RUPRI Leader – Interview with Mario Gutierrez on the future of healthcare

We sat down to talk about the future of healthcare with Mario Gutierrez, who serves as the Executive Director of the Center for Connected Health Policy (CCHP). Last year, Gutierrez participated in a panel with TSC Director Pamela Villacorta at the Governor’s Conference on Aging and Disabilities. We asked him about his perspective on the state of healthcare, his commitment to supporting rural populations, and his groundbreaking work with the CCHP.

About Mario Gutierrez
Prior to becoming the Executive Director at CCHP, Gutierrez worked for over 30 years in California’s nonprofit health sectors. He previously served as the Program Director for the California Endowment, where he focused in especial on the deployment of a 5-year, $50 million telehealth initiative in the state of California. He sits on the board of directors for both the California State Rural Health Association and OCHIN, one of the nation’s largest and most successful health information networks. He also chairs the advisory panel for the Rural Policy Research Institute (RUPRI), housed within the University of Iowa College of Public Health, which provides federal policy analysis and recommendations for the promotion of livable rural communities across the country.

Focusing on Rural Populations
Gutierrez began his career organizing farmworkers in rural San Diego. After earning his Masters in Public Health from the University of California-Berkeley, he focused on Native American travel health programs, a drive that came from “having a real appreciation for rural life.” With RUPRI, he advocates for programs that address increasing access to care and improving the quality of life to rural populations. Gutierrez has a self-professed “affinity for lifting up that particular perspective.”

Despite conventional cultural perception, Gutierrez points out, the state of California is actually about 80% rural. Aside from the strip of land along the coast that includes San Francisco in the north and Los Angeles in the south, California is a vast landscape of rural towns with industries of mountains, forestry, fishing, and agriculture. Much of his work targets the shortage of healthcare providers throughout the state, and promotes technological advancements that can “be a vehicle to overcoming those barriers.” Thanks in large part to Gutierrez’s efforts, California is now one of the most progressive states in the nation in terms of how it defines telehealth and its reimbursement.

The Future of Healthcare
Gutierrez and his team at CCHP are currently monitoring two key changes in healthcare:

1)    The movement away from a fee-for-service model toward universal payments and value-based care. Telehealth provides a way to increase access to services without increasing the cost of care. The incentive becomes, then, to keep people healthier. “Technology is now seen as a valuable resource instead of a way to increase the budget,” Gutierrez says. “It’s being seen more and more as a valuable tool for increasing access to care without sacrificing quality.”

2)    An explosion of the commercial direct-to-consumer healthcare, paid for by the individual but set at a price that would be close to what you would pay in terms of a deductible. The role of the consumer and consumer organizations are changing—demanding that we take full advantage of telehealth technologies to provide greater access to care and more convenience. “The notion of going to the doctor is changing,” Gutierrez says. “Now the client [or consumer] is at the center of healthcare. Not every visit requires a personal touch.” Because most people have access to high-speed broadband, he says, the use of technologies such as email and video have made a huge difference. Broadband access is still a barrier for many rural populations, however, creating a “digital divide” in terms of telehealth. Gutierrez notes that a lot of progress has been made in this area, though: some federal court cases have led to recognition that access to broadband is a utility rather than simply an information service.

Major Healthcare Policy Shifts
Gutierrez cites the Affordable Care Act as the most significant change that has transpired over his 30+ years in healthcare, calling it “transformational.”

“We used to always talk about getting services to the uninsured,” he says. “95% of the population is now insured. [The ACA has] created a new environment so everybody has some choice in terms of care. It’s been a real game-changer in that sense.” However, Gutierrez points out, the undocumented population remains uninsured, which continues to pose great challenges in terms of access to and administration of healthcare.

Gutierrez also notes that while other policy arms have failed to catch up, technology continues to advance: “In [the last] five years, you’ve seen dramatic changes in the remote monitoring world—very sophisticated devices that are no bigger than a quarter. It’s pretty remarkable. We see a lot of the technology driving the change as well. Even though healthcare policy hasn’t changed, the technology is moving beyond that.”

“[Technology is a] game-changer for a lot of barriers—not just distance and time, but language and diversity and conditions,” Gutierrez says. “Technology transcends all that.”

Identifying Nationwide Barriers to Telehealth
“The reform of Medicare is still a number-one challenge as we move into more of an aging population—improving coordination of care between providers and specialists, and between patients and their providers,” Gutierrez says. Medicare was passed in the 1965, he notes, and the provisions for reimbursement for telehealth were added to the legislation in 2000. At that time, Gutierrez says, “the technology was in its nascent stages as compared to now” (primarily live video). “Until those laws change, we’re still going to be stuck 20 years ago where technology was.”

Medicare payments and access to services are also outdated, Gutierrez says. “What we have embodied in the legislation now in terms of what gets paid out is both discriminatory and very limited. Medicare will only pay for certain services that are provided through live video. Store-and-forward telemedicine, remote patient monitoring, and other services are not covered—things that keep people healthier.” The provision that a member must receive care at a specific site, then, makes access very difficult for most of the country (particularly those living in rural areas).

Problems also arise from the fact that Medicaid, guided by CMS policies, gives each state a great deal of discretion in terms of how it defines telehealth services. “You may have one state—like Hawaii or California—that has comprehensive definitions of all healthcare services, and other states that only pay for live video,” Gutierrez says. “Until we get some consistency across the states, that’s going to continue to be a problem.”

In the meantime, CCHP has created an interactive map on its website that outlines how all 50 states define telehealth, as well as how they approach reimbursement, online prescribing, cross-state licensing and more. This is an incredibly helpful resource because, as Gutierrez points out: “Every state is different. No two states have the same approach.”

CCHP continues to advocate for consistency across state lines. “We’re actively involved in groups—such as the National Conference of State Legislators—bringing awareness to state legislators.” Gutierrez cites Hawaii as a fantastic example of a state that has made strides in terms of telehealth policy. Their laws were initially quite limiting—“which is ironic because they’re composed of islands,” Gutierrez says. The CCHP helped them to rethink their laws, and now they have one of the most forward-thinking policies in the nation. Gutierrez points to Mississippi as another leader in telehealth policy.

The Future of Healthcare
“My own feeling is that medical care is just one aspect of multiple human needs,” Gutierrez says. A team-based approach, then, would work wonders for the overall advancement of the holistic well-being of the population. In the future, he hopes, nutritionists, social workers, crisis intervention teams, and mental health professionals will all become a part of how we approach healthcare. “[That will] go a long way for controlling chronic diseases and keeping people healthier,” he says.

A Passion for People
Gutierrez has been hard at work on healthcare policy and advocacy for several decades. What keeps him going?

“We have a national perspective,” he says of CCHP. “And I can see over the horizon and know that every day we’re making a real difference and changing the way people think about telehealth. For me it’s all about health equity: improving access to care and removing barriers to care.”

“The power of the technology is pretty amazing,” he says. “How do we corral that technology and use it in a way that’s most effective? We’re on the edge of a lot of change and we’re in the center of it. We’re not trying to make money here; it’s really about advancing the best policies to improve healthcare for all people in this country. That is what’s so powerful: every day there’s something new we can do and ways that we can advance this work.”

“It’s not just a job; it’s really about a way of life,” Gutierrez says. “Trying to provide leadership on multiple levels—to the undocumented, farmworkers, Native Americans, aged and disabled populations—that’s what really drives my commitment to this work.”

About the Center for Connected Health Policy
CCHP was established in 2008 by the California Health Care Foundation with the mission of integrating telehealth technologies into the healthcare system and improving policy that promotes telehealth. It is currently funded through the Public Health Institute. The organization has been designated as the National Telehealth Policy Resource Center, which provides assistance and analysis of telehealth policy and legislation to twelve regional telehealth policy resource centers across the country. As Gutierrez puts it, “[Our] focus is understanding how technology can transcend the barriers to access to care to improve access to quality care for all underserved.”