Roundtable Discussion on Telehealth / Telemedicine

1 ROUNDTABLE DISCUSSION HELD BY

THE NEW YORK STATE SENATE 2 LEGISLATIVE COMMISSION ON RURAL RESOURCES

-------------------------------------------------- 3

ROUNDTABLE DISCUSSION ON 4

TELEHEALTH / TELEMEDICINE 5

-------------------------------------------------- 6

Legislative Office Building 7 Hearing Room B

181 State Street 8 Albany, New York 12247 9 January 9, 2012

10:00 a.m. to 1:00 p.m. 10 11

PRESIDING:12

Senator Catharine M. Young 13 Chair 14 Assemblywoman Aileen Gunther

Vice Chair 15 16 LEGISLATIVE MEMBERS PRESENT: 17 Senator David Valesky

Ex-Officio Member/Special Advisor 18 Commission on Rural Resources 19 Senator Kemp Hannon

Chair, Senate Committee on Health 20

Assemblyman Richard Gottfried 21 Chair, Assembly Committee on Health 22 Senator James L. Seward

Chair, Senate Committee on Insurance 23

Assemblyman Joseph Morelle 24 Chair, Assembly Committee on Insurance 25 1 LEGISLATIVE MEMBERS PRESENT (Continued): 2 Senator Neil Breslin

Senator Timothy Kennedy 3 Senator George D. Maziarz

Senator Thomas O'Mara 4 Senator Patricia Ritchie 5 Assemblyman Daniel Burling

Assemblywoman Barbara Lifton 6 Assemblyman Philip Palmesano 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 1 ROUNDTABLE PARTICIPANTS: 2 Gregory S. Allen

Director, Division of Program Development & 3 Management

NYS Department of Health, 4 Office of Health Insurance Programs 5 Rachel Block

Deputy Commissioner of 6 The Office of Health Information Technology

Transformation 7 New York State Department of Health 8 Betty (Van Huizen) Couture, RN

Vice President, Business Development 9 Advantage Home Telehealth, Inc., Buffalo 10 Dr. Frank Dubeck, M.D.

Vice President, and Chief Medical Officer 11 Excellus Blue Cross and Blue Shield; 12 Stewart Gabel, M.D.

Medical Director, Office of Children & Families 13 New York State Office of mental health 14 Cynthia Gordon, RN, MSN

Director of Telehealth Services 15 Rochester General Health System and InterVol

(via teleconference) 16

Frederick Heigel 17 vice President, Regulatory Affairs, Rural Health

and Workforce 18 Healthcare Association of New York State 19 Victoria G. Hines, MPH

President, and Chief Executive Officer 20 Visiting Nurse Service of Rochester & Monroe County 21 Thomas E. Holt

president, and Chief Executive Officer 22 Lutheran Social Services 23 Michelle Mazzacco, MBA

Vice President, and Director 24 Eddy Visiting Nurses Association,

St. Peter's Health Partners 25 1 ROUNDTABLE PARTICIPANTS, Continued: 2

Laurie Neander, RN, MS 3 Chief Executive Officer

Basset Healthcare Network At Home Care, Inc. 4

Kenneth Oakley,, Ph.D., FACHE 5 Chief Executive Officer

Western New York Area Health Education Center, 6 Lake Plains Community Health Network, Inc. 7 Alexis Silver

Vice President for Clinical Policy 8 Home Care Association of New York State 9 Denise K. Young, MBA, HCM, CSP

Executive Director 10 Fort Drum Regional Health Planning Organization 11 Mary Ann Zelazny, BA

chief Executive Officer 12 Finger Lakes Migrant Health 13 14 ---oOo--- 15 16 17 18 19 20 21 22 23 24 25 1 SENATOR YOUNG: (No audio.) 2 Some of you have traveled across the state, 3 and it's great to have your experience and your 4 knowledge and your expertise today. 5 This is telemedicine and telehealth, and 6 putting the pieces together. 7 As you know, telemedicine and telehealth is 8 interactive two-way participation between 9 health-care providers and patients in real-time. 10 And, actually, there are about 12 states 11 that have put in place reimbursement mechanisms 12 for telehealth and telemedicine. 13 In New York State, and it's represented by 14 the people around this table, we have pockets of 15 success. And, so, the challenge is putting the 16 pieces together, because everyone thinks this is a 17 great idea, especially for rural areas. 18 As you know, we deal with isolation, in many 19 cases, in rural areas. There's limited access, in 20 many cases, to health care. And so we need to put 21 the pieces together. 22 And so, today, is a free-flowing discussion 23 from these experts in the room, to talk about what 24 policy decisions do we have to make, as a state, in 25 order to take this to the higher level. 1 So, again, thank you so much for coming. 2 I'd like to introduce my colleagues. 3 And, we'll be asking for comments from 4 Vice Chair of the Legislative Rule Resources 5 Commission, and that's Assemblywoman Aileen Gunther, 6 who is to my left; 7 But we're also joined by the Chairs of the 8 respective Committees of Health, and Insurance, in 9 the Senate and the Assembly. 10 So we have: Chairman Jim Seward from the 11 Insurance Committee; 12 And, my colleague Kemp Hannon, who is Chair 13 of the Health Committee in the Senate; 14 And, we have, also, Richard Gottfried, who is 15 the Chair of the Assembly Health Committee; 16 And, Joe Morelle, who is the Chair of the 17 Insurance Committee; 18 We have, Barbara Lifton, from the Assembly. 19 She's also on the Rural Resources Commission, as is 20 Phil Palmesano from the Assembly; 21 And, we also have, Senator David Valesky, is 22 an ex-officio member of the Commission. 23 I think I covered everyone. 24 Vice Chairperson Gunther, would you like to 25 say something? 1 ASSEMBLYWOMAN GUNTHER: I think -- am I on? 2 Well, I want to welcome all of you to this 3 important hearing. 4 I represent both, Orange, and Sullivan, 5 County. 6 And, I also practiced nursing in 7 Upstate New York for many, many years. I'm not 8 going to tell you how long, because I don't want to 9 date myself, but I know the problems with getting 10 quality care to Upstate New York. 11 You know, often, we have one cardiologist. 12 I just met Dr. Gabel, and he's a child 13 psychologist. And, we don't have any in the 14 Sullivan County region. 15 So, I know how important telemedicine is. 16 It's cost-effective. It brings quality 17 health care to the areas that need it most, and, 18 reimbursement is key to this issue. 19 And I think that we have the technology. You 20 know, we're bringing broadband to different areas 21 of New York State that need it most, in rural 22 areas. 23 So I think now is the time, because we're 24 looking for savings, and we're also making sure that 25 people stay out of the hospital. But we can only do 1 that if we can offer them primary care. 2 So, I think this is the way we have to go in 3 New York State. It's cutting edge. 4 And, you know, we've been collecting data for 5 a very, very long time, and it's time to do 6 something with this data, and know where -- and 7 where, and who needs health care, and primary health 8 care and specialty health care at -- health care in 9 New York State. 10 So, I thank you for coming, and I will -- I 11 hope it's going be a really interesting discussion. 12 SENATOR YOUNG: Thank you, Assemblywoman. 13 Would any of my colleagues like to add 14 anything at this point? 15 Assemblyman Gottfried. 16 ASSEMBLYMAN GOTTFRIED: Well -- okay. 17 Well, I just want to note, that I think all 18 regions of the state have a lot to learn and 19 benefit from on this topic. 20 And, I am looking forward to learning a lot 21 about where -- what we, as legislators, and as a 22 state, can do to help move this forward. 23 SENATOR YOUNG: Thank you, Assemblyman. 24 I'd like to go through the roster of the 25 participants today. 1 We have, Rachel Block, the deputy 2 commissioner of the Office of Health Information 3 Technology Transformation in the New York State 4 Department of Health; 5 Gregory S. Allen, director, division of 6 program development and management, the Office of 7 Health Insurance Programs through the New York 8 State Department of Health; 9 Dr. Stewart Gabel, the medical director, 10 Office of Children and Families, New York State 11 Office of Mental Health; 12 Kenneth Oakley, chief executive officer, the 13 Western New York Area Health Education Center, 14 Lake Plains Community Health Network, 15 Incorporated; 16 Frederick Heigel, vice president for 17 regulatory affairs, rural health and workforce, 18 Healthcare Association of New York State; 19 Alexis Silver, vice president for clinical 20 policy, Home Care Association of New York State; 21 Frank Dubeck -- Dr. Frank Dubeck, 22 vice president, and chief medical officer, 23 Excellus Blue Cross and Blue Shield; 24 Cynthia Gordon, RN -- RN, MSN, and she'll be 25 via teleconference -- so we can prove our point -- 1 director of telehealth services, Rochester General 2 Health System and InterVol; 3 Victoria G. Hines, MPH, president, and 4 chief executive officer, Visiting Nurse Service of 5 Rochester and Monroe County; 6 Thomas E. Holt, president, and 7 chief executive officer, of Lutheran Social 8 Services; 9 Michelle Mazzacco, MBA, vice president, and 10 director, Eddy Visiting Nurses Association, 11 St. Peter's Health Partners; 12 Laurie Neander, RN, MS, chief executive 13 officer, Basset Healthcare Network at Home Care, 14 Incorporated; 15 Mary Ann Zelazny, BA, chief executive 16 officer, Finger Lakes Migrant Health; 17 Denise K. Young, MBA, HCM, CSP, executive 18 director, Fort Drum Regional Health Planning 19 Organization; 20 And, Deborah Robbins, RN, MPA, director, 21 clinical and sales support, Advantage Home 22 Telehealth, Incorporated. 23 Now, I do realize that some of the 24 participants have brought PowerPoint 25 presentations, which is great, and we will get to 1 those. 2 I want to point out, if you can't see the 3 screen over here, there are these gizmos that -- 4 up here, that will be broadcasting also. So, you 5 can look upward as that presen- -- those 6 presentations are going on. 7 I would like to start with Dr. Ken Oakley, 8 just to give some remarks. 9 And, really, today is free-flowing 10 information. This is a discussion. It's not just a 11 presentation. 12 So, if you have facts and figures and data 13 and stories that you want to share, that's 14 wonderful, but, we also want to encourage an 15 exchange. 16 So, if somebody is saying something, and you 17 want to add, or challenge, do anything like that, 18 please feel free, and I will call on you. 19 But, Dr. Oakley is someone who I have known 20 for many years. He's been a force in health care 21 in the Western Region, and now to the 22 Central Region. 23 And he actually has a personal story about 24 the impact that telemedicine has had on his personal 25 life. 1 So, I'd like for you to share that, if you 2 don't mind, Dr. Oakley. 3 DR. KENNETH L. OAKLEY: Good morning, 4 everyone. 5 Can you hear me all right? 6 Okay. 7 Again, I originally come from 8 Cattaraugus County, so I have known Senator Young 9 for a number of years. 10 ASSEMBLYWOMAN GUNTHER: I can't hear. 11 SENATOR YOUNG: Ken, hold on one second. 12 I don't believe that the mic is on. 13 SENATOR HANNON: You got to get it turning 14 red. You got to push this button. And it's very 15 hard to see the red light. 16 DR. KENNETH L. OAKLEY: It was red. 17 It is red. 18 Can you hear me now? 19 SENATOR YOUNG: Yes. 20 You have to get very close to it. 21 DR. KENNETH L. OAKLEY: I just have to stay 22 very close it to. 23 I'm sorry. 24 Again, I come from Cattaraugus County, and 25 I've known Senator Young for a number of years, as 1 she has said. 2 Fourteen years ago, next month, my oldest 3 grandson was born with some severe abnormalities. 4 He had a severe cleft lip and severe cleft palate. 5 They weren't connected, which is extremely rare. He 6 had underdeveloped vocal cords, and underdeveloped 7 ear canals. 8 He spent the first 11 years of his life 9 really struggling with all kinds of issues, 10 including psychiatric issues. 11 He was diagnosed with a number of different 12 things. He was put on adult medication when he was 13 8 years old because it was the only way they 14 thought they could control him at the time. 15 And he spent 11 years in -- and he -- and 16 over that first 11 years, he probably saw a child 17 psychiatrist twice, because that's the most we could 18 find in the Southern Tier at the time. 19 He averaged approximately 90 days a year 20 institutionalized either in a hospital or in some 21 other controlled environment, for 11 years. 22 Finally, three years ago, through the local 23 health department, we were able to arrange a 24 teleconsultation with the experts at Columbia. It 25 was a pilot program going on in the state. 1 And, my daughter and my grandson and the 2 local medical team spent over three hours, 3 together, doing this consult via telemedicine. 4 The result of that was, that the experts at 5 Columbia basically said: They blew the diagnosis. 6 There were several diagnosis that were just totally 7 wrong. That he was actually on medication that 8 potentially was going to kill him eventually. It 9 was absolutely the wrong medication that was tearing 10 his body apart. 11 So, they adjusted his medication. They 12 changed his diagnosis. And, they also totally 13 changed the way they went about his treatment, and 14 his learning plans, and everything else. 15 Now, that didn't take away the fact that I 16 have a special-needs' grandson. I still do. 17 There's no question about that. But since that 18 telehealth consult, and since those adjusted 19 medications, and the adjustment treatment plans, 20 and everything else, instead of spending 90 days a 21 year institutionalized, he's averaged, over the last 22 three, 7 days a year institutionalized. 23 That translates into, somewhere between, 24 $40,000 in saved medical expenses just in the last 25 three years. 1 So, while I have been, and I continue to be, 2 a very, very strong advocate for rural telemedicine, 3 because I'm a health-care administrator, and I grew 4 up in rural Cattaraugus County where we didn't have 5 much -- still, some places don't have much when it 6 comes to professionals -- I also am a person who 7 has seen firsthand that telemedicine, can, and does, 8 work. 9 And, so, I'm both a professional and a 10 personal advocate. 11 Thank you. 12 SENATOR YOUNG: Thank you, Ken. 13 And, I know that you have worked very hard, 14 secured a lot of grants, to get a network up and 15 going in the Western Region. And I believe it 16 stretches all the way to the Central Region now. 17 Maybe you could share what you've done in 18 order to accomplish that? 19 DR. KENNETH L. OAKLEY: Certainly. 20 One of the critical aspects of this, is -- 21 is, because I'm in health-care administration, I'm 22 not a direct service provider, I really wanted to 23 focus on making the infrastructure possible, to 24 bring telemedicine to life, and to bring advanced 25 [unintelligible] education and training to the more 1 rural areas. 2 So, over the last, probably seven or 3 eight years, I've been working on developing a 4 broadband network that is going to link, probably, 5 when it's all said and done, over 40 facilities 6 together with a high-speed broadband fiberoptic 7 network, to really encourage and allow advanced and 8 telehealth and telemedicine. 9 But beyond that, it doesn't take advanced 10 stuff to do many aspects of telemedicine, 11 particularly when we're focused on primary care. 12 And, when we're talking about primary care, 13 we need to be able to get it out using standard 14 Internet IP-type addresses, and that kind of stuff. 15 So, basically, I've been working and 16 advocating the administrative and infrastructure 17 side, to allow facilities, home-health agencies, 18 large health systems, and whatnot, to really do 19 the kinds of applications that they need. 20 Now, there's also a health-workforce aspect 21 to this because it's a different way of doing 22 business. And -- and, so, as an area 23 health-education center, we're also prepared to work 24 with clinical staff, to work with office staff, to 25 realign work flows and whatnot, to make telemedicine 1 as efficient and effective as it can possibly be. 2 SENATOR YOUNG: Thank you. 3 One of the things that I'd like to throw out 4 there, is that, as you know, we do have successful 5 systems, but they're not statewide. 6 The question for the participants today, 7 is: What are the barriers that get in the way of 8 having a statewide system? 9 And, what policy decisions should we make in 10 order to ensure that we can have a statewide system? 11 So, I'll just throw that out. 12 Anybody want to jump in? 13 Yes? 14 DENISE YOUNG: Is it on? 15 Okay. 16 SENATOR YOUNG: You know what? I think what 17 we need to do is, have it close to your mouth. 18 SENATOR HANNON: And identify yourself. 19 SENATOR YOUNG: And identify yourself. 20 You're Denise? 21 DENISE YOUNG: Denise Young, Fort Drum 22 Regional Health Planning. 23 We have a rural health-care pilot project 24 from the FCC, funded through USAC. We have 25 28 sites connected on high-speed fiber. 1 The real barriers we have to actually 2 launching: 3 So, we have the infrastructure in place where 4 we could do some pretty comprehensive in a very 5 rural area of New York. 6 What we need is reimbursement, across the 7 board, for -- if it's not reimbursable, we -- who's 8 going to provide the service? 9 So, we can have little pockets, and we do 10 reach out whenever we can have a pocket. 11 For example: OMH has access to a child 12 psychiatrist. We use it, but it's not enough. 13 So, we need across-the-board reimbursement, 14 all-insure. 15 And, from not only, because, with the -- and 16 we're very excited about Medicaid covering. Very 17 excited about seeing it cover telemedicine. But, 18 the way I read it, unless I read it wrong, it's only 19 from Article 28 to Article 28. 20 And, psychiatrists in New York State are at 21 OMH Article 31 clinics; so, therefore, covering 22 psychiatry, we were all set. 23 We had a clinic in Brooklyn, all set to 24 provide services to our region for child psychiatry, 25 and saw they're not eligible to provide services 1 because they're an Article 31 clinic under the new 2 Medicaid coverages. 3 So -- so, we need that to be across the 4 board. 5 Most of -- in New York, at least in rural 6 New York, many of our specialists are not 7 hospital-employed, so those are independent 8 physicians. 9 Again, if we're only Article 28, we don't 10 have access to the specialists that we actually 11 need access to because they're not in Article 28s. 12 So, that reimbursement issue is huge. 13 And then the second thing is, credentialing. 14 So, credentialing: Where they are 15 credentialed, how they are credentialed. You know, 16 what credentialing we're recognizing; whether we're 17 recognizing it at the originating site, or we're 18 recognizing it at the -- at the site where the 19 physician is. 20 If we recognize the credentialing at the site 21 where the physician is, then -- if we're making a 22 referral for any other thing, we're actually sending 23 the person, physically, to that location, then we 24 recognize the credentialing where that provider is. 25 If -- but, with telemedicine, we say: Well, 1 they have to be credentialed on both ends. 2 It -- so, it really does gum-up the system. 3 So credentialing is a large issue. 4 And then, the final thing -- as you can see, 5 I thought about this question. 6 The final thing that is a challenge, is that 7 there -- and I think Ken said it very well, in 8 relation to: It takes people to help physician 9 practices change; to change how we practice 10 medicine, to incorporate telemedicine. 11 It takes people to champion that. 12 And, there is no way to pay for those people. 13 So we need leadership for those people. We 14 need to have those people that are going to be able 15 to do that, and those people will have to have an 16 income. 17 So -- so we need to figure that out. 18 So... 19 SENATOR YOUNG: Thank you. Thanks, Denise. 20 Greg Allen, would you like to respond to 21 that? 22 SENATOR HANNON: [Inaudible.] 23 SENATOR YOUNG: And he's from the New York 24 State Department of Health, Insurance Division. 25 GREGORY ALLEN: Hi there. 1 Thanks very much. 2 First of all, I just want to say, I grew up 3 in Columbia County. And, the second place that I 4 practiced services, as a social worker, was 5 Wyoming County. So, my sense of the lack of 6 availability of things that are available in an 7 urban center comes from personal experience. 8 So, if anything, at least there's the guilt 9 that keeps on giving, that goes with that 10 experience -- 11 [Laughter.] 12 GREGORY ALLEN: -- in terms of Medicaid 13 policy. 14 I'll just say, that, our staff have been, you 15 know, working aggressively on trying to eliminate 16 some of these barriers (a) to pay for the service, 17 and then, (b) to change the things that dance around 18 payment, that make payment availability not really 19 available. 20 So, the -- on the credentialing side, we 21 heard a lot of comments about, that the spoke site 22 was having trouble having the horsepower to do the 23 credentialing that was available at the hub site. 24 So we now allow that spoke site to just enter 25 in a contract with the hub site to achieve the 1 credentialing. 2 That being said -- 3 SENATOR YOUNG: Could you explain for the 4 neophytes -- 5 GREGORY ALLEN: Yeah, sure, what a "spoke" 6 and a "hub" is? 7 SENATOR YOUNG: -- what a "spoke" and a 8 "hub" -- 9 GREGORY ALLEN: So, there's a wheel, and then 10 there's these spokes -- 11 SENATOR YOUNG: Right. 12 GREGORY ALLEN: -- and then there's the hubs. 13 It's -- 14 SENATOR YOUNG: I grew up on a farm, and I 15 have my own concept of what that means. 16 So, if you could explain it in health-care 17 terms? 18 GREGORY ALLEN: Yeah, sorry. It's growing 19 close up to the wagon. You know, you just sort of 20 figure everybody -- 21 So, that, the "hub site," in general, is the 22 center that would be offering the consult. 23 The "spoke site" is the site that would be 24 receiving the consult. 25 So, very often, the hub site might be located 1 in the more urban area that may have more access to 2 specialty medicine, specialty behavioral-health 3 services. 4 The spoke site is the -- is the -- perhaps 5 the rural site that would be receiving those 6 consults, would have the patient at the spoke 7 site. 8 The hub site, very often, has more resources 9 to be able to do both credentialing and privileging. 10 So, what we've done for the spoke site, is to 11 allow the credentialing that takes place in the 12 hub site to be available to it, the professional 13 credentialing. 14 "Is this person properly credentialed to 15 provide the service?" -- we'll make that available 16 to the spoke site through a contract, so that you 17 don't have to duplicate the credentialing. 18 Recently, Medicare -- so -- and credentialing 19 is really checking in to make sure the person is -- 20 Privileging is another issue, which we're 21 working on. 22 Medicare just recently -- and we've been 23 drafting behind Medicare, trying to copy the 24 Medicare policies, so that we don't have a different 25 policy in both public insurances. 1 A remaining issue, and it's in the 2 presentation, so I could skip over it when I get it 3 to save us some time, is the privileging. 4 The privileging, we would -- we currently 5 require at both sites. 6 Medicare recently came out with rules 7 allowing the privileging to be facilitated, or 8 fast-tracked -- and we're still learning about 9 this -- at that spoke site. And, we're working on 10 that right now. 11 There may be some legal impediments, but 12 we're working on those right now. 13 So -- but our goal, clearly, is to make the 14 reimbursement available so that we can provide the 15 service. 16 SENATOR YOUNG: So, when you say there are 17 "legal impediments," potentially, you are looking 18 into those, and you'll let the Legislature know what 19 those are? 20 GREGORY ALLEN: Absolutely. 21 SENATOR YOUNG: Okay. 22 GREGORY ALLEN: Absolutely. 23 And we're actually, just, working on this 24 right now, with counsel, as we speak. 25 So, we'll -- we'll keep you and 1 Senator Hannon, certainly, posted on our 2 investigation. 3 SENATOR YOUNG: Thank you. 4 SENATOR HANNON: And the question that 5 Ms. Young raised about the Article 31 and the 6 Article 28, and, are we having cross-match here? 7 GREGORY ALLEN: Yes. 8 So, right now, we are -- we expanded -- my 9 whole -- I can do my whole presentation through your 10 question, thank you very much. 11 We -- 12 [Laughter.] 13 SENATOR HANNON: It's a setup. 14 GREGORY ALLEN: That's good. 15 So the -- we expanded the availability 16 outside of the hospital. We had previously had this 17 available, hospital OPD and ER. 18 We've now may it available to freestanding 19 diagnostic and treatment centers, and other sites, 20 but, we have not yet made it available in the 21 mental-hygiene clinics. 22 And, I'll take that back from this hearing as 23 an action item for us to work on. 24 SENATOR YOUNG: Great, thank you. 25 Okay, who else? 1 Yes, Frederick. 2 SENATOR HANNON: How about the director from 3 the mental health? 4 SENATOR YOUNG: Okay, Dr. Gable, would you 5 like to contribute? 6 DR. STEWART GABEL: Well, there's many 7 things -- (no audio). 8 There are many things that we're doing. 9 I think some of the issues that have been 10 raised are very real. 11 One of the things that, really, at our 12 programs for children, are designed, essentially, 13 to address the fact that there are very limited 14 numbers of child psychiatrists in 15 Upstate New York areas. 16 Actually, there's -- there are only about 17 7,000 -- 7,400 child and adolescent psychiatrists in 18 the country. 19 And in some ways, New York is very 20 fortunate because it has about one-tenth of them in 21 New York State. However, they are very, very 22 heavily distributed in downstate areas, so there's 23 a tremendous shortage of child and adolescent 24 psychiatrists in upstate areas. 25 And 20 -- roughly, 20 of the 60 or so 1 counties in New York State do not have any child 2 psychiatrists, and another 10 to 15 have only one 3 child psychiatrist. 4 So the question that we've come up with, is: 5 How do you begin to provide child-psychiatrists' 6 services to places where there are no child 7 psychiatrists? 8 And that's really what's led to our, 9 telepsychiatry, telemedicine, programs. And we do 10 a number of things in that area. 11 ASSEMBLYWOMAN GUNTHER: May I just interrupt, 12 Dr. Gabel? 13 DR. STEWART GABEL: Yes. 14 ASSEMBLYWOMAN GUNTHER: I would be very 15 interested in hearing your whole presentation. 16 DR. STEWART GABEL: This is essentially it. 17 ASSEMBLYWOMAN GUNTHER: Our first meeting, 18 I'm very interested. 19 DR. STEWART GABEL: Okay, well, this is 20 essential -- this is -- I'm kind of going through 21 some of that, if that's okay? 22 ASSEMBLYWOMAN GUNTHER: I don't want to miss 23 anything, so if you would go through the whole 24 thing, I'd appreciate it. 25 DR. STEWART GABEL: And -- so, essentially, 1 what we're doing is, saying: 2 How do we provide the child-psychiatrists' 3 services when there are no child psychiatrists? 4 How do we provide the child-psychiatrists' 5 services for the 20 percent of American school 6 children who have diagnosable mental-health 7 disorders? 8 That's a very large number. 9 Most of those youth do not get treated, at 10 all. And some get treated in a less-than-adequate 11 way. 12 So telepsychiatry is a real advance that 13 allows us to bring services to underserved rural 14 areas. 15 And we do that in three ways: 16 Firstly: In our psych- -- in the 17 psychiatric -- New York State psychiatric hospitals 18 in upstate areas, that serve mainly adults, 19 several also serve children. They often don't have 20 child psychiatrists treating those children. 21 We provide telepsychiatry services to those 22 hospitals, to provide child-psychiatrist 23 evaluations on the youngsters who are admitted. 24 We also provide child-psychiatrist 25 consultations to several of the community 1 mental-health centers in the upstate rural area, 2 and all are eligible. We don't have equipment at 3 all, but all are eligible for those services. 4 And when Dr. Oakley mentioned the benefit 5 of the service that his grandson had received, and 6 spoke about the Columbia consultation, I was 7 thinking that's probably an OMH service that, 8 fortunately, was available for your grandson, 9 through the Office of Mental Health. 10 Finally, what we do, is provide a very unique 11 and innovative program called "Project Teach." 12 Project Teach is the training and education 13 for the advancement of children's health. 14 Essentially, the American Academy of 15 Pediatrics, the American Academy of Child and 16 Adolescent Psychiatry, have basically said, 17 Pediatricians and family physicians are in 18 positions to provide mental-health treatment to 19 children. 20 They've spoken about that for pediatricians, 21 but it would be true for family physicians too. 22 But how can a pediatrician and a family 23 physician provide mental-health treatment for 24 children, because there are more of them than there 25 are child psychiatrists. 1 But there's a strong effort now, across the 2 country, for that to be so. 3 But, in order for that to happen, the 4 pediatrician, the family physician, need to have 5 available consultation, available support, available 6 education, so that they can do a good job at 7 providing this mental-health treatment that many of 8 them want to do, and that the American Academy of 9 Pediatrics supports their doing. 10 So we provide consultation -- 11 child-psychiatrists' consultation and training and 12 support to these other providers so that these 13 youngsters in the primary-care practice can 14 receive mental-health services. 15 We're also now -- from the point of view of 16 telepsychiatry, we have a pilot program, whereby, 17 office-based telepsychiatry units, mobile units, 18 are in a number of practices in the state. 19 And just beginning now, that if a youngster 20 coming to a private pediatrician's office could be 21 seen by a child psychiatrist, you know, 22 50, 100 miles away, and receive help and 23 evaluation and diagnosis and recommendations to the 24 pediatrician, to provide that treatment. And, then, 25 periodic follow-up with the child psychiatrist as 1 well, also by telepsychiatry. 2 So those are the things we're doing. And 3 we're, really, I think the field is moving. 4 The field of mental-health treatment for 5 children, in a broad sense, a large part of it, of 6 course, moves toward the kids who never get to 7 see a mental-health professional, but who, in fact, 8 have significant mental-health disorders. 9 That's the 20 percent -- that's probably 10 most -- 75 percent of that 20 percent that have 11 mental-health disorders, they come to primary-care 12 physicians. 13 And we have to be able to work with them, and 14 they're not always coming to child psychiatrists, 15 but they will be seeing, probably more and more in 16 the primary-care practice office, and telepsychiatry 17 is becoming a real option for them to be seen in 18 that -- in those practices. 19 And that's the kind of thing where -- is 20 where the future moves. And, hopefully, I think 21 that will be a great benefit to the youngsters in 22 the state. 23 SENATOR YOUNG: Dr. Gabel, that's great 24 news. 25 One of the questions I have: So, you have 1 this three-pronged system, which seems like it's 2 really bringing and delivering services where 3 they're needed. 4 How do you pay for it? 5 DR. STEWART GABEL: Well, these are 6 OMH programs, and they're paid for by OMH funds. 7 And, in fact, we have contracts, often -- 8 it varies, but we have contracts with, mainly, 9 academic medical centers that provide these 10 services. 11 So, the services to the community 12 mental-health centers is through 13 Columbia University. 14 The services to the upstate psychiatric 15 hospitals, OMH hospitals, are through the 16 State University of New York, upstate in Syracuse, 17 and through NYU. 18 The programs to private pediatric offices 19 that, now, are just beginning the telepsychiatry 20 notion are twofold: 21 One, through a private hospital, 22 Four Winds Hospital. And, then, through a 23 consortium of five academic medical centers that 24 have banded together to provide this. 25 So, we now have statewide coverage -- not all 1 through telepsychiatry, but statewide coverage of 2 consultation to primary-care practices around the 3 state. 4 And that consortium -- that consortium is a 5 group of five academic medical centers: Buffalo, 6 Rochester, Syracuse, LIJ, and Columbia. 7 So, that's how we do it. 8 But these are OMH funds, contracting with 9 these centers. 10 And I think the issue that was raised 11 earlier, about, "Well, can this be done privately?" 12 well, I think it's -- that's a financial issue, of 13 course, and a difficult one. 14 And the other question that I think was 15 raised by DOH, of course, is the question of 16 reimbursement. 17 Pediatricians and family physicians, with 18 appropriate supports, such as we provide, on the 19 clinical side, can be trained, and can be supported, 20 in providing mental-health services to children in 21 rural areas, but they will need to have adequate 22 reimbursements to do that. 23 There are, 20 percent of the kids who come to 24 the private pediatric or family -- pediatric office, 25 20 percent of the kids in the country, or the 1 family physicians who have problems such as this. 2 ASSEMBLYWOMAN GUNTHER: Dr. Gabel, right 3 now, a lot of the rural pediatricians are already 4 treating mental-health issues. 5 DR. STEWART GABEL: Right. 6 ASSEMBLYWOMAN GUNTHER: We have so many 7 children with the diagnosis of the spectrum of 8 autism, and they're giving them Ritalin, and those 9 kinds of medications. 10 And, beyond the pediatric office, you know, 11 we have a whole thing with education. Like 12 education, our counselors. 13 And we have this, to me, it's like an 14 epidemic of children on the spectrum. 15 And, we really have, few and far between, as 16 far as care for these children in my area. 17 I know where Four Winds is, but that seems 18 that it's already when the child is in an episode, 19 and it's like keeping that child away from 20 Four Winds. 21 And right now -- 22 DR. STEWART GABEL: Right. 23 ASSEMBLYWOMAN GUNTHER: -- like tel- -- to 24 me, telemedicine, and having, you know, 25 Columbia Presbyterian being able to intervene before 1 that kind of -- you know, before you reach 2 Four Winds. 3 Which, honestly, if I can just throw this in, 4 you know, I represent an area, we had Middletown 5 psych center, and now we have Rockland psyche 6 center. 7 Sullivan County, I think, has access to three 8 beds. 9 So, often, these children in Upstate New York 10 are sitting in a regular -- a regular room in a 11 hospital, with constant awareness, for up to two or 12 three weeks. 13 So, you know, providing the reimbursement, in 14 the long run, will save money. And, you know, 15 getting from Point A to Point B, sometimes, in 16 New York State, takes a very long time. 17 But I know that, in where I represent, this 18 kind of intervention would be so valuable. 19 DR. STEWART GABEL: This intervention that 20 I that you're referring to, Assemblywoman Gunther, 21 is, in fact, available throughout the state under 22 Project Teach, in which primary-care physicians 23 can receive consultation for the youngsters in 24 their practices, by child and adolescent 25 psychiatrists. 1 Now, most of that is telephone. 2 If it's a serious thing, they can be seen 3 directly face-to-face. 4 And we're beginning to get involved with 5 telepsychiatry even to the primary-care provider's 6 office. But, that's just beginning now. 7 But the sense of tele -- of consultation 8 around mental-health problems by a child 9 psychiatrist, for all of the primary-care providers 10 in the state, is now available through 11 Project Teach. 12 On my presentation, which I've just, 13 fortunately, been able to give you, in new large 14 part, there's a website that tells exactly that. 15 Or, people can call me, or whatever, and we can hook 16 up the right person to get to. 17 SENATOR YOUNG: Thank you. 18 Senator Seward had a question. 19 SENATOR SEWARD: Yes. 20 Thank you, Senator Young. 21 I must admit, I come to the table today, both 22 as Chair of the Insurance Committee and as a local 23 senator, with a bias in favor of telemedicine, 24 representing a, basically, rural upstate district. 25 And, my most direct exposure to this topic is 1 through Laurie Neander's organization, 2 At Home Care, which services Otsego, Delaware, 3 Chenango, and Herkimer Counties; a good deal of 4 real estate in the upstate region. 5 But my question is this, to Dr. Gabel, and 6 others that are involved with this issue, is: 7 As we look at the -- getting over, 8 particularly in that barrier of reimbursements, 9 and possible expansion of a system in New York, what 10 body of evidence is there, that, in terms of the 11 outcomes being comparable to -- between a -- in 12 comparing a regular office visit, and having 13 services rendered, you know, on the face-to-face 14 basis, or through this telemedicine approach? 15 I mean: Is there -- are there comparable 16 outcomes? 17 Is there a body of evidence that could be 18 provided, as we move forward, particularly trying to 19 get over the -- this barrier, particularly of 20 reimbursements? 21 Is it comparable? And, should it be 22 considered comparable? -- in terms of outcomes. 23 DR. STEWART GABEL: I could take some of 24 that. 25 It's hard to do a direct experi- -- empirical 1 study, because the kids [unintelligible] would be 2 different. So, if they're different, you can't 3 quite compare them. 4 But, there is a body of evidence from around 5 the country that this is a well-received, favorable 6 service, supported by those who provide it, and 7 supported by those who receive it. 8 And there's no evidence that there's any 9 difference in acceptability, in satisfaction, or in 10 outcome, between psychiatric services provided to 11 youth, direct face-to-face or through telemedicine. 12 In fact, and by law, as I understand it, in 13 New York State, they're considered comparable 14 services. 15 If a telepsychiatrist provides, actually -- 16 and this is another advance that we are just 17 beginning to look into also, for rural counties, or 18 for rural hospitals in the rural part of the state: 19 Well, how do you -- one thing, is providing an 20 evaluation so others can follow through. But, 21 many clinics and providers want the actual 22 services, often the medication, to be provided by 23 the psychiatrists, who can follow up regularly, 24 and is more involved with that. 25 Well, that's a separate issue. That's 1 actually treatment by telepsychiatry, treatment by 2 telemedicine. 3 That's also being done now. And could be 4 done. 5 It's not being done very much in our state by 6 the Office of Mental Health. 7 But, again, this is all very feasible. And 8 New York State considers, a person who provides 9 telemedicine services, as I understand it, to have a 10 patient, like, as if they were in the same room 11 together. 12 So, in some sense, it's a comparable service. 13 SENATOR YOUNG: Thank you. 14 Dr. Dubeck, from Excellus, would like to 15 respond also. 16 DR. FRANK DUBECK: Ah, yes. 17 I'm not in the mental-health field, but I'm 18 aware of at least two pilot studies that were done 19 under grants: 20 One in Rochester, with school clinics; where 21 school nurses would actually asynchronously send 22 information to a pediatrician, who, by the end of 23 the day, would come back with a diagnosis and 24 treatment plan before the child went home, 25 significantly decreasing ER visits. Saving costs 1 there; 2 Another one with Ruth Winestock [ph.] in 3 Syracuse, with diabetics, where she tele-Skyped with 4 them into the North Country, and significantly 5 decreased re-admissions of diabetics, compared to 6 prior. 7 So, those kind of studies are out there; 8 they're small. 9 From the standpoint of mental health, 10 especially with child psychiatry, I think what you 11 have to compare, is, this teleconsult with the child 12 psychiatrist versus no access to a child 13 psychiatrist, which is, in reality, what we have. 14 And, I can't see how that's better. 15 SENATOR YOUNG: Thank you. 16 Yes? 17 DR. KENNETH L. OAKLEY: I just wanted to also 18 reference the work that's being done in Rochester, 19 because I actually met with 20 Dr. Ken McConnecky [ph.], last week, and to talk 21 about his TeleAtrics program. 22 He has done several studies, actually, that 23 have been peer-reviewed, and published. 24 And one of his findings was, that -- that 25 while doing those pediatric consults within the 1 school system, with the kids, the quality was there, 2 the satisfaction was there, but, also, they were 3 able to demonstrate a 22 percent reduction in 4 ER visits, because the kids didn't have to wait 5 until dad or mom got home from work; and, then, when 6 the pediatric practice is closed, say: Oh, guess, 7 what? I really do have a sick kid. I'm going to 8 take them of the emergency room. 9 By avoiding that; by actually making that 10 services available, the parent was allowed to stay 11 at work, and, there was a significant reduction in 12 evening ER visits from that identified population. 13 SENATOR YOUNG: Thanks, Ken. 14 Please give your name. 15 BETTY (VAN HUIZEN) COUTURE, RN: Yes, my name 16 is Betty Couture [ph.]. I'm from Advantage Home 17 Telehealth. 18 And, I apologize for the fact that I say, I'm 19 Deborah Robbins, but, she had an emergency come up, 20 and she couldn't make it. 21 So, basically, what I would like to say, 22 again, is the fact that we do need reimbursement 23 codes. 24 We like to say, Advantage Home Telehealth, 25 we're a full-service solution company. We use, 1 really, mobile technology, and, we like to bring the 2 exam room to the patient, whether that's at school, 3 at work, or at home. 4 And, so, one of the things that we feel is 5 really important, is that we provide the ability 6 for -- if a patient's in the home, to even have that 7 consult there. 8 And, so, that's what we're working towards. 9 So, we really need, 3G, 4G network as well, 10 or Internet capability in the home, and we can do a 11 lot with regards to video conferencing. 12 One of the things, though, if you want to 13 look at just vital-sign monitoring, we are -- we 14 have demonstrated quite a significant reduction in 15 costs. 16 We did -- we took care of 17 five congestive-heart-failure patients in Kansas. 18 And, within four months, of those five, 19 one of the patients, we saved around 20 two hundred to two hundred fifty thousand, and, 21 another one, three hundred to five hundred thousand, 22 just in preventing ER and hospitalizations. 23 So, if you're monitoring blood pressure, 24 weight, blood oxygen, blood glucose, there's so much 25 that you can do. 1 Our clinical call center calls the 2 patients, and we really work with them, to find 3 out: What it is they're eating. What it is they're 4 doing. 5 And another key aspect in all of this, is the 6 medication component. 7 And we have a medication device that, 8 actually, we can view from our call center, to see 9 what medications are in their medication bin, and 10 make sure they're taking the right medication, and, 11 reminding them on how to take their medication. 12 And, so, that's huge. 13 And, so, if we have the chance, if anybody 14 wants to speak to us about that. 15 But, really, what's the barrier for us, is 16 the reimbursement codes. 17 SENATOR YOUNG: Thank you. Thanks very much. 18 Yes, Mary Ann. 19 MARY ANN ZELAZNY: I would like talk what 20 we're doing in the FQHC world. 21 Out in Finger Lakes Region, we have 22 community and migrant house centers. 23 And, of course, as many of you know, one of 24 the biggest problems that we're all dealing with 25 now, is the integration of behavioral-health 1 services into the primary-care setting, because we 2 know it saves money, because we have the patients, 3 through the primary-care docs. 4 And, so, if we can somehow bring in the 5 behavioral-health specialists, right to where the 6 patient is in a rural area, when people cannot get 7 to where they need to go, which is usually in an 8 urban center, we have been able to see a substantial 9 drop in folks having to enter back into the 10 mental-health system. They are able to get their 11 services through us. 12 So what we do, is, when a patient comes 13 into one of our health centers, and they -- and we 14 see a lot of diabetics. We see a lot of folks that 15 don't speak English. So, reaching out to -- we have 16 an agreement now with another FQHC downstate, where 17 we have access to their 18 bilingual/bicultural-licensed clinical social 19 workers, who see our patients. 20 But what we're doing with our regular 21 community patients as well, is, when they come in 22 to see the primary-care doc, and we do their 23 screenings for them as part of the 24 patient-centered medical-home process, they will get 25 screened. 1 And, if it's determined that they need to see 2 a counselor, the counselor is on site. We have our 3 own licensed clinical social workers. And that 4 patient is able to go to any of our sites, if they 5 need to, and access those counselors through 6 telehealth, because we have access at all our 7 sites. 8 But then what we do, is, of course, with our 9 patients, they need to have a visit with a 10 psychiatrist, usually about every six to 11 eight months, to go through, and make sure their 12 meds are okay, and to really make sure that we're, 13 as a primary-care center, doing what we need to do 14 to make sure that that person is stable. 15 So, we have arranged with a hospital that has 16 a psychiatrist, who -- at -- when the patient is 17 referred to the psychiatrist, the patient comes 18 back to his primary-care site where they're 19 comfortable. The counselor sees the patient for the 20 first few minutes. Then the telehealth session 21 begins with the psychiatrist, with the counselor in 22 the room for the first couple minutes, just to 23 introduce, and make sure everything's, you know, 24 going to run smoothly. 25 The counsel leaves the room, waits outside, 1 and then the patient is able to meet with the 2 psychiatrist, not on the third floor of the hospital 3 where the mental-health clinic is that a lot of 4 people won't go to, because it means that, "Oh, I 5 have mental-health issues," and, trying to get 6 people to go to the mental-health clinics is a 7 struggle sometimes. 8 So, the patient will see the psychiatrist. 9 And, then, at the end of the session, the 10 counselor goes back into the room, with the 11 psychiatrist and the patient. They all go back over 12 the treatment plan, and make sure that everybody's 13 on board with what's going on. And we really try to 14 include the patient in that discussion. 15 And, then, we have an electronic 16 medical-records system, so that the counselor puts 17 all of those notes directly into the patient 18 chart, and we receive notes from the psychiatrist. 19 The benefit of this system, is our patients 20 are not having to leave their primary-care setting 21 for care. 22 It's so hard to get them in anyway. We drive 23 so many patients across the Finger Lakes Region 24 of New York State to get them care. And, to try to 25 bring them to a psychiatrist in Rochester, is just 1 not feasible all the time because, there's just so 2 many cars, and so many staff members, that can drive 3 patients. 4 The problem with the whole system is, is 5 that, of course, we can't bill. 6 So, what we're doing, because, in order for 7 us to keep our patients healthy -- 8 We believe it's cheaper to keep them healthy 9 and in the primary-care setting. 10 -- we have come into an agreement with the 11 psychiatrists, and he gives you a really good 12 deal on our visits. 13 But, it isn't so -- it's not sustaining. You 14 know, we can't keep using our own resources, to try 15 to pay for everybody's psychiatric visits. But, we 16 know it does keep people healthier. 17 And it also keeps us all -- what's really 18 important for -- from the primary-care perspective, 19 is, it's educating our primary-care docs. 20 We have the learning curve. To understand 21 behavioral-health issues is huge. 22 So, that -- that telepsychiatry visit gives 23 our counselors and primary-care docs the ability 24 to start to learn the language of what the 25 psychiatrists are saying, because it is pretty 1 intense sometimes. 2 And it's been an educational learning moment 3 for us, but it's also been really great for the 4 patient because they don't have to travel to another 5 place. And in rural settings, they're not going 6 to get there. 7 So, reimbursement is huge for us. 8 SENATOR YOUNG: Senator Hannon has a few 9 questions. 10 SENATOR HANNON: In addition to what you're 11 doing in behavioral health, you've really become, as 12 an FQHC, a center for the migrant workers. And, in 13 fact, I think you've started a network around the 14 state. 15 Maybe you could just tell us a little bit 16 about that, because my guess is, that's a whole 17 different population, even when you come to physical 18 health. 19 MARY ANN ZELAZNY: Well, we -- what we've 20 done is, we had to get telehealth capabilities 21 because we just do not have the facilities to be 22 able to serve all of the farm workers that come to 23 the New York State area and get them the care they 24 need. 25 And, you know, language is a huge barrier, 1 transportation's a huge barrier. 2 One of the things we do for the migrant 3 children, is that we go into the migrant Head Start 4 centers and provide dental cares as a routine 5 service to the kids. 6 And we're now starting to go into regular 7 community Head Start programs. 8 One of the major issues that we all encounter 9 when you deal with little kids in the Head Start 10 sites, is about 40 percent of those children have 11 advanced decay in their mouths. 12 And when you have a child that has advanced 13 decay in their mouth, they are not able to focus on 14 what they need do. It affects their education. 15 It affects their home life. It affects 16 everything. It affects their health. 17 So what we did, is, we were -- we had really 18 no choice, we hooked up with Eastman Dental up in 19 Rochester. And, we went to them, and said: Listen, 20 we'll give you a telehealth camera. We need to have 21 access to you. 22 Because, currently, Eastman Dental, the 23 pediatric center, is one of the few places in 24 New York State, in our region, where children can go 25 and get surgeries done, or nitrous oxide given to 1 them, so they can get their teeth taken care of. 2 Little kids, you can't take them to a regular 3 dentist to get those teeth fixed, if you have a 4 dentist available. 5 So, we hooked up with Eastman Dental. 6 And now what we've -- the problem with taking 7 a child and referring them to a pediatric dental 8 center, is, it includes at least four visits to 9 get that child taken care of, a completed treatment 10 plan. 11 So, what we have taken is, the telehealth 12 capabilities, and we've taken four visits down to 13 one visit, which is the day of the surgery. 14 So, we do three of those visits via 15 telehealth. 16 And, what's really nice, is that the child is 17 seen at the Head Start center by the pediatric 18 dentist, and the hygienist that sees the child 19 regularly is there providing the actual -- she's 20 presenting the patient to the -- to the pediatric 21 dentist up in Rochester. 22 And, then, the parent is able to come to that 23 Head Start site as well, if they would like to meet 24 with the dentist, because they can all see 25 everybody. And the child gets to meet the dentist 1 that's going do the surgery on them that day, so 2 that they're comfortable. 3 The problem -- one of the biggest problems 4 that this dentist has told us -- the pediatric 5 dentist, is when a kid comes up to his office in 6 Rochester -- 7 And if you've ever been to Eastman Dental, 8 it's a very busy place. 9 -- and these children are terrified. 10 It's an urban center. People are 11 uncomfortable going up there. It's very busy. 12 But their waiting list, once you get seen by 13 a consult, is eight months to get surgery, because 14 they're so busy. 15 So what we've done, is, been able to get the 16 consults and the pre-op, all that done, so that 17 the child then waits for their surgery, which 18 Eastman has given us slots, so we're down to about 19 four months. So, we're pretty fortunate. 20 When we started this process, we looked at 21 our data. And, when we would refer a patient before 22 telehealth, we had about a 15 percent success rate, 23 that those children would actually make it up to 24 Rochester and get their teeth taken care of. 25 Now that we've got this process going in 1 place, we have 83 children that we have gotten 2 through, either with any nitrous oxide or surgery, 3 and we have a 97 percent success rate. 4 And we directly attribute that to the use of 5 telehealth. 6 But, also, we have -- one of the things we've 7 also done, because we're in a rural area, is we have 8 case managers that we assign to all of our kids that 9 end up going through the telehealth process, because 10 there is a lag time between your consults and your 11 surgery. 12 So, the caseworker calls them, and says: 13 "Don't forget, your surgery's in a couple of 14 months" -- you know, to keep people on track. 15 And to make sure, do you -- you know, "Do you 16 have a way up there?" 17 You know, "What are your barriers to 18 getting that care?" 19 And, "Do we need to drive you?" 20 SENATOR HANNON: Yeah. 21 Who's -- and the revenue stream that's paying 22 for -- 23 MARY ANN ZELAZNY: We pay Eastman Dental for 24 those visits. 25 SENATOR HANNON: FQHC? 1 MARY ANN ZELAZNY: Yes, we pay. 2 And, then, when the child goes up for the day 3 of surgery, they're able to bill child's Medicaid or 4 Child Health Plus. 5 SENATOR YOUNG: I'd like to point out that 6 we've been joined by Senator George Maziarz, 7 welcome, and, Senator Patty Ritchie. 8 Thanks for coming. 9 Okay? 10 Oh, I'd like to have some remarks from 11 Tom Holt, from Chautauqua County. 12 THOMAS HOLT: Thanks, Senator. 13 And, I'm here representing the long-term-care 14 aspect of telehealth and home-based monitoring. 15 We've been involved in exploring this concept 16 for about six years now. And, I think much of 17 what's already been said around the policy side and 18 the reimbursement sides applies to just about all 19 of us, if not all of us, in terms of some of those 20 barriers. 21 But one of the challenges that we've found, 22 and Dr. Dubeck made reference it to as well, is 23 that the research that's out there really is not a 24 lot. 25 And there's a lot of good anecdotal 1 information, a lot of good anecdotal experiences 2 that many of us have had. Certainly, our 3 organization has had. But, to wait and rely on a 4 preponderance of evidence is going to hold us back. 5 So, that would just be an observation, or a 6 comment, to make. 7 But I think even more fundamental for us, 8 despite the successes that we've had, has been the 9 challenge of consumer education and awareness about 10 what telehealth and home-based monitoring systems 11 and technologies are, and what they can do, to 12 encourage independence and to keep people at home 13 longer. 14 We joke about the fact, that when we give a 15 presentation to seniors, there's universal 16 acceptance. They all point to what we talk about 17 doing, and say: This is terrific, for you. 18 And then, you know, the 85-year-old turns to 19 the 87-year-old, and says: This technology is going 20 be great for you. I don't need it yet. 21 [Laughter.] 22 THOMAS HOLT: So, we have a lot of work to do 23 in terms of educating our senior population, about, 24 how these technologies can really help keep folks 25 independent, and out of hospitals and out of nursing 1 homes. 2 And, I think we've got lots of anecdotal 3 experiences to share, and I won't bore with you 4 those today, but I think that issue of consumer 5 understanding, and even provider understanding, 6 about how this technology is emerging, and can be 7 used, is critical to the success. 8 SENATOR YOUNG: Congratulations on what 9 you've been able to do. 10 Tom is from my district. And, it's 11 phenomenal, some of the services that can be 12 provided, whether it's monitoring people's blood 13 pressure, their weight, and so on, right in their 14 homes, or in -- wherever they're living. 15 In an apartment setting, in your case. 16 One of the issues that you brought forward 17 too, in addition to what you just said, is that some 18 of the seniors feel like Big Brother is watching. 19 Could you address that a little bit? 20 THOMAS HOLT: Sure. 21 The first monitoring system that we put in 22 place is -- we would consider it to be a passive 23 monitoring system. Really, it's about a thumb-sized 24 motion sensor that's located throughout the 25 apartment or the home. 1 And, we're all creatures of habit. And, very 2 early on, your pattern of behavior becomes known. 3 And, so, this system really monitors by 4 exception. 5 When things out of the norm begin to appear, 6 we, as sort of the back office, are notified about 7 what those changes in behavior are. 8 And, they could be very minor. Or, they 9 could be that someone has not moved for an extended 10 period of time, and require a more active 11 intervention. 12 The seniors have found that to be 13 difficult, initially, to accept that. You know, 14 despite the fact that it's not active monitoring, 15 there is this sense of Big Brother that's happening. 16 And I should make mention of the fact, that 17 we just know now opened a new apartment building, 18 which we've called the "Smartman Building," that was 19 funded with HEAL grant. 20 So, I think a big part of this is access to 21 capital. And I know we've talked about what some of 22 the barriers are. 23 We would not have been able to do what we're 24 doing in this new apartment building were it not for 25 the HEAL Program, which allowed us to get into this 1 new style of housing. 2 But, each of these 14 units come hard-wired 3 with this passive monitoring system in it, so, all 4 the seniors coming into that building are going to 5 have to agree to participate in this monitoring 6 program. 7 And, so, over the course of next couple of 8 years, I think we're going to be in a position to 9 talk a little bit more specifically about, how the 10 educational process, and the acceptance process, of 11 seniors went. But, certainly, there is a concern 12 about Big Brother watching. 13 One of the successes that we've had, frankly, 14 has been in trying to market, if you will, to the 15 children of the seniors. 16 And, the seniors, when it's suggested to 17 them that their kids are gonna be a whole lot more 18 comfortable knowing that there's some kind of 19 monitoring happening, more often than not, the 20 seniors will agree participate if they think that 21 they're doing it to make their kids a little bit 22 more comfortable. 23 In a small rural county, like 24 Chautauqua County, where I'm at, we're getting 25 older, we're getting poorer, and more and more of 1 the young folks are moving away. 2 And, so, the idea of trying to target the 3 kids that have left the area, and keep them 4 connected with the seniors, is something that we're 5 very, very intrigued by. 6 SENATOR YOUNG: Are the seniors intimidated 7 by the technology, in some cases? 8 THOMAS HOLT: I would suggest that it's 9 probably like society in general. There are some 10 folks that are very easy to get into technology, 11 and very comfortable with it. And the same applies 12 with seniors. 13 There's a lot of folks that are really 14 turned on by the technology, and have found, you 15 know, really interesting ways to use them in their 16 everyday lives. 17 And there's some, that it's not for them. 18 But I think that's the case with kids and 19 middle-agers, and just about everybody. 20 ASSEMBLYWOMAN GUNTHER: My mother is 21 85 years old, and I lost my father last year. 22 They were married 62 years. 23 And, you know, first time alone in the house, 24 the whole nine yards. They spent seven days away. 25 So, anyway, we had to get something because 1 we were afraid she was going to fall. 2 And I said: Mom, it's like having a 3 roommate, you know. 4 [Laughter.] 5 And she was, like, okay with it. 6 You know, I explained it that way. 7 And she said, "Yeah." And she was, like, 8 "Okay." 9 And, you know, we pushed in, and Val came on. 10 She goes, "Yep, like a roommate." 11 SENATOR YOUNG: That's good. 12 ASSEMBLYWOMAN GUNTHER: Yeah, it was good. 13 SENATOR YOUNG: Alexis Silver, from 14 HANYS [sic]. 15 ALEXIS SILVER: Thank you. 16 I represent home-care providers, three of 17 whom are with us here today, to talk about some of 18 their remote telemonitoring projects. 19 I would like to, first of all, point out 20 there is a lot of data available that shows the 21 value of home monitoring as opposed to 22 physician-to-physician or spoke-to-hub. They're 23 really different utilizations of the technology. 24 Here, in New York, we have almost 25 100 providers that do home telehealth through the 1 Medicaid program. This is a program that's been 2 very successful in reducing hospitalizations, and 3 reducing health-care-utilization emergency room 4 visits, and also, in some cases, physician visits, 5 as people can be tended to by their home-care nurse 6 before an event happens. 7 I would like to mention, to get to 8 reimbursement, that that current program is at risk. 9 As home care is kind of being dissected, we 10 aren't quite sure how it's going be put back 11 together, but the home telehealth program, which is, 12 actually, a separate funding stream at this time, it 13 is part of the Medicaid-modeled contract. 14 However, a lot of providers are having 15 difficulty, having -- with their managed-care 16 companies picking up that Medicaid piece for 17 telehealth. 18 And, also, within managed long-term care, it 19 is not currently being reimbursed by the managed 20 long-term-care program. 21 So, we'd like to see -- because we have 22 tons of data that support the value of this 23 service, we'd like to see some kind of movement on 24 an alternate funding stream, whether it goes 25 across -- across -- well, I'm not sure what to call 1 our Medicaid programs now, with telehealth. But, 2 for example, it's not reimbursable for 3 TBI programs; for patients that are -- as the 4 home-care industry becomes, basically, more of a 5 subcontractor, it's going to become more and more 6 difficult for them to provide that service in a 7 consistent stream. 8 I'd also like to point out, if you're looking 9 for a large data, the V.A. has incredible data. I 10 think they're currently rolling out up to 11 50,000 units for home telehealth. They found that 12 so successful. 13 It's really, really credible data. There's 14 also a lot internationally. 15 So, uhm... 16 SENATOR YOUNG: Yes, we'll go to 17 Dr. Dubeck. 18 And, we also are joined, via teleconference, 19 with Cynthia Gordon, who is a nurse at 20 Rochester General, and she has a presentation. 21 So, we'll go to Dr. Dubeck, and then we'll 22 go to Cynthia. 23 DR. FRANK DUBECK: I've heard lots of 24 comments about payment, and things like that. 25 And as one of the payers in the room, I sort 1 of wanted to get the feel of the room before I spoke 2 up. 3 [Laughter.] 4 DR. FRANK DUBECK: We've been following 5 Medicare's outline for telehealth since Medicare 6 went on-line. 7 Just recently, we passed a policy, 8 internally, for our commercial business. 9 The biggest hurdle: Is there anything in our 10 member contracts to cover it? 11 And, we took the position: This is just an 12 office visit. This is for clinician-to-clinician 13 type of office visit. 14 We were told by our attorneys, we better file 15 rider with the Insurance Department, and that will 16 be coming. But, I think, instead of waiting for 17 that, we wanted to make this available, to help it 18 take off. 19 It is a way of the future. 20 And, our concern is, with every new service, 21 there's the potential for it being churned, 22 overused, and draining the system of more money than 23 it's saving. 24 That is a concern. 25 The other thing, with emphasis on 1 alternative-payment mechanisms, between medical 2 home, ACOs: 3 Do we want to really create another 4 fee-for-service clique? 5 Or, that this should be some sort of, weekly, 6 monthly, you know, part of the ACO payment, part of 7 the medical-home case-management fee, especially in 8 the primary-care sector, when you're talking primary 9 care to patient maybe in their own home? 10 The problem with telemedicine, in my mind, 11 it's multi-dimensional, and you have to focus your 12 conversation on what dimension. 13 We've heard about provider to provider; 14 I mentioned patient to primary-care doctor. 15 We've heard about psychiatry. 16 We've heard about monitoring of home-health 17 agencies. 18 And, each of these bring their own 19 concerns, in terms of judicious spending of the 20 precious health-care dollar. 21 But, we are in support of telemedicine going 22 forward, and we're taking steps, on our commercial 23 business as well, as we have been doing with it 24 Medicare. 25 SENATOR YOUNG: Thank you. 1 Cynthia, are you ready? 2 CYNTHIA GORDON, RN, MSN: Yes, we're ready. 3 SENATOR YOUNG: Okay. 4 CYNTHIA GORDON, RN, MSN: Can you hear me? 5 SENATOR YOUNG: Yes, I can hear you; we can 6 see you, which is great. 7 And, why don't you go ahead with your 8 presentation. 9 CYNTHIA GORDON, RN, MSN: I'm giving a real 10 quick snapshot overview of what we've been doing for 11 the last five years. 12 We've developed a pretty multi-disciplinary 13 telehealth network here in Rochester, New York, out 14 of Rochester General Health Systems. 15 Right now, we're interfacing. Our first 16 program was with our sister hospital, or our 17 affiliate, which is Newark-Wayne Community Hospital, 18 which is where I'm talking from. 19 In the room here with me today is, 20 Dr. Arun Nagpaul, who is medical director of the 21 hospital at Newark-Wayne Community Hospital; 22 As well as, Karen Schaffer, who is -- 23 Carol Schaffer, who is our nurse practitioner for 24 our telehealth program. 25 We, right now, are interfacing with over 1 14 specialists. When we first started, we started 2 with one. 3 We're also connected with several nursing 4 homes. 5 One thing that I'd like to bring up, as we 6 speak about nursing homes, and I have to reiterate 7 other people's concerns as far as reimbursement, 8 and credentialing. 9 Credentialing, certainly has been eased up 10 over the last few months, with CMS. 11 But, specifically, when we're speaking about 12 nursing homes, great venue to be able to offer 13 health care and specialty consults to the 14 patients in that community, but, the big problem 15 that we have, is with Medicare reimbursement. 16 And just to bring it to light so you all 17 understand: If you're in a health-physician 18 shortage area, you can get reimbursed. If you are 19 not, you cannot. 20 And a simple example: We have a hospital 21 that's close to us, Blossom -- our nursing home, 22 rather, which is Blossom View, which is in Sodus, 23 which is not considered to be a health-physician 24 shortage area. And Sodus, to me, is more rural than 25 Newark; and Newark is. 1 So, there's a lot of discrepancies in what 2 really is considered rural, and what is not. 3 And that really needs to be lifted as well, 4 so that we can really do a very good job of being 5 able to offer telehealth to patients throughout 6 the entire state, whether they're in an acute-care 7 setting, a physician's office, or a nursing home. 8 What I'd like to do is, I'd like to speak 9 specifically about what we've been doing here at 10 Newark. 11 I'm going to let Dr. Nagpaul speak on that, 12 on our behalf; but, we implemented an ICU 13 critical-care consult service here, in a pilot 14 stage, for the last several months. Something 15 that's been a discussion for a really long time. 16 And, he's going to speak to it, from his vantage 17 point, as far as being, the hospitals here at 18 Newark. 19 DR. ARUN NAGPAUL: Good morning. 20 Thank you for the opportunity to talk to you 21 about telemedicine. 22 You know, it's a challenge for rural 23 hospitals to recruit physicians, in general. And 24 even in Upstate New York, that challenge is even 25 greater. 1 But, to get specialists to come out to 2 rural hospitals is almost impossible. 3 So, luckily, with our partnership with 4 Rochester General, we have 14 different specialties 5 that we access via telemedicine. That amounts to, 6 approximately, 50 additional medical-staff 7 members, who don't physically come to our 8 100-bed hospital or so, but, are able to give care 9 to patients via telemedicine. 10 One of the prime examples is our ICU. 11 So, we have a hospitalist team; so, hospital 12 doctors that take care of the ICU patients. 13 But, we don't have an intensive-care doctor. None 14 of the rural hospitals can really afford an 15 intensivist. 16 But, in our situation, using telemedicine, we 17 have an intensive-care doctor round every ICU 18 patient every day, which offers us support, as far 19 as -- 20 [Telephonic interruption.] 21 -- [unintelligible] management, and -- 22 Want to answer that? 23 -- and some of the more high-tech medications 24 that we use. 25 We went from a 5-bed ICU to an 8-bed ICU over 1 the last year, because we're taking care of sicker 2 and sicker patients, and keeping them here in the 3 patient's community instead of transferring them -- 4 transferring the patients out. 5 And, in large part, we're able to do that 6 because we have the backup of the intensive-care 7 doctors. 8 If there's a problem overnight, we can access 9 the intensivists overnight. 10 On weekends: Just last week, there was a 11 cardiac arrest in the ICU. 12 We have very competent doctors, but it was 13 nice to whip up the telemedicine unit and talk to 14 the intensivist, who is in the ICU in Rochester; get 15 some advice. 16 In addition to that, it's not just physician 17 care that's beneficial, they have an ICU pharmacist 18 available to them, which we don't have on staff 19 here. 20 So, we were able to use his knowledge in 21 resuscitating the patient, as far as what 22 medications to give the patient. 23 And when we look back at our data, we've seen 24 that we're keeping sicker patients at our small 25 rural hospital, and our mortality rate has gone 1 down. 2 So, I think the telemedicine is part of that 3 success. 4 I don't know, Carol's been part of the 5 telemedicine program, from the nurse-practitioner 6 standpoint, for years. 7 Anything to add? 8 CAROL SCHAFFER, N.P.: We get involved on a 9 consult service, and then we can actually follow the 10 patients, day to day, until they're considered 11 stable enough to release back to the hospitalist 12 care. 13 So, we're actually interfacing with these 14 physicians, not only through telemedicine, but 15 day-to-day rounding, which makes them feel more 16 comfortable. 17 And, then, we can see them as outpatients 18 further on down the road. 19 So, their care doesn't just stop here; it 20 keeps on going, until they're considered stable 21 enough to release. 22 DR. ARUN NAGPAUL: And, in telemedicine, it 23 isn't just talking to the doctor on the other side. 24 We have a digital stethoscope, so the 25 doctor's able to hear heart sounds, able to hear 1 lung sounds. 2 And, after a while, the patient feels no 3 different than -- interacting with the physician as 4 if they're in the room. 5 So they really -- they really see past that 6 technology, and accept it, I think. 7 The other thing it allows us, we also do 8 outpatient visits here. 9 So, we're about 40 minutes away from 10 Rochester. So, there's some patients in this 11 rural area that feel Rochester is the big city, and 12 they won't go there for a follow-up appointment. 13 So, we're really bringing the doctors to 14 them, in the outpatient setting. And I think a lot 15 of patients would not have received their care. 16 They would have just ignored the follow-up visits. 17 But now that we're able to bring the visit to 18 them, I think that's really improved the health care 19 of our community, in general; not just in the 20 hospital, but also on the outpatient side. 21 And, each month, we're setting a record for 22 more and more consults in telemedicine visits, 23 as -- you know, not only do we need to -- the 24 patients to buy into this, but we need our medical 25 community, the doctors, to refer to the 1 telemedicine office. 2 And I think, over the last couple of years, 3 Sidney and Carol, and our system, have done a good 4 job of making telemedicine, you know, a routine 5 rather than something that's novel. 6 CYNTHIA GORDON, RN, MSN: The one thing I 7 would like to point out here, is this is our 8 tele-ICU cart. 9 And on the cart, we have a computer that has 10 the technology downloaded on it, so that we have a 11 digital stethoscope. 12 And, so, our physicians -- I don't know if 13 anybody's aware of the technology that's out there, 14 but anything that's digital can be communicated 15 through any of this televideo-conferencing 16 equipment. 17 So, we have the digital stethoscope. We have 18 a generalized exam cam, which gives you much more 19 powerful focus and view of the patients, whether 20 it's a wound care, or rash, or whatever. 21 So, think of anything that's digital, whether 22 it be those two things, or OvaScopes, 23 ophthalmoscope, and it goes on and on and on, it 24 could be attached to these units, so that when 25 you're doing a consult with a patient, with 1 exception of a psychiatric visit, most other 2 consults need some type of peripheral added to it, 3 to make for a full consult. 4 One think that we've done in our office, and 5 I'd like to add this to the very end, is, you know, 6 I'm very much involved with The 7 American Telemedicine Association, very much 8 involved with the nursing [unintelligible], as well 9 as other states within that organization. 10 We were faulted by some of our -- the bigger 11 organizations, like UC Davis, and even, Phoenix, 12 Arizona, where they do a lot of telemedicine, 13 because their telepresenters are registered nurses. 14 And that's great. 15 But we decided, in our particular 16 environment, we have a nurse practitioner who's the 17 primary person, who's the telepresenter. 18 We do have a backup RN, but it's because 19 we're doing so many multi-disciplinary rounds on 20 these patients, we're interfacing with so many 21 different types of specialties, we felt it was 22 important to have an advanced-practice nurse. 23 And, that's really been beneficial to us in 24 our practice. 25 So, I just would like to share that with you, 1 because I think it's something that people need to 2 consider when they're putting together a program; 3 that, sometimes you need somebody that has that 4 advanced-practice acumen to be able to do a very 5 good telepresentation for the physician on the other 6 end. 7 And, so, since we're interfacing with 8 nephrologists, intensivists, and it goes on and on 9 and on, that just helps to make a better consult. 10 We also do a lot of geriatric consults, which 11 I think speaks to the aging population. And they 12 work out very well for us. 13 SENATOR YOUNG: Thank you. 14 Does anyone have any questions? 15 We want to sincerely thank you. 16 We wanted to prove the point today, that this 17 actually does work. 18 We appreciate the demonstration. 19 We wish you a lot of luck. 20 And, I personally would like to come out and 21 see things firsthand, someday. 22 So, thank you so much. 23 CYNTHIA GORDON, RN, MSN: Any time you'd like 24 to come, we'd love to show you. 25 SENATOR YOUNG: Thank you. 1 Laurie's had her hand up three times, 2 Assemblywoman Gunther tells me. 3 So, Laurie Neander, who's an RN from 4 Bassett Health, could you chip in? 5 LAURIE NEANDER: Good idea here. 6 Thank you. 7 I really appreciate being here today. 8 And, really, I wanted to expand on some of 9 the comments that have already been made, that the 10 barriers -- 11 Excuse me. 12 -- related to -- 13 Excuse me. 14 -- to expansion of telehealth programs, which 15 have been, I believe, proven very successful. 16 And the evidence -- just to kind of back up, 17 we launched our program, a home community-based 18 program, in 2004. So, quite a number of years 19 ago. 20 And, initially, we rolled out the program, 21 talking with our Bassett board of directors, and so 22 forth, the hospital executives. 23 We didn't address it in terms of reducing 24 hospitalization, because that wasn't very popular in 25 '04. 1 But, we did -- we launched the project, 2 really looking at workforce shortages, which 3 continue to be very acute, of course, in rural 4 areas. 5 So, actually, over time, our project, we now 6 have 140 units in the field, and they are in the 7 field at all times. 8 And our telehealth project leaders routinely 9 ask me to invest in more units, because the need 10 continues to increase. 11 But, what we've been able to demonstrate, is 12 that, ten remote monitoring units is the 13 equivalent of one full-time RN. 14 And, when you look at the cost of providing 15 direct-care services to a patient who lives in 16 Old Forge or Fishezetti [ph.], areas that we know, 17 the cost to send a nurse on a random basis, based on 18 traditional home health-care models, just doesn't 19 make sense. 20 So, we've been able to address workforce 21 shortage. 22 And then, certainly, on the patient-care 23 side, the evidence, and that we've collected over 24 time, demonstrates extreme patient satisfaction. 25 We never use the word "computer," installing 1 a unit in an 85-year-old patient home. 2 We always talk about it in terms of, this is 3 part of your disease-management plan that your 4 physician has prescribed. 5 And we've very been very successful 6 installing the units, and monitoring these patients 7 for a period of time. 8 Our evidence is, over time, CMS issued 9 re-hospitalization rates; that, we have reduced 10 our re-hospitalization rate, from a continued 11 statewide and national average of 28 percent of all 12 patients who are served by home health-care 13 providers, at some time during their course of 14 care, end up back in the hospital. 15 That's a lot of people: 30 percent -- 16 28 percent. 17 We've reduced ours to 16 to 18 percent. 18 So, the evidence demonstrates, and this has 19 been consistent over time, as our program 20 continues to mature. 21 So, I think you asked about solutions. 22 I wanted to give you a little bit of 23 information about our history, and so forth. 24 I think solutions really revolve around, 25 maybe even, just as, over time, the Department of 1 Health have provided acute-care hospitals, 2 critical-access hospitals, a hybrid type of 3 health-care delivery. 4 I think, that, because the barriers are so 5 significant in the state, for home care, they are 6 county barriers. You know, that we operate, as 7 Senator Seward mentioned, in four counties. But, 8 heaven help us if we venture into Schoharie. 9 So -- but there are patients just over the 10 line that really could benefit from these services. 11 So, we know that. 12 So, if we were to eliminate those barriers 13 that include specific operating regions, expand. 14 I have thought for a long time, that if we 15 could look at regional telehealth programs, they 16 could be tied to medical home. They could be tied 17 to home-care providers, which are ultimately, I 18 think, tied to home-care providers anyway, because 19 that's what we do in the communities that we serve. 20 And I think, that, to address the question 21 about -- and there was a concern, I understand, 22 about overuse, is that, you know, we look at 23 providers that have experience; demonstrated 24 experience, demonstrated results. That, we have 25 specific screening criteria. 1 I know my colleagues at the table, we all do. 2 We have -- we do not put a unit in every 3 patient home. It's not indicated for every person. 4 But, for patients who have chronic disease 5 health-care conditions, where we can expand use of 6 the services, I think consumer alignment of 7 incentives is really important, that we demonstrate 8 our results, but, we also engage physicians, 9 providers, referral sources, health plans, and 10 patients. They all have to have some kind of -- 11 something in it for them. 12 So, for consumers, I think that's a problem 13 everywhere. That, unless consumers are on board, 14 and I think telehealth is a real positive method to 15 do that, repeatedly we hear: 16 Improved compliance; 17 Or, if I had only realized -- if I'm a 18 diabetic, if I'd only realized that that cookie I 19 ate last night had such an impact on my condition. 20 So, maybe we look at, you know: If you want 21 to receive health-care coverage in the state of 22 New York, then you need to participate in your 23 health. 24 You know: You need to stop smoking. Healthy 25 behaviors. 1 Or -- I mean, I realize co-payments are 2 difficult. 3 I could go on and on, but, I think about this 4 all the time. 5 And it really is in line with everything that 6 the MRT: the recommendations, efficiencies, quality, 7 outcomes. 8 But, we need to -- reimbursement, sounds 9 like, definitely, to get providers involved. 10 We need, credentialing, privileging, 11 addressed, I agree. That's what I hear from the 12 medical providers within Bassett Health Care. 13 I'll stop, because I could go on and on. 14 ASSEMBLYWOMAN GUNTHER: Seems like you've 15 had a ton of successes. 16 And I was wondering if you could share some 17 of those statistics about your data that you've 18 collected about, the re-admissions, et cetera. 19 LAURIE NEANDER: Yeah, I -- 20 ASSEMBLYWOMAN GUNTHER: Also, 21 Bassett Hospital -- 22 LAURIE NEANDER: Sure. 23 ASSEMBLYWOMAN GUNTHER: -- in Cooperstown -- 24 LAURIE NEANDER: Yes. 25 ASSEMBLYWOMAN GUNTHER: -- like, what's 1 your -- around Cooperstown; and, how far do you go? 2 And, how many units again? 3 LAURIE NEANDER: We have -- 4 ASSEMBLYWOMAN GUNTHER: You used to come to 5 Sullivan County, I know. 6 LAURIE NEANDER: Only when needed, and 7 authorized. But, we aren't in Sullivan, the home 8 care -- 9 ASSEMBLYWOMAN GUNTHER: No, the home care -- 10 LAURIE NEANDER: -- Bassett, yes, the 11 network. 12 ASSEMBLYWOMAN GUNTHER: -- you used to do a 13 lot of work with us. 14 LAURIE NEANDER: Yeah. 15 Well, as I mentioned, the network, as a 16 whole, is, you know, definitely looking at ACL 17 models and network interrogation, disease-management 18 pathways that are acute care to post-acute care. 19 We work together, in terms of trying to 20 identify applications for telehealth. 21 For example: We've had patients in the 22 community that receive home dialysis. And, with 23 additional support monitoring, then they're 24 comfortable, and they can be at home, rather than 25 transporting, you know, to a dialysis center 1 three times per week. 2 As an example: We've dabbled in school 3 obesity; children with obesity. 4 Stroke; one of the problems, just -- I 5 think this is actually something I just recently 6 learned -- the telestroke program, apparently, the 7 hub to, uhm -- 8 Get me terminology correct. 9 GREGORY ALLEN: "Spoke." 10 LAURIE NEANDER: -- spoke, the EMT rules 11 prohibit the patient to be transported to the spoke. 12 They have to be transported to the hub. 13 And, so, there's a conflict between, what 14 we're able to do medically, in treating a patient in 15 a rural area, and a rural hospital remotely using 16 the expertise, just as the ICU expertise you just 17 heard, because of the EMT policy. 18 So, it just seems so big. It almost 19 seems, to me, that -- I guess that's where I come 20 from, when I mentioned the hybrid model, because 21 there's so many conflicts between so many 22 entities, health care, that -- that, maybe, we just 23 need to transform, to do it quickly, to address what 24 we know is a solution: a separate model that 25 waives -- provides providers waived 1 privileges. Or -- 2 Do you know what I'm saying? 3 -- to reduce those barriers. 4 And, you know, I just think New York State 5 has a real opportunity to take the lead, nationally, 6 there. 7 SENATOR YOUNG: Assemblyman Gottfried. 8 ASSEMBLYMAN GOTTFRIED: Can you tell me what 9 the "EMT issue" is that you referred to? 10 LAURIE NEANDER: I could refer you 11 specifically to the physician, Dr. John May, at 12 Bassett Health Care, who provided me that 13 information, because I consulted with him last week, 14 just to get an update, coming here today. 15 And, I was not aware of that; but, 16 apparently, the EMTs are required to take -- 17 transport the patient to a stroke center, rather 18 than a community hospital, where the patient might 19 be provided care using video conferencing with a 20 specialist M.D. Neurologist, presumably. 21 ASSEMBLYMAN GOTTFRIED: Okay. Thank you. 22 SENATOR YOUNG: Did -- Department of Health, 23 did you want to jump in on that? Greg? 24 FREDERICK HEIGEL: Would you like me to, 25 Greg? 1 GREGORY ALLEN: Yeah, go ahead, Fred. 2 SENATOR YOUNG: Fred Heigel, from -- 3 FREDERICK HEIGEL: Fred Heigel, from HANYS. 4 And, we've struggled with this, and we're 5 very strong supporters of the expansion of 6 telemedicine in New York State; Supporters of the 7 telestroke initiative undertaken by the 8 Department of Health. 9 And where the breakdown comes in, is with 10 the emergency medical-services community, because 11 they have certain protocols they need to follow to 12 where they transport patients. 13 And, in the telestroke program, there's a 14 neurologist at the hub site to view the patient at 15 the spoke emergency department, and make 16 determinations, primarily, of whether or not to -- 17 what drugs to treat the patient with, depending on 18 the type of stroke they're experiencing. 19 The problem is, though, that there are 20 protocols in the EMS community that won't allow the 21 potential stroke patient to be transported to a 22 non-stroke center facility. 23 Now, we've worked with the Department 24 positively, with respect to getting stroke-center 25 designation for rural facilities. And, the 1 Department will accept the neurologist at the hub 2 site as fulfilling that responsibility, but there 3 are a variety of other responsibilities -- the time 4 to get the CT scan, a variety of other things -- 5 that are very -- very challenging for rural 6 hospitals to live up to, given that they have a very 7 small volume of strokes, fortunately, and, that 8 they're -- you know, they don't have an excess of 9 personnel to cover all these different services. 10 So, we've worked through that gradually. 11 You know, I know that the goal of the 12 Department of Health is to have, virtually, every 13 hospital in the state become a stroke center, and 14 have that capability. 15 It's a matter of being able to live up to 16 that capability. Then get that designation, to 17 allow the ambulances then to bring patients 18 there, that will ultimately, you know, make the 19 telestroke demonstration a bigger success. 20 SENATOR YOUNG: So, Fred, what needs to be 21 done? 22 FREDERICK HEIGEL: Well, you know, part of it 23 is -- is the shared capacity was out there. You 24 know, it's really not, necessarily -- you know, the 25 technician to run the CT scanner may not be there at 1 2:00 in the morning on a Sunday morning, sort of 2 thing. 3 You know, it -- just, the fact that there's 4 not enough to go around, there's not enough demand. 5 I'm not sure if we're going to be able to 6 solve every situation simply because of the 7 availability of the necessary personnel, versus the 8 standards they have to meet, which are uniformly 9 applied across the state to all hospitals. 10 So some rural hospitals probably aren't -- 11 and they have to make it at an individual judgment. 12 They certainly can tie into the telemedicine system, 13 but they may not be able to meet the other 14 standards, and that affects the, you know, ability 15 for ambulances to bring patients there. 16 Now, patients do come without ambulances 17 too. You know, the patients do arrive in a rural 18 emergency departments, and they do get treated, and 19 they do benefit from the -- you know, the telestroke 20 program. It's just not the entire population that 21 could, you know, be served by it. 22 SENATOR HANNON: So, what's the problem? 23 You don't have someone to run the CT scan to 24 provide the information to the remote neurologists? 25 FREDERICK HEIGEL: Yeah, that's just one 1 example, Senator, yes. 2 SENATOR HANNON: What other capacity -- 3 FREDERICK HEIGEL: And, you know, there are 4 time frames for each of these things to occur. 5 SENATOR HANNON: What other capacity is 6 missing? 7 FREDERICK HEIGEL: Well, you know, there's -- 8 it's -- you know, any hospital can probably call in 9 a technician to run a CT scanner, but, can they do 10 it in enough time to get the results to the 11 neurologist to make a decision in a time frame when 12 there's still clinically beneficial? 13 SENATOR HANNON: But what's the alternative? 14 Taking the patient to a stroke center? 15 FREDERICK HEIGEL: That's what happens. 16 SENATOR HANNON: And, so, suppose it takes 17 longer to get the patient to the stroke center than 18 it is to get the technologist to the rural hospital? 19 FREDERICK HEIGEL: I suppose that's possible, 20 and does happen occasionally. 21 You know, I just don't have any data on that. 22 But, you know, it's not just -- you know, 23 it's -- in order to get the stroke-center 24 designation, you have to have this capacity all the 25 time. You know, and that's a big load for many of 1 the rural facilities, particularly the smaller rural 2 facilities, to carry. 3 ASSEMBLYMAN GOTTFRIED: I -- 4 SENATOR YOUNG: Thanks, Fred. 5 I think the Department of Health wanted to 6 jump in? 7 Oh. 8 ASSEMBLYMAN GOTTFRIED: I would think it's 9 relatively simple -- emphasis on "relatively" -- to 10 write a regulation that said -- or protocol, that 11 says, that, if the spoke hospital is, at that hour 12 of that day, clinically, up to what has to be done 13 at the bedside, that the EMT could be told that 14 fairly quickly, while the ambulance is at the scene, 15 and, be authorized to take the patient to the spoke 16 hospital rather than to the hub. 17 Now, obviously, if the -- if the equipment is 18 not ready to be staffed at the time the patient 19 would get there, that's a different issue. 20 But, if the spoke hospital has the CT scan 21 and the technician to run it at that time, it would 22 seem to me a pretty simple regulatory change, to 23 tell EMTs to go to the spoke hospital for that 24 patient at that time. 25 SENATOR YOUNG: Dr. Dubeck, you had -- 1 FREDERICK HEIGEL: I was going to say -- 2 I'm sorry. 3 SENATOR YOUNG: Go ahead. 4 FREDERICK HEIGEL: -- that just kind -- that 5 sounds somewhat like -- you know, like a part-time 6 stroke-center designation to me. You know, during 7 select hours. 8 And -- 9 ASSEMBLYWOMAN GUNTHER: Is there such a 10 thing, in order to become a stroke center, you have 11 to be credentialed as a stroke center, wouldn't you? 12 FREDERICK HEIGEL: Yes. 13 ASSEMBLYWOMAN GUNTHER: And you also have to 14 have, like, a certain sample size? 15 Like, in other words: How many people come 16 in order to be able to say: 17 Geez, you're doing a great job; 18 Or, you know: We're not going give that you 19 designation. 20 It's like, Sullivan County, we transport all 21 of our MIs that need any kind of cardiac 22 intervention down to Westchester, or different 23 hospitals. 24 FREDERICK HEIGEL: Uh-huh. 25 ASSEMBLYWOMAN GUNTHER: And what happens to 1 hospitals, I think they become gun-shy, because, 2 then, usually, we transport all of our viable 3 patients; and, so, you're left with people that, 4 you know, there's not a lot of hope. 5 And, so, if you have three patients, and 6 two die, makes you look like you're a really 7 rotten hospital. But, they put that out in the 8 press. And you're, like: What, are you kidding me? 9 FREDERICK HEIGEL: You're right about that. 10 ASSEMBLYWOMAN GUNTHER: The patient with a 11 105, and with 900 comorbidities, and, there's no 12 way. 13 FREDERICK HEIGEL: You're exactly right about 14 that. 15 And that brings some reluctance on the part 16 of some rural facilities to, you know, even try and 17 be in the game, because the volume is so low, and 18 the risk, as you're describing, is pretty high. 19 SENATOR YOUNG: Dr. Dubeck, did you -- 20 DR. FRANK DUBECK: Yeah, if it was easy, it 21 would have been done. 22 SENATOR YOUNG: -- then Vicky -- 23 DR. FRANK DUBECK: One of the problems is, 24 that, stroke patients, when EMTs get there, 25 often look alike. And whether they could be handled 1 in a spoke hospital with an infusion of the right IV 2 drug, or, whether they need an invasive radiologist 3 to instrument them, which is not typically available 4 at the spoke hospital, there's no way an EMT's 5 training, no way I could do it in the field, without 6 the CT scan. 7 And, so, there has to be some sort of 8 judgment made, most of the time, where are most 9 patients going to get access to care rapidly, 10 because, with stroke, time is brain. 11 And that's the overriding principle. 12 And, so, you know, to put that judgment on an 13 EMT is way above their pay grade. 14 ASSEMBLYMAN GOTTFRIED: So it -- it -- I 15 mean, there are serious clinical issues that need to 16 be sorted out, but it -- at least, if it would make 17 clinical sense to take the patient to the spoke 18 hospital that is closer by, there shouldn't be a 19 regulatory, or a coverage, obstacle to doing that? 20 DR. FRANK DUBECK: Yeah, you want to leave it 21 to their judgment as to: Is it quicker to get them 22 to a spoke hospital and get an initial evaluation, 23 and then take them to the stroke center? Or, is it 24 just faster to get them to the stroke center? 25 We see many calls for air ambulances just 1 for that, so they can get right to the stroke 2 center. 3 SENATOR YOUNG: Thank you. 4 Vicky, would you like to contribute? 5 VICKY HINES: Thank you. 6 Can you hear me? 7 I actually want to follow up on a very 8 important comment that Laurie made about patient 9 engagement, because I think that is an unsung 10 benefit of telehealth that, perhaps, may be more 11 important than all of these other benefits that 12 we're talking about. 13 And just by way of background: We are -- 14 we're very similar. We're a home-care agency, so we 15 do what I call, both, "traditional" and 16 "non-traditional" use of telehealth. 17 By "traditional," I mean reimbursable; and by 18 "non-traditional," I mean, not. 19 So, I won't -- I won't beat that dead horse. 20 But, we do non-video biometric monitoring for 21 diabetics, heart failure, COPD. 22 And, like many of the outcomes you've heard 23 around the table already, our minimum outcome is a 24 25 percent reduction in rehospitalization and ED 25 use; and our max is between 50 and 60 percent 1 reductions. 2 So, we've had just some terrific results 3 from that. 4 We believe that one of the primary reasons 5 we have those results are because of the 6 patient-engagement perspective. 7 So, this is not clinician to clinician. This 8 is the patient interacting, on a daily basis, with 9 their own health status. 10 Most of the -- the good technology today is 11 relatively easy to use. And it includes, not just 12 the biometric monitoring, but also some education 13 components. 14 So, you have a patient who may have been 15 struggling with a chronic illness for a long time, 16 has had access issues; so, doesn't, either, easily 17 get to the doctor, or doesn't make those follow-up 18 appointments that we're so concerned about, and 19 we've heard about today. 20 But, they have an interaction in their home 21 every single day with the system, that tells them 22 what their A1C level is, or what their blood 23 pressure looks like, and helps them tie it back 24 to what they ate the night before. 25 And, we have so many just serendipitous 1 examples of patients who will say: Oh, my gosh. 2 I realized I can't eat baloney sandwiches. 3 I mean, that's a silly example, but the 4 reality is, these are folks who have been struggling 5 with illnesses for a very long time. And until you 6 put information and some control in their hands, the 7 bells don't go off. 8 I have been a big and vocal component of, we 9 have to design our health system around making sure 10 that patients feel that they have some obligation, 11 to pay attention, to take care of themselves, to 12 interact with the system in the right way. 13 And this is -- this technology is one way to 14 make it easy for them to do that; and, frankly, it's 15 really satisfying. 16 All of the results, certainly, that I know 17 of from home-care agencies that have been using 18 telehealth for quite some time, very high patient 19 satisfaction. And, in part, because, one, it 20 feels good to know that you're being monitored; 21 but, two, it feels really good to know that you 22 have some control, and that you're in a 23 decision-making mode. 24 And I don't think we have a system designed 25 around making the patient central to their own care, 1 and this helps us to get there. 2 SENATOR YOUNG: That's great. 3 Assemblyman Morelle. 4 ASSEMBLYMAN MORELLE: Thank you. 5 And thank you for -- everybody, for being 6 here this morning on a really important topic. 7 And I just wanted to underscore what 8 Vicky Hines has said. 9 I've spent a fair amount of time visiting 10 folks that have used the system they have in place. 11 And, indeed, talking to those individuals, 12 the sense of empowerment that they have over their 13 own well-being, is not only important for the system 14 to work, but it's important for them. And they 15 certainly seem to have embraced it. 16 And I think that's critically important, as 17 we're trying to get people to take more 18 responsibility in terms of lifestyle, and other 19 things that relate to their own health care. 20 So, I appreciate that. 21 But, I just wanted to thank everyone for 22 being here today. 23 SENATOR YOUNG: Great, thank you. 24 Michelle Mazzacco. 25 MICHELLE MAZZACCO: I think it was on, and I 1 turned it off. 2 Thank you. 3 I'm with the Eddy Visiting Nurse Association, 4 and we serve five counties in Upstate New York, two 5 of which, Columbia and Greene, are very rural, and, 6 the other three which have some very rural pieces to 7 them. 8 We have about 340 patients that we monitor on 9 telehealth on any given day. 10 And, later, I can share results with you of 11 two studies that we completed: 12 One of patients who were receiving in-home 13 services, combined with telehealth; 14 And one where we partnered with an insurance 15 plan, and provided telehealth as a standalone 16 service. 17 I want to go back to a comment that Lexi made 18 earlier, because, we have been fortunate, unlike 19 much of the discussion around the table today, in 20 home health to have Medicaid funding, thanks to 21 Senator Hannon and others. And that has made an 22 enormous difference. 23 We have a re-hospitalization rate for our 24 long-term home health-care program patients, who 25 are all eligible to be placed in a nursing home, but 1 are being cared for at home, that is equivalent to 2 our non-long-term home health-care program patients. 3 And that really is, because about 20 percent 4 of them are receiving telehealth on any given day. 5 I was surprised, as we see ourselves moving 6 into a Medicaid and a managed long-term-care system 7 in home health, not to see telehealth as a mandated 8 service. 9 So that would be one of our suggestions 10 today, is that you look at mandating that, and 11 requiring that telehealth be among the services 12 required by a managed long-term-care program, or a 13 care-coordination model. 14 It's not included today in the listing of 15 services that are required. 16 And when you look at the investment that 17 home-care agencies have made, and had some success 18 with, thanks to funding from the State, if that 19 isn't carried over from the long-term home 20 health-care program today into the managed care -- 21 managed long-term-care arena, it will be lost. 22 It can take years, as a home-care provider 23 today, to get a contract with a managed-care plan. 24 It can take more years to get use of that 25 contract, once you have it. 1 So, I think that incorporating it, based on 2 the evidence that we already have, regarding its 3 effectiveness, is important. 4 And I don't want to forget to mention, that, 5 you know, in rural areas that we look at surveying, 6 one of the opportunities that we see, is to use 7 telehealth in a preventive basis, and, including as 8 a standalone service. 9 So, for example: We have what are called 10 "kiosk tele-home-care units" that we place in 11 various senior apartment buildings in the area. 12 We'd like to be able to expand that to, you 13 know, being on Hunter Mountain, at a community 14 center or a church, or whatever building is where 15 seniors congregate, and to be able to allow them 16 to share one piece of technology with swipe cards, 17 which is what we use today in other sites, to 18 monitor their chronic illness and disease 19 management, but, there isn't funding for that. 20 So, even if that was to be funded on a 21 demonstration or a pilot basis, to gather outcome 22 data, I think it would be very helpful, on a 23 preventive basis. 24 The two studies that we did, one was in the 25 long-term home-health-care program, and it was 1 funded by a Department of Health. 2 There were 31 patients served, who received 3 telehealth for 12 months, and we compared their 4 outcomes, 12 months before, to 12 months 5 during, telehealth. 6 We had a 31 percent reduction in emergency 7 room visit rates, and a 42 percent reduction in 8 hospitalization rates. 9 We then enrolled 53 members, in partnership 10 with a local health plan, who received 11 tele-home care only, in a second study. 12 Their average age was 72, and 56 percent of 13 these members had more than two chronic diseases. 14 We reduced re-hospitalization rates by 15 55 percent; emergency room rates by 29 percent. 16 Data provided from the health plan, $1.1 million 17 savings. 18 The only cost area that they saw increase, 19 was pharmacy costs went up 2 percent, and we 20 attribute that to the fact that we were successful 21 with medication adherence. They were actually 22 taking the meds they were supposed to take. 23 So, you know, we're kind of beyond the 24 "evidenced" stage of this. We see telehealth as 25 effective in conjunction with home care. 1 We also see it effective in a preventive 2 mode, separate and apart from tele-home care, as a 3 standalone service. 4 If we can avoid that acute episode, we often 5 don't need telehealth even after -- afterwards. 6 And bringing telehealth in rural areas, to 7 community centers, senior centers, churches, in a 8 kiosk-shared format, would be a very cost-effective 9 way, but there has to be a way to pay for the 10 RN time to do the monitoring. 11 And that's what limits us today. 12 Thank you. 13 SENATOR YOUNG: Thank you. 14 At this time, I'd like to go to Rachel Block. 15 And, I know Greg Allen also has a 16 presentation, but we'd like to hear from the 17 Department of Health. 18 RACHEL BLOCK: Thank you. 19 And I'm not going go through my presentation 20 in detail. I'm just going to pull out a few 21 highlights which I think are relevant to the first 22 question, which you posed, that is really what the 23 Commission wanted to accomplish today, which is: 24 What are some of the barriers, or, potentially 25 opportunities, to develop a statewide capability to 1 support telehealth? 2 As I think many of the members, as well as 3 the stakeholders who are here today, know, we've 4 been working for the past five years to develop 5 what we call "The Statewide Health Information 6 Network of New York." 7 And the basic idea here, was to coordinate, 8 on a statewide basis, but also to facilitate, at the 9 community level, the development of the 10 health-information technology capabilities that are 11 necessary in order to have a patient-centered 12 system, and to really mobilize information at the 13 community level, which are relevant for the 14 particular health priorities of those communities. 15 So what we think we have accomplished through 16 the governance, technical, and other activities that 17 we have supported, primarily funded through the HEAL 18 New York Program over the last five years, is the 19 statewide identification of key priorities which we 20 want the technology to be able to support. 21 Telemedicine, currently, is on the radar 22 screen, but it was identified through our consensus 23 process as a little bit more of a longer-term 24 priority. 25 So, the Commission's input would be very 1 valuable, in terms of helping us to establish where 2 we should be ranking this in the relative scheme of 3 things of various other things that the stakeholders 4 had already identified. 5 We also have regional health-information 6 organizations, which many of the stakeholders here 7 today have been active participants in, and they 8 really accomplished two important purposes. 9 By bringing those community stakeholders 10 together, they can identify the most efficient 11 means to deploy technology across the community. 12 Instead of having each provider out there 13 trying to figure this stuff out on their own, they 14 can come together and jointly determine what kinds 15 of technology capabilities may be helpful to solve a 16 particular health or health-care problem, and then, 17 jointly support that through funding. 18 But the other key element, which was really a 19 side benefit, that I don't know that we understood 20 we were facilitating when we started this, is that, 21 each of those RHIOs has brought together the key 22 clinical stakeholders and the key payer 23 stakeholders in their community, to be an active 24 part that collaborative process of determining the 25 priorities. 1 And, in certain cases, some of these very 2 issues around payment, and the support for various 3 technology and care-coordination models, have 4 actually advanced, to some degree, through those 5 community-based discussions. 6 So, the RHIOs evolved to be much more than 7 just about technology; but, really, how to 8 facilitate the use of technology, in the community 9 context, in order to help achieve the health 10 priorities for that community. 11 The other component which the RHIOs have 12 helped to support, though, is what we call 13 "adoption support." 14 This is really involving, and several of the 15 comments today address this as well, that you 16 don't just put the technology out there and expect 17 it to be used, unless you understand the 18 capabilities that are necessary, in terms of, 19 staffing, the work flow that would be associated 20 with the new technology. 21 And this would apply, not only to telehealth, 22 but, really, to many other new technologies in 23 health-care settings. 24 So, one of the things that the RHIOs were 25 able to do, is, identify the resources that can 1 actually go out and assist those practice settings, 2 in terms of the appropriate use of these tools and 3 technology. 4 Finally, one important component of this, 5 several comments have been made today, about: 6 What is the evidence to support this? 7 And, what kinds of research has already been 8 done? 9 A key component to the health IT program 10 funded through HEAL has been the independent 11 academic evaluation of the various 12 health-information technology programs that we 13 have implemented. 14 And, so, we have a whole suite of both 15 qualitative and quantitative studies, focusing on 16 cost, quality measures, outcomes, patient 17 experience, as well as studies that are looking just 18 at the process of implementation, so we can better 19 understand how to improve and make that more 20 efficient. 21 And it would be, I think, quite reasonable 22 across all of these domains -- the governance, the 23 regional health-information organizations, the 24 technical services associated with the 25 Statewide Health Information Network, the 1 implementation support capabilities, and, finally, 2 the evaluation -- to work with us, to say: Here's 3 how we would like to really integrate telehealth as 4 a key component across all of the domains of what 5 the infrastructure that we have already developed. 6 So, I thank you for being here today. 7 It's actually been extremely informative for 8 me as well. 9 And, if there are any questions, happy to 10 take them; but, also, to have follow-up discussions 11 with the members if you would like to pursue this 12 further. 13 SENATOR YOUNG: Rachel, how can the 14 Commission get the studies that you referenced? 15 RACHEL BLOCK: I can -- in the slides, 16 there's actually a listing -- a high-level listing 17 of all of the different studies which are currently 18 being conducted under the health IT program. 19 And, we could certainly arrange a briefing, 20 or a webinar, with the lead investigators, if you 21 would like more detail. 22 SENATOR YOUNG: Okay, great. 23 And, I want to point out, if people brought 24 supporting information or presentations, we'd like 25 to have copies for the Commission. 1 If you could make sure that we get those 2 before we leave today. 3 Greg, did you have a presentation that you 4 would like to give also? 5 GREGORY ALLEN: I will spare us the pain of 6 doing my presentation, but I will also just do, 7 quickly, some comments. 8 SENATOR YOUNG: Senator Hannon said, if 9 you're not allowed to do your presentation, you're 10 going to kill Senator Hannon. 11 So, we don't want that to happen. 12 So -- 13 GREGORY ALLEN: I can also publicly promise, 14 no death to Senator Hannon. 15 [Laughter.] 16 SENATOR YOUNG: Thank you. 17 SENATOR HANNON: Well, let me just give you 18 background. 19 The State is going through the Medicaid 20 Redesign Team. 21 And, the key leader of assembling a vast 22 number of recommendations in the studies to support 23 that, falls at Greg's feet. 24 And, it's been done quite well, and there's 25 lots more to be done. 1 But, the interesting part, for what the 2 Commission has done, is to take rural health, take 3 telemedicine and telehealth, and give it a priority 4 that, probably, it did not have. 5 So, this is very useful. And it's where -- 6 it's a mutual, I think, learning experience for the 7 Commission, and for Mr. Allen. 8 SENATOR YOUNG: Thank you. 9 GREGORY ALLEN: Thank you very much, 10 Senator Hannon. 11 I'd just say, that, you know, as part of 12 Medicaid redesign, we -- we, at the 13 Health Department, took this seriously. We've been 14 working on going in collaboration with the hospital 15 associations, our legislative colleagues, and many 16 of the folks around this table, to try to utilize, 17 in many ways, to get out of the way; and, also to, 18 not only just pay, but make sure that we didn't 19 create barriers around that payment. 20 I just want to reflect for a second on what I 21 heard today in our take-homes, if that's helpful, 22 and then just a quick list of a couple of 23 opportunities that might not have been mentioned 24 here today. 25 The first thing I heard, is that, we really 1 need be flexible in terms of who's in the program; 2 and that includes mental-health clinics, and also 3 physician and practitioner offices. 4 So, I'm going take that as a take-home to our 5 policy team, to add to our Medicaid redesign 6 proposal here, to take a look at including those 7 entities importantly in this. 8 The other is, that we should look 9 aggressively at privileging; to do whatever we can 10 do to eliminate barriers on privileging, like we did 11 on credentialing. And, we'll that back as homework 12 as well. 13 I know there's a lot of activity and a lot of 14 discussion on the EMT issue. I know many smart 15 folks have been engaged in that, outside of the 16 payment-policy window that I look at, but we'll 17 continue to engage with Fred and his colleagues, in 18 trying to do whatever we can do to help on the EMT 19 issue. 20 The other I heard was, paying for 21 non-physician time, for monitoring, and other 22 activities. 23 I know that we -- you know, we do pay for the 24 doc time, the nurse-practitioner time. 25 I heard RN time is an issue. We'll take that 1 back as well. 2 I also heard that we need to take a look at 3 regionalizing this availability, and looking at 4 getting rid of, sort of, boundaries that get in the 5 way -- potentially, of service-area boundaries that 6 might get in the way. 7 And I think that that sort of keys back to 8 my "opportunity" list. 9 The first big opportunity is another piece 10 that the MRT launched, which is the health homes. 11 Health homes really are a building on the 12 patient-centered medical home. It's a way to take a 13 multi-disciplinary-, multi-institutional-layered 14 look at our highest-need patients, and provide 15 care management in a different way. 16 I think telemedicine and telehealth can be 17 critical strategies in achieving the goals of 18 those projects. 19 And may -- I took the comment of: Do we 20 really want to add this as one more fee-for-service 21 clique, or should we try to create some kind of 22 consolidated payment opportunities? 23 And the health home may be the structure from 24 within which to think about consolidated payments 25 for population-based health, again, so that we can, 1 maybe, get out of having to invent a rule for every 2 payment, and then watch that. 3 And that -- that really sequences well with 4 our desire to get out of fee-for-service, and to get 5 into a more of a care-management mode, and paying 6 for care managements. 7 The other opportunity is connected with 8 health home. We've been trying to do some flexible 9 certification, potentially across behavioral-health 10 services, mental-health, substance abuse, and 11 physical health care. 12 I think that can remove some of the 13 barriers we talked about, in terms of Article 31's 14 playing. And, we might be able to do something 15 quickly on that. 16 And the last is, a -- really a stop-gap. And 17 it's outside of the space of this, but it's a 18 commercial; and that is, that the Medicaid program 19 pays for transportation. 20 And as part of the Medicaid Redesign Team, 21 we've installed transportation managers in many 22 counties. We're eventually going to go statewide. 23 Many rural counties are currently covered by 24 this. 25 And the job of those managers is where this 1 is not installed, where we really cannot plug 2 somebody into local health, that we can bring them 3 to the health care that they need, and that Medicaid 4 will pay for that. 5 And we're working very hard to get those 6 managers to do a good job with being sensitive to 7 the needs. 8 And then the last stop-gap I'll mention is, 9 "call us." 10 When -- what it -- really, we don't like to 11 hear are special stories of unique patients, that, 12 because of a payment rule, or an individual-access 13 problem, we couldn't get somebody the care they 14 need. 15 Our staff worked very hard on individual 16 circumstances, to get services for patients that 17 need it, as do our health plans. 18 So, I would just encourage people, that, as 19 special circumstances come up, and special 20 patients come up, that those be -- we be made 21 aware of those, and how our policy might be 22 conflicting with providing good care or timely care. 23 With that, you know, I appreciate the 24 opportunity. 25 I learned an awful lot here today. I thought 1 this was tremendously valuable. 2 ASSEMBLYWOMAN GUNTHER: I have one question 3 about the health homes. 4 Would that limit the usage of telemedicine 5 now? 6 Like, in other words: Would it be only a 7 specific population that you're saying, because 8 about the clique and the payment? 9 So, you know, when I was listening to Laurie 10 talk about, like the dialysis patient, and I think 11 about being on Medicaid, and we're paying the 12 transportation to go to the facility for the 13 dialysis, and, we're saving because they're not 14 getting infections because they're in a community 15 situation; versus, like, creating another, like, 16 limitation of smart and cost-effective medicines. 17 So, I don't know that -- you know, I 18 understand what Frank said about the -- you know: 19 Do we want to have another clique? 20 And I think, you know, this is personal. 21 And, sometimes, when I think about, you know, 22 the practitioners, and you listen and you listen, 23 that we're so afraid, you know, to spend a little 24 bit of money to get a lot of results; and, so, 25 that we end up limiting because we're afraid. 1 And, in all honesty, it's like the best way 2 to deliver care. 3 So, when I think about, like, framing it to, 4 like, a home-health model, or a health home model, 5 again, you know, we do that, right now. 6 And, you know, I think about, like, my 7 patients that go to dialysis. The money that we 8 spend to transport that patient, when Laurie's doing 9 it in the house, and preventing infection, it's 10 just, like, amazing stuff. 11 And I -- you know, I hope that, you know, 12 New York, we're doing so many great things. 13 So, I'm hoping that we'll do the same thing 14 in the care -- the delivery of health care. 15 And, you know, I think that -- I always 16 believe, when I worked in a hospital, and -- you 17 know -- 18 And not that I'm an expert at all. I just 19 was lonely old nurse. 20 -- but they -- when we created policies and 21 procedures, we always went from the bottom, up; 22 not from the top, down. -- because, it's these men 23 and women that are in the field, that can really 24 teach us how to, like, deliver the best quality, but 25 cost-effective. 1 And they know. 2 They know. And they, like -- I remember -- I 3 know, that when the home-health folks come and 4 visit me, they're beating their head against the 5 wall, because they know they've got it. 6 But, they want someone to take what they have 7 and they -- you know, you have all of this 8 data-driven information. 9 I mean, this is, like, the coolest stuff 10 around. 11 And, I think that, you know, let's go with 12 it. 13 SENATOR YOUNG: Well, could he respond to 14 what Assemblywoman Gunther said? 15 GREGORY ALLEN: Thank you. 16 I think those are apt concerns. 17 I would say, on the concern about creating 18 another layer that actually produces a barrier, 19 rather than facilitates, is an apt one. 20 The health homes really are targeted to 21 people with multiple chronic conditions. 22 So, I believe that they're a very appropriate 23 structure for us to think through, removing some of 24 these barriers, and trying to figure out an entity 25 to attach some form of a global payment to. 1 There are other entities. It is just one I 2 mentioned as one opportunity among many. 3 There's also our -- the growth of health 4 plans, the special-needs' plans of ACOs, that 5 may also offer similar opportunities to, sort of, 6 crack this nut. 7 In terms of the -- just the comment, I think, 8 is just that it's very hard to just keep adding 9 individual fee-for-service elements, then with a 10 control element on top of those. 11 And, really, what we ultimately want to do, I 12 think, is vest the decision-making as far down in 13 the service-delivery chain as we can, again, so that 14 those "lonely old nurses" can influence the policy 15 about what needs to be delivered to a patient. 16 And, as far as that gets away from my desk, 17 and is more -- and as more of that localizes, and 18 people feel the impact of good decisions and poor 19 decisions, relative to resource allocation, locally, 20 I think we're probably a little closer to achieving 21 population health. 22 SENATOR YOUNG: Thanks, Greg. 23 Senator Seward. 24 SENATOR SEWARD: Yes, I would agree with 25 Assemblywoman Gunther; this is cool stuff that we're 1 talking about here today. 2 And, unfortunately, I need to leave to 3 conduct a committee meeting. 4 But, before I do, we've heard, in terms on 5 the reimbursement issue, you know, is involved with 6 the Insurance Committee. I guess we're on the payer 7 side of the equation. That, we've heard through 8 Director Allen, in terms of what's happening in the 9 public programs in New York, and the Excellus 10 policy in terms of commercial policies. 11 Other than that, is it safe to say, it's 12 pretty uneven out there, in terms of private 13 insurance carriers, in terms of what is covered in 14 terms of these telemedicine services? 15 I mean, is it -- 16 FREDERICK HEIGEL: It varies, and it's 17 inconsistent, between payers. 18 That was one of the points I was going to 19 make, you know, that consistency would help, 20 because, you know, when you treat a patient, you 21 don't necessarily differentiate based on payer. You 22 look at what they [no audio]. 23 So, there is that variation. 24 You know, and if I may, also, if I could pick 25 up on that: What we tried to do, from the 1 association perspective, is really a two-pronged 2 approach, and you maybe think of one prong. 3 One is, we're trying to educate our members 4 with respect to what you can do in New York State. 5 And that continues to change, and improve, but 6 there's old myths out that there that create, 7 almost, their own barriers. You know, we can't do 8 that in New York; and, oh, yes, you can. 9 And what we have tried to do, is, we brought 10 in folks, like Cynthia, and like Ken, and I 11 visited Laurie, and I know Mary, to showcase their 12 operations. To show what can work in New York 13 State, and it can be done here, in an effort to, you 14 know, knock down some of those myths. 15 But, at the same point in time, what we're 16 trying to do, is address the barriers that our 17 membership raises. 18 And our membership is statewide, so we hear a 19 whole range of different things. 20 We worked very closely with Greg and his 21 folks. 22 I see Ron Bass over there, in the Medicaid 23 Office. 24 They've been very good working with respect 25 to Medicaid. They've assisted us in working with 1 the surveillance people at DOH, with respect to the 2 credentialing issues, and Medicare shifted into that 3 in the last year or two. 4 But it seems, like, every time we identify 5 and address a barrier, well, the next one down the 6 road comes up. 7 And Greg was talking about that on the 8 credentialing of -- privileging piece. There's also 9 a requirement that hospitals do, quality assurance 10 peer-review. 11 And in the hub-and-spoke monitor he 12 described, for example, well, the spoke is linked to 13 the hub because they don't have that specialist 14 at -- you know, at the spoke; and, so, how are they 15 going to do quality assurance without some kind of 16 very elaborate, expensive process? 17 That's kind of one of the next hurdles we 18 have to, you know, figure out a way to address. 19 And as I mentioned earlier, in response to 20 Senator Steward [sic], there is an inconsistency 21 between payers. 22 So, as I think we've heard, you know, a 23 common theme here today, that, you know, the 24 barriers are, reimbursement and credentialing. 25 And, as we move through those, and work 1 through that, they will be addressed, and, 2 hopefully, in short order. 3 A couple of things we haven't really 4 addressed, though, is, you know, there are 5 telemedicine providers from out of state. 6 Most of what we talked about here were really 7 within New York State. There are telemedicine 8 opportunities for New York State facilities, you 9 know, from firms out of state. 10 I know that brings in some competitive 11 element, but -- to apply New York State standards to 12 out of state. You know, it varies, by state to 13 state. 14 So that really raises, for example, the 15 credentialing issues, you know, and how far you have 16 to look back, for example. 17 And, so, the mismatch between some of the 18 New York State requirements, with the federal 19 requirements, certainly with other states, is 20 somewhat of an impediment for expanding telemedicine 21 to include, you know, these national providers, 22 some of them are international providers, in fact. 23 And, to bring specialty services, and access, and 24 quality, you know, to some degree, even addresses 25 the physician shortage we're seeing in this state. 1 But I do think -- you know, we've heard a 2 common theme, and we certainly believe that it's -- 3 telemedicine and telehealth is part of the 4 health-care delivery system of the future. And 5 there's a substantial potential there, I think a 6 very real potential, to save the delivery system a 7 fair amount of money, and improve quality at the 8 same time. 9 And I thank you for the opportunity to be 10 here today. 11 SENATOR YOUNG: Thank you. 12 Yes -- 13 ASSEMBLYMAN GOTTFRIED: Question? 14 SENATOR YOUNG: -- Assemblyman Gottfried. 15 ASSEMBLYMAN GOTTFRIED: I have a question for 16 Greg Allen. 17 In home health-care and managed long-term 18 care, how does Medicaid, or does Medicaid, and if 19 so, how, cover costs of telehealth, telehealth 20 monitoring? 21 I know there has been a concern about 22 home-health agencies' costs of providing these 23 services, taking up space under their administrative 24 cap, rather than being treated as a treatment cost. 25 How do you sort all of that out? 1 And are -- can we expect some new thoughts, 2 or actions, in that area? 3 GREGORY ALLEN: Assemblyman Gottfried, thanks 4 for the question. 5 I'm definitely pinch-hitting when it comes to 6 telehealth and managed long-term care. 7 I'll give you what I know, and I'll take the 8 rest back. 9 We do pay for telehealth services for folks 10 that meet certain risk profiles in Medicaid. And, 11 we've done that through demonstration funding. 12 We've got three levels of funding. 13 And, actually, the uptake of those services 14 is much larger than our telemedicine uptake has 15 been. It's been a -- an area that we think there 16 could be a lot more volume, but there's pretty 17 decent volume there on most of it, on the 18 home-health monitoring side. 19 Some of which is what we heard about today, 20 has been funded by Medicaid, and paid for through 21 that demonstration. 22 I have to take back the interface between 23 that and the managed long-term-care product, in 24 terms of what's paid for there, because I don't know 25 the answer to that. 1 It's an excellent question, and I apologize. 2 I just don't know the answer. 3 ASSEMBLYMAN GOTTFRIED: Okay, thank you. 4 SENATOR YOUNG: Okay. 5 Senator Hannon. 6 SENATOR HANNON: Yeah, as we're discussing 7 the topic of the roundtable, was telehealth and 8 telemedicine. 9 And,I think Mr. Allen's point is -- is, I 10 think the tip of an iceberg, because, we have two 11 different, really, topics here that we've had to 12 explore. 13 Obviously, there's a number of problems 14 that need to be resolved, and addressed, in regard 15 to telemedicine. 16 Telehealth is a lot simpler. 17 You don't have credentialing. You don't have 18 privileges. You don't even need a lot of the new 19 programs that have come forward to advance the 20 regional health-informational networks. We don't 21 have electronic billing as a problem. 22 What it does offer, as I think Michelle said, 23 from the Eddy, is the fact that there are 24 statistics that prove you can save money. 25 The problem has been, is we don't have enough 1 take-up in New York State. 2 To the extent that you are a payer, whether 3 it's the State as Medicaid, or whether you're a 4 private payer, you're very afraid of the "build a 5 field and everybody will come," and you have an 6 overutilization. 7 There is a need to take a hard look at what's 8 been done, and to say: Wait a minute, you can have 9 an immense amount of savings to the health-care 10 system by using telehealth. 11 I think your point, with the migrant worker, 12 the dental, you decreased the number of visits from 13 four to one. 14 That's a serious -- going for a dental 15 operation is very serious, but statistics prove it 16 can lead to enormous health complications unless 17 addressed; health complications a system will also 18 have to pay for. 19 So, I think there's a need to focus on what 20 we have, as, kind of, maybe an elementary 21 infrastructure, and say: What do we do to make this 22 something that's a useful infrastructure? And go 23 from there. 24 And that would be the first take-away. 25 The other problems -- I think, telemedicine 1 itself offers such great hope. 2 I had not known, at all, the extent to which 3 child psychiatry was needed, and can be addressed by 4 telemedicine. 5 The questions of stroke are just, you know, 6 obviously, a lot of good minds have been working 7 very hard to try to figure that out, but that's for 8 better care. 9 So, I would just want to differentiate that 10 we have a lot of advances. And I think this has 11 been a most, most useful roundtable. 12 And, thank you very much. 13 SENATOR YOUNG: Thanks, Senator. 14 Thank you. 15 Yes, Rachel. 16 RACHEL BLOCK: Just one follow-up to Kemp's 17 point. 18 One of the things that we have heard, is a 19 barrier to telehealth expansion; and, also, the 20 related issue of, sort of, broader mobile-health 21 applications, personal health records. 22 There's lots of different ways that you 23 could describe utilizing existing technical 24 capabilities to share information in new and 25 different ways. 1 But, there are three attributes of the 2 Statewide Health Information Network, which we 3 believe are going to be critical in order to 4 facilitate that expansion. 5 And one of the things that people are very 6 concerned about, is, whether you can appropriately 7 identify the individual patient, and have a means 8 of verifying that that patient is who we think that 9 patient is supposed to be. 10 And that's, both, on the consumer side, as 11 well as on the provider side, the ability to 12 accurately identify the correct provider who is 13 supposed to receive that information, or to transmit 14 that information. 15 And, then, building into that the capability 16 to authenticate the identity of those consumers 17 and/or of those providers. 18 And those attributes, which are key 19 features of our security, and the core services 20 that we're enabling through the Statewide Health 21 Information Network, would greatly increase the 22 trust that both consumers and providers would 23 have in utilizing telehealth, along with many of the 24 other health IT things that we have. 25 SENATOR HANNON: At risk of correcting a 1 commissioner, that's telemedicine. 2 Telehealth allows a lot of the home-health 3 agencies, who already know their patient, who are 4 the providers, and are supervised quite fiercely 5 by the State and local Social Service Districts, 6 to provide, and actually save on the order of, 7 thirds -- three-quarters of the amount expended by 8 State and federal government -- State, federal, and 9 local governments. 10 So it's -- that's what I call "telehealth." 11 You're describing, because you do have a real 12 problem with all of those things that are legitimate 13 open questions, with telemedicine. 14 And, so, if we separate out, the easier path 15 for earlier resolution, is with telehealth. 16 The more difficult one, or all of the 17 problems articulated, with telemedicine. 18 And we haven't even begun to deal with the -- 19 what Mr. Heigel talked about, the "interstate" 20 questions, because, we're certainly not the 21 geniuses of the world when it comes to health care. 22 RACHEL BLOCK: So perhaps one of the 23 benefits of this exchange, is that one of the 24 things the Commission might do, is advance a little 25 more specificity in the definition of those terms. 1 I was using "telehealth" in a broader 2 context, to capture information that might be 3 exchanged, not just between two hospitals and 4 physicians, but the broader community, and also 5 linking to the consumer. 6 SENATOR HANNON: That's why I wanted to 7 clarify. 8 Thank you. 9 (Pointing) Right there, Mary Ann. 10 SENATOR YOUNG: Yes, Mary Ann. 11 MARY ANN ZELAZNY: One of the things that I 12 just want to bring up, and, you know, I am a huge 13 proponent of telehealth, telemedicine...anything 14 that will get our patients seen. 15 But I got to tell you, one of the biggest 16 barriers we have: We have a clinic in 17 Cayuga County, which is 20 minutes from Ithaca, 18 which is a -- you know, Cornell University. 19 We can't get Internet. 20 So -- 21 ASSEMBLYWOMAN GUNTHER: You can't get 22 Internet. 23 MARY ANN ZELAZNY: So, there's a lot of 24 places in this great state of New York that we can't 25 use our EMR system because we don't even get the 1 Internet that we need. 2 So, I think that, you know, as we stand, 3 talking about telehealth, there's a lot of rural 4 communities that have no access to Internet. 5 Or, you know, cell-phone technology is good 6 for some pieces of telehealth, but not all. And for 7 video streaming, it doesn't work. 8 So, it's a huge problem for all of us, that 9 we have to keep in mind as we talk about this. 10 ASSEMBLYWOMAN GUNTHER: You're right. 11 They're doing some expansion in my area. 12 We have many places. You can't use a cell 13 phone in my house. 14 MARY ANN ZELAZNY: My house, I can't. I 15 don't have a cell -- it's sort of nice, but -- 16 [Laughter.] 17 MARY ANN ZELAZNY: -- you know. 18 SENATOR YOUNG: Senator Hannon just remarked 19 that -- 20 SENATOR HANNON: I think your -- that the 21 point you made, is -- I saw on the agenda, for the 22 Executive Office of Technology to address, and the 23 question. 24 But, I think you bring home, you know, in the 25 context of this roundtable, something as a big need. 1 SENATOR YOUNG: That's exactly right. 2 I mean, you look at my district -- 3 SENATOR HANNON: I mean, when they talk, at a 4 national level, of, "Oh, we need everyone to have 5 access to broadband," we think it's, Wyoming, or 6 Montana, or something. 7 MARY ANN ZELAZNY: No. It's King Ferry, 8 New York. 9 SENATOR YOUNG: Yep. 10 Great. 11 Anyone else? 12 I would like to close -- 13 BETTY (VAN HUIZEN) COUTURE, RN: I just want 14 to -- 15 SENATOR YOUNG: Oh, sorry. 16 Betty. 17 BETTY (VAN HUIZEN) COUTURE, RN: I just 18 wanted to make a comment to -- with regards to the 19 telehealth technology, there is so much innovative 20 products that are out there. 21 We're launching a program in California, with 22 the kiosk. And they -- the population is elderly, 23 and they can't log in to a computer; and, so, we're 24 using facial recognition and voice activation. 25 And, as well, we have the capability for 1 mobile kiosk. And, there's so much Bluetooth 2 technology out there. 3 They were talking about the Bluetooth 4 stethoscope, or the -- sorry -- the digital 5 stethoscope. 6 We can make that Bluetooth, so a nurse can 7 actually go in and transfer the cardiac sounds, or 8 the lung sounds, and send them to a cardiologist, if 9 they feel that there's a problem with this patient. 10 And so, again -- and Michelle mentioned 11 prevention. 12 I think that's just really key, that when you 13 start seeing somebody that has elevated blood 14 glucose, if you monitor them, and teach them, we 15 won't have the renal dialysis happening further down 16 the road. 17 And, so, Catharine mentioned, just a little 18 bit of spending can save a lot. 19 And I really believe that we can do that. 20 SENATOR YOUNG: Great. 21 I'd like to close, and thank all of the 22 participants today. 23 I think this was extremely valuable. 24 And, the entire purpose of the Commission on 25 Rural Resources, is to identify the needs in rural 1 areas, and bring services and improved quality of 2 life. 3 And, certainly, by expanding and elevating 4 telemedicine and telehealth, be able to do that for 5 patients across upstate who may not have access to 6 quality services right now. 7 So, what we're doing is extremely important. 8 And I want to thank you, because, what we'll 9 be doing now, is interfacing with the Department of 10 Health. 11 But, all of you, if you have additional 12 information, or want to communicate with us, I would 13 urge you to do so, because I'll be working with my 14 colleagues on the Commission, my colleagues on the 15 Health Committee and the Insurance Committee, to 16 bring these issues forward, and figure out: 17 Okay, we've identified the barriers. How 18 do we get over those barriers? 19 And I want to thank the Department of Health, 20 because I know they've been working diligently in 21 this area. 22 So, I look forward to continuing to work with 23 all of you. 24 And, just want to thank you for your 25 participation, and for all of your expertise. 1 (Whereupon, at 12:26 p.m., the 2 roundtable discussion, held by the New York State 3 Legislative Commission on Rural Resources, 4 concluded.) 5 6 ---oOo--- 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25