2018, the house will do the motion. >> and question time in the canadian house of commons comes to a close. members are moving on to other business. you can watch this again tonight on the c-span networks or later on our website c-span.org. this coming thursday, democratic and republican members of congress will face off in the 57th annual congressional baseball game for charity. the game will be placed at nationals park. live coverage begins at 7: p. eastern here on c-span3. you can also watch it on our website at c-span.org or listen with the free c-span radio app. health care industry analysts and providers testify about the challenges facing rural hospitals including incentives for doctors to serve in rural communities. the role of tell a medicine services. and changing medicare reimbursement pay rates to hospitals and physicians.

telemedicine. >> the hearing will come to order. i would like to welcome everyone to today's hearing. the topic today is rural health care, which is a critic cal iss for every member of this committee and so many others. i've long considered it a special mission to create the same rural payment opportunities that many of our nation's urban counterparts enjoy. representing a western state, i detand the challenges our rural hospitals and providers face to deliver high quality medical care to families in

environments with more limited resources. in the senate rural health care policy boasts a history of collaboration on both sides of the aisle. ke for example back in 2003, when we passed a medicare modernization act, mma included a comprehensive health care package taylored specifically with rural communities, hospitals and providers in mind. yet the mma finally put rural providers on level pla field with their neighbors in larger communities. the law also put into place common sense medicare payment provisions that help isolated and under served are of e country provide access to medical care as close to home as possible. however, while the vast majority of rural health payment policies enacted in the mma permanent, some were only

temporary. and in the years following these t temporary provisions have become known as medicare extend tears. as we know the problem with tend t national funding takes priority over developing a robust strategic plan for the future. although som partisan and bipt health care policies medicare payments, many rural and frontier health care providers still face significant obstacles attempting to successfully participate in medicare system reforms and bun gel payment arrangements. while these changes t con emphasize new ways to pay providers, medicare existing strategies to preserve access to health care in rural areas still rely on specialmbsent programs that either supplement inpatient hospital payment rates

or provide cost based hospital payments. now, these special payment structures may work just fine in certain parts of the country. but even with the wide range of special medicare rural payment programs, some smaller communities are home to hospitals still find it hard to achieve financial stability. the reasons, as we will learn from the expert witnesses on the panel today, are complex and multi facetted. for example, when compared to their urban counterparts, on average, the 4 million medicare beneficiaries living in rural and frontier areas are less affluent, suffer from more chronic conditions and higher mortality rates. to make matters worse, small rural hospitals continue to be

more heavily developed or dependent on medicare inpatient payments as part of the total revenues. at the same time we are seeing a steady nationwide shift away from inpatient care to providers offering more out patient services it seems to me. many rural hta ser as central hub, but some strug toll keep their facilities operating in the black in order to meet local demands for a full range of inpatient outpatient and rehabilitation services. resolving these issues is no easy task. clearly, for some communities medicare special rural payment structures, i guess i should say, may stifle innovations that

rural health care systems. o one consistent theme that we will hear from our witnesses today the need for flexibility. they are not is asking congress for one size fits all federal policy. they want the flexibility to design innovative ideas that are taylored to meet the specific needs of the communities they serve. they need the federal government to support data driven states an local innovat that have the promise to achieve results increasing access to basic medical care, lowering cost and improving patient outcomes. the federal government cannot tackle this challenge alone. while i was pleased to see it release the area straugt earlier this month, i believe this

administration led by secretary azar still needs to help prioritize new models while also reducing regulatory burdens on rural and frontier providers. state and local officials must be aggressive in their efforts to design transformive policies and programs that meet their unique rural health care needs. and the federal government really needs to listen. weuld listen to what these folks have to say and how we can -- what some of the solutions really are. in my view, states should be the bringing ground to test new ideas. however, it is 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 is so important for rural communities to work

together, share resources, and develop networks. the federal governmentust continue to recognize the important differences between urban and rural health care service delivery and respond with targeted fiscal responsible solutions. by pulling our knowledge, expertise and financial resources, we can work together to develop targeted payment policies that ensure appropriate access while also protecting medicare beneficiaries and american taxpayers. now, i'm looking forward to hearing some of those innovative ideas from our witnesses here today. but before i turn to our ranking member senator wyden, i want to bring one important item to the attention of the committee. the medicare payment advisory commission other wise known as med pack, has submitted a statement for the record

outlining the commission's latest recommendation aed athen shurg access to emergency development services for medicare beneficiaries living in rural communities. i encourage all members to review med pack's statement and ask that it be made part of the official hearing record. with that, let me now turn to my partner onhis commission senator wyden for his opening statement. >> thank you, very much, mr. chairman. and fir i want to say right 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. we did that with respect to tenure for chip. we did it by the way in the rural area related to medical extend tours where we were talking about literally life and death matters like ambulances. so i want to make sure we understand on this side we think it is very doable to come up with a bipartisan product. each year i hold open to all

town meetings in every rural county and there i meet with many leaders from the health care field. and they tell me there are a few thave them aai for what lys is coming down the pike. fit, 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 of course is a public document, indicates that another assault could be coming. 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

out there for decades, if you want to turn rural america into aacrifi zone or a hostile shut down and people can't get the health care they need, the fastest way to do it is by slashing medicaid. second, people in rural areas today feel their local hospitals are already teetering on ts brink of tir or he local hospital goes under, that means no more emergency departments available in a crisis. now, this isn't a far off theoretical problem. decades ago, back when getting routine health carmore often meant spending mult tal nights in the hospital ininpatient bed rural hospitals were much more secure. they could afford then to maintain emergency department. but that service may be on the ropes now becauseural hospitals are under such huge financial pressures.

offering a variety of inpatient services and keeping the emergency room open is extraordinarily expensive. at the same time, more and more americans are turning to outpatient settings for chronic care, rehab, a routine surgeries. since 2010, 83 rural hospitals have closed their doors. and hundreds more are in dire straights. in fact, excuse me, rural services have been closed since 2010, 83 rural hospitals. >> btom le, when you live in a big city like portland, chicago, or los angeles, you take it for granted there is always going to be an emergency department nearby. but rural americans who fear their hospital will be the next to close are left wondering what's going to happen if their son or daughter breaks allege in a high school basketball game. i heard exactly that kind of

concern just a couple of weeks ago in rural oregon. where would the family go if a olderneuffered a stroke? would 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 health care. in my view it's sp one when you are working to prevent rural america for turning into that sacrifice zone where people cat get the care they need. and i'll just close by this point. i've already indicated i think we can produce a bipartisan product here. i mean, a country as wealthy as ours looks like we spent about $3.5 trillion last year on health care. for that amount of money, you could practically send every family of four in america a check for $40,000 and say, here, get health care. it ought to be possible to

guarantee that rural americans are not on the outside looking in. thank you, mr. chairman,king forward to working with our colleagues and getting bipartisan product. >> thank you, senator. let me just set the recor straight. the decline in rural hospitals started long before medicaid expansion. and prior to the trump administration, of course. weather touting medicaid expansion or blaming trump, i hope we can set politics a side and evaluate whether medicaid and medicare are yielding appropriate response to assist states and communities. that is after all the purpose of this bipartisan hearing. we cannot spend more money in medicaid and expect to solve every problem. so i look forward to continued discussion with our he can period of time witnesses about what more can be done to ensure federal dollars are being spent

judicial usually and wisely to help our rural hospitals and providers. so we need to do that. i would like to expand 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 are set to testify. first we will hear from dr. george pink humana distinguished professor in the department of federal policy and management at the gul ings school deputy of north carolina rural health research program and senior research facility at center for health services research. prior to receiving his phd incorporate finance, dr. pink spent ten years in health care

management. dr. pink hold it is bachelor degree from the university of calgary, master's degree in health administration from the university of alberto, and phdi university of tore and toe. our second witness, dr. keith jay mueller will be introduced by my good friend committee member senator grassley. senator grassley, if you like, u can proceed right now with your introduction. >> okay. bch i do that, since rural hospitals have been brought up, i'd like to point out to my colleagues and particularly senator wyden, because he brought up, i have a bill in, goes by the acronym reach, that i think about half of the senate cosponsoring, and in fact you may be a cosponsor of it. i hope people look at that. because that is an alternative to the possible closing of som ra hospitals. it's my privilege to welcome

another iowian dr. keith mueller. doctor -- dr. mueller is renown expert on rural health care. interim dean at public health at the university of iowa. he directs the rou pay, which is acronym for the center for rural health at university of iowa. he was published more than 220 scholarly articles and received national recognition for his health care. welcome, dr. mueller. >> thank you. >> next to speak will be miss connie martin she will be introduced by senator bennett. >> thank you, mr. chairman.

and thank you so much for holding this hearing. rural communities have long been struggling with scarcity of health care providers and facilities. tht has exacerbated the challenge with opioid epidemic which has hit rural americans particularly hard. i'm pleased to introduce my colleague in colorado. miss martin has been working to serve for more than 30 years. prior to being named ceo in 2013, miss martin serveon chief operating officer. completed regional institute of health and university of colorado. also the health care executive program at the ucla and der school of business. graduated from school in mon cello. pivotal role. and presidential search

committees and member of the economic development corporation. i look forward to hearing miss martin's testimony. thank you, mr. chairman. >> thank you, senator bennett. now the fourth witness to speak is kay thompson also from iowa and also be introduced by senator grassley. >> it's my honor to introduce you to the committee. she's eulogy point. sue is also the ceo of unity point accountable care. a nurse by training. and she's the first iowan to be named to the medicare payment advisory commission. as you said, mr. chairman, known as med pack for shor sue's professional achievement in expertise will speak for themselves. however, i'd like to say that a part of her legacy is sitting behind her today. so i'm going to talk about her

family that's involved in rural health care as well. nate thompson is sue's son. nate is ceo of story county medical center critical access hospital in away. and daughter in life nate's wife, ashley is governmental relations specially for point. dr. caitlyn thompson is sue's daughter. she's a psychiatrist working with berryhill mental health center in fort dodge, iowa. and chad behnke is sue's and husband for point clinic. so sue it seems to me like your faly is as much involved in rural health care as you are. welcome to the committee. >> thank you. >> thank you, senator forprovid introduction.

our final witness will be dr. kar karen murphy introduced by senator casey. >> thank you. privilege to introduce dr. murphy. at kaiser health system. i knowerrom our hometown. and she has a long record of service in health care. she served our state as pennsylvania secretary of health. she was president ceo of the moses taylor health system. her education is substantial. dr. of philosophy and business administration from temple fox school of business and mba from manage i wood university. my mother and daughter a sister managemerry wood. bachelor of orts from university of scranton. and nursing diplom so whether it's nurszing itself,

which was her calling, as well as a real commitment to the reform in the health care delivery system, in so many ways, karen has brought a passion and degree of excellence to these issues that i think is unmatched. so karen, dr. murphy, welcome. >> thank you, senator case see f casey fnding off introduction i would like to thank the witnesses for being here today, in particular for their testimony in advance of their patience and flexibility as members will be moving in and out of today's hearings because we have other markups going on. so i have two or three markups going on right now. personly, i must have to leave to attend the judiciary committee mark up. with all that out of the way, dr. pink, we'll 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 global public heekt at north carolina chapel hill. we research rural heekt care delivery and funded by the primarily by the rural health poll sismt i'm here to discuss what we know about rural hospital closures and start with all too common story. coa lynn ga medical center is 24 bed acute care hospital with 200 employees. on may 1st it announced after 18 months of losses totaling $4.5 million, it is ininsolvent and close in june. it will read 17,000 people without an emergency room in the

city. the nearest hospital is adventist health in hanford which is over 40 miles away. colinga second hospital in san joaquin valley to close in the last six months. tulare medical center 112ed hospital closed six months ago. across the country, 125 rural hospitals have closed since 2005. 83 since 2010. why is this happening? many reasons, but long-term unprofitability is an important factor. years of losing money results in little cash, debt payments that knts be made, charity care and bad debt that can't be covered, older facilities, and out dated technology. why do they lose money? small rural hospitals serve patients who are older, sicker, poorer, and more likely to be unor underinsured. they staff emergency rooms with

small populations and low patient volumes. combine this with reimbursement reductions, professional shortages and many other chool engs and you can see why i prefer being a psso a rural hospital executive. what happens after a closure? some convert to anoer te health care facility, but more than one half no longer provide any health care services. they are parking lot empty buildings, and apartments. patients travel average of 12.5 miles more to the next closest hospital, but many travel 25 miles or more. for the old, poor, and disabled who cannot afford or do not have access to such transportation, these distances can be very real barriers to object tank needed care. who is most affected? we have investigated communities served by rural hospitals at high risk of financial distress because they may be the next facilities to close. these communities have

significantly higher percentages of people who are black, unemployed, lacking a high school education, and who report being obese and having fair to poor health. in other wds, vulnerable people. if the hospitals that serve these communities reduce services or ultimately ose, already vulnerable people will be at increased risk. what can be done? try to improve what we have by exploring ways to better rul hospils ingrate es needs and closure would have the grea consequences on the communities. preferably we should develop something new. at meetings around country,he most common frustration i hear is the lack of model to replace hoital.r closed we have acute care, inpatient hospital, hospitals with emergency rooms on one end and primary care clinics on the other end. we need something in between.

there is no shortage of in ovasive ideas. 8 to 10 new role models have been imposed by organizations. profound challenges facing providers that rural communities are not going away. we need to step up the pace of innovation, and development of the medicare policies and regulations 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. >> well, thank you so much. we appreciate you having you here and appreciate your expertise. mr. mueller, we'll turn to you now. >> chairman hatch, ranking member wyden and members of the finance community, thank you for this opportunity to talk today. while some things have changed in the 30 years i've been

conducted rural health research and policy analysis, things remain the sa. we have new tools in health care to help sus continue our quest to establish a high performance health system in rural america. we have interesting debates over that time, including whether aftermathospital payment in the 1990s, considering health care reform in those years, majorhanges in medicare payment and nefits, changes through the patient a protection and affordable care act, and now a renewed and welcome decision what we should be doing to best serve the needs of rural residents. i've benefited from exchanges with this committee and throughout. starting with the conversation senator roberts and i had when i testified as part of the panel which i now chair, to the house committee on agriculture in 1993, we provided analysis of the house security act by

assessing their impacts on key rural considerations. senator roberts may remember, and it looks like he does, sharing appreciation for the straightforward analysis that we provided which help give me the confidence to continue bringing forward the best we can offer from policy analysis. of course, then roberts may not have liked the thumbs up thumbs down that milo cy local newspap provided. front d cent policy discussions. we did the balance bugtd act of 1997. mma that senator hatch referred to in 2003, and of course in 2010. provided feedback to this committee and others and folds up with analysis of rural impacts of new policies, including calling attention to unintended consequences of the

bba in 1997 before that term was as ubiquitous as it is now. i've come to appreciate the n k nexus with needs of our policies health care services. as president of the association in '96 i represented the needs of rural providers in policy discussions. one of my funded projects in early 1990 was working with providers to provide template for them. my engagement with that and the panel and rural telehealth center in iowa host of topics to this committee, including rural pharmacy, implications of changes and health care delivery and organization, delivery system reform initiatives, and

the evolution of the marketplace and health insurance coverage and the role of telehelp. my written testimony includes specific research findings on some of those topics, along with policy considerations. i would like to share some important questions tconsider for the future of medicare aco program. are there benefits other than savings related t cnges i delivery models that help a chief the triple-a of patient experience, better health, and lower costs? should there continue to be different tracks? should variations of advance payment perhaps as grants continue to be available? finally, what is the next iteration of payment reform that builds from the experiences of acos? perhaps global budgeting we'll hear about later. i now offer five rural considerations for policies designed to encourage delivery system reform. one, organization rural health systems to create inter gray tive care. two, build rural system capacity to support integrative care.

three, facilitate rural participation and value based payments. four, a line medicare payment an performance assessmen policies with medicaid and commercial payers. and five do the payment systems. popular density distance to providers and the need for infrastructure investment. new models can build on the strengths of the rural system, notably primary care. thank you for this opportunity. and i look forward to your questions. >> well, thank you. we appreciate having your testimony here today. so to miss martin at this point. >> thank you for the opportunity today to timeshare our health care story. i'm the ceo of a small health care system located in the san luis valley swi a rural agricultural based community in southern colorado. we serve six counties roughly the size of and safeet for nearly 50,000

residents. two of the counties are the poorest in colorado. nearly 70% of our patients are covered by medicare or medicaid with less than 20% having commercial insurance. with this challenging payer mix, we are constant struggle to rema financially viable. rural hospitals around the country are appreciative of this commitment to rural communities and hopeful that meaningful help is on the way. our system is kwom priced of 49 bed sole community hospital and 17 bed critical access hospital. we operate five rural health clinics, two of which are provider based. th p provided 2500 hospital visits. 58,000 outpatient services. and overinic visits. we are a level 3 trauma center and only facility that delivers babies, provides surgery, or has any type of specialty care for 120 miles in any direction.

we serve veterans, farm workers, college students, tourists, and our own friends and families. we are resilient and creative team of health care pro vie derder providers. we are largest in the region with staff over 800. and many have lived in the area for generations. as for me i moved to the valley in 1985 and began my health care career entry level it position. back when the personal computer was new technology. and have worked my way into the current ceo role. our staff struggles with the cost of meet tg regulatory requirements which are sometimes different and conflicting across payers. our system must report on dozens of measures for the medicare quality. however, our private insurer's ask us to report yet more sometimes on the same very topic

but using a different definition. this complex and confusing data reporting takes time away from what really matters which is delivering on our health care mission. recruiting and retaining a qualified workforce is another challenge for rural providers. we've been fortunate to provide partnerships with local schools that develop and maintain our workforce. specifically grow your own programs. from para medic training to hosting medical students, interns sthips and mentoring those pursuing a health care mba. we collaborate with the local health center to host training track program. we are set to have the first two physicians complete this training in june of 2019. we do have our workforce success stories to celebrate as well with two family medicine physicians in our system to return to their childhood homes to care for friends and neighbors. and we have a physician who 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. however, federal payment systems and delivery models must recognize the unique circumstances of providing care in a rural community. and they must be updated to meet the reality and challenges of how health care is delivered today and into the future. about 10 years ago the critical access hospital that is part of our system now approached us for help. nearing closure and in dire financial condition, we entered into a partnership to provide management services and flg shat support. in 2014, this critical access hospital fully merged into the system that is today san luis health. such partnerships are not available to many rural hospitals. we see the result with hospital closures across the country.

and today 12 rural hospitals in colorado are operating in the red. therefore, i'm here today to ask for your support and consideration for new financial models to consider our needs. including the creation of a 24/7 rural emergency medical center designation as such as the american hospital association has recommended and senator grassley has championed and ask you to provide appropriate resources, flex abltd and ongoing dialogue with those of us in rural america whota ready to innervate, work hard and meet the current challenges of caring for our friends and neighbors. in a country as great as ours, where you live should not determine if you live thank you for your remarks. >> thank you so much. i'll turn to you now. >> thank you, and good morning. thank you for this great opportunity to address the committee on several of the challenges facing health care in rural america and offer up some ideas for potential solutions.

now i would be remiss if i did not take this opportunity to publicly thank our senator from iowa, senator grassley has made access to quality health care in lure hall regions of our country a priority. thank you for frgs you do for iowa and our country. before assuming my job at the corporate office of unity point healthy was c of a smault health system affiliated in fort dodge iowa. trinity is 49 bed hospital including a group physician clinics and home care clinics, and most recently a tweener. as it participates in the rural demonstration program. trinity has former management agreements with five critical access hospitalsnd close referral relationships with sister unity metropolitan

markets including des moines. classified as pioneer aco, trinity took responsibility for improving t quality and lowering total cost of care for approximately000 10,dicare beneficiaries attributed to them thisural northwest iowa community. they did this successfully hand continue to do so as the next generation aco. it is through this work the challenges facing rural health communities, hospitals and providers have become so pal 'pa bly clear to us. first challenge to highlight is dichotomy and incentives that exist those who operate under total cost of programs like acos, medicare advantage programs and bundled payment programs and rural counterparts who operate under fee for service cost based reimbursement methods. 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 a trributed move in and out of the rural facili facilities in the nation. they would ask where do we fit in? and today the answer to that question is you don't. the policy approach has been to exempt them from value based policy all together. we submit this approach is not working and needs to change. rural health care can fit into value based payment models. so you wonder, is unity point health advocating that this be reconstructed? and to that we answer no.

we are requesting it be renovated. this brings me to the second challenge i must highlight and this challenge is the greatest, access to health care services in rural areas. bringing quality careo 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 the distance opinion service centers, lack of comprehensive community services ant healthcare workforce dead zones. we propose the renovation of healthcare delivery in you'll areas include a value-based component tied to medical outcomes and expenditures and separate and distinct payment structure is developed for the portion of cost-based reimbursement that pays for t costs associatedith access in rural areas. while our written testimony goes into greater detail, how such a system could be structured, i offer you some playful dos and

just one don't as we design this type of system. dos. do enagehe ms 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 for the additional cost of bringing access to rural markets, and do support bills like the reach act that allow rural hospitals to transition to new designations designed to meet modern needs, and do continue to allow telehealth practice to extend the reach of our in-person providers, and with the utmost respect just one don't. don't embrace a policy that allows free standing ambulatory surgery centers to establish residents in rural markets and cherry pick patients by

procedure. further straining the viability of commuty hospitals. i challenge you to find one for-profit free-standing asc that has an emergency room. in close, healthcare entities are the backbone of many of our rural communities. we need our rural healthcare delivery systems to be viable. 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. miss murphy. we'll turn to you. u'll be our final witness. >> chairman hatch, ranking member widen and members. committee. thanks for inviting me to testify about rural hospitals. in addition to my clinical background which you've already head, i spent two years at cmmi before assuming my role as secretary of health working on the state innovation models initiative. today i would 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 systems in pennsylvania. i was struck by the financial instabilityf the rural hospitals. i found that the -- that in research i found that the situation in pennsylvania was being replicated across the country. pennsylvania has the third largest rural population in the united states. 67 of our 169 hospitals in pennsylvania are in rural communities. more than 58% of those hospitals in rural areas have mounting financial pressure resulting in break-even or negative operating margins. we began to look for a solution. after having worked on the maryland payer model while cm the impressive results, we decided to design a similar model for rural hospitals in pennsylvania. we worked collaboratively with cmmi on designing the model.

i would also like to acknowledge senator casey and his office's support as we designed this model. the design period was launched in january of 2017. the objective of the model are to provide a path to improving health and healthcare delivery in rural communities. the model changes the way participating hospitals will be reimbursed. the model replaces the current fee-for-service system with the multi-pair gloekt budget based on the hospital's historic net revenue. like maryland, the payment model in pennsylvania is designed to include all payers. however, it was necessary to develop a new med theology since maryland has the authority to establish hospital rates and pennsylvania does not. the model moves rural months from focusing on in-patient centric healthcare services to a greater focus on outpatient centric healthcare services with an emphasis on population health and care management t.replaces the current fee-for-service

system with little emphasis on quality and safety to a payment mod they will includes directive sentives to improve quality and safety and eliminate subscale service lines. rural hospitals are encouraged to move from traditional care models directly delivered on site to innovative care mod that's are enabled by technologies such as telehealth, video conferencing and remote montrifnlg the vision that rural hospitals will invest in care coordination such as reaching out to patients who frequently used the emergency room services and connecting them with a provider. it also includes population health and preventive care services such as chronic disease prevention programs and behavioral melt initiatives, including those targeting substance abuse disorder with the expansion of medical homes to include medication-assisted treatment program. they will address community issues that lead to detrimental

health outcomes. participating hospitals are expected to develop a transformation plan that could outline an innovation approach to improving health and healthcare for the communities they serve. they are encourage tolled work with community agencies such as united way, area agencies on aging, drug and alcohol treatment centers to developer is vices based on their community needs. to provide participating hospitals with support, pennsylvania floons create a rural health redesign center. cms has entered a coove agreement with pennsylvania to provide up to $25 million over five years to support the rural health redesign center. this will provide a way to deploy capabilities to support all participating hospitals. pennsylvania's planning to engage six hospitals in the initial performance year, gradually expanding to 30 rural hospitals in pennsylvania. we're a participant in the initial phase. the geisner ceo has been a

staunch support supporter since its insemgs as it builds on our envision of focusing on improving health and value creation for each community we serve. we're looking forward to working with the state on this very important initiative. the financial challengesf rural hpitals today are the result of a changing healthcare industry. they may not be able to offer the same services that they did in the past, but it is possible that they can be leveraged to improve the health of those residing in rural communities. next week i'll be speaking of the global budgeting summit at johns hopkins university. 26 states have registered to participate. the federal government has the opportunity to engage additional stat in pennsylvania rural health model. implementing across diverse states would give us the opportunity to evolve this innovative payment and delivery model. thank you for your interest in aiding rural hospitals. i, too, believe rural communities deserve access to healthcare, and we must continue

to work to identify innovative approaches that are a pathway to that goal. >> thank you so much. i think this testimony has been very interesting today. let me just start with you, miss martin, and in your testimony you referenced times when your hospital system has been on the verge of financial crisis in the past. how did you leverage resources and streamline service delivery so that or operationes to stay financially viable, and can you talk about what you think an appropriate medicare margin should be for small and nonprofit rural hospitals like yours? >> thank you, senator. >> yeah. >> i think it's interesting when you talk about margins for rural hospitals. i think 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 3% to 5%, we consider that a very successful year and so ihink

different areas have different needs. so much depends o your infrastructure and what you need to replace as far as equipment and facilities go, so i think for our system and from my perspective those are the margins we're trying to achieve. so many times we're under 1% or sometimes in the negative. i think wt we did initially over the past few years is put our two systems of care together, the critical access hospital and our sole community hospital, and we are -- we used the economies of scale, you know. we have one ceo for that rural system of care. we have one finance department. we share a lot of services between our two organizations, and that makes it cost effective to run the different departments. you know, we have a person who is an expert in laboratory or a person who is expert in imaging, and they help larger

organizations when you can divide them across a couple of communities. the other thing we do. we're really frugal. in rural america we're very thoughtful about what we buy. we don't provide services that our community doesn't need because we don't have that luxury. we have to match our services to the needs of our community. we have built our primary care ba or these past few years and that has made a substantial difference with keeping our care close to home and we've added specialty services that are the highest need for our patients and our community. for instance, we've added oncology services in the past three years. we started out with a model where we brought a specialist a day or two a month and we built that to where we do have a full-time provider. i think part of our challenge is one single specialist in a rural community, you know. you hav to have the connections to have coverage a support for that individuals so those have

been some of our strategies. we are not a lucrative health system as all? thank you. let me go to you, dr. murphy. first let me say that there's a lot of exitment around the pennsylvania rural health model that clearly hold greatromise and i'm personally pleased to see cms with states to help design rural integrad healthcare strategies. is there any concern about the pennsylvania's new global budget payment method that rural hospitals might lose incentives to be efficient in providing healthcare services, and, secondly, how do you think your state's rural hospitals will figure out ways to low costs and improve for what they know they will be getting under the budget. >> thank you. i think the challenge is which is why ip cnn to look.

it is a test to defrt if we could transform rural hospitals in a way that is efficient and improves -- and improves health as well as healthcare delivery services. there is a monitoringomponent within the global budget methodology that we'll check. the mold is evalurom day one that will determine the appropriateness of the services and the inability or unintended consequences to occur so that's belt within the test of the model, but i think the goal is here, there's a transformation plan that goes along with the global budget with monitoring metrics throughout the live of the global budget so the capital 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 players, so i believe the model is row left in the way that they will verbal our for those intended consequences? let mow turn to senator wyden. >> thank you very much, mr. chairman. i think it's been a terrific panel. next week when i have opened everybody up to hearing, i'm going to remember, miss martin, what you said where you live should not determine if you live. iooked around the room and practically the whole place got whiplash when you said that because that really sort of sums up the challenge. colleagues, let me give you my sense of where we are in terms of the bipartisan possibilities going forward. we had the bipartisan budget act. we got five years of additional

funding for several important programs for rural communities, tending the medicare dependant hospital program and increasing payment for hoe-volume hospitals and as i touched on earlier the tlans add-ones. >> that first you some measure of predictable for the next five years. but it seems to me we've got some he have lifting to do in the next five years. i understand this calamity did not arrive on us in 15 minutes. we're in the going to solve it in 15 seconds. so i would like to do it for purposes of kind of going forward in a bipartisan way here as we move under the efforts of the colleagues of both sides. i would like to go down the row ave eachfou ge me what would be your top priority

for medicare as it related to longer term stability for rural prov and particularly for rural seniors in our country because we know that you have disproportionate number of seniors in rural communities so right down the row. top priority for medicare for this kind of long-term stability that we hav ance t work on because we've got at l a little predictability for the next five years. just go right down the row. >> 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. emergency roompingt i would say my top priority is maintaining access to emergency care. good. >> mr. mueller. >> i would say me would be billeding that integrated system that i talked about that would

include non-hospital-bas services, particularly both post-acute care or after a hospitalization care for the elderly with chronic conditions addressed in part by the chronic ovre act and we forward wit some of the innovations come out of that. >> good, miss main. >> the flexibility to develop a model in each rural community that meets their needs so tha they can keep emergency care and can keeper is vices. >> what would -- that's a very good point. what would be your top priority for flexibility, because we're all interested in that. >> right. i think it would be to allow critical access hospitals to develop -- to emerge into a different model which would limit their need to have in-patient beds and to be able to be emergency departments and do outpatient care and keep the financials healthy in that model. >> good. miss thompson? >> top priority would be recognition of the difficulty and acquiring and retaining providers to rural commues. >> so if you could wave your

wand, what would we pursue because that's enormously important. what would we do by way of provider policy. >> rural healthcare and rural communities create an environment that is unique in this country. the community cares for each other, and i think 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 i think quite frankly could create a platform for transforming healthcare for the country. >> let's do this base want to give miss murphy the chance to wrap up this rnd. i would like to, and the chairman is alway very gracious about this. let's keep the record open for you all to give us as many concrete ideas for getting more providers to rural america because this is enormously important and we've tried loans

and we've tried this and that. look, we all understand that year after year we're faced with this question of whether there's going to be anybody to keep the lights on. in other words, you've got buildings and light but you've got to have people who can run them. rit. >> mission murphy, you're one priority for medicare as we use this period ase've got five years to really push hard for longer term. >> expand the test for global budgets to different states. >> very good. mr. chairman, thank you. only seven seconds other. >> okay. senator roberts. >> thank you, mr. chairman. i'm very grateful that we're holding this hearing on rural healthcare in america. it's long overdue. the congress tries to focus on the unique needs as espoused by all the witnesses. people in rural areas, the healthcare challenges faced by these constituents. i have the privilege of serving

as the co-chair. the senate rural healthcare caucus as wells an ever enthusiastic and helpful co-chairman senator heidi heitkamp of north dakota. we have the same challenges, and weave long said that rural residents deserve the same quality healthcare as their urban counterparts. i think every witness has gone over that. there's no reason why rural communities should be left behind as other areas continue to expand their healthcare system. dr. mueller, thanks so much for reminding everybody that i was here in 1993 as you were and it indicates that this has really been a long-term battle. i can remember clear back when twae hew and secretary joe califano. ihink at the time all of a sudden there was a reg that came out tt said before any rural hospital could receive a medicare reimbursement, three doctors had to review all of the

patient -- all of the patients 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, but then i decided i would be a good thing to be for that because maybe one of the doctors would stay if in fact they were inspecting the hospital, but it's been a long-term effort. i wanto focus -- by the way, we have 86 critical access hospitals in kansas, and i hope that when we renovate i think miss thompson said we should renovate, we should not eliminate, we're on first base or second base, you know, trying to hold on. i don't want to get picked off by all of a sudden saying know to the critical access or moving to some other thing without knowing where we're going. i wanted to concentrate on the workforce situation and have you

communitying all of that. recruiting and maintaining and changing taffe is one of the biggest challenges that we have. our physician assistants an nurse practitioners may be the only primary care pvider available. we have to drive quite a few miles to get to that hospital leave you -- to that hospital when you have to travel 200 miles to get there. the federal regs that come between the provider and patient, i'm talking about the 69-hour rule and the face-to-face regulations, things that just don't -- it just takes a terrible amount of of time and experience and if you could really focus o that, what suggestion could you make and we'll start with dr. pink. >> senator, i would defer that question to my colleagues who have much more expertise on that

than i do if that would be sfwlrt that would be fine. dr. mueller? >> two suggestions. one is looking at medicare conditions and partipation and what's required for supervision, the kind ofng you alluded to from the califano yrs that still exist today and, second, whatever we can do to open up even more the use of telehealth services to support the rural healthcare professionals and we had some of that as i mentioned earlier in the chronic air act. >> you mentioned telemedicine. there were three unique places where telemedicine was to start out. this was back in the '8 a 0s. one was in new mexico at a indian reservation and the other was in an island in maine and the other was if kansas between

cardin city and dodge. we announced that and all of a sudden they said don't start that because we found a doctor. after all that hard work i want that they found a the doctor came and they were not like your two doctors, the two that came back. six months the doctor was gone and in the meantime we lost the opportunity for the telemedicine and now we have it back and it's just, you know, very typical. now you've got 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's been referred to by miss thompson, but on the federal reg side, which one would you pick? >> i think i would pick the aligning quality measures so that as we measure value in community, they are relevant to who we are and what we provide. right know we provide so many

different measures to so many different agencies and they are not always meaningful in moving us ahead with our quality. for instance, some of thngs that we report on. ume that wo is so small tha one single fallout appears to make out look like we have a lesser that will than maybe our urban the u.n. parts is a meaningful point and then the evolution of meaningful use which has certainly improved the technology in the healthcare industry and with the pace that the change is coming and the expense that it takes for rural facilities to keep up, i worry those about kind of measures really getting between the doctors and their patients. >> miss thompson. consistent with my concern around access to providers. i would strongly recommend continuing to expand the use of telemedicine. >> dr. murphy? >> i think the two, i think the

relaxation a medicare indications in terms of allowing rural hospitals to maybe executes moore innovative strategies in recruiting physicians and we have rules that prohibit that, and secondly i think the relaxation or the acceleration of the ability. medicare program to waive certain requirements for rural hospitals and their overall management. >> thank you all for your testimony. >> senator enzi. >> thank you, ippreciate that the hearing is being held and appreciate the great talent that we have to do it. >> i didn't see her. >> i'll yield. >> senator cantwell. you were next. senator enzi said he would yid. >> mr. cman. >> yes. >> if i could, i think in order

of who is here, it would be enzi next and then senator kassity and then senator cantwell of the senators who are here. >> appreciate that. >> senator enzi, why don't you >>oceed. hank you, thank you. again, i appreciateal and the fact that we're having this. i come from the least populated state in the nation. our biggest city is 60,000, and all of our towns are at least 40 miles apart. we only have 19 towns where the population exceeds the elevation. i have one county that's the size of delaware, and the city, and you get to be a first class city when you hit 2,500 people and they just did, is 2,500 for the hole. we try to keep a hospital open

there which means usually just having a physician's as tap the. this is a critica hearing for us, and i'll begin my question withis thompson. the way medicare pays rural hospital including critical access and sole community like we have in wyoming, it's closely related to in-patient services. as medical providers have shifted towards providing more and more ver vices on an outpatient basis, is the in patient metric still the most appropriate measure for hospital costs? >> i think that's a great point. i'm not certain that it is. you know, when we began our work in the pioneer aco, the eire question around utization of in-patienter iserse is we very much at hand because that's what drives the freedom nance of spend and what calculated the pmpm and in contract with the federal government in the aco, you know, we essentially made a promise that we were going to reduce that total cost of care while improving quality to the

medicare beneficiaries. as a result of a lot of focus work and investment in reducing spend. we've reduced inpatient utilization, and a lot ofhese services moved to outpatient. what i think is more important in terms of a takeaway for this hearing is notty that we reduced the spend or the quality. both quite important and both predominant. what we believe is so important is we need to rethink policy around healthcare is how -- how strong and how -- how absolutely woven together a rural community is in commitment to caring for its patients, and in that lies some secret sauce in terms of how we rethink not just payment for hospitals or how we think

about inpatient or payment for physicians is or payment for home care which is typically how we think about policy development, but rather how do we look at an organized system of care defined community, whether it's a rural hospital with six counties they are serving and create and accountability and motivate a community to want to come together whether in a globa payment model or in some model that gets us out of this siloed way of thinking about how we organize payment structure in rural america. and in that way of thinking i believe we'll transform not only how we pay for care how but care is delivered and how we recreate an entirely new healthcare system that. to mow was the most important thing. >> i'm running out of time. >> i'm sorry. >> thank you very much. for dr. murphy, medicare useto allow states whether to designate hospitals as critical

access. i understand we've prohibited state-based desig nations because of concerns they were overutilized by allowed hospitals had already earned that state-basedesignation to keep it. in cases where the critical access designation may have been overutilized, how do hospitals compare to the cms definition of a critical access hospital? >> so, i think the dev -- i think the definition of critil accessospitals, senator, and whether it's a in a

hospital for the uninsured and often interface with my colleagues who are in an emergency room with some understaffed critical access month and so understaffed that they frankly had to send all their patients to the hospital where i worked, and so a lot of what i will say now will reflect that perspective. let me first go here. i'm interested in the medicare wage index and which hospitals with the higher cost structure get more? if you will, the more get more.

now, it seems as if under current law based upon your geographalre ral hospitals in my state cannot compete with the urban hospital because of medicare policy which tells the urban hospital we're going toe you more. and so obviously if you're a nurse and you have to decide where to work you would tend to go where you would earn more. the cost of wages, current policy does not have a floor or ceiling in place for an adjustment in which the cost of wages is considered when reimbursing providers, and so, as i just said, urban hospitals get more rural rest. i could asknyfou this question. dr. pink, does the look of a ceiling or floor for the medicare wage index frankly give a reverse incentive? for the urban hospitals to keep increasing wages to make it harder for a rural hospital in louisiana or iowa or tennessee to compete and to be able to

keep that nurse who lives close to home home? >> senator, we have done some research on the various rural designations that congress has created, and there are some of these designations where the wage index does play a key role. for example, once study we completed last year we found that many of these sole community hospitals in the country, it's 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's no advantage to -- to taking it. they take the pps payment instead of the sole community, so i believe it is an issue. we have not send it beyond community hospitals, for example. >> we'll say that senator isaacson has a bill of which i co-sponsored to put a floor into the medicare wage index which we

do think would help rural hospitals substantially. secondly, and i'll stay with you, dr. pink. over the last decade there's been a lot of consolidation in hospital systems just for folks to see. obamacare passed in '09, kind of an infliction point. whether or not it's causal or associated we don't know and wanted to show others so you can see as well but subsequent to '09 you can see that the number of consolidation episodes has increased about doubling year to year. now, we know that that increases cost. there's good data showing that prices at a monopoly hospital are 12 percent higher than those markets with four or more rivals, and i could give more evidence to that. dr. pink, given that these mergers coincided with rural hospital closures, i don't know the answer to this and i'm asking you this. has consolidation by large hospital systems reduced

competitions or increased prices and have kind of resulted in rural hospital closures. >> we have not studies urban mergers and acquisitions, senator. i can say that for many rural hospitals and small communities, merging with a larger health system has been the only option available to them, where they are literally faced with the choice of do we have nothing or are we bought by a large system? >> now, miss thompson raised the issue of the acos not being extended to a rural area but presumably if a rural hospital consolidated they would just extend their aco out to the rural. miss thompson, has that not occurred? >> that has not occurred. >> porquio pas as my french teacher would say? how come not?

>> it reduces any opportunity because they reimburse based upon the costs based upon the medicare patients they are caring for so they don't have an opportunity to see the savings associated with it. >> you get the consolidation which may keep the doris open t me move on.he benefits are i've got nine seconds left. miss martin, we 'ear heard about the rise of free standing e.r.s like in texas and colorado and several of you mentioned when these facilities close nokes' main complaint is they want an emergency room nearby. facilities are providing increased access to e.r.s in rural areas were not financially feasible to have entirely acute care hospitals. the opponents argue that they are cherry picking, and although i'm told they take anybody who comes and that -- that the physician-owned facility, the fact that physicians own it is

an issue. currently the if a significances are not reimbursed by medicare or medicaid process. if we allow these facilities to be reimbursed by medicare and medicaid, would this be a good thing for your rural area, increasing access to rural e.r. care full, or not in. >> i don't believe that it would be a good thing in a rural area. the free standing e.d.s that have originated in colorado are l 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 convergence from a critical access shot that you keep care located close to a community -- >> let me stop you for a sec. it's impractical if somebody has a head injury. you're not going to have a neurosurgeon in a rural hospital and quite not likely have a general surgeon. just because a general surgeon -- my wife is a general surgeon. she cannot maintain her practice because there's not enough

volume and your payer mixes are so poor. i think that the emerging paradigm is if you stabilize a patient, do as much as you can and then 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 ft. range market. in our rural community and the hospital i work in we do have general surgery and some of the critical access hospitals that neighbor us do a lot of stabilization in transferring and that's what we do in the rural facilities. i think that keeping an emergency department in a rural cility is very positive and something that we need to do collectively. my statement is simply that the free standing emergency departments that have started on the front range have not -- >> got to the wrap it up because i'm way over. okay. i'm sorry, i didn't mean to interrupt and i'm two northamp minutes over and my folks have been forbearing. thank you so much for your answers. thank you all.

>> not to beat a parliamentary horse to death, but senator cantwell, if you would like to be a member of the always powerful senate agriculture committee, if we recognize people on a bipartisan basis going back and forth as opposed to the tor schedule as espousd by my distinguished government from oregon. so for the third time i'm delighted to recognize you. >> just for senator cantwell. >> thank you, mr. chairman and i would look to be at the moment ex-officio to the ag committee and so appreciate your leadership and all that you're doing to express that 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, miss martin, when you gave your statement, but the statement by

you about where you should live should not determine if you live resonates in lots of my state. the access to healthcare through the medicaid expansion was big in rural communities in my state, writ large 600,000 people in our state got expanded coverage, but we have counties like douglas and chilean, again, so that the chairman knows where 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 attorneys 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 a quarter out of medicare over the next two decades. is that problematic, miss martin, for rural? >> i think certainly the aca expansion mid 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, and so the coverage for patients allows patients to get access to care. it's improved the financial bottom line of certainly our organization, and 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 -- over 50. i don't know what the latest numbers are, but yet 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 that it's a difference mix as a population as it relates to how you build a how you build a delivery system. me expon is so cro thitical. wanted to ask about telemedicine because that's another delivery system that i think for us we have this project echo, the university of washington, working with harborview. you've heard of it obviously in your state as well. it's allowed medical professionals from seattle to consult with people over near the yakima basins, some of our clinics to talk about some of the most highly complex patients for hepatitis "c" and substance use disorders. so how do we -- what do we do about that as it relates to the

think fee-for-service is any t kind of friend to that cost-saving technology and that cost-saving collaboration tt' existing. >> i think in our community we're modestly beginning to the use of telehealth, and ptf ou c that we don't have the resources for a lot of the startup 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 startup expense for -- particularly 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, and we're trying to build that for oncology coverage and for cardiology coverage, and it would actually save the system money. for instance, when a person goes into the emergency department and we have one cardiologist in the community, when that pern

is not there, we have to -- if e warrant, we have to transfer them to another area to be evaluate bid a cardiologist. they oftentimes get transferred, evaluated and then they are dismissed from the hospital. if we could have card allergy services available 24/7 we would save the expense of an air transport or ground transport for a person with cardiology problem. >> and there's no rean that you can't with telemedicine. >> yes, ma'am. >> it's just getting it recognized into the sis them some way. >> and paid for. >> well, right, that's what i meant. recognized into the system, and 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 the do better. thank you. >> senator carper. >> thanks so much. >> my first question for the witness is how many counties are there in america? is it all right. let the record show they have no idea. [ laughter ] the consequence is 3,007. delaware has three counties, and the southernmost county is called sussex county. that's the third largest county in america. we don't have many of them, but we make them big. sussex county we raise more chickens than any countyn america and last time i checked we raised more sbooeps and raise more lima beans and have more five-star beaches than any county in america, all in one county, sussex county, and we have a lot of rural areas, and a lot of people who live in rural areas despite all of that. we've got a lot of people who live along the coast, rehoboth

and lewiston, places like that, dewy beach, but rest of the county is largely agriculture, and we have some hospitals, rural hospitals. we have community-based outpatient clinics. we have a v.a. clinic that's actually quite good. we still have a lot of people who don't have access to healthcare because it's just so spread out in a big county. i want to talk a little bit about all of now that we've gotten that out of the way. i want to talk with you about costs flow from tobacco use. i think our calculus system i actually costing us, and i understand we're spending in this country an extra i would say $2 hundred billion each career because of our addiction to tobacco products and we're spending i'm told another 150 billion to 250 billion a year because of obesity from one end of the country to the other, incling in sussex county, but i -- i'm told that america's rural communities are still more likely to use tobacco products

than other parts of our country. our rural communities are also more overweightnd obese and would i ask you what tools -- my second qstion of the day. what tools, what resources and what delivery resource reforms do we be used 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've talked about earlier was a new way to pay rural -- for rural health. i don't even say rural hospitals but a new way to reimburse rural hospitals and it's 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 programs, invest in substance

use disorder treatments, invest in the clinical -- or the health status outcomes that we're looking for and to -- and to end this disparity or to gradually decrease this disparity between royal health outcomes and those of the rural outcomes. that's the beauty of this model. it allows for the investment in care coordination. it allows communities to really take those chronic disease problems and re -- reallocate the dollars that they were receiving from subclinical care services but they had to provide because that's the only reason they got paid. it now allows them to address this population health more. >> let me ask the four other witnesses. if any of you agree with what you said. would you raise your right hand. >> all right. >> if any of you have something that you would like to add to what dr. murphy said, miss martin. >> i would just like to add that an investment in primary care providers because i think that

is the relationship that impacts patients' behaviors and impacts patients' ongoing quality of life and so in so many communities it's the importance of the primary care provider that impacts those behaviors. >> anybody else who would like to add to that. and how do you pronouce your name? >> keith mueller. >> mueller, the right way. >> yes. i would add to that the investment in public health infrastructure. come at that in two ways, one, encouraging collaboration between the healthcare and the clinical secretary ore and the public health sector which the acl model and, two, direct investment into public health agencies. >> okay. one quick last question. who are your recommendations to improving access to mental health treatment in rural and underer is served areas and we'll start all the way over on my left, please. who it be dr. pink. >> yes, sir.

>> please. >> again, i would defer to my colleagues. i've 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. >> miss martin. i think it's investing in the education and programs where as a community hospital we can educate and train a workforce of our own. we have an extreme shortage in the number of qualified professionals in that area. >> okay. thank you. >> miss thompson. >> yes, i believe it's to further study the integrated health home model that is at place with our medicaid population, and i think there's a great deal to learn that and a great deal of excitement to create in young folks that we can get into high schools and motivate them about the advantages in mental health. >> anything else to add?

>> a system where they can access urban centers. >> tell me where you're all from. dr. murphy? >> i'm the chief innovation officer at guyser in. >> been there before. you guys do work. >> unity point health in des moines, iowa. >> family health in alamosa, colorado. >> university of iowa. >> university of north carolina, chapel hill. >> okay. >> well, you've come from a long ways, we thank you, and we thank you for the work you do. it's really important for our country and for the people of our country. thank you so much. >> senator portman. >> thank you. chairman roberts and to the panel, i was here earlier to hear your testimony and i appreciate the challenges we face in the area. i come from ohio and we have a lot of urban hospitals and a lot of rural hospitals and sadly

some are closing down or consolidating. in my state one of the issues that's particularly difficult to deal with in the rural areas is the opioid epidemic, and i would think if you did a, you know, per capita analysis of the opioid epidemic in my state you would find in the rural area the problems was even more acute than it is in some of our suburban and rural are although it's 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 that we have more and more children who are being born with neo-natal abstinence syndrome meaning they have to be taken through withdrawal themselves and we've got problems who are taking moms who are addicted and week them off their addiction and helping to ensure these babies are more and more without the neo-natal abstinence syndrome but it's overwhelming. our new natal units and i'm sure it's 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 the birth and then the babies go home and there's not the ability to continue to monitor in rural areas, and i guess what i'm asking you today. you mentioned t opioid epidemic el earlier, but to the hospital ceos maybe you could help me a little on this. what services do your hospitals offer to support the lonr term recovery needs of these growing number of children who have t neo-natal abstinence syndrome and for their moms and families and in particular if you work with kids with nas, how do you work to ensure that th families receive the support that they need? >> in our community we certainly have seen an increase in this issue. just last year about11% of the babies that we delivered had this syndrome that you speak of, and we eve 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 and oftentimes unfortunately they are going into foster homes because if the mother was a user, unfortunately, they are placed with -- in foster families, and so we have pediatricians who try to work with these families and developmentings and we have like a grass roots community organization that involved the schools, early childhood development and some of our primary care providers, and together we're trying to sort of leverage and learn resources. it's a challenge because there's just not a lot of information about that. we hear from our school teachers, particularly elementary schools, that they don't feel equipped to deal with the challenges that some of these young children bring to the class rom, 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. >> yeah. any others?

>> senator, as geisner we're developing a program for non-substanc a and their children born with neo-natal abstinence syndromee would intervene when the mother begins medication treatment prenatally, andhen we what we say wrap our arms around the mother and baby with services such as behavioral health services, addiction medicine, counseling, pediatric services and other social services that would enhance the likelihood of the mom staying in recovery after the painy is born,o the idea behind it is that we would test and offer these services for a pier of um to two years and determine what -- what test, 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. and we did pass legislation here called the recovery addiction act which has a special title for pregnant moms, post-partum moms and kids with nas a since that time we've passed a budget which increased the funding for that, so those who rnts aware of that. apply for it. we're looking for good pilot programs around the country but i think miss martin is right. dr. murphy is right. if we can 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 babes as well as the moms take advantage of the moment. many moms are facing the addiction because of their pregnancy and they don't want their kids to be born with this syndrome and they wanted to go into treatment and how do you once the baby is born, using the

suboxone treatment that is week them off of the opioid and how do you keep them in the treatment program and longer term recovery and use the family relaonship to help kindle some better prospect for longer term facility? and in the rural hospitals, the rural settings, we have a particular challenge and i appreciate to you being here today. another question on the stark law, but i'll offer that as a question for the record. senator bennett and i have some legisln i want to get your views on. thank you. >> well, thank you, senator. coop, you're up next. >> thank you, mr. chairman. must be high noon. so thank you for holding this hearing. we have in my home state of south dakota lots of challenges and accessing healthcare services in rural areas and we have providers that work diligently with creative solutions and there's still barriers and complications that they face on a daily basis and

part has to do with traveling long distance and having limited transportation options. they are big hurdles for people to overcome and attracting providers, of course, to rural areas is another challenge that we face. too often we lose south dakota tans if they train in other states and we have a unique issue in south dakota as well with our tribal communities making sure that they have access to healthcare services due to the pervasive problem that indian health care services throughout the great plains region continue to have. i look forward to working with my colleagues on this committee and continue to address solutions that will help with many of these challenges in. your written testimony you mentioned tt multiple studies have been created on how telehealth helps to expand areas in rural areas. you have a current project that looking at healthcare in south dakota that ranges from

emergency department, eicu, e-pharmacy, behavioral health and more. i've seen some of this technology firsthand. i know they are working hard to innovate. for this committee's benefit, could you discuss what you've learned so far about this you've learned so far b about the a model aend how it's helped increase access in our state of south dakota? >> thank you, senator, for the question. i'll focus on what we've learned about the use of health in the emergency rooms because that has impressed us the most. what that has done is basically since i mentioned earlier, cms conditions of participation. the condition was changed a number of years ago to allow meeting the necessity for an on call physician through the use of telehealth because you can have add an vanced practice physician in the er that can

quickly access a board certified physician, but more important even than that is the finding that the use of that kind of tel ler health helps in recruitment of prov this help to aader point f the more we can do to support those professionals in a local environment, the greater likelihood is they'll come through tl because that's how they want to practice withhe support of board certifiy eied physicians and the greater likelihood they'll stay. the other quick example is in the case of the pharmaceutical services. inside the hospital in particular, which is how the e health sweuite from a variable reaches out. you can meet the requirement frs a review of medication as it's being prescribed much more efficiently and effectively through the use of telehealth. >> we've put forward policies

signed into law that will reduce barriers to medicare and promote te telhealth and medicare advantage and other areas. including and treats stroke patients. these are significant advancements. i'm wondering if there are other areas where technology can transform delivery rural care in other states. what should we be looking for from your perspective. ue to comment on that as well. we're making headway. what else should we be doing. >> we should learn as rapidly as we can from medicare advantage plans so that we can transfer that knowledge of into the basic and affect reimbursement policy as was mentioned this morning

adds one of f the bear yirs to health. prz. >> i would add that providers i young people have grown up with technology. familiar to them and it gives them a lifestyle that is something that is. >> i have another question with ehrs and how that affects service delivery. myimisxpired, so i'll submit that for the record thank you. >> we thank you, senator. >> sedly we have four more. just imaginely appeared here.

>> senator warner. >> one of the issues was raised in testimony, but i'm increasingly see iing kind of isolated areas there may be two competing hospital systems and they leave an isolated island in between where the two systems catch area comes and you may have rural communities with single dock and -- done a great job, about to leave and because it fall in between, nobody's wanted to take this region. without any kind of coverage.

provide the back office coverage. it's relatively high affle. how are we going to get the it there? is tr any systemic things we can do? whether it be a slight increase in terms of reimbursements, attractive on a longer term? >> the geographically redefined -- we see that in the community that with the retirement of the community or the closure of the hoital, you have a gap in coverage and i hope that statewide leaders

there. i think for the age of physicians going and starting practices on their own, if it hasn't come to an end, it's slowly coming toen a end and i think it's going to be working with existing rural health care system sos that they have the financial means to do a start up in a practice i think lowerayment for phicians makes a difference with that and medicaid reimbursement makes a difference in rural communities because when you have 70% mediciare, medicaid, like you do in my community, you can't make a private model business work. >> this notion of an individual dock going has to have some kind of back office operation to support him or her. if you have other ideas, i know back in the '90s, johnson's foundation had a huge cut 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, has anyone

thought about beyond what we, the government could do in terms of reimbursement levels or loan forgiveness? insecentives to health care systems to make sure you don't leave these isolated islands not having 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 ji, those are program, things that will help small hospitals like ourselves to get providers that will go to theseommunities through long-term incentives. that's what comes to find for me. i think the idea of critical access hospital or a rural hospital like the one we have in alamosa, being a able to get paid under a different model 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. >> i wanted to add on this, i think the notion of a higher reimbursement level then to stems to kind of drop r some providers so they could qualify is a real ko nund rum. this will be my only question. >> when you have the hospital systems, you want to make a perfect. with the requirement of for a new doc to go into this. we've got to find a way to crack this code. thank you, mr. chairman. >> thank you, mr. chairman.

i think ti thank the panel. >> in telemedicine, particularly for rural health care, it's really an area we can do much better. proud to join some of my colleagues in legislation that would allow for medicare reimbursements. >> i would talk about what we do in maryland, we are the only state in the county they that has an au pair rate structure for hospital reimbursement. we went to the next plateau, couple of years ago, and just approved this month, the final aspects of this demonstration. the rate of health care costs rather than just the hospital element of it. we have an all payer struck which you recollect but coordinated with reducing the

overall cost of thatpatient's health care beyond the hospital care. there's incentives to keep people hello thhealthy. the western regional medical center uses tele monitoring for blood glucose and that can be incorporated into the all payer rate structure. they're helping to reimburse for that. to allow rural areas. this model, this is now being implemented in the state. how do we take this kind of a model in the rest of the country

that is still in the stove pipe rebim ursments. how do we take the model with more access to care in rural americ >> senator, thank you for that question. so i had the opportunity to work on the maryland model and you can share your enthusiasm with the model. there's an initiative looking to do what you just articulated. so taking the maryland model in a state that is not an all payer race setng state. and develop a different methodology.

and has also metrics involved in model. with eight more years of how do we transform and population health. we concurred it's a dwraet model and i had previously testified on your state next week, the johns hopkins school f o public health is conducting a summit for states to attend on global budgeting. it's my understanding that we have over 26 states that are interested in pursuing this. >> in colorado, we are 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 her mind, too. >> i would applaud the recognition of the current paent systemsor rural current america, while all designed at a certain point in time help save rural health care, at this point in time, are now setting rural health care back and not being able to move into population health and alternative models and macra. i want to applaud the work. the payment structure didn't allow on this to occur, so you have to find creive ways to do it. we should be k looking at some mechanisms that allow you to use a structure that brings down the overall cost.

that will be the driving force r utilization rather than they are part of ingrated care. trz. >> thank you, mr. chairman. >> i want to thank the chairman andanng member. they actually moved up hear thg morning because we anticipated that a number of of us would be this the ndaa markup. we did so well yesterday, we finished it last night, so i st appreciated the consideration. i want to say for the record, this is a crisis in our country. the cost of health care in recent uncommunities we doinnothing in the united states congress to address it at this moment. en he have more eninl sured and underinsured, we have more rural hospitals and stress and

insurance premiums go up for those of us who buy it. so every time the uninsured number goes up, it costs everybody who's paying, including taxpayers and including everyone who buys insurance. it'sll b about saving money in thelt care system. it's ironic to me that we're going back to the bad old days where uninsured number rs climbing. there's a lot of bills out there that helped. some bills that have been negotiated to the floor so we can provide relief. my issue i want to talk about, there was a good state audit.

by an auditor about a rural hospital and what was discovered is that there was a small rural hospital that transferred operational ownership through a lease agreement in november of '16. and all of a suddthere was this giant increase in laboratory billings. what happened is that the vast majority of these were for lab activity for individuals not even patients of f that hospital. billings began immediately after the management agreement dispite the fact the hospital in unionville, missouri, had not even begun processing tests. on the hospital payroll, 33 out of state fle bottomists to perform services throughout the country. it appears the hospital partners

reduced putnam to a shell organization for purposes of lab billing. this rning,'m directing a letter to inspector general at hhs to igatehis. evidently, this same group was involved in the northern district of f georgia sued on a pass through bill scheme at chester t. regional hospital. a large private insurance company has identified up to 3.3 million in payments. in recent months. those working in rural systems, is this a trend, are these companies coming ash and buyinging up the hospitals in to front for shading billings? have you seen this anywhere else? no. you have not. this letter is going to, to hhs

today. and i think there's some all likelihood i'm betting there's criminal activity somewhere and i think ou e kind of cap of payments. to fit touds state, particularly if the pillings are coming from a rural hospital. i know you've talked about the lack of doctors. i had the university hospital in columb columbia, missouri, say they were taking in more rural patients than they should. they were going to the university hospital mainly because that's where their doctors were. can any of you address maybe miss martin, you could address the real problem we have with ob-gyns being in rural areas and how we can incentivise doctors to say in these rural communities and stay? >> i think that workforce issues

are very much challenges in rural areas. i think we've spoke today about the loan repayment programs. the conrad 30 programs. i think they're very important to rural communitie i think it's about they want to s. they want to take care of patients. i think that we talked about telehet today because when physicians know that they can be covered when they're off and they're out or they don't feel the budd nburden of a 24/7 respe thety, i think that's a more satisfying opportunity as well. with ob-gyns, we're fortunate that we have three that work there and we work a lot with

nurse mid wooifto do first coverage for regular deliveries, to give them relief so their call time and quality of life is different maybe than what they would experience without those. it's the use and compliment. >> thank you. thank you, mr. chairman. >> senator brown. >> thank you, mr. chairman. ohio struggles with some of the highest rates of infant and maternal mortaty in the country. it's partly because we've underinvested in public health for decades. it's more complicated than that. between 2008 and 2014, 400 women died from pregnancy related caused in ohio. 2016, more than 1,000 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 disproportionally to the greatest extent. small towns more affluent th than -- dealt with this. i'm concern'm not in a conspiracy sort of way, but this has done nothing on infant mor l tallty. among low income people of color, especially. there is a national republican effort troubling that governors are as work requirements seem to be the new far right ring rage, even if they're getting treatment from opioids and even

if they're incapable of working, they're also nowooking to do work requirements on for medicaid in a way that will ab solve more rural white communities high unemployment from these work requirement, but will have these work requirements of inner city black families increasingly because they're really smart and figured out how to do it. legally apparently, but immor alley. i will stick to the question about that. a couple of questions. what do we do to support rural communities and proouing outcomes pr moms and babies?

>> we have to tan tan services. i think miss martin gave an example where there's adequate coverage. three physicians there where in case of emergency could cover for one another. a highintensity, an ob-gyn has a a high intensity schedule, so you need the numbers that miss martin talked b about to be able to effectively and safely render ry cal care. so i think in areas where they're fortunate enough to have the physician services onsite in a high quality manner, i think ould do that. i think we should work through other providers such as certified nurse prak tigs ners, to be able to offer some of the

care in the rural community when it's not b possible to do so. so a mom doesn't have to drive 35 miles for their monthly appointment. it's a very difficult service to staff in rural communities unless you have the kind of, number of physicians that miss martin talks about. >> i hosted a conference, host with us to host a conference for ceos for 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 hospital rs not part of the conversation and they rarely come to washington and so we hosted a number of them. one of the fes that came up was the challenge to face one attracting for us. so i'm sorry if there another hearing today, but from miss

martin's comments and dr. murphy's comments, i appreciate that. i'd like to go back, mr. chairman. i want toed to thank senator widen has been helpful on this medicaid work requirement. i know we're working on some .hing, but i want to c with just a comment. i wanted to thank grasly and casey that would allow pharmacists to bill for care. they can help em prove access to connick disease management. about a dozen in this community -- hopeful that

chairman hatch and wind will cot to this bill and other initiative to help you deal with the challenge you have in workforce, so thank you so much. thanks, senator roberts. >> i want to tell senator brown i'm anxious to work with him on the agenda. he's going to bat for folks who don't have clout and power and i want to thank him for his comments. we've been at it for almost two and a half hours. you all have been terrific, but what i'm struck by is i don't think we have mention over the course of two and a half hours, what is really the backbone of rural health care from sea to shining sea. that is rural health clinics. i'm heading home. we have 83 of them.

these are the backbone of health care. where people go for primary 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 wrap up is go right down the row again since we have this little window here to try look at what's important going forward. i don't think it gets much more important than niese, so start with you, mr. mueller. >> oimizinghe use of professionals by state policy, federal policy.

>> maybe i just need to wear my glasses, mr. pink. the suggestion made by dr. mueller i would endorse. the issue with rules that prevent the true integration of the health care provird. >> i think that so important. the co-chairs of this with our colleagues and our camp talk to me about this constantly. hardly a week goes by when she dot bring it up. this whole question of the comingling rules that miss martin is talking about. this just looks like a bureaucratic la la land to me. trying to sort this stuff out. so i'm going to talk with chairman roberts ab it. yes, ma'am. >> strengthening the support to these advanced registered nurse prak tigs nctitioners and pas w working in very isolated areas to give them the support, the

education, the retrain and the access to consultations. >> i got to tell you, we had it in our healthy americans act with eight democrats and eight republicans. you ought to be able to practice up to the top of your license and partilarly in these rural areas. thagsst that the another one. why you wouldn't let people practice up to the top of their license in a rural area. that's just common sense. yes, ma'am. what you doing? well, you have been terrific. we have been at it for close to two and a half 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.

we're trying to expand broad band. i think we started a revolution in medicare with our chronic care bill because we're move in from acute care, which back when i was director of the dwraet panthers was a pral. you broke your ankle. that's not mediciare anymore. today, it's cancer, diabetes, heart dise strokes. that kind of thing. so we have a terrific group of members led by senator shots and wicker come and make the case for telemedicine. they can't tap all the opportunities for tele medicine. so there are a lot of pieces to this puzzle, but you've given us a lot of suggestions. especially looking forward to the suggestions for the record with respect to how to get more providers in rural health care.

so mr. chairman, i think been a really good, really important hearing. people know i have very, very strong feelingshi i will not express again which will please the chairman about how damaging these medicate cuts would be. we can get a bipartisan package here. wouldn't have been a bad question ithe house today. looking forward to working with you, senator roberts. >> thank you, senator, and thank you for your attentans and your participation poed. this was in fact an important and very important conversation. we look forward to working with you in a bipartisan way.

we're privileged to represent small town america. dr. mueller, see, it was 1993 that you teed before me i guess and a here it is 2018 so i look forward to hearing you in 2033 when hopefully we have these things settled. ask any member who wishes to smut questions for the record to do so by the close of business on friday, june 8th. with that, this hearing is adjourned. thank you so much. [ inaudible ]

this coming thursday, democratic and republican members of congress will face off in the 57th annual congressal baseball game for it wille played at nation's park. live coverage begins at 7:00 p.m. eastern on cspan 3. you can watch on cspan.org or listen with the free app. >> next, a report on