The House Ways and Means Committee held a hearing entitled “Enhancing Access to Care at Home in Rural and Underserved Communities” on March 12, focused on a few themes: telehealth, hospital at home, home dialysis, home infusion, and remote patient monitoring—and seemingly was setting the stage for consideration of a number of pieces of legislation on these topics.

The witnesses included a home dialysis patient; a hospital at home patient; Dr. Nathan Starr from Intermountain Health, who oversees its hospital at home, home infusion, home dialysis, and telehospitalist program; Dr. Ateev Mehrotra, professor of health care policy and medicine at Harvard Medical School and hospitalist at Beth Israel Deaconess Medical Center; and Chris Altchek, founder and CEO of Cadence, a company that focuses on remote patient monitoring.

These programs were generally supported by both parties. There were many questions about regulatory barriers that could be lifted to ensure access to care in the home. There was a lot of interest in how the programs being discussed could allow more flexibility for patients and families across a variety of services while also extending clinical staff in a time of staff shortages. Rep. Claudia Tenney (R-NY) even went so far as to ask how these sorts of programs and technologies could help with New York State’s nursing home staffing mandate when nurses are in short supply.

Many of the questions from members focused on telehealth. During the pandemic, a number of waivers were put in place allowing Medicare reimbursement for a greater range of services. These waivers were extended until December 2024, so part of the purpose of this hearing was to hear about progress in telehealth in order to inform efforts to solidify a policy path forward before the waivers expire.

Some of the waivers in question include:

• Permanently removing geographic requirements for telehealth services;
• Allowing the home to serve as an originating site;
• Expanding types of practitioners who are able to bill for telehealth services (for example, allowing physical and other therapists to bill);
• Continuing to allow audio-only technology; and
• Continuing to allow the hospice face-to-face recertification to be done via telehealth.

There was not much disagreement regarding the value of telehealth generally. Many committee members agreed that it was “the silver lining” of the pandemic and there was broad acknowledgement that we cannot move backwards. There was discussion about how to ensure high-quality care and how to appropriately reimburse for telehealth. Dr. Mehrotra testified that telehealth reimbursement should be lower than in-person care and received some pushback because of the overheard of running a small practice. He did note later that for programs like telestroke interventions, targeting payment is important because the fixed costs in a rural area may need to be given consideration. He also noted that his research shows that the investments need to be targeted so as not to widen disparities. Given the topic of the hearing—rural and underserved areas—there was a lot of discussion regarding the need to allow audio-only telehealth.

The bipartisan Telehealth Modernization Improvement Act of 2024 was introduced on March 12, aligned with the hearing, by Reps. Buddy Carter (R-GA), Lisa Blunt Rochester (D-DE), Greg Steube (R-FL), Terri Sewell (D-AL), Mariannette Miller-Meeks (R-IA), Jefferson Van Drew (R-NJ), and Joe Morelle (D-NY). This bill would extend all the waivers discussed above, and others, permanently. The CONNECT for Health Act of 2023, another large telehealth package, has more than 60 cosponsors in the Senate and a number in the House as well.

Mrs. Belle Maddux, the witness who discussed her experience with home dialysis, effectively laid out the pros and cons of home dialysis. She talked about how when she went to a clinic, the staff often seemed under pressure to be sure a number of patients were dialyzed in a certain time frame, so she often did not get patient-centered attention. She also talked about the time it took to go to the clinic and how it lost her time at work and with her family. On the other hand, home dialysis (and the other home-based services discussed at this hearing) puts a lot of burden onto the beneficiary. Maddux has had to learn to do her own dialysis and noted that there needs to be more trained staff to facilitate these various modalities. She also noted increased costs for electric bills, garbage bills, and water bills from doing her dialysis at home, which would likely be a barrier to services. She noted the support she has gotten from her doctor and nurse, a point that relates to one of our concerns: With all of these innovations, LeadingAge is interested in how to expand care while making sure the training and support of beneficiaries and family caregivers are appropriately addressed in payment models

The hospital at home program is also being offered under a waiver that expires at the end of the year, and advocates would like to extend it. LeadingAge has members—especially home health members—who partner for hospital at home services.

The hearing did not discuss Medicare home health and hospice, though home health came up in relation to many of these services. Rep Smucker (R-PA) specifically mentioned a LeadingAge-endorsed bill, the Medicare Home Health Accessibility Act (H.R. 7148), which would change the statutory language defining skilled needs for home health to include occupational therapy as a qualifying service to receive home health, aligning it with the provision of other therapies under the home health benefit. We will submit a comment for the record on this hearing and continue to monitor all of these issues.