dakota and other facilities that avera supports. you can have an advance practice primary care provider not a physician in the er that
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can quickly access a board certified physician. more important even than that is a finding that the use of that telehealth helps in recruitment and retention of primary care providers. this goes to a broader point that the more we can do to support the professional activity of those healthcare activities in the local environment, the greater the likelihood they will come there because that is 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 support. the other example is in the case of pharmaceutical services inside the hospital in particular which is how he health from avera reaches out. you can meet the requirements for review of medication -- much more efficiently.
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we have put forward multiple policies that were signed into law this year that will reduce barriers in medicare and promote telehealth and medicare advantage in accountable care organizations and other areas. including and treating stroke patients. these are significant advancements. i am wondering if there are other areas where technology can transform delivery of care in rural states. what should we be looking for in terms of technology opportunities in medicare and medicaid from your perspective and missed thompson if you'd care to comment on that as well. we are making headway. what else should we be doing? >> we should try to learn as rapidly as we can. you mentioned the use of telehealth in aco's and medicare advantage plans so we can transfer that knowledge into the basic medicare system and affect reimbursement policy as was mentioned earlier this morning as one of the barriers
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to the expansion of telehealth. >> i would simply add, i think there is a great opportunity to attract a new generation of physician providers or providers in general to rural health. these young people have grown up with technology. it is familiar to them. it gives them a lifestyle that is something that is very attractive. i think it would help us answer the needs of recruiting to the rural area. >> mr. chairman i have another question i can submit for the record having to do with eh are -- eh ours and how that impacts delivery in rural areas. my time has expired so i will submit that for the record. thank you. >> we thank you senator. >> suddenly we have four more. they just magically appeared here.
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>> senator warner. >> thank you senator roberts. one of the issues, and i think ms. martin it was raised in your testimony. i am increasingly seeing isolated areas where there may be two competing hospital systems and they leave an isolated island in between the two systems. you may have rural communities with a single doctor and in my state the county of king george the doctor has been practicing 35 years. he is about to leave. because it falls in between two competing healthcare systems no one has wanted to take the region. should he retire, his system is being sold, we have a community
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that could go without any coverage at all. this problem of isolated areas where there is not a larger system to provide back-office coverage, even if the area has high affluence. this community has relatively high affluence, how are we going to get at that? are there any systemic things that we can do, whether it be a slight increase in terms of medicaid reimbursements or the reimbursements to make these islands more attractive on a long-term basis. >> i don't experience that quite as much in my region of colorado because geographically we are defined by a mountain range. anything within our valley we are covering and taking care. we see that more in the eastern plains of colorado where you will have a community with the retirement of the physician or the closure of a hospital, you have a gap in coverage. i really hope that the statewide leadership can make a
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difference in that and pushing people there. i do think that for the age of physicians going and starting practices on their own, if it hasn't come to an end, it is slowly coming to an end. i think it will be working with existing systems so that they have the financial means to do a startup in a practice. lower payment for physicians makes a difference for that. and medicaid reimbursement makes a difference in rural communities. when you have 70% medicare and medicaid you can't make a private model business work. >> this notion of an individual doctor having to have back- office operation to support him or her. do you have other ideas? back in the 90s a foundation had a huge focus on this issue of that underserved community. and practices opening up. as you said if you open up a
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practice on your own right now without additional support from an overall system it is really hard. 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 having coverage? >> my thought on that would be rural systems do look at that geography and make a difference. the idea of even the j one visa program. things that will help small hospitals like ourselves get providers that will go to these communities through long-term incentives. that is what comes to mind for me. i think the idea. access hospital for rural hospitals like one have in alamosa gives you the resources
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to take on the communities that don't have providers. i think it is a real challenge. i wish i had a better answer. >> anyone else want to add? i think the notion of a high reimbursement level, but then do create an incentive for some systems to drop providers so they can qualify for an increased reimbursement is a real conundrum. i would be happy to hear from anyone else on the panel. >> when you have a hospital systems that want to make a profit and they are not willing to stretch for these isolated islands and for a new doctor not going to the communities. real problem real issue. we have to find a way to crack this code. thank you mr.
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can do much better. now we want 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 health care 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
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overall cost of that patient's health care beyond the hospital care. so there's incentive to keep people healthy. by way of example, the western maryland regional medical center, which is the in the rural part of our state, offers care coordinators, navigators, and local practices. that can be incorporated in the all payer rate structure. that means all the third party payers are getting reimbursed for that. you can't get that in hospitals. so it works for rural areas that have full access to the continuum of services. so my point is, this model -- and this is now being implemented in our state. how do we take this type of a model in the rest of the
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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 health care costs in rural america? >> senator, thank you for that question. so i had the opportunity when i worked on the maryland model. i can share your enthusiasm with the model. and in pennsylvania, there's actually a pennsylvanian health rule initiative that's looking to do exactly what you just articulated. so taking the maryland model in a state that's not an all payer rate setting state and develop a different methodology but similar in the way that it includes all payers and has
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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 hologen, how do we focus on population health? we think of it as a great model. i had previously testified that in your state next week on the josh hopkins university of public health, it's conducting a summit for them to attend on global budgets. and we have over 26 states 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
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our community healthy and control costs is at the forefront of our mind, too. >> and i simply want to applaud the recognition that the current payment structure, the current payment systems for rural america, while all well intentioned and well designed at a certain point in time to help save rural health care, at this point in time are now setting rural health care back and not being able to move in to population health and the alternative payment models and macra. and i just want to applaud the work. >> thank you. and my concern is that i think the payment structure does not allow for this to occur. you have to find creative ways in order to do it. and we should be looking at some mechanisms that allow you to use a reimbursement structure modification that brings down the overall cost of health care in your community so that the hospitals are not
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the driving force for utilization, rather that they are part of the care. thank you, senator. >> thank you very much, mr. chairman. i want for the record to thank the chairman and ranging member. they moved up the hearing this morning because we anticipated that a number of us would be in the nda markup. we did so well in the nda we finished it last night. so i still appreciate 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 health care 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
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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's 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 health care system and making everyone responsible for their own health care bills. so it's just ironic to me we'll go back to the battle days where uninsured numbers are climbing and we're doing nothing right now to address it. and there's a lot of bills out there that would help. so 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 is a really good state
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audit done in my state about the auditor nicole gallaway 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 of laboratory billings. and what happened is the vast majority of these billings were for lab activities for individuals 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 phlebotomieses to perform laboratory services throughout the country. it appears that hospital
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partners reduced putnam to a shell organization for purposes of lab billing. this morning i'm directing a letter to the inspector general at hhf to investigate this. evidently this same group was involved in the northern district of georgia. sued on a path through billing scheme. 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 recent months. so my question to all of you that are researching rural hospitals and that are working in rural systems, is this a trend? are these companies coming around and buying up these hospitals for shading billings on lab work? have you seen this anywhere else? no. you have not. okay. well, this letter is going to
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-- to hhf today. and i think there's some you all likelihood, i'm betting criminal activity somewhere. and i think there should be some sort of cap on payment 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 missouri say they were taking in more rural patients than they should. rural patients were bypassing their local hospitals and going to university hospitals mainly because that's where their doctors were. can any of you address maybe ms. martin, make you can address, the problem we have with lbgyn of being in rural areas. and how we can incentivize doctors to stay in these rural
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communities and stay there? >> i think the workforce issues are very much challenges in rural areas. i think we spoke today about the loan repayment programs, the conrad programs, i think they're important to rural communities. but i think it's about easing the burden of them in small areas. they just want to be physicians. they want to take care of patients. when they can work at the top of their skill, they're more satisfied in a rural community. i think we talked about telehealth today. when physicians know 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 for them as well. we know with ob/gyn's, we're very fortunate in the community that we have three ob/gyn's that work there. and we work with nurse mid-
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wives to do first line coverage for call for regular deliver are yous to give them a little bit of re-- deliveries to give them a little bit of relief so their balance of life is different than what they would experience without those. so it's the use and complement of those advance practice nurses that helps to keep the ob's in our community. >> thank you. thank you, mr. chairman. >> senator vine? >> thank you, mr. chairman. my state of ohio struggles with some of the highest rates of maternal mortality in the history. probably because we've underinvested in public health in recent decades. from 2004 to 2014, many died and in 2016, more than a thousand babies died before their first birthday. obviously these losses and tragedies weren't felt equally across all communities.
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african american communities communities in our cities suffered disproportionately to the greatest extent. we also know that in terms of maternal and infant mortality, places like app la -- appalachia, ohio, they suffered more. i will stick with the topic of rural health care. i'm concerned that not in a conspiracy sort of way but this here, this committee has done nothing that i can see on infant mortality generally when the problems are equally acute. maybe more so in urban areas among low income people of color especially. there is a nationally republican effort troubling that governors are, as work requirements, seem to be the new far right wing rage in this country. work environments for food stamp beneficiaries, even if they're getting treatment for
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opioids, even if they're incapable of working. they're also now looking to do work requirements on -- for medicaid. and they're doing it in a way that will dissolve these work requirements. it will increase in black communities because they're really smart and figure out how to do it. legally apparently but immorally, if i could say that. but because this is about rural health, i will stick to the question about that. a couple questions. ms. murphy, if i could start with you, what -- what do we do to support rural communities and improving incomes for moms and -- outcomes for moms and babies? i'd like to hear your thoughts.
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>> i think we have to be realistic with maintaining ob services. i think ms. martin gave an example of adequate coverage, three physicians there in case of emergency they could cover for one another. it's a very high intensity -- an ob/gyn has a very high intensity schedule. so you really need the numbers that ms. martin talked about to be able to effectively and safely render on tech rich history cal care. i think in areas -- obstetrical care. i think in those areas where they can work on site in a high quality manner, they should do that. we should work with other providers such as certified nurse practitioners, physician assistant, perhaps to offer
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some of the obstetrical care in the delivery. so the mom doesn't have to drive 35 miles for their monthly appointment. but i think it is a very -- i think it is a very difficult service to staff in rural communities unless you have the kind of -- the number of physicians that martin talked about. >> >> thank you. a few weeks ago, i hosted a conference with abby and doug in our office. and veronica worked with us to host a conference with c.e.o.s with 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 of a strong workforce. sorry. i've been in another hearing
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today. but from their comments, i appreciate that. i'd like to before i yell back, mr. chairman -- and i wanted to thank, too, senator widen has been helpful on this medicaid work requirement. i know we're working on some things together. i wanted to thank him. i wanted to close on this comment. senator roberts, i want to thank grassily and casey with their work on a bipartisan bill we introduced together. senate bill 109 which would allow pharmacists to bill services in underserved area. pharmacists are probably not the greatest need in every case. but they're central to a lot of this, too. they can work then with rural hospitals to help improve access to basic health care services like immunizations and chronic disease management in their communities. about a dozen members of this committee -- if i could name them. thuman, scott, nelson, campwell also cosponsors of this. i know the chairman is not here.
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i'm hopeful that chairman hatch and widen will commit to working with senator grassily and me and this bill and other creative initiatives to help all of you deal with the challenges you have in workforce. so thank you all so much. thanks, senator roberts. >> senator widen? >> thank you very much. and before you leave, i would to tell i'm excited to work with what you've outlined. i want to thank him for his comments. we've been at it for almost 2 1/2 hours. you all 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 health care literally from sea to shining sea! and that is rural health clinics. and i'm heading home. we have 83 of them in my home state. i know ms. martin, you have a significant number of them. mr. mueller, you have expertise
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on this. in my home state from curry county to enterprise, these rural clinics are literally the backbone of health care. and they're where seniors goes 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'd like to do since we're getting ready to ramp up ask 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. why don't we start with you, mr. mueller. one item on their wishlist for the rural health clinics going forward. mr. mueller? >> optimizing the use of the nonphysician professionals by -- and this is state policy, scope of practice. but federal policy on participation requirements. >> mr. pink -- maybe i just
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need to wear my glasses. mr. pink. >> the suggestion made by dr. mueller i would strongly endorse. >> okay. >> the issue with colocation and comingling rules that prevent the true integration of the health care provider. i think that's so important. and chairman roberts is the cochair of this really important rural health caucus. they talk to me about this constantly. hardly a week goes by where she doesn't bring it up. but this whole question, the comingling rules that ms. martin is talking about, this just looks like a bureaucratic lalaland to me. so -- lala land to me. >> strengthening support for advanced registered nurse practitioners and p.a.'s and extenders that many times are working in very isolated areas
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to give them the support, the education, the training and access to consultation. >> giving them a bigger role. i got to tell you -- and we had it in our healthy americans act. our bipartisan bill with eight democrats and eight republicans. you should be able to practice at the top of your license and particularly in these rural areas. so mr. chairman, that's another one. why you wouldn't let people practice 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? well, y'all have been terrific. we've been at it for close to 2 1/2 hours. and i think to me -- you know, without rural health care, you cannot sustain rural life. this is not rocket science. there are a couple of pieces to the puzzle that are a part of this.
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we are trying, for example, to expand broadband. and one of the striking aspects about this is i think we've started a revolution in medicare with our chronic care bill. what we're doing is trying to move from acute care which -- when i was director at the panthers was a program. you broke your ankle, that's not medicare anymore. now medicare is cancer, diabetes, heart disease, that kind of thing. so we have a terrific group of members led by senator shots and wicker make the case for telemedicine. it's important for rural areas. but what we've seen in central oregon and the like, if they don't have broadband, they can't tap all the opportunities for telemedicine. so 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 health care because you can have the
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facilities, don't have the providers. that's that. so mr. chairman, a really good, really important hearing. people know i have very, very strong feelings which i will not expression again. that 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. 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. so we have a lot of work to do. looking forward to working with you, senator roberts. >> thank you, senator widen. and 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 in a bipartisan way on both sides of
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the aisle as we look forward to work on a path forward to improve our rural health care for all of us who are privileged to represent rural and small town america. dr. mueller -- let's see, it was 1993 that you testified before me, i guess. and now here it is 2018. so i look forward to hearing from you in 2033 when we hopefully will have these things settled. ask any member who wishes to submit questions to the record by the close of business on friday, june 8th. with that, this hearing is adjourned. thank you so much.
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coming up live on friday, president trump will be the commencement speaker at the u.s. naval academy in indianapolis, maryland. our coverage begins at 10:00 a.m. eastern on c-span. on c-span, two events on venezuela's recent presidential elections. we hear first from juan cruz and later in the morning, a conversation with a former president of the venezuelan
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national assembly at 11:00 a.m. eastern. commencement speeches next week in primetime. monday at 8:00 p.m. eastern, oprah winfrey, representative steve scalise, rod rosenstein, and joe kochen. me too movement founder, taronda burke, rose lynn gates brewer and nikki haley. wednesday, hillary clinton, rex tillerson, james mattis, and justin trudeau. thursday at 8:00 p.m. eastern, apple c.e.o. tim cook, governor john kay sick. governor kate brown, and congressman louise guttierez. representative mark meadows and atlanta mayor key that lance bottoms. next week in -- keisha lance
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bottoms. next week in c-span. election system vulnerabilities were the focus of a recent conference on hacking. election officials from los angeles and orange counties shared their views on some of the changes needed to help ensure the security of both. this is one hour. thank you very much and thanks for coming here. now that we're all suitably -- suitably freaked out, we can talk about some solutions and then we can listen to the computer science experts and engineers come back to further scare us after this panel. let me introduce my colleagues here. we really have an incredible group of people here today. to my immediate right is
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