Summary: House Ways and Means Committee Markup of Telehealth and Rural Healthcare Legislation
May 28, 2024 by AACOM Government Relations

On Wednesday, May 8, 2024, the House of Representatives Ways and Means Committee held markup  on various telehealth and rural healthcare legislation. View the full markup here.

WITNESSES 

  • H.R. 8261, the “Preserving Telehealth, Hospital, and Ambulance Access Act” (PASSED 41-0)
  • H.R. 7931, the “PEAKS Act” (PASSED 24-18)
  • H.R. 8245, the “Rural Hospital Stabilization Act” (PASSED 24-18)
  • H.R. 8244, the “Ensuring Seniors’ Access to Quality Care Act” (PASSED 25-18)
  • H.R. 8235 the “Rural Physician Workforce Preservation Act” (PASSED 24-16)
  • H.R. 8246, the “Second Chances for Rural Hospitals Act” (PASSED 24-16)

AMENDMENTS

OPENING STATEMENTS

  • In his opening statement, Chairman Jason Smith (R-MO-8) emphasized the Committee's dedication to improving healthcare accessibility for all Americans, particularly those in rural and underserved areas. He highlighted the dire situation faced by many rural communities, with 600 rural hospitals teetering on the edge of closure and concern for delays in emergency response times. Chairman Smith underscored the severity of the healthcare shortage, citing a 43 percent higher mortality rate among rural Americans as compared to their urban counterparts. The Chairman outlined the Committee's focus on legislative solutions, beginning with a bill protecting and expanding telehealth options. He detailed provisions within the bill, including expanded telehealth access regardless of patient location, and enhanced options for behavioral health patients. Chairman Smith also highlighted groundbreaking legislation allowing Medicare patients to receive hospital-level care at home. Additionally, he discussed measures to preserve emergency ambulance services, expand access to critical care in mountainous regions, and provide grants to struggling rural hospitals facing closure. The Chairman addressed the shortage of Certified Nursing Aides and doctors in rural areas, presenting bills aimed at bolstering these essential healthcare roles. Last, he discussed legislation facilitating the Rural Emergency Hospital designation, enabling more hospitals to offer life-saving care in rural communities. Chairman Smith concluded by affirming that these policies collectively represent a significant stride towards addressing healthcare disparities in rural and underserved regions.
  • In his opening statement, Ranking Member Richard Neal (D-MA-1) reflected on the significant healthcare advancements achieved under Democratic leadership, citing historic milestones that have enhanced Americans' health and well-being. He noted the unprecedented rise in health insurance coverage, with four out of five individuals gaining access to high-quality care for less than $10 a month. Ranking Member Neal underscored efforts during his tenure as Committee Chairman to expand graduate education spots, particularly targeting rural and underserved communities to mitigate systemic worker shortages. He lauded recent measures under President Biden's administration, such as capping out-of-pocket costs for prescription drugs and insulin for seniors and impending negotiations to lower drug prices through Medicare. Additionally, Ranking Member Neal highlighted the pivotal role of telehealth in delivering healthcare services, especially during the pandemic. He lamented the exclusion of underserved populations from current legislation, advocating for targeted assistance to both rural and underserved communities. Ranking Member Neal criticized proposed measures that could incentivize private equity investment in the healthcare system, warning about their implications for rural hospitals and the Medicare trust fund. He highlighted the critical role of Medicaid expansion in supporting rural hospitals and criticized Republican opposition to such measures. Finally, Ranking Member Neal addressed the threat posed by House Republicans' endorsement of Medicaid coverage cuts for millions, expressing disappointment at missed opportunities for comprehensive legislation.
  • In his opening statement, Representative Mike Thompson (D-CA-4) highlighted his efforts to champion telehealth over the past 20 years. He is a big believer in telehealth’s ability to save money and save lives. Purely by coincidence, Representative Thompson proposed legislation in 2019 to expand telehealth in Medicare during emergencies, right before the COVID-19 pandemic upended daily life and telehealth became a common practice. He lauded H.R. 8261 for extending Medicare telehealth flexibilities for an additional two-year window, and he is of the view that telehealth becomes a permanent fixture of the Medicare program. However, Representative Thompson recognized that telehealth merits additional study to confirm its clinical benefits and cost savings. Moreover, he underscored the importance of including guardrails that protect against overutilization and fraud — especially in the hospice recertification program ­— which was unfortunately not addressed in today’s markup.

DISCUSSION & TECHNICAL WALKTHROUGH

Mr. Dumas, the Majority Staff Director of the House Committee on Ways and Means, gave a technical walkthrough and summary of H.R. 8262 and the amendment in the nature of a substitute (AINS) offered by Chairman Smith. He then took questions:

  • Representative Lloyd Doggett (D-TX-37) and Representative Earl Blumenauer (D-OR-3) raised concerns that H.R. 8262 does not address the rampant fraud and waste that is occurring in Medicare-funded hospice programs. Representative Doggett noted that from the time between the COVID-19 pandemic and the passage of the Affordable Care Act (ACA), physicians were required to consult with hospice patients every six months in person. Telehealth flexibilities passed during the COVID-19 pandemic allowed this hospice consultation to be conducted via telehealth. As a result, Representative Doggett insinuated that patients would not be required to see a doctor in-person at all during their time in hospice. Mr. Dumas replied that hospice recertification would not require an in-person consultation, but that care would still be provided to hospice patients in-person. Next, Representative Doggett claimed that telemarketers are luring patients into hospice care through fraudulent kickback schemes. He asked Mr. Dumas if any provisions within H.R. 8262 address hospice fraud. Mr. Dumas replied that section 101 only extends telehealth to satisfy the face-to-face requirement in areas where there are not an active moratoriums for hospices or if the hospice provider is investigation by the Centers for Medicare and Medicaid Services (CMS). Representative Doggett also lamented the lack of guardrails for the ordering of expensive clinical lab tests and durable medical equipment. He offered an amendment to add anti-fraud protections in H.R. 8261 but it was voted down. 
  • Representative John Larson (D-CT-1) raised concerns around section 301, which he believes will raise premiums for patients. He cited to a University of Chicago study that found that annual federal spending on Medicare Part D premiums would increase between $3 billion and $10 billion and raise Part D premiums as a result of section 301. He asked Mr. Dumas if the Congressional Budget Office (CBO) has provided an analysis of the cost of this provision. Mr. Dumas replied that previous analyses by the CBO project Section 301 will save the federal government $700 million. Later in the hearing, Representative Bill Pascrell (D-NJ-9) echoed the sentiments shared by Representative Larson, fervently arguing the payments to clinical labs need to be put on a “sustainable path” and that section 301 would hamper the ability of labs across the country to provide accurate and timely testing to patients. 
  • Representative Blumenauer, Representative Brad Wenstrup (R-OH-2), and Representative Lloyd Smucker (R-PA-11) were pleased that H.R. 8261 extended the hospital-at-home program for five years, which they argued saves money, prevents unnecessary hospital visits, and frees up additional hospital beds. Representative Blumenauer called hospital-at-home one of the few “silver linings” that emerged from the COVID-19 pandemic, and he is hopeful that Congress will capitalize on these new innovations to increase access to quality care and lower costs to the healthcare system. In particular, Representative Blumenauer explained that hospital-at-home allows providers to take a more holistic approach when treating a patient and better understand the patient’s circumstances at home when prescribing treatment. Last, he noted that hospital-at-home allows patients to recover faster. 
  • Representatives Adrian Smith (R-NE-3), Vern Buchanan (R-FL-16), and Mike Kelly (R-PA-16) all voiced their support of H.R. 8262. They each touted the benefits of telehealth, which allows seniors in their districts to quickly access their provider. They noted that many of their constituents do not live near hospitals or have transportation or mobility issues, making it difficult for them to see their provider. The members also highlighted several of the provisions they secured in the bill, including the removal of originating site restrictions and expanding the number of practitioners eligible to practice telehealth under the Medicare program such as audiologists, speech pathologists, and occupational therapists. Later in the hearing, Representative Drew Ferguson (R-GA-3) touted the benefits of telehealth in expanding access to behavioral healthcare, especially for the nation’s youth that are experiencing an unprecedented mental health crisis. 
  • Representative Darin LaHood (R-IL-16) highlighted section 203 of H.R. 8262, which would promote access to lifesaving emergency medical services (EMS) for individuals that reside in rural communities. He noted that rural EMS providers face unique challenges, including increased geographic distances when responding to calls, difficulty recruiting and retaining an EMS workforce, and higher fixed costs over a lower volume of services. Representative LaHood explained that section 203 would extend Medicare add-on payments for ambulance services in both rural and urban areas through fiscal year (FY) 2025. According to Representative LaHood, years of below-cost Medicare reimbursement for EMS have hampered emergency medical personnel from hiring staff, updating equipment, and continuing to provide lifesaving services in their communities.  
  • Representative Danny Davis (D-IL-7) explained that several years ago, the House Ways and Means Committee established a task force to examine the healthcare issues plaguing urban and rural communities. The task force found that many communities face challenges accessing reliable broadband, a shortage of primary care physicians due to a lack of graduate medical education slot caps, transportation problems, and a lack of healthcare professionals generally. Representative Davis argued that the problems in healthcare access are not that different between rural and urban communities, and he urged the Committee to examine the plights of safety-net hospitals and behavioral health facilities.
  • Representative Terri Sewell (D-AL-7) wanted to “join in the chorus” of praising the benefits of telehealth. She was proud to be a strong proponent of audio-only telehealth, and she championed a key piece of legislation during the COVID-19 pandemic that allowed Medicare beneficiaries to utilize audio-only telehealth to speak to their provider. Representative Sewell also urged the Committee to extend the Medicare add-on payments for EMS for at least two years. Under the legislation being considered, the add-on payments would only last for nine months. 
  • Representative Judy Chu (D-CA-28) was excited to support H.R. 8261 in order to ensure that key telehealth flexibilities within the Medicare program do not expire. She argued that the legislation provides certainty to clinicians and patients while also ensuring the convenience of accessing care — especially for underserved communities. Representative Chu is pleased that Congress is continuing to innovate, but she believes that more can be done to protect patients from falling behind like those without internet access or that have language barriers. She noted that H.R. 8261 contains a version of her legislation, the SPEAK Act, which would require the U.S. Department of Health and Human Services (HHS) to establish a task force to improve access to health technology for the more than 25 million non-English proficient speakers living in America. Last, Representative Chu raised concerns around the increased fraudulent Medicare telehealth claims, and she urged the Committee to reinstate the face-to-face hospice recertification requirement. 
  • Representative Michelle Steel (R-CA-45) explained that approximately 175,000 of her constituents are limited in English proficiency, making it all the more crucial that telehealth expansion includes these vulnerable individuals. She further noted that limited English proficient residents have higher rates of hospital readmission and are at higher risk of misdiagnosis. Representative Steel touted one of the key provisions she secured in H.R. 8261, which would help promote telehealth access among non-English proficient speakers living in the U.S.
  • Representative Gwen Moore (D-WI-4) announced her intention to support H.R. 8261 and she was glad the bill only provided for a two-year extension of the telehealth flexibilities. She believes that more data needs to be collected on the efficacy and safety of telehealth before a permanent extension is made. She also does not want telehealth to become a means of “cost control” in communities where hospitals are closing down, and she argued that telehealth should serve as a supplement to the important in-person visits with providers. Furthermore, Representative Moore emphasized the need for guardrails to protect against fraud and abuse and stressed the importance that access to telehealth is done through an “equity” lens.
  • Representative Grant Schneider (D-IL-10) reiterated the critical benefits telehealth provides to patients and the ways in which the technology eliminates barriers to accessing care. He was particularly pleased that H.R. 8261 includes “delinking” provisions for pharmacy benefit managers (PBMs) in the Medicare Part D program. He claimed that these “delinking” provisions, which would sever PBM rebate compensation from the price of a drug, are projected to save the federal government $500 million. Furthermore, he argued that “delinking” would remove the incentive for PBMs to steer patients towards high-cost drugs when cheaper alternatives are available. Representative Schneider urged the Committee to consider extending these PBM reforms into the commercial market. 
  • Representative Greg Murphy (R-NC-3) underscored the importance of having payment parity for telehealth services, explaining that telehealth does not undo the high fixed labor and rent costs physician practices have. He wants to ensure that telehealth visits are reimbursed at the same rate as in-person visits. Representative Murphy also claimed that Medicare Advantage plans are “wreaking havoc” on the nation’s seniors, and he admitted that he does not have faith in private health insurers to pay the “correct” price for telehealth services. He voiced his opposition to Representative Doggett’s amendment to H.R. 8261, arguing that it allows CMS to deny coverage of lab tests and leave patients to foot the bill. Representative Doggett claimed that there was no pre-authorization requirement in his amendment. 
  • Representative Sewell offered an amendment to H.R. 8261 that would extend the ground ambulance and low volume Medicare dependent hospital add-on payments for two additional years. She did not understand why these programs were only reauthorized for nine months as the bill is currently written. Representative Sewell also urged the Committee to consider the Access to Ground Ambulance Medical Services Act, which would provide higher reimbursement levels for ambulance providers and extend add-on payments for low volume ground ambulance services and Medicare dependent hospitals to encourage EMS to continue to be offered in rural and underserved communities. Representative Carol Miller (R-WV-1) and Representative Wenstrup opposed the amendment due to the lack of pay-fors. 
  • Representative Miller spoke in support of her bill, the PEAKS Act, which would ensure Critical Access Hospitals in mountainous areas receive fair compensation for ambulance services and modify distance requirements for eligible Critical Access Hospitals and ambulance services. When the ‘mountainous terrain exception’ was created, parity was not included for ambulance services. This means that even though these mountainous Critical Access Hospitals qualify for the designation with a 15-mile radius, Representative Miller explained, their ambulance services must still meet the standard 35-mile radius requirement in order to receive reimbursement. Her legislation fixes this discrepancy by lowering the ground ambulance 35-mile requirement to 15 miles. Representative Pascrell and Representative Doggett voiced their opposition to the bill, claiming that it gives Critical Access Hospitals an unfair monetary edge over independent, local ambulance services by reimbursing the former more even though both entities service the same geographic area. They also fervently argued that the bill opens the door for predatory private equity investment in Critical Access Hospitals and surprise medical bills for patients since ground ambulances are not subject to the No Surprises Act. Representative Pascrell offered an amendment that would block private equity-owned Critical Access Hospitals from receiving funding authorized under the PEAKS Act.
  • Representative Randy Feenstra (R-IA-4) touted his legislation, the Rural Hospital Stabilization Act, which would provide a lifeline to rural hospitals on the verge of closure. His bill codifies the rural hospital stabilization grant program, which currently only exists as a pilot project. Representative Feenstra argued that his bill targets resources to rural hospitals with the lowest patient volume and that are at the highest risk of closure. The funding offered through the rural hospitalization stabilization grant program will allow hospitals to finance minor renovations, hire staff, and acquire needed equipment. 
  • Representative Linda Sanchez (D-CA-38) spoke in opposition to H.R. 8245, arguing that it excludes hospitals serving “medically underserved” urban communities from receiving grant funding. She noted that in 2019, several Democrat and Republican Ways and Means Committee members sent a letter to the Medicare Payment Advisory Commission (MedPAC), recommending that the commission add “medically underserved areas” as distinct geographic category in their report to Congress on rural and underserved communities. Representative Sanchez was dumbfounded that safety-net hospitals that provide uncompensated care would not be eligible for rural hospital stabilization grants. Last, she was disappointed that the bill allows for private equity-owned hospitals to receive grants. Representative Sanchez offered an amendment that would allow Federal Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to be eligible to receive grants under H.R. 8245. Representative Feenstra angrily voiced his opposition to the amendment, claiming that underserved communities already receive support through the Medicaid Disproportionate Share Hospital (DSH) payment program, and he implied that his Democrat colleagues do not support rural communities. 
  • Representative Ron Estes (R-KS-4) spoke in support of his legislation, the Ensuring Seniors’ Access to Quality Care Act, which he claimed would help combat the chronic staffing shortages many nursing homes across the country are facing. This bill prevents nursing homes with in-house Certified Nursing Aide (CNA) education program from facing suspension due to non-care related clerical violations. Representative Estes believes that the Ensuring Seniors’ Access to Quality Care Act is a “common sense solution” to keep CNA programs operational and assist nursing homes with staffing homes. He has heard from his constituents that 50 percent of nursing home CNAs are trained in-house. Furthermore, Representative Estes claimed that his bill would help nursing homes comply with the recently finalized nursing home staffing mandate.
  • Representative Chu stated that despite its name, the Ensuring Seniors’ Access to Quality Care Act fails to address the workforce challenges facing CNAs in nursing homes. Under current law, nursing facilities that are found to be in violation of Medicare rules have the opportunity to request a waiver from HHS and make their case for resuming training of CNAs. Representative Chu asserted that H.R. 8244 would “completely do away” with this process and “recklessly allow” underperforming nursing facilities to continue training nurse aides as long as their violations are not directly related to patient care. She argued that this exception fails to account for a multitude of practices that can harm patients and staff like falsifying patient or staff records or if a nursing facility fails to report incidences of abuse or neglect of residents. As the bill is currently written, it would permit nursing facilities to continue to train CNAs even if they are engaging in inappropriate or fraudulent practices. Instead of pursuing this misguided legislation, Representative Chu urged her colleagues to consider expanding the Health Professional Opportunity Grant program. 
  • Four years ago, Representative Murphy explained, the House Ways and Means Committee passed legislation to increase the number of graduate medical education slots to encourage physician training in rural communities. Despite this “landmark” achievement, Representative Murphy stated that there has been little growth in the number of physicians training in rural communities and that physicians tend to be concentrated in metro areas. He highlighted his legislation, the Rural Physician Workforce Preservation Act, which would ensure that unallocated graduate medical education slots go to rural communities. He also criticized medical schools for failing to take physician shortages seriously, noting that 61 percent of medical students are not planning to practice clinical medicine. Representative Sewell called the bill “well intentioned,” but said she could not support the bill because it unfairly prioritizes physician training in rural areas even though the program was originally created to give them preferential treatment. She added that the Rural Physician Workforce Preservation Act would arbitrarily redefine the allocation of graduate medical education slots to the detriment of two hospitals in her district that would no longer be eligible. Last, she claimed that many rural hospitals are not applying for graduate medical education slots in the first place because they cannot afford to train physicians. 
  • Representative Jodey Arrington (R-TX-19) touted his legislation, the Second Chances for Rural Hospitals Act, which would allow rural hospitals that closed as long ago as 2016 to reopen as Rural Emergency Hospitals and receive $276,000 in monthly payments from Medicare to support 24-hour emergency services. He also mentioned that he is looking forward to discussing reforms to the 340B program and how Medicare reimburses for swing-beds, but he did not go into specifics. Ranking Member Neal opposed the bill, arguing that instead of helping to keep struggling hospitals afloat, it would allow large, consolidated hospital systems to move into rural communities and siphon off patients from struggling hospitals. He added that there were no restrictions on the types of hospitals that could be re-opened, only that they recently closed since 2017.
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