American Health Information Community

Chronic Care Workgroup Meeting #16

Tuesday, June 5, 2007

**Disclaimer**

*The views expressed in written conference materials or publications and
by speakers and moderators at HHS-sponsored conferences do not
necessarily reflect the official policies of HHS; nor does mention of
trade names, commercial practices, or organizations imply endorsement by
the U.S Government.*

**[\>\> Judy Sparrow:]{.underline}**\
Welcome, everybody, to the sixteenth meeting of the Chronic Care
Workgroup. Just a reminder that we are operating in the public. Minutes
from the meeting will be posted on the Website and there will be an
opportunity at the end of the meeting for the public to make comments.
We have a rather jammed agenda today so without any further ado, I will
turn it over to Jennifer to introduce the members on the telephone line
and then we will go around the room here at ONC.

**[\>\> Jennifer Macellaro:\
]{.underline}**Okay. Sure. We have got Craig Barrett, your co‑chair, on
the phone. Frances Dare in for Jeff Rideout from Cisco Systems. John
Gifford in for Mohan Nair from the Regence Group. Brian Devore from
Intel. Dena Puskin from HRSA. And Eric Larson from Group Health. Did I
miss anyone on the phone? Okay.

**[\>\> Judy Sparrow:\
]{.underline}**Here in the room we have ‑‑

**[\>\> Jay Sanders:\
]{.underline}**Jay Sanders, The Global Telemedicine Group.

**[\>\> Karen Bell:\
]{.underline}**Karen Bell, ONC.

**[\>\> Tony Trenkle:\
]{.underline}**Tony Trenkle, CMS.

**[\>\> Yael Harris:\
]{.underline}**Yael Harris, ONC.

**[\>\> Judy Sparrow:\
]{.underline}**Great. Why don\'t we turn it over to the co‑chairs now?

**[\>\> Tony Trenkle:\
]{.underline}**Okay. Craig, did you want to have a few opening remarks?

**[\>\> Craig Barrett:]{.underline}**

My only remark is the constant need to focus and come up with a focus
area that we can really accomplish something that's of substance in a
relatively short period of time. Pretty obvious.

**[\>\> Tony Trenkle:\
]{.underline}**Okay. Well I think the first thing we will do is look at
the review and acceptance of the meeting minutes from the last meeting.
Any comments on that? Jay, you had a comment earlier. Did you have any
further, any comments you wanted to make?\
\
**[\>\> Jay Sanders:]{.underline}**

Yeah. Should I make my comments for the record? It just seemed on page 2
that in line, in section number 3 where it describes the Medicare system
it says, the sentence says the Medicare system, however, is misaligned
to promote efficiency and patient‑centered care. It sounds like the
thing that you don\'t want to do is promote efficiency and
patient‑centered care. I don\'t think that was the intent of that, that
sentence. I would probably have reworded it to say the Medicare system,
however, in its quest to promote efficiency and patient centered care is
misaligned.

**[\>\> Tony Trenkle:]{.underline}**

This was quoting this speaker at the last meeting. I don\'t recall what
the exact words were. But ‑‑

**[\>\> Jay Sanders:\
]{.underline}**If that is a quote, it has to stay as such. The only
other thing I have is ‑‑

**[\>\> Tony Trenkle:\
]{.underline}**Before you do ‑‑

**[\>\> Karen Bell:]{.underline}**

It doesn't have to stay as such, because these are minutes reflecting
the total. These are not the verbatim minutes. This is a summary, so we
can certainly make that adjustment.

**[\>\> Judy Sparrow:\
]{.underline}**Right.

**[\>\> Jay Sanders:]{.underline}**

And the other thing is where it references my comment about the article
written concerning telemedicine home care, it was not JAMA. It was the
Telemedicine and e-Health journal.

**[\>\> Judy Sparrow:\
]{.underline}**Okay.

**[\>\> Karen Bell:\
]{.underline}**Thanks.

**[\>\> Jay Sanders:]{.underline}**

Otherwise I would like to move the minutes be accepted.

**[\>\>\
]{.underline}**Second?

**[\>\>\
]{.underline}**Second.

**[\>\> Tony Trenkle:\
]{.underline}**Okay. All right. Why don\'t we then move to the
presentations for today? Karen, did you want to ‑‑

**[\>\> Karen Bell:]{.underline}**

I would be delighted to start off, thank you Tony. And the best part of
this particular piece of my job is introducing some new members to the
Workgroup.

But before I do, I just want to underline for everyone, new and old
alike, the broad charge of this Workgroup, which is to make
recommendations to the Community to deploy widely available, secure
technology solutions for remote monitoring and assessment of patients
and for communication between clinicians about patients. That very last
piece is all about coordination of care. And what I would like to
suggest is that we've spent quite a bit of time on the first piece of
this, the remote monitoring and assessment, and very little time on the
coordination of care around patients. And I think that as we welcome our
new members, there will be more of a focus on that part of our broad
charge.

So without further ado, I would like to just go through the list of our
new members and give you a little bit of an idea of where they come
from. And if any of them are on the line we will ask that they introduce
themselves as well.

The first is Cheryl Austein-Casnoff, joined us the last few meetings.
She\'s from the Health Resources and Services Administration, head of
their HIT unit. I know that today she\'s being represented by Dena
Puskin. Is that correct, Dena?

**[\>\> Dena Puskin:\
]{.underline}**That\'s correct.

**[\>\> Karen Bell:\
]{.underline}**Justine Handelman is with the Blue Cross/Blue Shield
Association. Has also been a very active in the Community but has not
officially been on the Workgroup. We are delighted to have you join us,
Justine. Are you on the line with us?

**[\>\> Justine Handelman:\
]{.underline}**I am. I\'m in a cab on my way there in person, but stuck
in traffic.

**[\>\> Karen Bell:\
]{.underline}**That seems to be an ongoing issue today.

**[\>\> Justine Handelman:\
]{.underline}**They've shut down a lot of roads today for some reason.
Thank you. I\'m happy to be on the Workgroup.

**[\>\> Karen Bell:\
]{.underline}**Thank you, Justine. Jonathan Linkous is also joining us,
from the American Telehealth Association. I believe he is not able to
join us today.

Steve McConnell from the Alzheimer\'s Association is also a new member
representing one of the chronic illnesses or chronic disease processes
that is very prevalent in our society and has a lot of morbidity
associated with it. And I believe Steve will be joining us at the next
meeting.

And that brings to date the number of people who have officially joined.
I know we are working with a few others. Yael, do you want to bring us
up to date, as of today, who else might be joining us?

**[\>\> Yael Harris:\
]{.underline}**Sure. As of today we are still waiting for confirmation
from someone from the American Diabetes Association, someone from the
American Heart Association, and someone from Continua. There we have it.

**[\>\> Tony Trenkle:\
]{.underline}**Karen, Paul Nichols is no longer on here. Did he leave
the group?

**[\>\> Karen Bell:\
]{.underline}**There has been turnover. Both the VA and the DoD. I know
we have lost some people from those arenas.

**[\>\> Yael Harris:\
]{.underline}**We identified those who had not attended a meeting in the
past year and sent them an e‑mail asking if they \--

**[\>\> Karen Bell:]{.underline}**

Paul was very active.

**[\>\> Tony Trenkle:\
]{.underline}**Paul was very active.

**[\>\> Karen Bell:]{.underline}**

Paul was very active. Yeah.

**[\>\>\
]{.underline}**Paul Nichols. He is here.

**[\>\>\
]{.underline}**He is on the list.

**[\>\> Judy Sparrow:\
]{.underline}**He is on the list, just not on the call.

**[\>\>\
]{.underline}**He is considered an alternative for ‑‑

**[\>\> Judy Sparrow:\
]{.underline}**Right.

**[\>\>\
]{.underline}**‑‑ Madhulika.

**[\>\> Tony Trenkle:\
]{.underline}**Okay. He is not on the list.

**[\>\>\
]{.underline}**This is the primary contact. For the VA, Madhulika
Agarwal. But Paul is the back‑up for him.

**[\>\> Tony Trenkle:\
]{.underline}**Thank you. If you could provide us, Karen, with a, not
only just an updated list but also who is no longer on the group. I
think would help us just ‑‑ okay, thank you, Judy.

**[\>\> Karen Bell:\
]{.underline}**Before we move on to the work of the day, I did want to
also share with everyone in the Workgroup the fact Rob will be
presenting at next Tuesday\'s AHIC meeting an update on some of the
recommendations that a number of the Workgroups made in May of 2006
which the Secretary has accepted. All of the May 2006 Chronic Care
Workgroup recommendations fall within that category. And wanted to give
each of you a little bit of a heads up of what will be presented and
give you an opportunity to provide me with a little feedback over the
course of the next few minutes after I run through the list and try
to verify whether or not you believe this is what your anticipation was
with respect to these recommendations.

To begin with, we had three recommendations that together were to
develop and expand the evidence base for secure messaging. This was to
look at, to see the effect of reimbursement strategies on secure
messaging. Included a pilot \-- I just wanted to add that Jon Linkous
has just joined us. \-- included a pilot. And also to look at the effect
of workflow on secure messaging. Those three we have lumped together and
are going to be presenting a RFP, a request for proposals, that will be
released very shortly, that will essentially address all of these issues
in a demonstration project or a pilot project that will test the value
of secure messaging and assess the merit of different payment
methodologies. The award will go to three separate sites. And we are
expecting at least some preliminary results by December of 2008. The
study may need to go beyond that in order to have a robust and long
enough period over which data can be gathered.

There was a recommendation 2.0 that HSS would convene state agencies and
professional societies to develop licensing alternatives that would
allow the provision of electronic care delivery across state boundaries.
On July 6th the health care practices task force of the National
Governor\'s Association which has been working on this will make
recommendations to state, to the State Alliance contractors that we
have, which is the NGA, to reduce licensing barriers to interstate
telehealth care delivery. We have an announcement at this point, the
task force has been very busy addressing these issues. They will be
making their recommendations, and we will be having them shortly. There
has been a tremendous amount of progress there.

We have recommendations in the 3.0 and 3.1 range which referred to
HITSP-defined standards for secure patient clinical messaging
transactions and Certification Commission criteria for system
interoperability. This is ‑‑ these are two recommendations which
unfortunately are in the red zone. The reason that they are in the red
zone is that we have very limited capacity to develop use cases. And
some of you may recall that at the January 23rd American Health
Information Community meeting, the Community was presented with a number
of use cases and was asked to rate them in different categories. That
led to a prioritization of use cases which included patient access to
information, quality reporting, and ‑‑ I\'m actually blanking on the
other one. It will come to me. The concern is that this particular use
case was not on the top three.

**[\>\> Tony Trenkle:\
]{.underline}**Clinical data to PHR ‑‑

**[\>\>\
]{.underline}**Right \[inaudible\].

**[\>\> Karen Bell:\
]{.underline}**So this will be put on a roadmap down the line, but it is
not being prioritized at the moment.

That leads us into the fourth set of recommendations, one of which was a
recommendation for AHRQ to conduct a synthesis of current knowledge of
health IT use by the elderly, ill, and underserved populations. AHRQ's
evidence-based practice centers request for task order, barriers and
drivers of health IT use for the elderly, chronically ill, and
underserved was put out for solicitation in May of 2007, with the
contract award expected July 31st of 2007. A lot of time and energy went
into the development of that particular scope of work but it is now
ready for primetime.

And then lastly, there was a lot of discussion about the fact that
secure messaging and other forms of remote care or telecare really
needed good solid broadband access in order to be made available across
the country. So there was a recommendation that HHS work with
appropriate organizations to report on secure messaging availability
through broadband across the country. We have been working with FCC who
has been tasked with expanding broadband technology across the U.S. The
current penetration rate is about 45 percent, though 75 percent of
Americans have access to the internet through broadband. And the
intention is that by 2014 FCC expects broadband access to be available
across the U.S. by executive order.

So that is a very quick overview of what will be presented to the AHIC
on Tuesday with respect to the recommendations that everyone has worked
so hard on last year. And again, I would just point out that with
respect to all of these activities, they are all under way. They are all
moving with the anticipated timelines, with the exception of the use
case work for interoperability and certification. So with that, I would
welcome any comments, concerns, or if there is any feedback that you
would like to provide to ONC at this point on the recommendations.

**[\>\> Eric Larson:]{.underline}**

This is Eric Larson. I\'ll just comment to say I thought we did a nice
job to see that many of our recommendations accepted.

**[\>\> Karen Bell:\
]{.underline}**Thank you, Eric. And maybe I will just stimulate with one
more question. The issue about interoperability, HITSP standards and
Certification Commission, is one that, as I said, will be a red flag.
And it is one that didn\'t reach the top prioritization, top of the
prioritization list by the AHIC. But if it is one that the group feels
is important, then perhaps we could have some discussion about that
because there will be two members here, both chairs, Tony and Craig will
be at that meeting, and perhaps may be asked to comment about the
importance of HITSP standards and Certification Commission criteria with
respect to interoperability for not only secure messaging, because
that\'s critical here, that was part of the recommendation, but for
remote care across the board. So if anyone has some comments, I think
that might be helpful for both Craig and Tony.

**[\>\> Tony Trenkle:]{.underline}**

Absolutely, Karen. I of course feel strongly that it should have been
one of the use cases. You and I have talked about this before. I know
you share that as well so ‑‑

**[\>\>\
]{.underline}**Do we know why it was not prioritized?

**[\>\> Tony Trenkle:\
]{.underline}**I believe they had a limited number of use cases they
were willing, or able, resource-wise, to work on, and for whatever
reason the other three were deemed as more important. Although this one,
I think, actually got put in the top three more than the others, some of
the others did. But it was never rated as the top one, and so I guess
the overall, in the overall scoring, I guess it came in about fourth,
didn\'t it? And ‑‑

**[\>\> Karen Bell:\
]{.underline}**I think one of the concerns that perhaps this group might
have, is that of all of the specific charges on the very first go
around, there were four. One had to do with lab interoperability.
Another had to do with secure messaging. A third had to do with the
electronic clipboard, medication management, and the fourth had to do
with public health information.

Use cases were written and established, and HITSP standards were
developed and certification processes developed for three of those four.
Even though secure messaging was one of the first four cut, they could
only do three. So secure messaging was the fourth there and got bumped
out of the first go-round of use cases. This was an opportunity to put
it back on the board ‑‑

**[\>\> Tony Trenkle:\
]{.underline}**Right.

**[\>\> Karen Bell:\
]{.underline}**‑‑ for the second round and it got bumped again down to
number 4 on the second round. And the Workgroup might want to think a
little bit through about how important this is to make sure it doesn\'t
get bumped on the third round, unless you are comfortable with it
getting bumped on the third round.

**[\>\> Tony Trenkle:\
]{.underline}**I guess my concern is that, given the limited number of
use cases that are done each year, this could take quite a while for
this to happen. I guess my concern is that we need to think about what
are ways to make sure this gets done sooner rather than later. And if
you\'re only do three use cases a year, or four as, it could take quite
a while, depending what else bubbles to the surface. I think that would
be a real problem as we try to move ahead here. I don\'t know, Karen, if
you have any thoughts on what could be done to expedite this being one
of the use cases, or is there room for additional use cases?

[\>\>**Karen Bell:**]{.underline}

Doesn\'t seem to be at the moment. We have pretty much an ability to do
about three a year. I think the real issue is the degree to which either
secure messaging information or any other information that\'s coming in
from remote monitoring can be incorporated into electronic health
records, both ambulatory and inpatient. If we believe that\'s something
very important to move the agenda forward, if the agenda is making more
remote care accessible, then this use case probably should be up front
on the next go-round. And it would be this Workgroup\'s responsibility
to very strongly voice the importance of that.

If on the other hand the Workgroup feels that there are other issues
that are more important over the course of the next year or two and that
that is not going to be a driver, then we don\'t have to be quite so
vocal about it. But I do think the Workgroup should weigh it in and at
least be able to guide Craig and Tony a little bit with respect to how
important this is in the next go-round.

**[\>\> Tony Trenkle:\
]{.underline}**I guess my question would be to the Workgroup is how much
of an issue is this? It seems to me this is certainly a critical issue,
but is it a show‑stopper here in terms of moving ahead in the remote
monitoring area?

**[\>\>\
]{.underline}**Are you combining secure messaging and remote monitoring
in one use?

**[\>\> Tony Trenkle:\
]{.underline}**It was one use case, I believe, yes.

**[\>\> Karen Bell:\
]{.underline}**Yes.

**[\>\> Tony Trenkle:\
]{.underline}**I thought ‑‑ yes, I think it did combine, if I recall it
did combine both.

**[\>\> Craig Barrett:\
]{.underline}**Golly, folks, what option do we have? If we really
believe remote monitoring and diagnostics, et cetera, is one of the most
important things going?

**[\>\>\
]{.underline}**Right.

**[\>\>\
]{.underline}**What about the idea of unlinking ‑‑

**[\>\> Karen Bell:\
]{.underline}**Well I think the concept is if we are going to go through
this process, and it is a use case process that looks at all these
pieces, the use case would look at it in a more robust way and so you
get it done, and get it done in one fell swoop.

**[\>\>\
]{.underline}**That makes sense to me. It seems to me that one of the
concerns or the barriers we\'re facing is concern about the essential
costs of secure messaging that I don\'t think has quite the same
implications for remote monitoring data.

**[\>\> Tony Trenkle:\
]{.underline}**Your recommendation would be to split them off and ‑‑

**[\>\>\
]{.underline}**Well, I think we have to think about that or talk about
it to see, because I hate to say we have all or nothing on this and end
up with nothing. Because I sense that there is quite a bit of concern
about secure messaging moving forward.

**[\>\> Tony Trenkle:\
]{.underline}**Well, I don\'t know that that was the show‑stopper here
though. I think it was more, the show‑stopper was more that the other
use cases were considered as more critical. So I guess the issue here,
Karen, is how do we get this more visibility? As Craig said, it is
basically a no‑brainer. So what can we do to make sure this gets ‑‑

**[\>\> Justine Handelman:\
]{.underline}**I know ‑‑ I just walked into the room \-- Justine
Handelman ‑‑ but I was listening on the phone. One thought is we have
our EHR recommendation and we have the personal health record
recommendation already on the table where there is work being done. And
this seems like it's a natural component that ties in. When you look at
the bigger picture, how do you build a road to a fully interoperable
system, interoperable electronic health records, interoperable personal
health records systems, this gets into it. There's a case to be made
that as you look at the other use cases on the table and where we are
headed, this is a component that\'s left out of the (inaudible) towards
the broader ‑‑

**[\>\> Tony Trenkle:\
]{.underline}**That\'s a good point. Is there a way, Karen, if we did
another version ‑‑ I know they have done a version 2.0 for the EHR. Is
there versions that can be done of that that would include remote
monitoring, for example?

**[\>\> Karen Bell:]{.underline}**

In terms of the EHR interoperability use cases?

**[\>\> Tony Trenkle:\
]{.underline}**Right. Uh‑huh.

**[\>\> Karen Bell:]{.underline}**

Right now the EHR use cases are limited to two. One is lab and the other
one is the emergency use case.

**[\>\> Tony Trenkle:\
]{.underline}**Right.

**[\>\> Karen Bell:]{.underline}**

It won\'t happen any quicker if it goes through the EHR route. I think
it would happen quicker if it stays in this route. Because again this
has been through two rounds, and it has not made the top three over two
rounds. So it would seem to me that it would be a time to really assure
that it is the next one done.

**[\>\> Tony Trenkle:\
]{.underline}**I would like to recommend that we, as we pull together
new recommendations, that we include something on that in the
recommendations strongly worded so that we can get it to move ahead
here. I think it is ‑‑

**[\>\> Frances Dare:\
]{.underline}**Related to that, it is, of the use cases that have been
presented, this is one, if it were added to the list that directly
engages with consumers. And there is good survey research from recent
work we've done and others ‑‑ this is Frances from Cisco ‑‑ that really
demonstrates consumer readiness to embrace secure messaging. There is a
demand for that service, if that would help promote this as well as one
of the group\'s recommendations.

**[\>\> Karen Bell:\
]{.underline}**That actually, that\'s a splendid idea. I think it does
require a vote though. Is there anyone \-- let's go backward here \-- is
there anyone on the Workgroup who does not think that this should be an
added recommendation at this time?

**[\>\> Eric Larson:\
]{.underline}**This is Eric Larson. I\'m in a very noisy place, so I\'ve
been on mute. I wanted to comment. I always thought that that was a
precondition for all of our other pieces of work. And to me, it\'s just
unthinkable that that would not emerge. And the last comment about
secure messaging being a way to connect with patients and highly
demanded is exactly what our experience has been at Group Health. And
the idea that a national health information system of some sort would
not be characterized as one in which interoperability were sort of a
baseline requirement just makes no sense to me. I feel almost
passionately strongly that whoever made the decision not to include this
needs to rethink it.

**[\>\> Karen Bell:\
]{.underline}**Well that certainly was a good way, I think, of
articulating the fact we will move forward. We will add this as a
recommendation for the next meeting on Tuesday. Everyone be prepared to
see the recommendation tonight. It will be coming around to you for
editing and comment before it actually gets sent out to the AHIC
members. So we will be looking to have each one of you sign off on it
when it comes through.

**[\>\> Tony Trenkle:\
]{.underline}**Karen, one last question on that. Is it included in the
NHIN testing, did they include any of that?

**[\>\> Karen Bell:\
]{.underline}**I think we can craft it so it moves forward and is
included in all of these things.

**[\>\> Justine Handelman:\
]{.underline}**Can I just ask \-- I might have missed it, having been in
transition. Is the next AHIC meeting they are going to approve the use
cases?

**[\>\> Karen Bell:]{.underline}**

No.

**[\>\> Justine Handelman:\
]{.underline}**Are you trying to put this on the agenda?\
**\
[\>\> Karen Bell:]{.underline}**

We are putting this on the agenda, on the next round it be number one.

**[\>\> Justine Handelman:\
]{.underline}**When is that next round?

**[\>\> Karen Bell:]{.underline}**

We started talking about it at the end of this year, in January. It will
come up again towards the end of this year. But it may be that the AHIC
and the Secretary feels this is important enough and that perhaps they
do want to change and move it forward and push this a little bit harder.
I don\'t know.

**[\>\> Tony Trenkle:\
]{.underline}**So will the next group of use cases be treated the same
even though the AHIC is looking to be privatized? It will be the same
process \--

**[\>\> Karen Bell:\
]{.underline}**That\'s right.

**[\>\> Tony Trenkle:\
]{.underline}**‑‑ for this year?

**[\>\> Karen Bell:\
]{.underline}**That\'s right. The next group will be coming up at the
end of this year, into 2008. So yes.

**[\>\> Tony Trenkle:\
]{.underline}**So it is critical that we get it on this one, then, for
the next steps.

**[\>\> Karen Bell:]{.underline}**

Critical we get it this year or next.

**[\>\> Tony Trenkle:\
]{.underline}**Right. Exactly.

**[\>\>\
]{.underline}**Okay. Could you make sure the alternates on the phone get
the document tonight?

**[\>\> Karen Bell:]{.underline}**

Absolutely, thank you. Good point. Thank you. Okay. Tony.

**[\>\>Tony Trenkle:]{.underline}**

Okay. I want to introduce Theresa Decaro. She\'s a deputy director of
our Medicare Advantage group. She was going to talk to us a few moments
about Medicare Advantage Plans and telehealth. There were some questions
that had come up and concerns how Medicare Advantage looks at
telehealth. We asked Teresa to give a brief discussion and open it up to
questions from the Workgroup members. Teresa, do you have some remarks
you want to make now before we open up for questions?\
\
**[\>\> Teresa Decaro:]{.underline}**

Sure, thanks so much Tony. The Medicare Advantage product line, about 19
percent of Medicare enrollees. And with, I mean, such a minor exception,
it is not really worth even counting, all of the Medicare Advantage
product lines are under capitated arrangement. And those capitated
arrangements are established through a competitive bidding process,
which I will touch bases on in a minute after I talk about how do we
define basically what is an allowable benefit when the Medicare
Advantage Plans establish what is in their benefit package.

And there is really sort of two worlds in the services that they
provide. You know, one is all of the Medicare part A and part B
services. Our health plans are required to provide those services, and
that is really the lion\'s share of what is in their benefit package.
Understanding I\'m not talking right now about the drug benefit and part
B, but of course that\'s another component, a third component.

So when they establish what their pricing is going to be for the part A
and part B services, the way the competitive bidding process works, and
I think it is important for people to keep this in mind, because really
what it really gets down to, I believe, for Medicare Advantage Plans is
can they provide a product in a particular marketplace that is a
competitively priced product, and do they believe that our Medicare
beneficiary would see any particular additional service for the way they
might price their part A and Part B services as a competitive edge,
something beneficiaries would like.

So to kind of give you the context again about how this pricing works,
in a given county in essence, you know, a health plan establishes what
their benefit package is and includes not only the services but what
their cost sharing arrangements will be on those services. And it has to
include all Part A and Part B services and, you know, whatever premiums
amount they think, you know, would be a part of that. It gets compared
to what\'s called the benchmark in that county. And the difference
between the benchmark and all plans are compared to that benchmark in
that plan, and what their actual pricing is, that amount of dollars, 75
percent of it is given back to the health plan to turn into additional
services, 25 percent of it goes to, back to the government.

And it is in that venue primarily that then plans take, and we refer to
it as the rebate amount. They take those dollars and then they can offer
what we refer to as mandatory supplemental benefits. There is other
things they can do. They can buy down the premium that they were
planning to do and that kind of thing. But we see a fairly creative
approach to what health plans believe would make that product more
marketable in an area. Now the typical thing that you would expect to
see, I think, would be dental and vision services, for example. You all
may or may not know that we have these special needs plans. You would
expect if you are somebody with chronic care, there might be other kinds
of support services that need to be provided.

In order to define a particular benefit in that second category, what
I\'m referring to as supplemental benefit, it does have to be
health‑related. So for example, you wouldn\'t be able to have somebody
come and walk a person\'s dog, even if that really was a very helpful
social service for somebody. And I mean that in all earnest. There are
people that you know are in the community and they need a lot of things.
We make a distinction in the Medicare program between health‑related and
non‑health‑related because the way the statute is defined, it really is
in essence an acute care-related benefit.

We think that, you know, without getting into the nitty‑gritty about
every kind of telehealth‑related service, that the service itself, you
know, would, generally speaking, as I understand it, be a part of a
health service. You know, I presume already, that there is a definition
under Medicare Part A and Part B about what constitutes telehealth for
Medicare Part A and Part B. I think the way that option works in
Medicare Part A and Part B it's not required, you know, that that\'s out
there. And because of that, our interpretation is that the way that
becomes, you know, part of the A and B benefit in Medicare Advantage is
in essence it would be possible for them to supplement, in essence,
their network. You know, if it is in a rural area, to use an example. If
in a rural area, providing some kind of remote monitoring, for example,
would be helpful, that is something we could entertain as plausible. We
have heard folks talk about monitoring, you know, and monitoring goes on
in a variety of venues. It is a big part of the special needs plan.
Whether that\'s done through some sort of electronic means or not, it is
certainly something that could happen.

I believe, as I\'ve been listening to the conversation today, that
secure messaging, here we are talking about, I presume, like mail and
all that kind of thing. Chances are that must be considered an
administrative cost in the bid. We have to go back and look at it. But
what it really gets down to for us is that Medicare Advantage Plans
activate net what our requirements are. Whatever dollars, you know, are
remaining, they have a lot of flexibility, if it fits into this health
definition about what they are going to do. But understanding this is a
competitive model and that they have to fundamentally believe there is
going to be an interest in this in their community before they would go
in this place. We don\'t require any services outside of the A/B benefit
package, and in fact we are precluded, in essence, from doing that. We
don\'t have the authority to do that.

The only other thing I would mention is that we do have several vehicles
through which we routinely communicate what our vision is, you know,
from year to year, to the plans, and we of course are in a constant
dialog with our health plans. And so it certainly is plausible for us
to, you know, raise the specter of this issue. It is my understanding
that we have already, you know, gone out and talked to some of our
health plans about, you know, what\'s happening on the secure messaging
front today and that kind of thing.

And that\'s really the story to be told. You know, it is ‑‑ our
position, I think ‑‑ when I say ours, I mean inside my group where, you
know, it is our interest to promote high value for beneficiaries in this
competitive bidding process, is that, you know, plans understand it is
certainly something they can provide. It is not clear to me the plans
don\'t understand that they could provide that. I do think it is an
interesting question about sort of the readiness of the Medicare
population, you know, for some of this. I think it is an interesting
question about whether, in rural areas in particular where it could be
difficult to meet our network access requirements, you know, whether
that\'s of interest to health plans. But you can see, actually, in the
distribution of Medicare Advantage Plans across the country, that there
are other rules, you know, that help health plans in essence meet our
access requirements. It is just not obvious on its face that they would
necessarily need this in order to meet those access requirements.

So with that, I\'m all ears about questions, will be happy to entertain
any ideas.

**[\>\> Tony Trenkle:]{.underline}**

Okay, thank you Teresa. Are there questions for Teresa?

**[\>\>\
]{.underline}**I have a question. Teresa, more information will make
sure I understand the Medicare Advantage Plan. It almost sounds a little
bit like what CMS had in the \'80s where they had managed health care
plans that would sign up Medicare beneficiaries. They would get a
prepayment at the beginning of the month to cover Part A and Part B, and
depending upon the location of the beneficiary, whether it was Dade
County, Florida, or middle America, would determine what that Part A and
Part B supplement would be.

If I\'m a CEO of a managed health care organization like Humana and I
have a thousand Medicare patients that have signed up for this plan, for
those thousand patients I will get a fixed amount for Part A and Part B,
and then I in turn will, in effect, sign up primary care doctors and
subspecialists within my network. I will pay them a certain amount also
on a monthly ‑‑

**[\>\> Teresa Decaro:\
]{.underline}**Under contract.

**[\>\>\
]{.underline}**Under contract.

**[\>\> Teresa Decaro:\
]{.underline}**And they have a lot of flexibility for what that looks
like.

**[\>\>\
]{.underline}**Exactly. Right. Now, in that plan, if I am that HMO CEO
and I want to use telemedicine to decrease, for some of my revolving
door patients who are noncompliant, if I wanted to use telehome care
into their homes, you don\'t in any way preclude that in terms of its
use, do you? In an urban setting.

**[\>\> Teresa Decaro:\
]{.underline}**No, there is no preclusion to anything I\'ve heard about
so far.

**[\>\>\
]{.underline}**So if I want to take out of the money you give me money
to put in a telemedicine system into the homes of half a dozen patients
who are constantly being readmitted, I can do that.

**[\>\> Teresa Decaro:\
]{.underline}**Right. Except understand that you have to sort of
actuarially put that together, and you\'re required to quantify that in
the bid in the beginning of the year. So there is a lot of differences
between now and the \'80s in terms of really how this works. And it\'s a
capitated payment. All of this information has to be provided up front.
You cannot provide benefits you don\'t have already in your benefit
package. You\'re required to market these things. And that doesn\'t in
any way necessarily discredit the point that you may be after here. I\'m
just simply clarifying that it is a much more competitive pricing
scenario today as a consequence of the Medicare Modernization Act than
it was in the \'80s.

**[\>\>\
]{.underline}**Right.

**[\>\> Teresa Decaro:\
]{.underline}**Also in the \'80s there were many more cost plans that,
the whole concept is really, there is only a very few of those.

**[\>\>\
]{.underline}**You\'re saying I need to put into my bid that I might be
using telemedicine.

**[\>\> Teresa Decaro:\
]{.underline}**Yes.

**[\>\>\
]{.underline}**And cost that out.

**[\>\> Teresa Decaro:\
]{.underline}**Yes.

**[\>\>\
]{.underline}**But if I do, that in no way is a disadvantage ‑‑

**[\>\> Teresa Decaro:\
]{.underline}**Well, it is because it will increase the cost of your bid
unless, in your actuarial work, you anticipate some kind of trade‑off
for having ‑‑ in other words, that creates some kind of an efficiency
that will reduce your cost somewhere else.

**[\>\>\
]{.underline}**Just for the record, I don\'t want it to be reflected
that the use of telemedicine would increase the cost of my bid. There is
a possibility of it being just the opposite and decrease the cost of my
bid. Because for my Part A ‑‑ Part A is hospital, right?

**[\>\> Teresa Decaro:\
]{.underline}**M\'hmm.

**[\>\>\
]{.underline}**For my Part A, I could probably increase my savings, you
know, in terms of Part A. So it could go either way, just for the
record.

**[\>\> Teresa Decaro:\
]{.underline}**I think really the issue is, you know, from a health
plan\'s perspective, if I could represent the health plans for a moment.
They have to actually believe that. And there has to be evidence of
that.

**[\>\> Joe Gifford:\
]{.underline}**This is Regence. Thank you for voicing the health plan
concern, and that\'s all unproven. So going in, your bid would go up, no
question. Five years from now, maybe we learn enough that that would be
different. But today it would go up. Thanks.

**[\>\> Craig Barrett:\
]{.underline}**So this is a classic chicken and egg question. You never
get there because there is an activation barrier to get over?

**[\>\> Justine Handelman:\
]{.underline}**This is Justine, with Blue Cross/Blue Shield and I wish I
had brought, and I can share with this group a booklet we did of our
plans, the Blue Plus plans that are in Medicare Advantage, and the
disease management, care coordination we are doing. In fact there\'s one
really good example, I believe it is Blue Shield that\'s in California
that has a disease management program for congestive heart failure where
they have remote monitoring in use, and in fact there is data that shows
that it has reduced hospital stays, or hospital admissions. I think it
is by 19 percent.

**[\>\>\
]{.underline}**Right.

**[\>\> Justine Handelman:\
]{.underline}**And that is going on right now in Medicare Advantage
through the disease management aspect of that plan. That\'s the only one
off the top of my head but I have a whole booklet that goes through
various examples of plan disease management. There may be more like that
but ‑‑

**[\>\>\
]{.underline}**It is a bit of a research question. The literature is
definitely mixed about cost savings. Just probably leave it at that.

**[\>\> Justine Handelman:\
]{.underline}**It doesn't go to the savings exactly, but it goes to the
reduced \--

**[\>\> Karen Bell:\
]{.underline}**I have one, one question \-- this is Karen Bell \-- and
it gets to one of the hearts of the issues we are dealing with right
now. There is legislation that basically, statutes that basically limit
the use of telehealth to certain geographies, certain settings, and to
certain sites, I would say, because it does have to be in a clinical
setting. So ‑‑

**[\>\> Teresa Decaro:\
]{.underline}**You\'re talking about the original Medicare. You\'re
talking about the service program.

**[\>\> Karen Bell:\
]{.underline}**M\'hmm. So my take away from what I just heard is that
that legislation, that statute does not apply to Medicare Advantage
Plans. Is that correct?

**[\>\> Teresa Decaro:\
]{.underline}**It does apply, in so much as it would be, it\'s a
Medicare Part A and Part B service. And so to the extent that it is
optional, I mean, nobody is required to provide this benefit under Part
A or Part B or for a beneficiary necessarily to receive it. If a plan
was able to supplement, in essence, you know, their access, I mean we
would certainly consider that under A and B as that is narrowly defined.
The distinction really to be made is anything outside of that it
definition would have to be a part of this supplemental benefit
definition I was just describing.

**[\>\> Karen Bell:\
]{.underline}**Right. But again just to underline, it is a very
important point that I think we all need to be absolutely sure about, is
that right now statutes precludes federal reimbursement, and that\'s all
it just says, for instance, in urban settings, urban situations.
However, a Medical Advantage Plan that has patients in urban situations
is not precluded from reimbursing its physicians for telephone services.

**[\>\> Teresa Decaro:\
]{.underline}**If they put it in their bid, if it is in their bid, then
it\'s paid for.

**[\>\> Karen Bell:\
]{.underline}**M\'hmm.

**[\>\>\
]{.underline}**Let me ask another question if I could. Do you have any
idea currently what utilization there is of telemedicine/telehealth by
any of your health plans?

**[\>\> Teresa Decaro:\
]{.underline}**Well, you know it is an interesting question. It is my
understanding that that was looked at before. I ‑‑

**[\>\> Tony Trenkle:\
]{.underline}**Not in total though. There was some anecdotal ‑‑

**[\>\> Teresa Decaro:\
]{.underline}**There is ‑‑

**[\>\> Tony Trenkle:\
]{.underline}**\-- Trish \[inaudible\], who used to be the director of
the group ‑‑

**[\>\> Teresa Decaro:\
]{.underline}**Right. I mean, I think that some health plans will first
of all, some of the special needs plans are implementing, you know,
certain monitoring protocols and that kind of thing, you know, which you
may or may not characterize as telehealth. I think a lot of that
information is communicated back over a telephone. And, you know, there
are some circumstances where, you know, the monitors are hooked up in an
electronic way to provide information. And so I think sort of the use of
the telephone primarily is something that goes on in some health plans
today. You know, for purposes of conveying information back you know
with the understanding that in Medicare Advantage Plan home health
services tend to be capitated. And you know, some nursing home services
are capitated. There is an operating environment, speaking of
patient‑centered care under a capitated arrangement, depending on how
you structure those services that, you know, a plan can trade off what
they think is potentially more efficient so long as there is overall
impact on utilization of services. That\'s all part of the equation of
deciding what they are going to provide or not.

Back to your question of, do Medicare Advantage Plans do this? I think
of telehealth, and you all know much more about it than I do, being on
this spectrum. I think on the, what I will refer to as the been around
for a while spectrum, I think there is some of that that goes on.
Chances are it is largely costed out in their administrative fees or
it's a part of some capitated arrangement that\'s going on around
disease management, depending how that\'s structured, in their contracts
with their providers. As far as sort of the more, you know, I think
medical‑wise type of, you know, remote surgery and that kind of thing, I
don\'t think that very much of that is going on at all.

**[\>\>\
]{.underline}**But if their contract with a provider, let\'s say related
to a hospital, includes taking an X‑ray and the hospital chooses to have
that X‑ray interpreted by a radiologist located in some other location,
I assume that your contracted entity would not really get involved in
that decision by the hospital, or would it?

**[\>\> Teresa Decaro:\
]{.underline}**I think you know, sort of a way to sort of step back for
a second and say, there is all kinds of things that go on obviously in
contracting with us and then with providers. I mean, our Medicare
Advantage Plans are all required to meet, you know, state and other
government rules. I don\'t know, you know, what kind of ‑‑ you were
mentioning earlier, Karen, about the interstate boundary issues\-- I
have no idea to what extent they come up. But I think it is an important
issue because to the extent that it is perceived, you know, as an
impediment, and this being one example, you know, that\'s something then
they would need to tend to, if they were going to structure for example
this remote reading and if there were to be some kind of state boundary
issue, they have got to have those things addressed in their provider
contracts.

**[\>\>\
]{.underline}**But even if it was within the state. Let\'s take the
state boundary issue out for a moment. If they choose, for example,
someone comes in and needs a dermatology consult and they choose to have
that individual seen by a dermatologist located in some other location.
Maybe within the same state, but seeing that person via telemedicine. I
assume the Advantage contractors would not get involved in that issue at
all?

**[\>\> Teresa Decaro:\
]{.underline}**I think that ‑‑

**[\>\>\
]{.underline}**Let, this is ‑‑

**[\>\> Teresa Decaro:\
]{.underline}**‑‑ they are involved in it in the following sense. They
are not going to pay for a service they don\'t have contracted to pay.

**[\>\>\
]{.underline}**M\'hmm.

**[\>\> Teresa Decaro:\
]{.underline}**And, you know, so let\'s assume for a second that you
know ‑‑ it just depends on exactly what the circumstance is. For
example, you know, if they have a relationship, a contract with \--
let\'s talk about physicians or radiologists for a second. That contract
would talk about specifically what are, what\'s the context in which
they are going to pay for those radiology services. So if that
radiologist was using, you know, remote access, I wouldn\'t be surprised
at all if that was a component of that contract. So when this thing
comes in, I presume that there is different codes for this stuff. You
know, they have to code, bill just like anybody else does. They would
recognize it and they would make a determination about whether that was
a part of their contract or not.

**[\>\> Joe Gifford:\
]{.underline}**Let me try adding the common practice nuance. So remote
reading of radiology images, specifically Australia, is common operating
procedure in most big hospitals right now, goes on just fine. In terms
of a dermatology visit, the visit codes, one of the rules of CPT visit
codes is face‑to‑face, so that does not happen standard. That requires a
separate code, requires telehealth and that\'s not going on. So that\'s
what\'s happening.

**[\>\>\
]{.underline}**But within this Medicare Advantage program, if I wanted
to bring the dermatologist in vis‑à‑vis telemedicine, and therefore not
have to pay him as much because he is not using his office and the
overhead expenses, and I can get that service for less, you\'re not
saying I can\'t.

**[\>\> Teresa Decaro:\
]{.underline}**Right.

**[\>\> Joe Gifford:\
]{.underline}**No that would be a contractual ‑‑ that would be a little
business project between the plan and the dermatologist. And I believe
Medicare would be agnostic there and I think that would all be fine. It
would have to be a separate contract and wouldn\'t be reimbursed in the
standard way which requires face‑to‑face. It would have a separate way
of describing it and way of paying for it.

**[\>\>\
]{.underline}**Now, I don\'t understand that last point. I\'m sorry, who
is this speaking?

**[\>\> Joe Gifford:\
]{.underline}**Joe Gifford at Regence.

**[\>\>\
]{.underline}**Joe, what I\'m asking is if I\'m getting, if I\'ve gotten
a contract, Medicare Advantage contract and I\'m getting ‑‑

**[\>\> Teresa Decaro:\
]{.underline}**You\'re the provider or you\'re the health plan?

**[\>\>\
]{.underline}**I\'m the health plan.

**[\>\> Teresa Decaro:\
]{.underline}**M\'hmm.

**[\>\>\
]{.underline}**And I\'m, you\'re capitating me. And I choose to provide
my subspecialty services in infectious disease, endocrinology,
dermatology vis‑à‑vis telemedicine. You\'re not saying I cannot do it
that way.

**[\>\> Teresa Decaro:\
]{.underline}**Right. All I\'m simply saying is, there is a dynamic, and
a big trade‑off about, you know, how hard is a health plan going to push
on the diffusion of that technology versus ‑‑ I mean, let\'s assume that
a health plan has some particular initiative that they want to do in a
marketplace. That would affect, to your point about maybe it would
reduce, you know, payments to dermatologists. I don\'t want to put too
fine a point on this. I\'m just saying that relationship and that
dynamic plays out now between the dermatology, dermatologists in a
particular marketplace and the health plan. They know what a health plan
is up to and are they going to collaborate on that? Are they going to be
helpful or say forget it I won\'t be in your network? It is just a
dynamic that plays out.

**[\>\>\
]{.underline}**I understand that dynamic. I just wanted to make sure I
could use telemedicine within the Medicare Advantage program. Plain and
simple.

**[\>\> Teresa Decaro:\
]{.underline}**Well, provided that, you know, all of the state and
federal rules are ‑‑

**[\>\>\
]{.underline}**Yes.

**[\>\>\
]{.underline}**All ‑‑ you know.

**[\>\> Karen Bell:\
]{.underline}**But the federal service rules don\'t apply to Medicare
Advantage ‑‑

**[\>\>\
]{.underline}**Right.

**[\>\> Karen Bell:\
]{.underline}**‑‑ is the bottom line.

**[\>\>\
]{.underline}**Exactly.

**[\>\> Teresa Decaro:\
]{.underline}**But they do apply. It is just, they do apply. It is just
they can do in addition, other things.

**[\>\> Tony Trenkle:\
]{.underline}**It can\'t do it within the Part A and B services ‑‑

**[\>\>\
]{.underline}**Right.

**[\>\> Tony Trenkle:\
]{.underline}**‑‑ so it applies but not completely.

**[\>\> Dena Puskin:\
]{.underline}**This is Dena Puskin. I\'m not exactly sure what you\'re
just saying in that latter part. It appears to me, and I think this is
what Jay is trying to get at, that if a plan decides that they are going
to offer dental services or something else as a part of their
supplemental program as a result of that 75 percent that they get back,
and they decide, that\'s a winner for them, that that\'s okay. That\'s
out of the standard A and B benefit plan, but if you get a contract and
everything else, that\'s okay.

Now let\'s take this to telehealth. Either it is biometric monitoring or
dermatology services or whatever. It is part of again what you might
call that supplemental service that would be essentially allowable
under, with the rebate dollars. Is that what you are saying?

**[\>\> Teresa Decaro:\
]{.underline}**It is what I\'m saying.

**[\>\>\
]{.underline}**Correct.

**[\>\> Teresa Decaro:\
]{.underline}**And I felt that your example was really a good one. You
know, I mean, I am agnostic about this frankly. But what that health
plan is going to be doing is saying, well, geez, am I going get
more enrollees because I\'m offering vision services or am I going to
get more enrollees because I\'m offering this telemedicine? And maybe it
depends on what is the need that telemedicine is filling.

**[\>\>\
]{.underline}**And a contractual deal. If the dermatologists comes to us
and say, hey, we have got a great idea. Let\'s buy this equipment and go
for it, we would evaluate that as a business proposition. Will it save
money, will it cost money, and so on. But that\'s how it would happen.

**[\>\> Karen Bell:\
]{.underline}**One of the things I would just like to offer. This is
Karen again. I think we certainly have made a big step forward
understanding a little bit about what could be covered, at least in a
Medicare Advantage Plan. That covers 20 percent of Medicare patients. We
heard 19 percent. Is there some opportunity for a recommendation from
this Workgroup to the AHIC that can be made to further support either
gathering more information with respect to the value of telehealth in
these particular environments or in some size, shape, or form, incent
health plans to put more of their resources towards telehealth? Just
throwing that out there as a question because this could be a possible,
one of several possible recommendations for next week.

**[\>\> Craig Barrett:\
]{.underline}**As part of that question, Karen, can the speakers tell us
of any examples where people have actually come in and proposed
telehealth in any form?

**[\>\> Joe Gifford:\
]{.underline}**Here at Regence, I will say no. They're not interested.
They are busy. They are doing just fine.

**[\>\>\
]{.underline}**I want to go back to the California example. As a part of
what California has been doing, is they do offer a certain amount of
telemedicine. Actually, under, I believe, their Medicaid/Blue Cross
contract. I don\'t know under the Medicare. Would it, Karen, be helpful
to get that study and that information from California? That may help
frame some of your thinking.

**[\>\> Karen Bell:]{.underline}**

Justine ‑‑

**[\>\> Justine Handelman:\
]{.underline}**I don\'t know the Medicaid, but certainly I can reach out
to our plans. We have two Blue plans in California that operate under
Blue Cross/Blue Shield. I know in Medicare Advantage Blue Shield is
doing something on congestive heart failure.

**[\>\>\
]{.underline}**There was a study actually done several years ago when
they had a contract from the state for the Medicaid program to look at
just this kind of thing for telemedicine. And it was Blue Cross who
managed the study. Len Schaeffer was ‑‑

**[\>\> Karen Bell:\
]{.underline}**WellPoint.

**[\>\>\
]{.underline}**I\'m just wondering whether getting some of that, because
California has done a lot, I think you\'re right to reach out in terms
of what the plans are doing. Just because it may help shape how you talk
about this as a recommendation based on ‑‑

**[\>\> Karen Bell:\
]{.underline}**One of the things I would like to underline is that we
have an opportunity to make a recommendation today, and shape it today.
If we don\'t do it today, we will, you know, basically put this off for
some time. We have heard over the course of the past year a lot of
testimony in bits and piece, you know, the 19 percent on the hospitals,
decrease in hospital admission. There\'s been a lot that others have
brought forward as well. So we have heard various types of testimony,
but as Joe has suggested, it is also mixed. It is a point where, I
don\'t think there is any one plan, including Medicare, or any one payer
that is absolutely convinced that it will be worth its while to pay for
telehealth services up front. So given that, I would again just put out
whether or not we need to think about a recommendation today that could
go in this direction or whether we would want, you would want to choose
to table this type of recommendation for down the line around Medicare
support through its Medicare Advantage Plans to either garner more
information or other, some size, shape or form, incent telehealth use
and \--

**[\>\> Joe Gifford:\
]{.underline}**My vote at Regence here, is it\'s a research question.
Get a narrowly defined - for one thing, telehealth is way too broad a
topic. You need to narrow it, come up with one really specific use case,
like video dermatology, and study it and learn the exact cost behaviors
of it, otherwise it is not going to happen.

**[\>\>\
]{.underline}**When we say telehealth I assume we are eliminating
telehealth for non-face‑to‑face services like radiology and pathology,
which have been reimbursed by Medicare, all private insurers that I\'m
aware of for 30 years. I\'m assuming that\'s not what we are talking
about.

**[\>\>\
]{.underline}**What do you mean eliminate it?

**[\>\>\
]{.underline}**For what we are talking about here. I\'m assuming ‑‑

**[\>\>\
]{.underline}**That\'s already happening.

**[\>\>\
]{.underline}**That\'s been happening for radiology and pathology, for
remote cardiac reads, for monitoring pacemakers.

**[\>\> Karen Bell:\
]{.underline}**Medicare does not consider that to be telehealth and
reimburses that as it reimburses direct service.

**[\>\>\
]{.underline}**Right.

**[\>\>\
]{.underline}**Or it may consider it to be telehealth but they define
the issue with respect to traditional face‑to‑face practice. And they
have viewed radiology, as in the real world of radiology that the
radiologist usually is not required to meet with the patient. Now most
radiologists will disagree with that, but fundamentally that\'s the way
you have gone about it. You have sort of put telepathology in that same
category, but not officially, as far as I understand. And you put it in
officially for the remote monitoring relative to EKGs, Holter monitoring
type of ‑‑ so it is really the issue of face-to-face that you\'re
defining here.

**[\>\> Tony Trenkle:\
]{.underline}**But I think it is important to define what we are talking
about. I think Jonathan brought up a good point.

**[\>\>\
]{.underline}**In the Medicare manual it has a definition called
non‑face‑to‑face. It has a number of examples including examination of
tissues, in reference to that. So I\'m assuming pathology is in \--

**[\>\>\
]{.underline}**Right.

**[\>\>\
]{.underline}**‑‑ is included. And when you get into what\'s required
face‑to‑face, what\'s not. That\'s an issue certainly under some
consideration now, for example is there a requirement for
face‑to‑face for dermatology. But that\'s another question.

**[\>\> Tony Trenkle:\
]{.underline}**Karenm when you say a recommendation, what would you be
looking at in terms of ‑‑ I mean I think we heard some good testimony
and questions here. I guess I\'m not clear as to what you would be
looking for in terms of a recommendation. Because recommendations go to
the Department, so what are you talking about in terms of
recommendation?

**[\>\> Karen Bell:]{.underline}**

Well, I\'m thinking that, there is an opportunity, a possible
opportunity \--

**[\>\> Tony Trenkle:]{.underline}**

Right.

**[\>\> Karen Bell:]{.underline}**

\-- if the Workgroup is interested, in a recommendation that could be
made to the Secretary to somehow incent or encourage the use of
telehealth in Medicare Advantage Plans. It could be anything from moving
forward with some demonstration projects to show its value and we could
be very specific about, talking about it in secure messaging or perhaps
remote care. There would be a number of things that could be considered.
There could be other recommendations that, you know, and I\'m sort
of nonplussed to think of them at the moment. But could be more specific
around including telehealth as one of the options. You suggested that
you cannot mandate what\'s in the supplemental \--

**[\>\> Teresa Decaro:]{.underline}**

Right.

**[\>\> Karen Bell:\
]{.underline}**‑‑ but there may be other ways that health plans could be
encouraged, particularly in certain areas, to consider telehealth as
part of their supplemental coverage. I\'m just throwing those out as a
possibility.

**[\>\> Tony Trenkle:\
]{.underline}**You\'re looking at ways to incentivize the plans to offer
it more.

**[\>\> Karen Bell:\
]{.underline}**And study it more.

**[\>\>Tony Trenkle:]{.underline}**

And study it.

**[\>\> Karen Bell:\
]{.underline}**If we need to study it more to make it more widely
available and prove its value, then perhaps that\'s a demonstration
project. I don\'t know. I\'m just throwing those ideas out, basically
suggesting that we have an avenue for a recommendation around telehealth
use in the managed care environment. We will have to come back to it in
the fee for service environment later on in this afternoon\'s
discussion. But we could possibly move forward with the recommendation
here if the Workgroup thinks it is worthwhile.

**[\>\>\
]{.underline}**How would that differ from the recommendation, there is a
recommendation that\'s been made already to do, or the talk here to ‑‑
some pilots and ‑‑ \[inaudible\] focused on Medicare Advantage.

**[\>\>Tony Trenkle:]{.underline}**

Those are more narrowly defined as secure messaging.

**[\>\>\
]{.underline}**Right.

**[\>\>\
]{.underline}**These would be the use of monitoring devices?
\[Inaudible\]

\[audio interference\]

**[\>\>\
]{.underline}**Do we know of any Medicare Advantage Plans that are now
using telemedicine?

**[\>\> Teresa Decaro:\
]{.underline}**It depends how you define it. I think we just talked
about a whole bunch of examples. You know, the pacemaker. We have got
these special needs plans where, you know, there is some disease
management stuff going on. And some of that information is communicated
over some, you know, electronic line as opposed to, you know, a nurse
practitioner or an aid going and collecting that information. I mean, I
think it is an interesting question about, you know, what\'s the value
of the intervention? Is it the collecting the data or is it the fact it
got transmitted electronically? These are the big challenges around this
to ‑‑ \[inaudible\] comment around, what is the research question here?

**[\>\>Tony Trenkle:]{.underline}**

The answer ‑‑

**[\>\>\
]{.underline}**You were saying in the contract that I submit, and I\'m
the CEO of a managed health care organization. In the contract I submit
to you ‑‑

**[\>\> Teresa Decaro:\
]{.underline}**M\'hmm.

**[\>\>\
]{.underline}**‑‑ I\'ve got to indicate whether or not I\'m going to be
using telemedicine. Is that correct?

**[\>\> Teresa Decaro:\
]{.underline}**You know, it depends on whether it's an administration
cost to another service that\'s being provided. Because I think what I
see today in our supplemental benefits is that. In other words, I don\'t
think that the example that you just gave is an example that somebody
thinks of as telehealth. They think of that as disease management.

**[\>\>\
]{.underline}**That\'s right then. That\'s correct. But I would ‑‑

**[\>\> Teresa Decaro:\
]{.underline}**So I do think that ‑‑

**[\>\>\
]{.underline}**‑‑ suggest you don\'t have a single plan that has been
submitted to you an in which they have specifically stated they are
going to use telemedicine to deliver some of their care. And I think one
of the reasons you probably don\'t is they probably don\'t know that
they could use telemedicine in their Medicare Advantage Plan.

**[\>\> Teresa Decaro:\
]{.underline}**I think they probably do. I will look to the people that
represent Blue Cross/Blue Shield and Regence to answer that question.
People know what a health service is.

**[\>\> Joe Gifford:\
]{.underline}**Of course we do. We have been around the block. But this
is too granular. First of all, you can\'t just use the word, you know,
telemedicine. That\'s way too broad. Does that mean we talk on the phone
to somebody or does it mean ‑‑ you know what I mean. It is way too
broad. The specific services could be listed as benefits. And, no, of
course the health plans understand that.

**[\>\> Karen Bell:\
]{.underline}**I\'m going to ask another question. This is probably
going to be more confusing than not. If there were some changes on the
fee for service side so that there were expansion, for instance,
geographical expansion of what could be available in telehealth that
would become then part of Part A and Part B, and that would be part of
what the Medicare Advantage Plans would cover.

**[\>\> Eric Larson:]{.underline}**

This is Eric Larson. Could I make a comment on this recommendation? I
just went off mute.

**[\>\> Karen Bell:\
]{.underline}**Please, Eric.

**[\>\> Eric Larson:\
]{.underline}**I think this would be a good time to try to make a
recommendation, especially in the context that Medicare Advantage Plans
are under a lot of scrutiny now as to why they might justify their
special rates. It would seem to me that one of the questions we might
ask, to what extent do Medicare Advantage Plans that use secure
messaging and other forms of, however we want to define it, services
that are delivered electronically, not just traditional, adds value as
well as what it costs to do it. Because there are both sides to that
equation. My guess is that if you looked at our organization, Group
Health, and other organizations that use this in their Medicare
Advantage Plans, they could probably come up with a calculus and a
metrics to say this is worth it or it is not.

**[\>\>\
]{.underline}**And the point about really narrowing the definition is
spot on, if we were to narrow that down to home-based monitoring of
people with chronic conditions using devices like the Health Buddy
device from the Health Hero Network. There is a body of evidence from
the VA which you could consider one flavor of the capitated player. Some
of that is in the peer-reviewed literature, some of it not. But it would
be nice to have complementary studies based on that specific technology
that approached telehealth out of the private sector as well.

**[\>\>\
]{.underline}**As research.

**[\>\>\
]{.underline}**Yes. As a research study.

**[\>\>\
]{.underline}**Because you won\'t replicate VA results ‑‑

**[\>\>\
]{.underline}**Understand. But the point being, that specific definition
of that kind of technology and that approach to care has some evidence
to its efficacy in reduced inpatient and emergency room utilization. So
you cannot take the VA findings and say they fit the private sector, but
it is a place to start because they had some positive results.

**[\>\> Karen Bell:\
]{.underline}**What about the possibility \-- this is Karen \-- because
we do need to move on, of moving forward with a recommendation that the
Secretary evaluate and consider a demonstration project through Medicare
Advantage Plans that looks specifically, and maybe we can make it as
narrow as the use of home-based monitoring devices in patients with
chronic illness.

**[\>\> Craig Barrett:\
]{.underline}**Whatever you do, Karen, just make it so plain and simple
that people don\'t have to jump through hoops to get there.

**[\>\> Karen Bell:]{.underline}**

Okay.

**[\>\> Craig Barrett:\
]{.underline}**I mean, listening to this conversation as a non-medical
person, kind of suggests why we have not moved in this direction. This
is one of the most confusing conversations I\'ve been in in some time,
as to what\'s legal, what\'s not legal, what you need approval for, what
you don\'t need approval for, et cetera, et cetera. I mean we can read
X‑rays in Australia but we cannot read heart rates down the street.

**[\>\> Karen Bell:]{.underline}**

Right.

**[\>\> Craig Barrett:\
]{.underline}**I mean, it is ridiculous.

**[\>\> Karen Bell:]{.underline}**

Well I think a demonstration project will begin to get us there. We will
try to make it as basic and simple and leave plenty of room for
discussion on this it at the AHIC meeting. Is that okay?

**[\>\> Craig Barrett:\
]{.underline}**Thank you.

**[\>\> Eric Larson:]{.underline}**

This is Eric talking here again. I think to make it simple, you could
actually use phrases to say what has already been occurring, as part of
the demonstration project. Because some of this is just happening as we
speak because people get frustrated with the complexity that was just
discussed.

**[\>\> Karen Bell:\
]{.underline}**Okay.

**[\>\>\
]{.underline}**Well, I think that what\'s important though is it sort of
demonstrates the financial incentives have a lot to do with how all this
gets teed up, is really the point of my comments. I would encourage you
all, there have been a number of studies conducted by our office of
research and demonstrations that in one way or another involve
home-based monitoring and to sort of appreciate, you know, what the
evaluation results of that have demonstrated. That would certainly, you
know, involve the Medicare population. Those demonstrations would have
been on the fee for service population, I believe.

**[\>\>Tony Trenkle:]{.underline}**

Yes, they would have been.

**[\>\> Karen Bell:\
]{.underline}**Okay. I think we have enough to move forward. We'll come
up with something this \-- watch your mailboxes tonight, please,
everyone, and we will see if we can get signed off from everybody by
tomorrow end of day. Thank you so much Teresa.

**[\>\> Teresa Decaro:\
]{.underline}**Yes.

**[\>\> Karen Bell:\
]{.underline}**It was very helpful. Could I jump into the 2:00 p.m.
discussion?

**[\>\> Tony Trenkle:\
]{.underline}**Go ahead.

**[\>\> Karen Bell:\
]{.underline}**Okay. This was the brainstorming areas for broader
interpretation of existing statute. And I believe Amy Hunsberger is on
the line. Is that right, Amy?

**[\>\>Tony Trenkle:]{.underline}**

Not supposed to be on until 3:00.

**[\>\> Karen Bell:\
]{.underline}**No, I had asked her to participate starting at 2:00. We
are going to call Amy. She has some individual presentation that she may
choose to make, but e thought it would be helpful to have her on board
because the real crux of this discussion is now thinking through what we
can offer the fee for service population. We can, as I say, move forward
with some sort of a demonstration in the Medicare Advantage part of
Medicare. That still leaves 81 percent of Medicare beneficiaries without
any type of access. So there were a couple of comments that were made a
little bit earlier. And again, I think we do need some legal input on
them. I would like to at least share with you some possibilities that we
may be able to move forward with in terms of some, some recommendations
here.

The first, and this is again, it is the legal part here. But that the
Secretary support the development of legal guidance that defines the
physician office by diagnostic services and treatment rendered rather
than by the definition of walls and floor, mortar and concrete. Comment.

**[\>\>\
]{.underline}**Say that again?

**[\>\> Karen Bell:\
]{.underline}**The issue here is that current statute, and we have
talked about this before, precludes reimbursement for time and expertise
if that is expended on a patient that\'s in their home as opposed to
coming into the office. Unless the physician actually goes and makes a
home visit and then he is paid for the home visit. But taking care of
patients remotely right now, even though all of the technology may be
available to see, listen to, examine, short of doing the appendectomy on
the kitchen table, the clinician will not get reimbursed for it. The
real intent here is to develop some guidance that will alter the
definition of physician office and make it clear that it is by the
services and treatment rendered, not necessarily by the environment.

**[\>\>\
]{.underline}**Well, that\'s a ‑‑ that\'s a tough one. Now that, you
know, we have a lot of technology to provide richer services, that is,
that\'s very tempting. The current legal structure got there for a
reason. And I think, don\'t know, but I think you would want to go back
in the annals of the OIG for fraud and abuse because I believe it was
felt that it was simply too rife for gaming. The most obvious case is a
patient calls you on the phone and you say, gosh, why don\'t you put
some cream on that and call me tomorrow, and then you charge for that.
Simply put, the costs of the program go way up if that\'s permitted. So
this is not a simple topic.

**[\>\> Karen Bell:\
]{.underline}**Well, but we have just been blessed by having Amy walk
into the room here. So she\'s now here to help guide us. And I will
assure you, she\'s brought in a book that\'s as thick as Gray\'s Anatomy
used to be. Social Security Act.

Amy, we\'re discussing whether or not it would be reasonable for the
Secretary to support the development of some legal guidance that would
define a physician\'s offices by the diagnoses made and the treatment
rendered, using possibly the advantages of remote technology and
electronic information, rather than by the four walls and the floor. So
that I as a clinician could, or Jay ‑‑ he should probably jump in
here ‑‑ could listen to your heart, essentially look at your EKG, get
the results of your blood and urine tests, listen to your heart, get
your weight, get your vital signs, look at any skin lesions you may have
through the video techniques available. And could therefore consider my
work, which I would be doing in perhaps an office or even my home, as
being considered to be an office. Because everything I would do in my
office with you, I can do with you, with you in your home.

**[\>\>\
]{.underline}**Can I give you a bread and butter example that happens
every single day? Okay. I have a patient with congestive heart failure
who calls me on the phone and says, Doc, I\'m not feeling well. And I
say, Mr. Jones, please step on the scale. And he steps on the scale and
says, doctor, I\'m five pounds heavier than I was two days ago. And I
know immediately that he is retaining fluid. He needs to have, let\'s
say, an additional diuretic introduced. And I tell him that over the
phone. All right? I can\'t bill for that service. However, if I\'m
smart, I tell him to come in my office and I put him on my office scale,
and I tell him the same thing I would have told him over the telephone.
Now I can, now I can bill him for that service. Instead of the excess
cost for everybody, in terms of bringing him in my office, can we define
the, what I do functionally as opposed to what I do structurally?

**[\>\> Amy Hunsberger:\
]{.underline}**Right. And I am not sure, actually, of the origin of
this. But there has always been a face‑to‑face requirement under
Medicare. And the whole system is sort of built on that. The fact that a
patient is sitting right in front of you, and you touch, see, hear,
feel, and communicate two-way, in‑person.

**[\>\> Craig Barrett:\
]{.underline}**It used to be that if my PC went bananas you had to be
face‑to‑face with my PC to fix it. You don\'t have to do that anymore.
It used to be with your telecommunications system, to de-bug it, you had
to be face-to-face. You don\'t have to be next to it to do that. Every
other industry I can think of has come into the 21st century, and we can
basically sit here and debate about how to bring the health care
industry into the 21st century.

**[\>\> Tony Trenkle:\
]{.underline}**She\'s talking about the legal authority. She's not
talking about whether it makes sense.

**[\>\> Craig Barrett:\
]{.underline}**You know, Tony, I\'m married to a lawyer so I know all
about legal authority.

\[laughter\]

**[\>\>\
]{.underline}**\[inaudible\]

**[\>\>\
]{.underline}**That\'s right.

**[\>\> Craig Barrett:\
]{.underline}**But, you know, how do we get around this?

**[\>\>]{.underline}**

But if I would, I would say it is not quite ‑‑ I wouldn\'t frame it that
way. The telephone has been around for 80 years. This is, at its heart,
a telephone issue. Very smart people with a long history have made the
decision to not pay for that telephone ‑‑

**[\>\> Craig Barrett:\
]{.underline}**I would challenge that. I don\'t think it is a telephone
issue. The data acquisition you can get today is not a telephone issue.

**[\>\>\
]{.underline}**But decisions were made about telephone visits. All I\'m
saying is there were good reasons by smart, well‑intentioned people to
not permit telephone visit payments. And we should be sure we understand
testimony from them as to why those decisions were made.

**[\>\> Dena Puskin:\
]{.underline}**This is Dena.

**[\>\> Karen Bell:]{.underline}**

I think the other thing is we have had a lot of testimony over the last
several months about the fact that we are getting data from very
different ways now. We can all talk about the fact that we always used
to do things by carbon copies and mimeograph. The availability of
electronic information is so different from what was available when
these laws and statutes went into place that we really need to rethink
what we should do and how to address the laws and statutes. Some of them
we can do with guidance, and some of them we may have to change.

**[\>\> Dena Puskin:\
]{.underline}**This is Dena Puskin. One of the benefits having been
there when it happened is that I can tell you the background, at least
in terms of telemedicine. The reason that it is face‑to‑face is, in
part, because we didn\'t have a good way of defining what a
store-and-forward or comparable kind of interaction would be as it
differed from a telephone consult. So you can go back further as to why
they didn\'t want to include simply telephone, but when you get to the
issue of the actual telemedicine legislation and then implementation,
part of it was we did not know enough how to define something called a
store-and-forward visit or encounter, for the purposes of legislation,
that would be different than a telephone encounter. And part of it was
to define the standards because there was concern about fraud and abuse.

That being said, it seems to me that part of the issue is we are in a
better position to begin to define in a standard way what the value
added would be of this kind of service, above and beyond a telephone.
And that the question really comes down to, how to define it and what
the issues are in defining it. And one of the ‑‑ if you look back at the
statute there is two places in the country where they allowed for a
natural experiment in so‑called store-and-forward types of technology
and encounters. And that was Alaska and Hawaii, neither of which have
really done an enormous amount to give us the literature that we need.
However, I think we need to go back and, before we get too legally
entangled to realize that part of the reason was we didn\'t have enough
information at the time and perhaps we may now, or we may be on the
verge of it.

**[\>\> Karen Bell:]{.underline}**

Well, you know ‑‑ go ahead John.

**[\>\> Jon Linkous:\
]{.underline}**This is Jon Linkous. The origin of the requirement for
face‑to‑face came out of the development of the CPT coding procedures,
by AMA largely. And that discussion early on was led by AMA. There is no
legislative statute that requires face‑to‑face. It is not in the
legislative language. It is in the regulatory language that came out of
the AMA. There is no requirement from a federal legal perspective, very
narrowly defined, and one could define it differently, I know.

**[\>\> Dena Puskin:\
]{.underline}**They defined it as a consultation, and that led to what
it led to.

**[\>\> Jon Linkous:\
]{.underline}**And the consultation is defined not in legislation but ‑‑

**[\>\> Dena Puskin:\
]{.underline}**That\'s right. It is defined in regulation. But by the
use of that term, and there were some other considerations. It was not a
total accident.

**[\>\> Jon Linkous:\
]{.underline}**Right. But then at the same time, CMS has declared in one
of the rulings early on, Dena, you may remember this, one of the
regulatory proceedings, that they did consider interactive video to be
the same as face‑to‑face.

**[\>\> Dean Puskin:\
]{.underline}**Right. That\'s right.

**[\>\> Karen Bell:\
]{.underline}**Well, to get back to the initial question: can we, or are
we interested in asking the Secretary to develop guidance which would
redefine the physician office by the diagnostic services and treatments
rendered? Because that would then allow two things. One, allow a very,
allow the development of some very specific guidelines for what that
would entail, i.e., E & M codes, constituencies, could be applied. And
two, it could allow for auditing in the same way care is now audited.
You cannot audit care on a telephone, but you can certainly audit care
that is being documented electronically. So I\'m looking at Amy now.

**[\>\> Amy Hunsberger:]{.underline}**

I do think, you know, I was not fully prepared to answer this question
in particular, but I do think off the top of my head that there are a
number of concerns that would be raised by doing that in terms of fraud
and abuse, Stark, anti‑kickback type issues, just to name one that leaps
to mind. There are a lot of things that are built on a physician\'s
office as a physical location. And I think a broad definition of
physician office being sort of, where the physician is delivering a
service, regardless of where that is and regardless of what, by what
means, would sort of interfere with some of those things.

**[\>\> Karen Bell:\
]{.underline}**So if we were to write guidance that takes these things
into account, that\'s still something we could do. Or the Secretary
could do. Not we, the Secretary ‑‑

**[\>\> Amy Hunsberger:]{.underline}**

I would think that it is not inconceivable. But I\'m saying there are a
lot of ‑‑ that may not be a very straight forward easy thing to do.

**[\>\>\
]{.underline}**Given the fact there is the potential for fraud and
abuse, there is no issue about that. But also, given the fact that with
telemedicine there is potential for documentation unlike any
documentation you would ever have with a patient in your office, that
would then potentially do a lot to answer questions of fraud and abuse.
It seems to me it might be worth pushing the questions out. Not to say
the decision should be made, but perhaps push the question out in this
iteration, a decision could be made by the Secretary, and looking
seriously at ways to resolve the types of questions you have put on the
table.

**[\>\> Amy Hunsberger:\
]{.underline}**Let me ask, is this an effort to get around statutory
limitations that, originating site issue? Because, you know, if ‑‑ it
may be frankly easier to pursue a legislative ‑‑

**[\>\> Tony Trenkle:\
]{.underline}**I think, Amy, that\'s really what the group is looking
at. Is there a way within current statute to do some of the flexibility
we have been talking about or does it require a legislative fix? That\'s
what we are ‑‑

**[\>\> Amy Hunsberger:\
]{.underline}**The Secretary does have some authority to add originating
sites. There is a SNP authority that was passed with the MMA. I think it
is 414. And, you know, maybe a legislative fix to give the Secretary
greater discretion would be in order, as opposed to sort of trying to
change the whole conception of what is a physician\'s office. Maybe
there could be ‑‑

**[\>\> Craig Barrett:\
]{.underline}**Hey Tony?

**[\>\>Tony Trenkle:]{.underline}**

Yes, Craig.

**[\>\> Craig Barrett:]{.underline}**

Can you just imagine this discussion going on about ten years ago, that
to take money out of your account you had to physically go to the bank
because of fraud and abuse and because it had to be a face‑to‑face
transaction?

**[\>\>Tony Trenkle:]{.underline}**

Yes, I understand where you\'re coming from.

**[\>\> Craig Barrett:]{.underline}**

This is a phenomenal discussion. If it is illegal, it is illegal. So
fraud and abuse, I presume, from a doctor\'s office, I can fake a
patient coming into my office or I can fake an electronic communication
with a patient, can\'t I? What\'s the difference?

**[\>\>\
]{.underline}**And Craig, let me just underline what you\'re saying.
Fraud and abuse keeps getting brought up every single time we have this
discussion and it\'s an apples and oranges issue. It doesn\'t matter
what we are talking about, there is always susceptibility to fraud and
abuse. You address that. Whether it is telemedicine or non‑telemedicine,
that\'s one issue.

There is one other issue not hasn\'t even brought up. That is the whole
issue of quality of care. There is this assumption that, gee, if I take
the patient\'s blood pressure in my office, that is a better blood
pressure than if I take it at home. Well, I would beg to differ very
strongly, that taking the patient\'s blood pressure at home is a much
better physiological assessment of their blood pressure than taking it
in my office. I will go even more specifically. Taking a patient\'s peak
expiratory flow rate at home is a much better determination of what
their true lung function is when they are breathing all of the antigens
and contaminants in the air where they live than in this more sterile
environment of my office. So I would predicate that in fact the quality
of care is much better by taking certain evaluations where the patient
lives and works, not where I live and work.

**[\>\>\
]{.underline}**There is another dimension, though, besides fraud and
abuse. And that\'s that telemedicine reduces friction. And in the
economic equation, reduced friction will increase use of services. That
is, as the Dartmouth people have well shown, where there is supply,
there will be demand. That is, demand is infinite. Whenever supply is
provided, use of services goes up. Quality does not necessarily go up.
The Dartmouth people have demonstrated that well. That\'s beneath this
concern. I wouldn\'t want to substitute the concept that anywhere you
provide it is equivalent. I would want to put into this regulatory
structure, to study the concept ‑‑ it would have to be marked. That is,
services provided remotely would have to be viewable as that within the
administrative structure. There would be a difference. There would be a
face‑to‑face code and a remote code so that this phenomenon could be
understood as it went on.

**[\>\>\
]{.underline}**Let\'s address the increased use issue. If I have
increased use with a patient who stays at home versus reducing that
patient\'s need to be re‑hospitalized, I can dramatically increase the
amount of service given at home and keep my costs the same, if not lower
my cost.

**[\>\>\
]{.underline}**Also assuming the current utilization is the appropriate
level of utilization, when in fact we know plenty of populations
underutilize the physician and, you know, non-acute-based services which
would then prevent a subsequent acute care need such as an ER or
hospital admission.

**[\>\>\
]{.underline}**Those are all research assertions that have not yet been
borne out in the literature.

**[\>\>\
]{.underline}**I don\'t think that\'s true.

**[\>\> Karen Bell:\
]{.underline}**I think we heard a lot of reports and we have had a lot
of public testimony that actually has been borne out. So I think that it
has not been borne out across the board at a very large metaanalysis,
for instance, or a very large randomized control trial. But there\'s
been enough peer review reports that more than suggest that it does bear
out. So having said that, I think that the real question we still need
to come back to is how we want to structure a recommendation, or how you
want to structure a recommendation given the current statute that
essentially prohibits care in the remote environment.

**[\>\>\
]{.underline}**As you stated, I would like to move your motion. I would
like to move it, I'd like to make it as a motion.

**[\>\> Karen Bell:\
]{.underline}**That was the one that basically broadens the definition
of a physician office.

**[\>\>\
]{.underline}**Yes.

**[\>\> Craig Barrett:\
]{.underline}**Yea, and verily so.

**[\>\>\
]{.underline}**Was that a second, Craig?

**[\>\> Craig Barrett:\
]{.underline}**You bet your life.

**[\>\>\
]{.underline}**Are there any, are there any dissenting votes?

**[\>\> Joe Gifford:\
]{.underline}**Again, I would just ask the question that if this meant
that the payer is unable to detect whether a visit occurred face‑to‑face
or remotely, I think that would be against the interests of both the
Medicare payer as well as the private payer.

**[\>\> Karen Bell:\
]{.underline}**I absolutely agree with you on that, Joe. I think
everybody else would too. We want to be as clear as possible on what\'s
happening so we can learn from it in the future. All right. So that
gives another piece of work for us to do and for you to look for
tonight.

There was an interesting discussion that we were having a little bit ago
that Dena Puskin brought up. That\'s the fact that both Alaska and
Hawaii have access to reimbursement for store-and-forward technologies.
They have not been studied for some time to our knowledge. And the
question then becomes, is there something we would want to recommend ‑‑
these are all things that pop from ideas that all of you have given us
before. So I\'m just parroting back here to you all. Do we want to move
forward with some sort of recommendation that the Secretary shall study
the effect of remote store-and-forward technologies in Alaska and Hawaii
and then subsequently determine whether or not there should be expansion
of those services?

**[\>\>\
]{.underline}**So moved.

**[\>\>\
]{.underline}**Anybody second or dissent?

**[\>\>\
]{.underline}**I would second that as ‑‑

**[\>\>\
]{.underline}**Any dissenting votes? Is that a consensus? I get nervous
when I hear consensus.

**[\>\>\
]{.underline}**\[inaudible\]

**[\>\>\
]{.underline}**Okay.

**[\>\>\
]{.underline}**Should I reconnect the phone now?

**[\>\> Craig Barrett:\
]{.underline}**We will have to be face‑to‑face to vote on these things,
Karen.

\[laughter\]

**[\>\> Craig Barrett:\
]{.underline}**It is the fraud and abuse over the telephone.

**[\>\> Tony Trenkle:\
]{.underline}**That\'s right. We are going to discount it to the people
on the phone.

**[\>\> Karen Bell:\
]{.underline}**We have got three already in addition to the one we had a
little earlier about pushing the use case forward.

**[\>\> Tony Trenkle:\
]{.underline}**Could you review the three?

**[\>\> Karen Bell:\
]{.underline}**Yes. There is a fourth one that someone had brought up as
well. The first one was that CMS develop demonstration projects to
establish the value of remote care monitoring in patients with chronic
illness through MA plans. And the second was that the Secretary consider
and support legal guidance that defines a physician office by diagnostic
services and treatment rendered. The third is that the Secretary shall
study and expand as appropriate coverage of store-and-forward
technologies beyond AK, Alaska and Hawaii.

And there was a fourth idea that someone set forth. And that was given
the fact that there are various bills that pop up on the Hill from time
to time. And that as they come through, they are brought to the
attention of the Secretary\'s office so that this fourth recommendation
would be that the Secretary support any bills that widen the scope of
reimbursement for remote health care services. Want to think about that
one for a while?

**[\>\>\
]{.underline}**Read it again.

**[\>\> Karen Bell:\
]{.underline}**The Secretary shall support any Congressional bills that
widen the scope of reimbursement for remote health care services.

**[\>\> Craig Barrett:\
]{.underline}**That\'s a pretty broad statement.

**[\>\>\
]{.underline}**I think ‑‑

**[\>\>\
]{.underline}**Yes.

**[\>\>\
]{.underline}**Okay.

**[\>\>\
]{.underline}**‑‑ problems and unintended consequences.

**[\>\> Karen Bell:\
]{.underline}**So the three we have are probably strong enough. For
starters?

**[\>\>]{.underline}** **[\
]{.underline}**Oh, yeah. You didn\'t include ‑‑ I\'m, I want to know why
you didn\'t include anything about facilities in terms of expansion
of (inaudible) services? That was the first thing that was mentioned in
terms of legality there is the ability of the Secretary currently to
expand originating sites and could be potentially more.

**[\>\> Karen Bell:\
]{.underline}**And those would have to be done under the rubric of a
demonstration project first ‑‑

**[\>\>\
]{.underline}**Well, could be. But there is approval right now for
expansion within scope nursing facilities. And that\'s ‑‑

**[\>\>\
]{.underline}**There is an if to that, of course, if the Secretary makes
certain findings.

**[\>\>\
]{.underline}**It is based upon the Secretary\'s findings, yes. Well,
actually ‑‑ well ‑‑

**[\>\> Karen Bell:\
]{.underline}**So I think what I'm hearing, though, is that if \-- the
Secretary should consider expanding the scope in terms of settings,
based on demonstration projects? That you would have to do a
demonstration project to ‑‑

**[\>\>\
]{.underline}**I think that would be ‑‑ yes. And I would also, would
hope this group would encourage the Department to make a final decision
on expansion of nursing facilities. It's been pending for years now.

**[\>\>\
]{.underline}**Okay.

**[\>\> Craig Barrett:\
]{.underline}**Sorry. I missed that.

**[\>\>\
]{.underline}**Can you explain what ‑‑ \[inaudible\].

**[\>\>\
]{.underline}**Yes. Congress gave the administration pre‑approval to
allow skilled nursing facilities to be an originating site for
telemedicine, but at the same time required a study to be done by CMS in
conjunction with another part of HHS on what the evidence has been to
date. That report was due to Congress, I believe a year ago last
January, going on a year and a half, something like that. Maybe two
years.

**[\>\>\
]{.underline}**It was \'05.

**[\>\>\
]{.underline}**Dena, you're more familiar than I am. And that report is
still lost somewhere in the woodwork. And there\'s been no decision
made. And it seems to me that that\'s probably an important thing to
bring forward, particularly if you look at the literature about how
important it is to have medical, clinical services in the nursing homes
and how really poorly that need's been met.

**[\>\>\
]{.underline}**The report is actually at the level of the Secretary. Has
not been \[inaudible\] by the Secretary ye, but it has been presented to
the Secretary. And from what I\'ve seen, the findings show that overall
there is value to telehealth in a (inaudible) setting but no (inaudible)
drawn because it was a study of existing research that had been done,
which was fairly limited in its scope. It was not a brand new
demonstration. It instructed AHRQ to review all existing research. They
had a limited basis from which to draw their evidence.

**[\>\>\
]{.underline}**How recent was that study done? There\'s been a lot of
research in the last year, even, that\'s come out.

**[\>\> Dena Puskin:\
]{.underline}**This is Dena Puskin. The literature really goes back to
2004 really. 2004, 2005. Basically 2004. Because that\'s when it was, it
was due 2005, I believe, and I believe the actual literature review was
as of sometime 2004.

**[\>\>\
]{.underline}**So since that time there\'s been two years worth of
studies. I hate to say that the report should be delayed. But there\'s
been so much time and there\'s been such need, and its not met yet.

**[\>\> Tony Trenkle:\
]{.underline}**I don\'t know that the group as a whole knows a lot about
this study. I don\'t know that I would want to put this as one of the
recommendations, Karen. We can get more feedback on, maybe from CMS or
whoever. But I don\'t know that it is appropriate to put that in as a
recommendation at this point.

**[\>\> Karen Bell:\
]{.underline}**And I think that one of the things that we could do
however is consider a recommendation that the Secretary review, and this
will happen throughout all of HHS, the Secretary review options for
expanding originating sites, or expanding the settings for which
telehealth can be useful. And then move forward demonstration projects
as appropriate. We could move in that direction. It wouldn\'t be
specific, but it would at least point in the direction that we certainly
need more information gathered.

**[\>\>\
]{.underline}**Karen, correct me if I\'m wrong, but my understanding
would be that if the Secretary embraces the recommendation concerning
the definition of care delivery, being the functional care delivery as
opposed to the physical care delivery, that would obviate, that would
take care of the issue of originating sites.

**[\>\> Karen Bell:\
]{.underline}**We were quite specific it would be physician offices.

**[\>\>\
]{.underline}**Right. Well ‑‑

**[\>\>\
]{.underline}**\[inaudible\]

**[\>\> Karen Bell:\
]{.underline}**Yes. That\'s right.

**[\>\>\
]{.underline}**That would be a simple step from there.

**[\>\> Karen Bell:\
]{.underline}**So a lot less complicated than getting into some of these
other areas.

**[\>\>\
]{.underline}**Right. Rather than defining each little location. Just
that the care is delivered.

**[\>\>\
]{.underline}**Even determine is that service rendered valuable, and
that alone would suffice.

**[\>\>\
]{.underline}**Right.

**[\>\> Karen Bell:\
]{.underline}**So what is the thought about this one? Should we stick
with the three we have or continue to discuss moving this one forward,
Jon?

**[\>\>\
]{.underline}**Well, I think at least with, the demonstration would be a
good step. I sure would like to see some recommendation that the
Secretary at least review and release their report. I'm comfortable with
that.

**[\>\> Karen Bell:\
]{.underline}**Any other thoughts and comments about this particular
area from anyone else on the phone?

**[\>\> Craig Barrett:\
]{.underline}**Just go with what you really want. You really want this
to be a service as opposed to a face‑to‑face oriented activity. Correct?

**[\>\>\
]{.underline}**Right.

**[\>\> Karen Bell:\
]{.underline}**Yes.

**[\>\> Craig Barrett:\
]{.underline}**Why don\'t we put all of our wood behind that arrowhead?

**[\>\> Karen Bell:\
]{.underline}**Now, Amy, do you see any major obstacles that could come
back to ‑‑

\[laughter\]

**[\>\>\
]{.underline}**That we will hold you accountable personally.

**[\>\> Karen Bell:\
]{.underline}**Just to make sure we are covering our bases here.

**[\>\> Amy Hunsberger:\
]{.underline}**You know, Jon pointed out earlier there are specific,
partially, you know, a factor of the coding \[inaudible\] code and to
the extent that physicians bill based on CPT codes, you have
descriptionsof services that include the physical presence of a
physician and a patient. Even if the Secretary were to say a
physician\'s office \[inaudible\] I\'m not sure that you would get past
that immediately. There is one little hiccup, potential hiccup.

And then you know, I do think that, you know, I can\'t rattle them off
the top of my head, but I\'m certain that there are ‑‑ this is a
construct that flows throughout the payment system in Medicare for
physicians and practitioners, and that the Stark laws and the
regulations and the fraud and abuse, False Claims Act all have been sort
of built on and premised on. So you really have to, you really have
to ‑‑

**[\>\>\
]{.underline}**Think about those.

**[\>\> Amy Hunsberger:\
]{.underline}**Right. There is a lot to think about. And, you know, if I
were you, I wouldn\'t be throwing all my eggs in that basket, I guess is
what I would say. I will go out on a limb here and say that.

**[\>\>]{.underline}**

Is it worth then drafting that recommendation that the Secretary, in
seeking guidance to do this needs to look carefully at the, I don't know
the words, at the ripple effect this may have on CPT and where changes
may be warranted and passed on Stark, and anti-kickback and other ‑‑
should we put in some words around that all those issues need to be
looked at carefully for what barriers are as well as the impact and
concerns that would have to be looked at carefully. You want to make
sure that you don\'t open the door for bad things happening but you
allow the \[inaudible\] this technology.

**[\>\> Amy Hunsberger"\
]{.underline}**Right. And you know, to some extent the Stark laws, a lot
of this is regulatory, but there are some statutory constructs there as
well. So regulations ‑‑ \[inaudible\].

**[\>\>\
]{.underline}**Hearing what you\'re saying which would, I think, might
make a very circuitous path for the Secretary to try and embrace that
one recommendation. I\'m wondering if we ought to put Jon\'s suggestion
in as a subset of that recommendation. So at least there can be some if
he finds that it is going to be very difficult to do initially, at least
we have a step‑wise approach to defining locations that are now eligible
for initiation of services.

**[\>\>\
]{.underline}**And demonstration ‑‑

**[\>\>\
]{.underline}**Yes, just trying to be practical, given what you just
said.

**[\>\>\
]{.underline}**Well, it seems as though what we are talking about in
terms of, you know, the expanding \[inaudible\] doing demonstrations,
goes along with seeking guidance for, you know, altering the definition
of a physician\'s office. It seems like they go hand in hand so they
should be combined together instead of two separation recommendations.
That\'s what I would see this as.

**[\>\> Karen Bell:\
]{.underline}**Any other comments? Let\'s go back to, generally we find
that when we do recommendations each one pretty (inaudible) ‑‑ so we
would do a recommendation like a 1.0 and then a 1.1 and then a1.2. So I
think that\'s maybe what we could do with this. So put it all together
in one particular basket and make it 1.1, 1.2, 1.3. Without having to
get into real statutory changes at this point. I think that\'s really
the issue, Amy. We were trying to see what we could do without statute,
because statute change will take two to three years. And the Secretary,
I think, wants something that he can move forward with relatively soon
as opposed to two to three years out. So our real need to have you here
today was to get your read on how much flexibility we have within
statute as it is written now. We have regular updates, and I guess this
is the other piece. There are regular updates to Social Security, Social
Security Act. Is that the mode, if we were to recommend statute change,
it would have to go through an annual update of Social Security or how
would we ‑‑

**[\>\> Amy Hunsberger:\
]{.underline}**For regulatory change?

**[\>\> Karen Bell:\
]{.underline}**M\'hmm.

**[\>\> Amy Hunsberger:\
]{.underline}**There is a physician fee schedule review every year, an
update every year. You know, that\'s always a vehicle. That has to come
out. And there are various regulations and other payments of funds that
come out on a regular basis. I mean, the logical place \[inaudible\]
that comes out in the summer, and then there is a final review that
comes out, you know, in November.

**[\>\>\
]{.underline}**Can I ask you a question? How much flexibility does the
Department have in issuing a national coverage decision?

**[\>\> Amy Hunsberger:\
]{.underline}**You have got me out of my league on that, honestly. I do
know NCDs are non‑regulatory, but there is an NCD coverage decision
process. And I know the public can submit items to be considered. And
there\'s a time window within which they are considered. And there is an
evidence review and there is a process to adjust things and issuing
those.

**[\>\>\
]{.underline}**With ‑‑ if I understand the current process, if you
wanted to add, for example, additional service areas covered under the
existing telehealth program ‑‑

**[\>\> Amy Hunsberger:\
]{.underline}**Right.

**[\>\>\
]{.underline}**‑‑ CPT codes. You would submit those in December, as part
of the annual physician review process.

**[\>\> Amy Hunsberger:\
]{.underline}**Right.

**[\>\>\
]{.underline}**Could you also submit potential changes through
the national coverage decision as well?

**[\>\> Amy Hunsberger:\
]{.underline}**In other words, to define new telemedicine services
through a coverage decision?

**[\>\>\
]{.underline}**Yeah. I know it\'s been done regionally. For example,
remote diabetic retinopathy ‑‑ there is a couple of regions that ‑‑
\[inaudible\].

**[\>\>\
]{.underline}**Local coverage.

**[\>\>\
]{.underline}**Yes, local coverage ‑‑

**[\>\> Dena Puskin:\
]{.underline}**Jon, this is Dena Puskin. I don\'t know if you were
present but about a year ago AHRQ had a, sort of a consensus conference,
it may have been a year and a half ago, on where the literature was in
terms of telemedicine. Part of the discussion was to have folks in from
Medicare ‑‑ I know we have them on the phone ‑‑ to talk about national
coverage decisions versus local coverage decisions.

**[\>\>\
]{.underline}**Oh.

**[\>\> Dena Puskin:\
]{.underline}**And the point that was made then, and I don\'t know if it
is still true now, was that the level of evidence needed for national
coverage decision was quite a bit higher in terms of efficacy and
effectiveness than is required for local decision. And I was wondering
if the folks from Medicare would be willing to comment on that.

**[\>\> Karen Bell:\
]{.underline}**Dena, Tony stepped out for a few moments and I don\'t
know that there is anyone else on the line, unless you could respond to
that.

**[\>\>\
]{.underline}**No, I don\'t know.

**[\>\> Dena Puskin:\
]{.underline}**I think that was a very important part of the discussions
strategically at the time about how to go about, you know, the issues
between coverage versus \[inaudible\] side of the house in a way. But
they did have a person, I remember at the time, who I believe was in
charge of the group that does coverage decisions. And she went through
all the steps at the time that were required for coverage decision, for
a national coverage decision. And, I mean, I think that\'s important to
understand.

**[\>\> Karen Bell:\
]{.underline}**Dena, just to let you know, Tony came back. And I will
just bring him up to speed. Dena was pointing out that it is her
understanding that a national coverage decision requires a level of
evidence that\'s much greater than a regional or a local coverage
decision. And that was predicated on some discussion we were having on
whether or not telemedicine coverage, telehealth coverage could fall
under the rubric of national coverage.

**[\>\>Tony Trenkle:]{.underline}**

Right. I think we had some discussion with that with our Medicare
operations people several meetings ago when they talked about that.

**[\>\> Karen Bell:\
]{.underline}**Right. So it is more intensive.

**[\>\>]{.underline}**

But that is another possible avenue?

**[\>\> Tony Trenkle:]{.underline}**

Potentially. I mean, I have to get an interpretation of that. They are
much more well versed in it than I am.

**[\>\>\
]{.underline}**Like to (inaudible) with it too, because if it goes the
other way, that\'s policy for the ‑‑

**[\>\>Tony Trenkle:]{.underline}**

Right.

**[\>\> Karen Bell:\
]{.underline}**What about, any other thoughts or comments about any
ideas that we might want to advance, that hadn\'t come to us earlier,
that anyone on the phone may have right now? Amy, do you have any other
comments about the various legal authorities to expand coverage for
telehealth?

**[\>\> Amy Hunsberger:\
]{.underline}**No, I looked at your meeting minutes from last week, or
last meeting, and it looks like you guys understand those fairly well.
What the limitations are, the geographic limitations, the originating
site, the scope of practitioners that are permitted to furnish
telehealth services, the definition of telehealth services, I don\'t
think I really have anything to add to that. If you were to put certain
specifications on paper, I\'m sure we could look at those and give you
some thoughts, notions, or ideas.

**[\>\> Karen Bell:\
]{.underline}**What we may do is include you on the list tonight of
people reviewing the recommendations. If that\'s okay with you. If you
see anything that\'s a red flag, you could let us know. If that\'s okay
with you, we can do that.

**[\>\>\
]{.underline}**For clarifying purposes, so we will get recommendations
that will actually go to AHIC next Tuesday, on the 12th, asking them to
approve them.

**[\>\>\
]{.underline}**Right.

**[\>\>\
]{.underline}**Okay.

**[\>\> Karen Bell:\
]{.underline}**If we get them tonight, we can go back and forth on them
tomorrow. I think the latest they will be able to go out is tomorrow
night, first thing Thursday. It will give us a little bit of time to
review them. Doesn't necessarily mean the AHIC will accept them,
doesn\'t mean the Secretary will accept them, but at least we can be as
specific as we can. I suspect they will lead to a very lively
discussion, as did the EHR Workgroup recommendations on the last go
around. Are there any other thoughts or comments on this? Very quiet
group. Should we adjourn so that we can get to writing these
recommendations, after public comments?

**[\>\> Tony Trenkle:\
]{.underline}**Karen, before we adjourn, can you talk about next steps
here after these AHIC recommendations as, assuming we submit some
recommendations to the AHIC for the next meeting, what is the next steps
for the Workgroup following this?

**[\>\> Karen Bell:\
]{.underline}**I would suggest that there be possibly two. The AHIC
recommendations may require some more work. They may get sent back to us
for clean‑up or specification or a number of other things. We are just
not sure what\'s going to happen with them. That would be obviously one
next step, if it comes to that.

The second next step though is going back to the broad charge,
recognizing that what we are really talking about here is better
coordination of care. So we would, I think, take on the next piece of
work which would be looking at ways to assure we had better coordination
of care across multiple providers, using whatever types of electronic
communication that\'s applicable in that particular situation. So it
really is, I think the coordination of care for the chronically ill
would be the next big piece that we look at.

**[\>\>\
]{.underline}**Could you summarize what we've decided to submit?

**[\>\> Karen Bell:\
]{.underline}**We decided to submit four recommendations. I will
summarize them. We will have to think them through, the language a
little bit more carefully in the next few hours.

The first one is to make a recommendation that the Secretary move
forward with the use case for interoperability with respect to remote
care as quickly as possible. And that it be the very next high priority
item. And we will move again, as quickly as possible, and we will point
out it has been bumped twice.

The second recommendation is that CMS, or the Secretary for CMS,
consider and support a demonstration project that will demonstrate the
value of telehealth in management, in the managed care setting, in the
Medicare Advantage setting, specifically for patients with chronic
illness, with the intervention being access to remote monitoring
devices.

The next recommendation was for a, the Secretary to support the
development of guidance that will take into account concerns such as
fraud and abuse, Stark, et cetera, to redefine a physician\'s office by
services rendered, i.e., diagnoses made and treatment offered.

And then the last recommendation is the one we have just been talking
about which ‑‑ I\'m sorry. The last recommendation would be the one
about studying the advantages and benefits of store-and-forward
technology that has been used in Alaska and Hawaii, and then have the
Secretary make recommendations about expanding that beyond Alaska and
Hawaii as appropriate.

**[\>\>\
]{.underline}**Okay. Good.

**[\>\> Karen Bell:\
]{.underline}**I think to some people it looks like we have just made a
tiny step. I think to others it is going to feel like we have just gone
to the moon. I don\'t know where each one of you stand. I feel like we
have just gone to the moon.

**[\>\> Craig Barrett:\
]{.underline}**I vote for a tiny step.

\[laughter\]

**[\>\> Karen Bell:\
]{.underline}**That's what I thought, Craig.

**[\>\> Tony Trenkle:\
]{.underline}**I'm in Craig\'s corner, there.

**[\>\> Karen Bell:]{.underline}**

Well, if anyone has any other big steps, then please, please let us know
by close of business.

**[\>\> Craig Barrett:\
]{.underline}**All right. Karen, you\'re going to need feedback on stuff
you send us tonight ASAP. Right?

**[\>\> Karen Bell:\
]{.underline}**Right. Certainly by morning. We will be ‑‑ you know, we
recognize we have people in all sorts of time zones. So I know it is
only noon on the West Coast. It is 3:00 here, but we will get something
out in the next few hours to everyone. Basically by our time tomorrow
morning, I would say 9:00, if everyone can either look at it tonight or
look at it when you first come to work in the morning and then shoot it
back to us, that would be very helpful.

**[\>\>\
]{.underline}**Do you have the alternate\'s e‑mail addresses?

**[\>\> Karen Bell:\
]{.underline}**I think we do. Do we have all the alternate e‑mail
addresses?

**[\>\> Yael Harris:\
]{.underline}**Yes.

**[\>\> Karen Bell:]{.underline}**

Okay. Just to be on the safe side, for every alternate on the phone,
please e‑mail Yael Harris, yael.harris@hhs.gov. So we'll make sure that
you get it back. Okay. If it is time for public comment, I will return
this back to the chairs. Thank you for your discussion.

**[\>\> Jennifer Macellaro:\
]{.underline}**This is Jennifer. I've just put a slide up that\'s got
the number up for anyone listening over the Web. If you\'re already
dialed in, just go ahead and press star 1 to alert the operator. And I
will check back with you in a minute.

We do have a member of the public calling in. Could you open Maria
Friedman\'s line?

**[\>\> Karen Bell:\
]{.underline}**Hi Maria.

**[\>\> Maria Friedman:\
]{.underline}**Hi everybody. I\'m representing RxHub at the meeting
today, and I have two comments. The first harkens back to my previous
life, long life in the Department. That\'s about the legislative process
and how legislative and statutory changes get sent forward. Another
avenue is the A-19 process. Every year the call that goes around for
various legislative and statutory changes that the various OPDIVs and
agencies would like to see, and those get sent up. Very frankly, very
few of them ever get forward to the Hill. But that\'s the formal process
that\'s used for that.

But my other comment is really more germane to the discussion is
something you might not be aware of. The Alaska RHIO, which is called
the Alaska Federal Health Care Access Network, is going to use
telemedicine technologies to mobilize 248 sites in Alaska and that will
include military installation, installations, Alaskan native health
facilities, regional hospitals, small village clinics, and State of
Alaska public health nursing stations. I don\'t have details on exactly
what they mean by telemedicine technologies, but it seems like this is a
brand new initiative that might be of interest and finding out more for
your discussion.

**[\>\> Dena Puskin:\
]{.underline}**This is Dena Puskin. I\'m the project officer who is just
completing some of the funding of that. They have actually been deployed
for quite a long while. They have just been phasing them in. And they do
have quite a bit of unanalyzed data. And they will hopefully be getting
more. But that, if you want some more on that, I can certainly help you
with that because I\'ve funded them for five years to develop that
system out of HHS. The Indian Health Service and we and the military
have funded that together. But the larger earmarks in the last few years
have actually come through HRSA.

**[\>\> Maria Friedman:\
]{.underline}**I think that's an example of some of the many exciting
opportunities going on out there. Of course on the private sector the
broadband folks are really pushing a lot of initiatives as well. So
anyway, those are my comments. Thank you very much.

**[\>\> Karen Bell:\
]{.underline}**Thank you very much, Maria. We will follow‑up.

**[\>\> Jennifer Macellaro:\
]{.underline}**This is Jennifer. I don\'t have anyone else on the phone
today.

**[\>\> Tony Trenkle:\
]{.underline}**Okay. Craig. You want to move to adjourn?

**[\>\> Craig Barrett:]{.underline}**

So moved.

**[\>\>\
]{.underline}**Second.

**[\>\>Tony Trenkle:]{.underline}**

Okay.

**[\>\> Karen Bell:\
]{.underline}**Thank you all. We will be in touch.