The Virginia Association of Personal Care Providers support HB 1831, which will allow for the more efficient and effective delivery of personal care services by allowing nurse supervisory visits to take place via telephone communication. We have learned through the COVID-19 pandemic that telehealth and telephone communication can safely be used in the provision of care. HB 1831 will allow providers to more efficiently provide supervision of home care attendants and will allow them to be more readily available to address any question, concern or issue that may arise. This bill will allow for more supervision to occur.

I am for nurse practitioner to be able to practice without a doctor being there

Addressing topics for perspective is a form of growth.

Part of the flexibility allowed during the COVID public health emergency was the use of telephonic supervisory visits. This bill will make permanent that change that allows a licensed nurse to conduct telephonic supervisory visits. These visits are for the sole purpose of evaluating the performance of duties and tasks in a care plan by trained health care workers. Supervisory visits are not nursing assessment visits nor are they intended to evaluate the individual receiving care. Individuals receiving assistance with activities of daily living are not under medical supervision for these services. This change will allow licensed home care agencies to continue their operations in an efficient manner and better utilize licensed health care professionals. I ask that you please support this legislation.

HB1915- Children are the future. Teachers care for our future and should be paid in a way that reflects the sentiment that we care for the future of our country. HB1987- This should be allowed for mental health especially. Many mental health in-person appointments are missed because someone’s mental illness keeps them from leaving the house or the person doesn’t have childcare at the time where they need to make the appointment. Telehealth will help with accessibility.

The Virginia Poverty Law Center strongly supports HB 1987 which extends and clarifies Medicaid telehealth services and remote monitoring of many health conditions. During this horrible COVID-19 pandemic, Virginia (and the U.S.) has gained new appreciation for the value of tele-medicine. Both providers and patients have benefited from easier access to medical care and improved monitoring of chronic conditions. The Medicaid program has fully participated in authorizing more telehealth during the pandemic. HB 1987 builds upon this experience and maintains valuable telehealth services to Medicaid enrollees. I have two concerns about the FIS for HB 1987. The estimated costs to DMAS appear inflated because (1) the FIS seems to count all telehealth services as ADDITIONAL services, rather than replacements for appointments and services that would normally occur; and (2) the FIS doesn't consider any cost benefits or reduced hospital/ED services which are very likely to result from better access and monitoring through telehealth. Thank you for supporting HB 1987. Jill Hanken, VPLC Health Attorney

We support this bill. Extending the use of telhealth in Virginia will benefit those with chronic conditions that live in our underserved communities. It can also reduce hospitalizations and other health care costs by helping to control conditions such as diabetes, high blood pressure, etc.

Chairman Sickles, members of the Subcommittee, good morning. I am Dr Karen Rheuban, Director of the UVA Center for Telehealth and board chair of the Virginia Telehealth Network. Thank for the opportunity to speak to HB1987, which directs the Department of Medical Assistance Services to cover remote patient monitoring services for priority, high risk, high cost patients and conditions. Remote patient monitoring programs improve patient outcomes, and lower the cost of care. I would respectfully like to address the fiscal impact statement prepared by the Department of Planning and Budget. UVA began our remote monitoring program in 2014. Based on our prior data, and the first 6 months of FY 21, we anticipate monitoring approximately 6200 high risk patients this year. For those monitored patients with the conditions identified in this bill, we project a reduction of 25,034 hospital bed days. These reductions result from hospital admissions and readmissions avoided and shortened length of stay. With an average total cost per bed day of $2015 for low case mix index patients, we conservatively project cost savings across all payers of $50,443,510 in FY21. In addition, our data demonstrated a reduction in emergency department visits for our monitored patients by 14%. One additional note for consideration as it relates to the costs of remote patient monitoring: many patients only require 30 days of monitoring, others only 3 months, rather than as projected, all patients for a full year. Medicare has covered remote patient monitoring for a broad range of conditions since 2018. We urge the committee to consider this additional information, particularly regarding cost savings to the Medicaid program, when considering the true fiscal impact of HB1987. Thank you.

My name is Stephen Grammer, from Roanoke. I encourage you to pass HB1987 and HB2124. HB1987 would allow people who without transportation easier access to being able to communicate with their primary doctors. This also would be cost-effective, due to the fact that people will not have to get ambulances going to hospitals over non-emergency situations. HB2124 would allow people with disabilities to get treatment for COVID. We are on a very low-budget, and can not afford to pay out of pocket for treatment. Again, I encourage you to support HB2124 and HB1987. Thank you for your time and consideration.

January 20, 2021 Chair Mark Sickles Health Welfare and Institutions Committee Virginia General Assembly 1000 Bank St Richmond, VA 23219 RE: HB 1987--Physical Office Location Amendment to Conduct Telehealth Chair Sickles and Member of the Committee, On behalf of Hims & Hers, a direct-to-consumer digital health company, we urge you to preserve access to healthcare treatment for thousands of Virginians by removing language recently added to HB 1987 that would require a physical office or relationship with a practice” in order to conduct telehealth in the Commonwealth. This onerous and unnecessary language will have a chilling effect on direct-to-consumer health platforms like Hims that are providing care to thousands of Virginia residents during a global pandemic but do not have a physical location. Especially during the COVID-19 pandemic, it is critical that we encourage, not curtail telehealth usage, and reduce nonessential, face-to-face encounters between patients and healthcare workers while maintaining the highest quality of care. At Hims & Hers, we connect patients to licensed healthcare providers for medical consultations and treatment across all 50 states. Our platform is powered by virtual care, without an in-person visit, which is a care delivery model that has been embraced by state legislatures, hospitals, healthcare providers and patients across the country. Since our launch in 2017, we’ve powered more than two million digital healthcare visits across a variety of conditions, ranging from sexual health to psychiatric health. In response to the pandemic, Hims & Hers has incorporated access to additional telemedicine offerings, including primary care services, mental health support groups, and access to at-home COVID-19 testing kits. We believe providers should always be held to the highest standard of care regardless of the mode of delivery, and that is why providers on our platform are licensed, highly-credentialed, and held to evidence-based clinical standards. Our executive team and board of directors are composed of some of the most experienced minds in healthcare, like Dr. Toby Cosgrove, former CEO and current Executive Advisor of the renowned Cleveland Clinic, and Dr. Patrick Carroll, our Chief Medical Officer (CMO), the former CMO of Walgreens. We recognize that telehealth is not an appropriate mode of care delivery for all conditions, and that is why we rely on licensed providers to make those determinations and refer patients to the appropriate healthcare systems and platforms. However, the current proposed physical location requirement in HB 1987 would effectively ban Hims and other direct-to-consumer digital health platforms from providing care in the Commonwealth. This is especially troubling for those in underserved areas, where telehealth is a lifeline for receiving quality care. We hope that you will remove this language from the bill, and ensure that quality care is preserved for thousands of Virginia residents. Sincerely, April Mims VP of Public Policy Hims & Hers, Inc cc: Vice Chair Rasoul, Committee Members, and Clerk Rushawna Senior

To the Members of the Committee: On behalf of the Virginia Community Healthcare Association and the 155 community health center sites across the Commonwealth that serve over 355,000 Virginians in medically underserved communities, we ask for support for House Bill 1987. Remote Monitoring Services would be invaluable in monitoring the health conditions of some patients, particularly those recently released from a hospital setting. In North Carolina, a pilot program conduced several years ago in a community health center led to significantly reduced A1C numbers in diabetic patients. For cardiac patients, one can cerrtainly see the benefit of having remote monitoring at home after having stents, or having a heart attack. On the last paragraph on audio only services – this has been an important part of delivery of services in medically underserved areas that have limited access to internet broadband services. In some parts of the Commonwealth, video is not available due to limited bandwidth. Although not mentioned in the bill, I would ask the committee to remember that when a health provider does provide services by audio only, they bring to bear their full knowledge. Reimbursement for audio only services should be at a full and regular rate, not a discounted rate, as the services of the provider requires their full abilities. Thank you, Rick Shinn - Director of Government Affairs Virginia Community Healthcare Association

VACo supports this legislation in keeping with our long-standing position in favor of the use of telemedicine to provide long-distance clinical care, patient and professional education, and public health, as well as support for flexibility in the delivery of these services.

On behalf of the Virginia Association of Community-Based Providers (VACBP), the largest association of private-sector providers of community-based behavioral health services to Virginia's Medicaid population, I want to express our support for HB1987. The ability to provide and be reimbursed for behavioral health services delivered via telehealth and telephone has been absolutely critical to our members as they have worked to meet the needs of Virginia's most vulnerable residents. We applaud DMAS, DBHDS and DMAS for their quick action to develop the regulatory framework within which services could be provided early in the pandemic and in close coordination with providers. We support efforts to continue to allow use and reimbursement for telehealth and telephonic delivery of services where appropriate throughout the duration of the current public health crisis and beyond it. Thanks to Del. Adams for introducing this bill and for her commitment to identifying how telehealth can continue to be leveraged to increase access to quality healthcare services for all Virginia residents. The VACBP also supports HB2197, which would create a workgroup to evaluate and provide recommendations for the permanent use of virtual supports and assistive technology for the ID/DD population in Virginia. We believe that such an effort that is collaborative and inclusive will yield valuable insight that can guide future policy in this space. Thanks to Del. Runion for introducing this bill.

Teladoc Health would like to register our concerns with amendments to House Bill 1987. Recognized as the world leader in virtual care, Teladoc Health directly delivers millions of medical visits across 175 countries each year through the Teladoc Health Medical Group and enables millions of patient and provider touchpoints for thousands of hospitals, health systems and physician practices globally. Specifically, we strongly oppose the amendment to Section 54.1-3303 B. As written, the bill would require that a Virginia-licensed health care provider practicing using telemedicine and prescribing Schedule II–V controlled substances also have a physical office practice in the Commonwealth or an immediately contiguous jurisdiction. This provision has no clinical basis and is an arbitrary restriction to Virginia-licensed practitioners who treat patients using remote technology. The clinical guidelines for telehealth and telemedicine are anchored in standard of care, and the Commonwealth should maintain such standards and continue to tie state policy to federal restrictions on prescribing controlled substances. A requirement for a physical practice in Virginia or an immediately contiguous jurisdiction is an artifact of “old thinking” and would gut the ability of telehealth to deliver access to affordable quality health care. This bill fails to acknowledge the capacities of technological innovations in medicine. Today there is no other state with such an antiquated requirement in statute or regulation. Federal law (Ryan Haight Online Consumer Protection Act of 2008) already imposes rules around the prescription of controlled substances (Schedules II–V). This is simply bad public policy and ill-advised. Simply stated, the standard of care should dictate whether or not a prior physical examination of the patient is required prior to diagnosis and treatment of the patient, including prescribing Schedule II–V controlled substances. After the establishment of the valid professional relationship and treatment in accordance with the standard of care, geographic restrictions on follow-on care are arbitrary. We are very appreciative of the hard work that has gone into this legislation and respectfully request the sub-committee reject the proposed amendment. Thank you for your consideration. We are happy to answer any questions.

On behalf of the ATA and the 400 organizations we represent, I am writing to express concerns about an amendment made to HB 1987 in §54.1-3303 (B). In its revised form, HB 1987 would create unnecessary and impractical barriers to the establishment of telehealth services across Virginia, limiting practitioners’ ability to prescribe vital medications to their patients throughout the state based on arbitrary geographic restrictions. Currently, the bill would place geographic restrictions that determine the practitioners who can provide prescriptions to their patients, the language reading: “To prescribe a Schedule II through V controlled substance utilizing telemedicine, prescribers must maintain and practice or maintain a relationship with a practitioner at a physical office practice in the Commonwealth or in an immediately contiguous jurisdiction in order to unsure availability for an in-person examination when required by the standard of care.” In mandating the existence of a physical presence for practitioners to prescribe Schedule II through V controlled substances, the language establishes an arbitrary geographical barrier that would limit Virginians’ access to the prescriptions they need to lead healthy lives. When applied to real-world scenarios, the requirement proposed in this amendment is not practical in protecting Virginians’ safety or ensuring their access to accessible and high-quality care. If this bill were passed with the amended language, a Virginia citizen located in Alexandria could legally receive a prescription from a provider in Memphis, Tennessee (as Tennessee shares a border with Virginia), 881 miles away. However, a practitioner in Philadelphia, Pennsylvania, just 146 miles away from that same citizen, could not prescribe this patient’s medication simply because Pennsylvania does not border Virginia. Moreover, this language is not needed because if an in-person examination is needed to meet the standard of care for prescribing, then the practitioner would already be violating the standard by using telehealth technology to do so - regardless of whether they have a physical office or a relationship with a practitioner in Virginia or a “contiguous jurisdiction.” Simply put, there is no overlap between when a practitioner can use telehealth to prescribe medication and when an in-person exam is needed to prescribe, making this proposed amendment unneeded. Finally, the language also is likely in violation of the 10th Amendment. While the 10th Amendment gives broad discretion to states to regulate the health, welfare, and safety of its citizens, it still cannot “arbitrarily” or “capriciously” violate the Commerce Clause when doing so. The requirements imposed by this bill certainly would legally violate the Commerce Clause by limiting an out-of-state practitioners’ ability to practice medicine in Virginia despite the fact that they are licensed to practice there. The ATA applauds other aspects of HB 1987 which guarantee that nothing shall preclude coverage of telehealth services by insurers, including those services which involve remote patient monitoring. However, the ATA strongly objects to the amended language, and we believe that passing House Bill 1987 in its current form would be a step backward for patients and practitioners in the Commonwealth. We urge you and all of your colleagues to strike the amended language in §54.1-3303 (B) before considering the approval of this bill.

It is essential to address the demand for healthcare in a practical way - and these proposals are safe, evidence based, and needed. HB1987: Reimbursement for remote patient monitoring is proven to improve quality of care, lower readmissions, and lower travel and treatment costs. Remote patient monitoring is an essential benefit that allows patients to leave the hospital and get the same quality of care at home. For high risk pregnancies, it can cost as little as $26 a day to provide this service with higher convenience, better care, and keeps a hospital bed open for someone else who might need it more. Compare that to a $5,000 a day stay in the hospital with lower convenience, higher costs, and lower satisfaction. The Governor wisely removed reimbursement barriers to providers to offer this service to those suffering COVID-19 with great results. Virginians deserve access to this benefit and remote patient monitoring needs to be reimbursed immediately. HB1737: Nurse practitioners have safely served their communities with 2 years experience during the pandemic, and states across the country already allow for them to practice with the scope of practice with less restrictions that we have in Virginia. We need frontline healthcare workers practicing to their full capability and this reform achieves that safely. HB1747 / hb1817 : Enabling providers s to practice to their full capability is essential. Nurse practitioners deserve the opportunity be certified and practice according to their skills and education. This common-sense reform helps front line care providers to be more efficient and useful in serving in care deserts. In the same way, we should better leverage physician assistants in the field who could do more but are restricted by regulatory barriers. HB1769: Virginia law, unfortunately, puts walls between patients who are seeking care from licensed providers beyond our state lines. The commonwealth of Virginia does not care if a patient gets in the car and travels to another state to get treatment from an outstanding provider, but if a Virginia gets on the information highway, it can lead to criminal charges who is merely offering care to a Virginian in need of it. When the law was written, a phone was tethered to the kitchen wall. Today, our phones are supercomputers that can provide detailed healthcare information to a doctor in real-time. Our laws are still looking backwards in healthcare - not forward. Patient behavior is seeking better care with more convenience. This bill removes barriers between patients and providers across the country.

Please consider putting these bills into effect.

In favor of programs to better facilitate the development and progress of my community.

Representing many groups of the EMS community I have heard horror stories from providers who have responded to calls for patients whom the providers have no idea what the problem is. There is a need to know what the problem or illness is prior to arriving or even leaving their headquarters in order to get the PPE on and be ready. We appreciate Del. Aird for submitting this bill in order to assist the EMS providers across the state.

Managed care organizations are contracting with third party audit organizations to recoup payments made to home care providers. Often times, these third-party organizations are aggressive, are paid based on the amount of reimbursement recovered and apply arbitrary standards inconsistent with both Medicaid and Medicare guidelines. House Bill 2022 (2021) introduced by Delegate Chris Head would require plans operating in Virginia to develop clear and transparent audit processes. Any changes made to provider requirements must be communicated in writing to all home care, home health or hospice providers 90 days prior to their effective date. Home care and hospice agencies shall have access to clear and consistent training on the audit expectation and process prior to implementation. These audit processes would consist of an opportunity for home care and hospice agencies to work collaboratively and correct any technical errors identified, provided the plan of care was followed and patient care was delivered. Managed care organizations shall not contract with a third-party audit organization that are paid on a contingency basis. All appeals processes shall be conducted by an organization that is not a subdivision of either the managed care organization or the third-party audit organization. This bill would restore a fair and equitable audit process.

I am for nurse practitioner to be able to practice without a doctor being there

The Virginia Nurses Association strongly supports HB2111 and appreciates the inclusion of nursing in the membership of the task force. We look forward to continuing this important work.

In favor of programs to better facilitate the development and progress of my community.

Voices for Virginia's Children, on behalf of the Racial Truth & Reconciliation VA coalition with over 400 members, is supportive of HB2111. In 2019, Virginia Mercury reported that Black women in VA were 3 times more likely to die after giving birth than a white woman, a disparity Gov. Northam made a goal to eliminate by 2025. In order to do so, we must identify and evaluate disparities in existence in order to combat them through equitable policy responses. COVID-19 has especially highlighted the disparities that contribute to poor health outcomes and further impact marginalized communities. This policy is a step in the right direction in improving maternal health and birth outcomes. Thank you, Del. Herring for championing this bill.

On behalf of the Virginia Association of Community-Based Providers (VACBP), the largest association of private-sector providers of community-based behavioral health services to Virginia's Medicaid population, I want to express our support for HB1987. The ability to provide and be reimbursed for behavioral health services delivered via telehealth and telephone has been absolutely critical to our members as they have worked to meet the needs of Virginia's most vulnerable residents. We applaud DMAS, DBHDS and DMAS for their quick action to develop the regulatory framework within which services could be provided early in the pandemic and in close coordination with providers. We support efforts to continue to allow use and reimbursement for telehealth and telephonic delivery of services where appropriate throughout the duration of the current public health crisis and beyond it. Thanks to Del. Adams for introducing this bill and for her commitment to identifying how telehealth can continue to be leveraged to increase access to quality healthcare services for all Virginia residents. The VACBP also supports HB2197, which would create a workgroup to evaluate and provide recommendations for the permanent use of virtual supports and assistive technology for the ID/DD population in Virginia. We believe that such an effort that is collaborative and inclusive will yield valuable insight that can guide future policy in this space. Thanks to Del. Runion for introducing this bill.