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Remarks by Administrator Seema Verma at the Alliance for Connected Care Telehealth Policy Forum for Health Systems

Remarks by Administrator Seema Verma at the Alliance for Connected Care Telehealth Policy Forum for Health Systems
(As prepared for delivery – November 15, 2018)

Thank you Krista for that kind introduction, and thank you all for joining us today.  It’s a privilege to be here with the Alliance for Connected Care. I’m glad I got to meet with your organization early in my tenure – and I’m particularly happy to continue our conversation on how we can make the promise of connected, coordinated care a reality by building it on a foundation of innovation.

At CMS, we’ve been working to lay that foundation, including through supporting innovation in health care on many levels.  Its part of our larger vision of moving to a system that is value based—that rewards value over volume by bringing the best to patients.  When we start paying for value, we will foster innovation as providers look for ways to compete for patients by providing the highest quality care at the lowest cost. 

We understand that relentless innovation is a crucial driver in creating value across all industries.  As Thomas Edison noted, “There’s always a way to do it better—find it.”  Healthcare, of course, is no exception.

Over the past several decades, thanks to improved diagnostic and therapeutic treatments and tools, healthcare has witnessed a myriad of innovations that have brought value, extended our lives, improved them, and created efficiencies in the healthcare system.

Healthcare innovation is in fact serving as a catalyst to improving quality of care, enhancing access to care, increasing efficiency in the system, and lowering healthcare costs.

Take the history of knee replacement surgery, for example.  Not long ago, knee replacement surgery always required a multi-day hospital stay, and then a lengthy and often painful rehab.

Today, a patient experiences an entirely different scenario:

• Innovations in anesthetics have allowed total knee replacement to become outpatient surgery for some patients.
• Replacement knees, custom-designed through a 3-D scanning and printing process, are allowing some patients to walk shortly after waking up from surgery, which speeds recovery and reduces pain.
• And doctors can now use a 3D model of a knee taken by a CAT scan to guide a robotic arm during surgery and spare as much of the patient's healthy bone and surrounding tissue as possible.

We’re also now seeing the same kind of benefits as more surgeries—including full knee replacements—are being moved to the outpatient setting. And some surgeries that used to require hospital care can now safely be done in ambulatory surgery centers.  Innovations in the procedures itself resulted in better patient outcomes, and the ability to provide care in a lower-cost and more convenient setting.  This is a prime example of how leaning in to technology can better health outcomes, lower costs, and drive efficiencies. 

And while some technology is specific to healthcare, some is not—such as our ubiquitous  smart phones.  But healthcare is also leveraging such technology.

Innovation is also giving patients more choices – and improving their overall quality of life.  When I travelled to California, I saw driverless cars on the road. With driverless technology, older adults could continue to live in their homes late into life. For example, In Japan, rural communities are populated by an increasingly older set of residents, as younger Japanese citizens move to cities.  This is leading to a shortage of transportation workers.  But driverless technology is slated to eventually address this exact problem, allowing seniors to remain in their homes and communities, using the cars to deliver meals.

Technology is also connecting patients to their doctors, even outside of the hospital setting, with devices like new glucose monitors—which we just approved—that can continually monitor vital signs and relay them to a practitioner.

When I recently visited the Cleveland Clinic, I saw firsthand innovative ways to use remote patient monitoring from a central hospital command center.  Their model uses a “mission control” operation where off-site personnel use sensors and high-definition cameras to monitor patients and assimilate data to trigger on-site intervention.  The Cleveland Clinic is also sending paramedics to seniors’ homes and connecting them virtually to doctors, which means doctors can see more patients in less time.

This type of approach can dramatically increase efficiency and improve clinical outcomes.  Additionally, when remote patient monitoring systems can send live-time data back to clinicians, adjustments to medication can be made for patients with hypertension, or diabetes, as soon as it’s clear these chronic conditions aren’t being controlled through a patient’s prescribed regimen. 

Wearable technology is also providing new data streams.  Patients can wear a watch that tracks their heart rate and can identify irregular heart rhythm, and may be able to perform an EKG, and doctors get insight into what’s going on with their patients outside the exam room. This is truly a whole new world of healthcare.

Technological innovations in healthcare have impacted me at a very personal level.  You may have already heard my story about my husband’s near death experience last year.  Thanks to the bystanders and the medical team that treated him, he was able to survive a very serious cardiac episode.  But even before he got the hospital, there at the airport was a defibrillator – and that defibrillator bought us time to get him to that great care.  It’s just another great example of technological innovation saving lives.

But taking it a step further, maybe we could have predicted his cardiac arrest before it happened if his electronic watch, or some other novel device, had been compiling information about his activities, his heart rate, his breathing, as well as other data – and sending it to his doctor.

Ultimately, that’s an illustration of both the current power and the future promise of innovation in healthcare.

Undoubtedly, innovation is the fuel that powers the engine of progress and creativity.  And while we’re on track for healthcare costs to represent one out of every five dollars of American GDP by 2026, it’s technology that will help ensure the sustainability of our healthcare system.

Fostering innovation is a priority for me, and an example is our focus on interoperability through the MyHealthEdata initiative.  The MyHealthEdata Initiative, led by Jared Kushner and the White House Office of Innovation, takes a comprehensive approach to ensuring that patients control their health information throughout their healthcare journey.  CMS is committed to moving this system forward.

The reality is that once information is freely flowing from the patient to the provider, it will help to spur innovation in the entire digital health information ecosystem…and the advances in coordinated, value-based and patient-centric care will be even greater than anything we can imagine today.   

Imagine if patients could authorize access to their records to researchers from all over the country who could not only develop specific treatments for their needs, but the researchers could also use that information to develop cures that could save millions of lives, like what the National Institutes of Health and ONC, are doing with their Sync for Science program.

In order to achieve this vision, machine interoperability must also be addressed. Earlier this year, I visited the Center for Medical Interoperability in Nashville and heard about doctors still having to put EKG results into a patient’s EHR. We have to get the electronic health record and all medical devices to connect seamlessly to the EHR. And I’m committed to removing any and all bureaucratic and legal obstacles to machine, device, and EHR system interoperability.

To this end, we are taking action.  We overhauled what was the Meaningful Use Program in order to focus on Promoting Interoperability.  And we’ve stated that hospitals that don’t give patients their data in the next two years will be penalized, and doctors’ incentive program will be tied to interoperability as well, pushing the system towards interoperability.  We did this because interoperability will spur the next generation of innovation.

Through MyHealthEData, CMS has launched a data revolution that is sweeping the health care market and changing the way we think about health care data and information. We are liberating data that will drive innovation throughout the entire health care system, and create new tools and solutions that will allow the system to deliver better value to patients.

Of course, we’re also looking to especially promote innovation by supporting and furthering telehealth, which is changing the very face of health care.

We know that—guided by what is best for patients—telehealth innovations could help usher in a new world of health care that is embraced by both patients and providers; that identifies new avenues of care delivery; and that improves the value of care by increasing its quality while lowering its cost.

For example, for stroke patients, response time is critical, as lifesaving clot-dissolving treatment can only be administered within 60 minutes of the onset of stroke symptoms.  A study done by Kaiser Permanente found that telestroke programs led to a 73 percent improvement in the rate of administration of this lifesaving treatment among stroke patients at hospitals with limited resources or limited access to neurological expertise.

Telehealth also gives patients choices.   It gives patients another way to access care and puts them in the driver’s seat as they seek out new options.  It is particularly vital for our elderly and disabled populations—as well as caregivers—where transportation issues can be a barrier to care.  

Telehealth also enables patients to become active members of the care continuum outside of a hospital setting and promotes long-term engagement between patients and practitioners.  Using technology, a patient managing a chronic condition can connect more frequently with their care team from home, and spend less time going to the doctor’s office.

Telehealth has especially provided a lifeline in rural areas that are characterized by great distances and a limited number of healthcare providers and specialty services.  With a growing aging population, rural healthcare cannot rely simply on traditional brick and mortar practices.  Technology can also reduce costs by lowering readmissions rates, as well as unnecessary hospital visits through better care coordination.

That’s why, as part of our “Rural Health Strategy,” advancing telehealth and telemedicine was identified as one of our five primary objectives.  But telehealth is not just a rural health issue—anyone who has faced DC traffic understands that people living in cities could benefit from virtual access to care.

As you may be aware, Congress authorized Medicare's Telehealth Benefit in 1997, and the benefit began in 2001.  There have been some updates since then, but  the law still means Medicare generally can’t pay for telehealth when patients are in urban areas —and can’t pay unless the patient goes into one health care facility in order to connect to a distant doctor remotely.  Medicare patients still can’t usually get telehealth from their homes.  That probably wasn’t considered necessary when the law was created, because internet connections were far slower, and video chats were not as commonplace as they are today.

But -- with 20 million people coming into the Medicare program, CMS understands that we need to embrace the promise of technology and innovation.

But Medicare’s rules and governing statutes are often a barrier to innovation, which is why I have significant issues with the Medicare for All proposal.  We too often see new products that don’t fit into the existing payment system, set up by the law. 

Now, sometimes, we can figure out a way to shoehorn new devices into the Medicare benefit design.  You saw the Trump Administration do this when we clarified policy to ensure that Medicare beneficiaries with diabetes can use aps on their phones to get readings and data from continuous glucose monitors.  But again, this was not easy.  It took years.  Meanwhile, patients went without new technology that could improve their health.   Many diabetics had this technology with their private coverage and when they entered Medicare – lost their access.

Historically, telehealth has been used to connect patients who are in one provider setting to a specialist located at a distant site.  But technology is moving quickly beyond that use, and CMS and Congress have to keep up.  There’s no reason today that seniors shouldn’t be able to use their smart phones to connect to their doctors—especially as it’s what patients want and need, and leverages today’s technology and innovation.  More and more of our Medicare beneficiaries are using technology in every aspect of their lives.

Recently I met with the Alliance of Community Health Plans – where we discussed a number of ways that telehealth is being successfully deployed. Wound care, mental health counseling, questions and challenges related to medication adherence, lifestyle coaching - these are all areas in which telehealth is being used to improve care for patients and helping providers to deliver value to their patients. 

Additionally, as we look to address the social determinants of health, we need to look to technology to address issues in cost efficient ways.  Whether its doctor to doctor consultations that prevent unnecessary referrals, or consultation centers that give local communities access to dozens of specialties from a single location, technology offers solutions.

That’s why this Administration has taken action.  We want to make sure that people across the country can take advantage of telehealth – not just those in rural settings.

Every year we’re adding new services to the list of what can be covered by Medicare via telehealth. This year, that includes prolonged preventive services, which includes wellness exams for patients with complex needs. 

But we can’t stop there – we’re committed to taking bold steps to foster innovation in this area, and I’m proud of the historic steps we’ve taken for the program:

• For the very first time, starting in January, Medicare will pay for virtual check-ins, meaning patients can connect with their doctors by phone or video chat.  As all of you know, many times a virtual check-in will resolve patient concerns in a convenient manner that gets them the care they need, and avoids unnecessary costs for the system.  This is an incredible step in the right direction for our beneficiaries.

• For the very first time, we will also be paying for virtual consultations between physicians, and evaluation of remote pre-recorded images and video.  For example, a patient could now text a picture of a mole on their skin to a dermatologist for examination.   
• Additionally, our recently released home health rule will enhance the ability of home health agencies to use remote patient monitoring for their Medicare patients.  This will allow patients to share more live-time data with their providers and caregivers.  Ultimately, this will lead to more tailored care, and improve health outcomes.
• Also new for 2019, under our final rules, Medicare patients receiving home dialysis will be able to receive their monthly clinical assessments via telehealth, from their homes.  And patients experiencing symptoms of an acute stroke will be able to receive telehealth services from mobile stroke units.
• Finally, we’ve also proposed options for modernizing and expanding telehealth through our CMMI models and demonstrations. When providers take accountability for healthcare costs, we want to give them more flexibility to innovate, so they don't have to come to CMS for permission to test a new approach to care delivery.  We’re particularly focused on using our waiver authority to spur innovation in the telehealth space.

These are exciting changes which will increase access to care, give patients new choices, and foster the type of innovations we need to strengthen Medicare and ensure its sustainability into the future.  And we know that, given Medicare’s size, whatever we do affects the entire healthcare market.

We also know that even bolder innovations are emerging in the private sector.  Private plans report very high patient satisfaction with virtual care – it’s no surprise patients like faster and more convenient access to care, which more and more senior are using.  Health plans are using telehealth to support patients in areas like medication management, so patients can get guidance from clinicians after they leave the pharmacy counter.  And patients are using video chats to learn how to use medical devices, even for complex cases like home dialysis.  We’re very excited for plans to have greater flexibility to bring this type of benefit to Medicare Advantage. 

Under a proposed rule released just a few weeks ago, in 2020, Medicare Advantage enrollees will have more options for receiving telehealth services beyond what is otherwise available in the traditional program.   Because again, we want to increase flexibility for entities, like Medicare Advantage plans, that take accountability for total healthcare costs.  The proposed changes for Medicare Advantage are a major step towards expanding access to telehealth services because the rule would eliminate barriers for private Medicare Advantage plans to cover additional telehealth benefits for enrollees in MA plans. 

Ultimately, whatever CMS is doing to promote telehealth, it’s really all about one thing:  To foster innovation and protect and strengthen the Medicare program in order to deliver on its  promise to our elderly and disabled populations.

Of course, we can’t accomplish this alone. This important work affects us all – our families, our friends and our future. My challenge, charge, and call to action today is for all of you to be our partners in this important work.  We need your ideas and input.  We need the benefit of your expertise and experience.  And we need to hear from you and work with you.  Innovation proves that in healthcare or any other industry, there’s always a way to do better.  So let’s find it together.

It’s been a pleasure to be here with you today, and I wish you a very successful forum that will help foster and promote not just telehealth, but innovation throughout our healthcare system.

Thank you.

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