FEDERAL POLICY AND BUDGET ISSUES FY 2019

FEDERAL POLICY AND BUDGET ISSUES FY 2019 The Medical Uiversity of South Carolia is the state s oly comprehesive academic medical ceter. MUSC is Chagig What s Possible i health care through our ogoig missio to provide excellece i educatio, research, ad patiet care. DAVID J. COLE, M.D., FACS, Presidet, MUSC Colcock Hall 179 Ashley Aveue Charlesto, SC 29425 843-792-2211 www.musc.edu Chagig What's Possible

TO THE SOUTH CAROLINA CONGRESSIONAL DELEGATION February 2018 O behalf of the faculty, studets, ad staff of the Medical Uiversity of South Carolia (MUSC), I am pleased to preset the South Carolia delegatio with MUSC s federal priorities for FY 2019. As our state s oly comprehesive academic medical ceter, we recogize ad embrace our resposibility to cotiue to iovate i every area of our tripartite missio of educatio, patiet care, ad research. There is a critical eed for iovatio i health care to address the atioal challeges of access, quality, ad affordability. Health care etities like MUSC must foster iovatio, ot just allow it, but actively ecourage it at every level from the laboratory, to the classroom, to the bedside, ad i our cliics. That s why you ll see the commo theme of iovatio throughout may of this year s federal priorities. As a collaborator i iovative research, health care, ad educatio efforts across the state, MUSC also has the uique privilege to serve as a drivig aget for the kowledge-based ecoomy. Educatio ad iovatio foster ecoomic developmet i the areas of life scieces, IT, ad biotech, all of which cotribute to the diverse South Carolia ecoomy. MUSC s stregth has always bee foud i the quality ad commitmet of its faculty, staff, ad studets. We cotiue to embrace a culture of compassio, respect, iovatio, collaboratio, ad itegrity; it is these istitutioal values that keep us focused o reachig our strategic goals: 1. Commit to Patiets ad Families First 2. Foster Iovative Educatio ad Learig 3. Build Healthy Commuities 4. Embrace Diversity ad Iclusio 5. Advace New Kowledge ad Scietific Discoveries At MUSC, we will cotiue to lead i the midst of the challeges ad opportuities that lie ahead i the world of health care. We sicerely appreciate the support we have received from the South Carolia Cogressioal delegatio ad hope you will cotiue to call o us whe we ca assist you or your costituets. Yours i service, David J. Cole, M.D., FACS Presidet, Medical Uiversity of South Carolia 1

FACTS AND FIGURES SC s oly comprehesive academic medical ceter Oldest medical school i the South; fouded i 1824 Six colleges with 3,000 studets i all areas of health professios. Colleges iclude Detal Medicie, Graduate Studies, Health Professios, Medicie, Nursig, ad Pharmacy 793 bed medical ceter More tha 13,400 employees 1,310 active voluteers at MUSC i FY2017 63.5 % of all livig MUSC alumi reside i S. C. ad cotribute to the state s ecoomy 1+ millio patiet visits per year Member of the prestigious Natioal Istitutes of Health (NIH) cosortium which oly icludes the 60 best biomedical research istitutios i the U.S. Home to: Holligs Cacer Ceter, oe of oly 69-Natioal Cacer Istitute (NCI) desigated ceters i the U.S. SC s oly atioally raked childre s hospital that will ope a ew facility i 2019 Oe of oly two Natioal Ceters for Excellece i Telehealth i the Uited States. South Carolia s oly trasplat program Level 1 trauma ceter Oly pediatric Level 1 trauma ceter i the state; 25,000 visits aually to the emergecy room Perform early 10,000 pediatric surgeries aually Uique to SC: Advaced pediatric heart ceter with a 99% survival rate for complex surgeries Extracorporeal Life Support Ceter Pediatric Bur Ceter Oly solid orga trasplat program (kidey, liver, heart) Boe marrow trasplat program RECENT ACCOLADES AND MILESTONES MUSC Health was amed by U.S. News & World Report for the third year i a row as the umber oe hospital i South Carolia. Four MUSC Health specialties raked: ear, ose & throat; gyecology; cacer; ad urology Six childre s specialties raked i the top 50 atioally: cacer; cardiology ad heart surgery; gastroeterology ad GI surgery; ephrology; eurology ad eurosurgery; ad urology SC s oly atioally raked childre s hospital MUSC has bee awarded a $600,000 grat from the Health Resources ad Services Admiistratio, a agecy of the U.S. Departmet of Health ad Huma Services. The award marks MUSC as oe of oly two atioal Telehealth Ceters of Excellece i the Uited States. 2

MUSC cacer researcher Chaita A. Hughes-Halbert, Ph.D., has bee elected ito the Natioal Academy of Medicie (NAM). She is the first woma ad first Africa-America from South Carolia to attai that distictio. The team at the Natioal Crime Victims Research & Treatmet Ceter, part of MUSC s Departmet of Psychiatry ad Behavioral Scieces, received a $18 millio grat from the Office for Victims of Crime (OVC) to establish a Mass Violece ad Victimizatio Resource Ceter. A team of researchers from 10 uiversities across the state, icludig some from the Medical Uiversity of South Carolia, has received a $20 millio, five-year grat from the Natioal Sciece Foudatio s Established Program to Stimulate Competitive Research (EPSCoR). The moey will help establish a ew iitiative: Materials Assembly ad Desig Excellece i South Carolia, or MADE i SC. MUSC broke groud for a ew pediatric medical campus i North Charlesto i Jue. The MUSC Childre s Health Ambulatory Campus i North Charlesto, a pediatric-dedicated, 100,000-square-foot facility, is scheduled to ope i early 2019 o the corer of Rivers Aveue ad Mall Drive. MUSC lauched Phase 1 of the Charlesto Medical District Greeway i collaboratio with the City of Charlesto, Roper Hospital, ad the Ralph H. Johso VA Medical Ceter. MUSC received the 2017 Health Professios Higher Educatio Excellece i Diversity (HEED) Award from INSIGHT Ito Diversity magazie, the oldest ad largest diversity-focused publicatio i higher educatio. This atioal hoor recogizes U.S. medical, detal, pharmacy, osteopathic, ursig, ad allied health schools that demostrate a outstadig commitmet to diversity ad iclusio. Durig its 38th Aual Summit, the South Carolia Chamber of Commerce amed MUSC the recipiet of the 2017 Excellece i Workplace Diversity Award i the category for medium ad large busiesses. I 2017, the Forbes list of America s Best Midsize Employers raked MUSC No. 74 out of 301 compaies with at least 1,000 employees. Withi that list, MUSC raked No. 11 out of 35 orgaizatios i the educatio idustry. MUSC ad Beaufort Memorial Hospital have aouced plas to form a joit veture that will expad health care services to the Bluffto commuity. Through a joit veture betwee their affiliates, MUSC ad BMH will ope a microhospital with a estimated 20 beds to serve both pediatric ad adult patiets. Voluteer advisors ow sit o our Patiet ad Family Advisory Coucils (PFACs). PFACs are a partership of family represetatives ad hospital staff workig together to meet the eeds of patiets ad families. Issues discussed iclude patiets, the eviromet, ad health care policies ad procedures. Families provide advice ad are part of the decisio makig process with the mai goal beig to provide a collaborative eviromet that will ehace the experiece for all patiets ad families at MUSC Health. MUSC was hoored i Becker s Hospital Review: 100 hospital & health systems with great wome s health programs 2017. EXPERTISE MUSC has cliical stregths i the followig areas: Cardiology, Gastroeterology, Neuroscieces, Orthopeadics, Pediatrics, Pulmoary, Psychiatry, Ocology (Holligs Cacer Ceter), Rheumatology, Stroke, Sickle Cell, Telehealth (SC Telehealth Alliace), ad Trasplatatio. However, you would be hard pressed to ame a area of medicie that MUSC does ot practice. MUSC also has cosiderable expertise i the area of health iovatio i may disciplies that are areas of atioal focus. MUSC is leadig ad ivestig i the followig, which help build the kowledge-based ecoomy i the Lowcoutry: Drug discovery Medical devices Regeerative medicie Bioiformatics Health IT Immuology ad immuotherapy 3

ECONOMIC IMPACT MUSC accouts for 12% of the Charlesto area ecoomy Nearly $4 billio ecoomic impact o the tri-couty area More tha 13,400 employees A additioal 14,000 jobs are supported by MUSC i other sectors brigig the total to early 28,000 jobs, which add more tha $1.8 billio i icome to the local ecoomy 1 i 12 jobs i the Charlesto regio is directly or idirectly tied to MUSC MUSC attracts $260M/year i research fudig, makig the istitutio the biggest maget for biomedical extramural research fuds i South Carolia (see graphic below) Two-thirds of all MUSC alumi (early 20,000) curretly work as health care providers i the state As costructio is uderway o the ew childre s hospital facility, a average of 984 additioal jobs will be supported by MUSC aually, pourig about $52 millio i icome ad $171 millio i ecoomic activity ito the tri-couty ecoomy MUSC's aual ecoomic impact o the Charlesto area: 27,711 $ 1,813,024,579 $ 3,847,646,066 Total employmet impact Total labor icome impact Total output or value of ecoomic activity ECONOMIC IMPACT BY MUSC ENTERPRISE SECTORS MUSC eterprise sectors Total employmet impact Total labor icome impact Total ecoomic activity MUSC Medical Ceter 13,812 $835,706,693 $2,086,668,064 MUSC Physicias 5,263 $463,242,369 $849,872,171 Medical Uiversity 8,636 $514,075,517 $911,105,831 Source: Ecoomic Impact Study for the Medical Uiversity of South Carolia, April 2016, by the Charlesto Metro Chamber of Commerce s Ceter for Busiess Research MUSC research fudig: $232.6M $218M NIH Fudig Total Fudig $247.8M $259.5M $250.3M $109.6M $112.6M $93.4M $88.3M $91.9M 2013 2014 2015 2016 2017 4 Source: Medical Uiversity of South Carolia

FY 2019 Priorities CLINICAL PRIORITIES: Health Iovatio Istitute... 9 The MUSC Health Iovatio Istitute will establish South Carolia as a leader i buildig ad maitaiig healthy commuities. The istitute will further lik medical research, cliical sciece, ad health iformatics i order to ecourage iovatio i traslatioal medicie ad health care delivery. The Health Iovatio Istitute will focus o servig South Carolia s most vulerable populatios ad addressig commuity health eeds. Telehealth... 10 MUSC s Ceter for Telehealth was recetly amed oe of oly two atioal Ceters of Excellece ad serves as the headquarters of the South Carolia Telehealth Alliace (SCTA). The SCTA brigs together a uprecedeted collaboratio of academic medical ceters, commuity hospitals ad providers, existig telemedicie systems, govermet leaders, ad other etities that believe all South Carolia residets should ad ca have access to quality health care, while effectively maagig the cost of providig care. MUSC has idetified a umber of federal budget ad policy iitiatives that would help foster the cotiued growth of telehealth i South Carolia. Orga Doatio Legislatio... 13 MUSC ad other trasplat ceters i the South ad Midwest believe it is time to explicitly direct HRSA ad the Uited Network for Orga Sharig to shift their focus away from orga allocatio toward geeratig more orga doors ad savig more lives, ad therefore have proposed amedmets to the Natioal Orga Trasplat Act (NOTA). MUSC-Clemso State Health Extesio... 14 MUSC is workig with Clemso Uiversity to help fill health care eeds i Aderso, Barwell, ad Williamsburg Couties. The MUSC-Clemso State Health Extesio will address such issues as childre s welless, ifat mortality, cacer screeigs, ad opioid addictio i order to close the gap o health disparities faced by rural ad uderserved commuities. State/Regioal Surgery Quality Demostratio... 16 BlueCross BlueShield of South Carolia provided $4 millio over three years to help support cliical practice trasformatio. Give this state-level support, MUSC would welcome matchig fudig opportuities to expad this program i South Carolia. South Carolia Opioid Reductio Program... 17 The state of South Carolia is uiquely poised to implemet ovel itervetios to reduce uwarrated opioid use give the robust etwork of cotiuous quality improvemet (CQI) programs. The overall goal of this iitiative is to reduce the amout of opioids prescribed to surgical patiets by 50%, reduce ew chroic postoperative opioid use by 50%, ad reduce opioid diversio ito our commuities. Disproportioate Share Hospital (DSH) Paymets ad the Childre s Health Isurace Program (CHIP)... 18 Disproportioate Share Hospital (DSH) paymets ad the Childre s Health Isurace Program (CHIP) are critical to our ability to provide care to South Carolia s most vulerable populatios. MUSC appreciates the South Carolia delegatio s support of the CHIP program ad asks Cogress to pass a delay i Medicaid DSH cuts through at least FY2020. Health Care Reform... 19 At MUSC, we cotiue to believe that ay health care legislatio must first be measured by the umber of people that will gai or lose access to care. A Medicaid block grat or per-beeficiary capitated paymet alterative to the curret Medicaid program would eed to take ito accout the fact that Medicaid operates differetly i almost every state. 5

RESEARCH PRIORITIES: Health Equity... 21 South Carolia raks 42d i the coutry i overall health, ad 45 of 46 couties i South Carolia are desigated as Medically Uderserved by HRSA. MUSC has the expertise, research, ad cliical capacity to address health disparities i South Carolia ad atioally. The Ceter for the Advacemet of Health Equity, Traiig, ad Diversity (AHEAD) will be established to promote ad advace health equity across the MUSC Health eterprise. Sickle Cell Disease... 22 Because of the high prevalece of sickle cell i South Carolia, the MUSC pediatric commuity has had extesive practice ad sigificat success with a prevetive medical regime for childre with sickle cell. NIH should make sickle cell research ad treatmet a higher priority for health disparities programs. Opioids Research ad Traiig Ceter of Excellece... 23 MUSC proposes a Ceter of Excellece to help the Southeaster medical commuity deal with addictio-related issues i a more proactive maer by developig ad promotig traiig materials for health care providers ad traiees i the area of opioids ad other addictive disorders. Mass Violece ad Victimizatio Resource Ceter... 24 The Natioal Crime Victims Research & Treatmet Ceter (NCVC) at MUSC was recetly awarded a $18 millio grat to establish the Departmet of Justice Mass Violece ad Victimizatio Resource Ceter. The Mass Violece Ceter will support the comprehesive eeds of victims of mass violece ad domestic terrorism ad assess the eeds of victims of other large-scale crimial icidets. Post-Traumatic Stress Disorder Cliical Research Ceter... 24 MUSC is a iteratioal leader i research o post-traumatic stress disorder ad its treatmet ad has idetified a eed for a itegrated ceter for PTSD research that would maximize syergy across researchers ad studies. Icreased fudig for the Natioal Istitutes of Health... 25 MUSC appreciates the successful efforts of Cogress to provide a $4 billio total icrease for the NIH over the previous two fiscal years. This was a tremedous victory for the may thousads of Americas ad their families who are affected by health challeges ad disease. MUSC urges the South Carolia delegatio to cotiue to support icreased fudig for medical research through the NIH. Support for the Holligs Cacer Ceter... 26 The MUSC Holligs Cacer Ceter (HCC) is oe of oly 69 Natioal Cacer Istitute (NCI)-desigated cacer ceters i the atio, ad it is the oly oe i the state. The more tha 4,800 patiets treated at HCC yearly have access to the latest cacer treatmets through a extesive etwork of cliical trials. The work doe at Holligs Cacer Ceter has a tremedous impact o South Caroliias, as will cotiued fudig for Natioal Cacer Istitute iitiatives. EPSCoR/IDeA Program... 27 MUSC supports full fudig for the EPSCoR/IDeA program. MUSC ad other research uiversities i South Carolia receive substatial fudig to icrease research ifrastructure ad trai ew geeratios of ivestigators through this program at five federal agecies. 6

EDUCATION PRIORITIES: Graduate Medical Educatio (GME)... 29 As health systems have come uder icreasig budget pressure from reductios i Medicare ad Medicaid paymets ad lost reveue from providig ucompesated care to the poor ad uisured, the expasio of residecy slots for medical studets has bee drastically limited. GME is the primary federal program that supports educatig ew physicias, ad reductios i fudig for GME could make the curret physicia shortage eve worse. South Carolia raks 37th i the atio i physicias per 100,000 people, accordig to the AAMC (2014). Rural Studet Loa Repaymet... 30 MUSC has idetified a eed to expad the atioal rural studet loa repaymet program to iclude physical therapists, occupatioal therapists, ad additioal detal studets who opt to serve rural commuities. Further, repaymet fuds should be applied to the frot ed of school debt so as to reduce paymet amouts, rather tha its curret form which oly reduces the loa terms. Natioal AHEC Program... 30 The AHEC Program improves the health of rural ad uderserved populatios through the developmet ad expasio of pipelie programs i medicie, ursig, detistry, ad other health professios by creatig ad expadig primary care rotatios for residets ad studets ad by providig educatio ad support i rural ad uderserved areas of South Carolia. MUSC appreciates Cogress cotiuig support for the AHEC program. Cotacts DAVID J. COLE, M.D., FACS Presidet Medical Uiversity of South Carolia Colcock Hall 179 Ashley Aveue Charlesto, SC 29425 Phoe: 843-792-2211 Email: coledj@musc.edu PATRICK CAWLEY, M.D., MBA, MHM, FACHE CEO of MUSC Health ad Vice Presidet for Health Affairs 171 Ashley Aveue Charlesto, SC 29425 Phoe: 843-792-4000 Email: cawleypj@musc.edu MARK SWEATMAN Assistat to the Presidet for Govermetal Affairs Secretary to the Board of Trustees Medical Uiversity of South Carolia Legislative Office 1205 Pedleto Street Suite 102 Columbia, SC 29201 Phoe: 803-734-0570 Email: sweatmmc@musc.edu MIKE ADCOCK ALLIE DODD Va Scoyoc Associates 800 Maie Aveue, SW Suite 800 Washigto, DC 20024 Phoe: 202-638-1950 Email: madcock@vsadc.com adodd@vsadc.com 7

Cliical Priorities 8

Health Iovatio Istitute The biggest challeges i health care iclude access, quality, ad affordability. Health care istitutios like MUSC have bee challeged to lower the cost ad icrease the quality of care, improve patiet satisfactio, ad create healthier populatios. Health iovatio ca fast-track those goals by discoverig ad deliverig ew methods, products, techologies, ad medicatios to treat patiets more effectively ad efficietly. MUSC s stregths i iovatio iclude: Drug discovery Medical devices Regeerative medicie Bioiformatics Health IT Telehealth The state of South Carolia falls ear the bottom of the list whe it comes to the healthiest states i the coutry. Therefore, ivestig i health iovatio through biomedical research ad cliical delivery is a tremedous opportuity to positively affect our citizes. Oe successful example of health iovatio i actio is the MUSC-led SC Telehealth Alliace, which provides critical ad specialty care to citizes i rural areas, imates, ad childre i uderserved schools. Further ivestmet i health iovatio esures that future iovatios are discovered ad delivered i South Carolia uder the leadership ad expertise of the state s academic medical ceter. The MUSC Health Iovatio Istitute would allow SC to be a leader i buildig ad maitaiig healthy commuities. The istitute would further lik biomedical research, cliical sciece, ad health iformatics to ecourage iovatio i traslatioal medicie ad health care delivery. The support ad structure of a istitute also makes MUSC more attractive to outside parters like corporatios ad o-profits that wat to help leadig health care istitutios tackle importat atioal ad SC-specific health eeds. A itegrated istitute meas more impact o the lives we touch at MUSC. The Health Iovatio Istitute would focus o servig South Carolia s most vulerable populatios ad addressig commuity eeds. Areas of cocetratio would iclude: Childre s Health MUSC has the oly Advaced Fetal Care Ceter i SC. MUSC will parter with hospitals ad other etities across the regio to icrease access to our atioally recogized materal-fetal medicie ad pediatric specialists. This area will bridge preatal ad postatal care for babies ad families to reduce ifat mortality rates. SC is curretly raked 42d i the coutry for ifat mortality, ad i some couties of the state the rates are worse tha i developig atios. Cacer MUSC has the oly NCI-desigated cacer ceter i the state, placig MUSC i the top 4% of all cacer ceters i the coutry. These ceters are istrumetal i the developmet of cliical trials ad outreach ad educatioal activities, empowerig MUSC to cotiue to reduce South Carolia s disproportioately large cacer burde. The Holligs Cacer Ceter will submit its reapplicatio for NCI desigatio i sprig 2018 ad appreciates the delegatio s cotiued support. Metal/Behavioral Health I order to respod to a atioal metal ad behavioral health crisis, MUSC strives to further develop statewide parterships to address opiate ad alcohol addictio as well as behavioral medicie. Our Ceter for Drug ad Alcohol Programs (CDAP) is raked i the Top 10 i the coutry, ad ew methods ad care plas that are developed there ca be deployed i local commuities to positively impact the substace abuse ad behavioral health crises. Chroic Disease MUSC has stregths i the areas of stroke, hypertesio, ad diabetes all areas of health where may South Caroliias suffer. SC is kow for beig the buckle of the stroke belt ad raks i the Top 10 i the atio i the percetage of the adult populatio with diabetes. Alog with other iovative parters, MUSC ca cotiue to develop ad deploy low-cost health techologies to help maage chroic disease amog uderserved populatios. Chroic disease has a disproportioately high ecoomic impact o the state. 9

Health iovatio will lead to ew breakthroughs i biomedical research ad fudametally chage health care by icreasig access ad quality of care ad decreasig costs. Several factors ad treds have led MUSC to propose a Health Iovatio Istitute to promote: icreased spedig o health care as a percetage of GDP; icreased support for medical research at NIH; the move toward more maaged care by federal ad private health care providers; the eed to address health care disparities ad chroic disease i order to reduce health care spedig; the eed to break barriers betwee research ad cliical care so that more people ca truly beefit from traslatioal medicie; the eed to positio South Carolia for the atio s precisio medicie iitiative; the eed for a multi-discipliary approach to atioal ad statewide health care challeges. The Health Iovatio Istitute is a importat part of the ew paradigm for health care that MUSC is embracig through our strategic pla, Imagie MUSC 2020, ad its goals, which iclude committig to patiets ad families first ad buildig healthy commuities. MUSC would greatly beefit from a federal fudig mechaism for capital projects such as the Health Iovatio Istitute. The FY2016 Seate Labor, HHS, Ed Appropriatios Report recommeded that $50 millio be set aside i a competitive fud to provide grats for ew ad reovated facilities as a first step i addressig this issue. I FY2017, the Seate Labor, HHS, Ed Appropriatios Report icluded $25 millio for biomedical research facilities. Most recetly, i FY2018, the Seate Labor, HHS, Ed Appropriatios Report icluded the followig laguage: Research Facilities Much of the atio s biomedical research ifrastructure, icludig laboratories ad research facilities at academic istitutios ad oprofit research orgaizatios, is outdated or isufficiet. For taxpayers to receive full value from their cosiderable ivestmets i biomedical research, scietists must have access to appropriate research facilities. Therefore, $25,000,000 is provided for grats or cotracts to public, oprofit, ad ot-for-profit etities to expad, remodel, reovate, or alter existig research facilities or costruct ew research facilities as authorized uder 42 U.S. C. sectio 283k. The committee urges NIH to cosider recommedatios made by the NIH Workig Group o Costructio of Research Facilities, icludig makig awards that are large eough to uderwrite the cost of a sigificat portio of ewly costructed or reovated facilities. MUSC supports a reewed federal commitmet to providig matchig fuds for buildig ew biomedical facilities to make way for iovatio at agig academic medical ceters. Telehealth Telehealth is meetig the eeds of icreased access, providig care sooer ad i some cases, more efficietly. Whe appropriately applied, telehealth ca reduce overall costs, especially whe faster care prevets costlier care dow the road. Telehealth ca be particularly effective i addressig the health care eeds of patiets who are located i medically uderserved areas ad be beeficial for all populatios as we improve care delivery efficiecy. MUSC Ceter of Excellece i Telehealth I September 2017, MUSC was otified by HRSA that the MUSC Ceter for Telehealth had successfully competed for oe of two atioal awards to develop a Telehealth Ceter of Excellece. The award is for $600,000 i the first year ad up to $2 millio per year for a additioal two years. The applicatio was developed by a multidiscipliary, 16-member team cosistig of key persoel from three of our five Uiversity colleges ad our cliical 10

health system. MUSC s compellig track record i telehealth program developmet ad leadership throughout South Carolia laid the foudatio for this award the first of its kid i the Uited States. As a COE, MUSC will fill importat gaps i the atioal telehealth ladscape through a combiatio of ogoig regioal ad atioal collaboratios, as well as proactive dissemiatio of telehealth resources. Furthermore, MUSC s COE will apply rigorous scietific evaluatio to COE objectives ad advace kowledge regardig how to achieve ext level telehealth. We ask that the delegatio support cotiued fudig for HRSA s Telehealth Ceter of Excellece program. MUSC Leadig Statewide Collaboratio MUSC s Ceter for Telehealth serves as the headquarters of the South Carolia Telehealth Alliace (SCTA). The SCTA is a uique collaboratio of academic medical ceters, commuity hospitals ad providers, existig telemedicie systems, govermet leaders, ad other orgaizatios that believe all South Carolia residets should have access to quality health care, regardless of where they live. With substatial fudig from the state legislature, the SCTA is ow offerig telehealth services to over 300 coected sites across South Carolia. Specifically, MUSC is coected to 26 hospitals, ad its tele-stroke program has cosulted o over 10,000 patiets i potetially life-savig situatios where every miute couts. With the MUSC tele-stroke program, EVERY citize i South Carolia is ow less tha a hour from expert stroke care. I collaboratio with a atioal tele-icu compay, MUSC has partered with 6 additioal hospitals to provide 24/7/365 tele-icu moitorig. Data related to this program shows that over 140 lives were saved i 2016. I additio to hospital-based programs, MUSC has several outpatiet programs deliverig urget, primary, ad specialty care to patiets from their primary care offices, cliics, schools, skilled ursig facilities, prisos, ad eve their homes, usig our mobile health techologies. South Carolia is primarily a rural state with pockets of desely populated urba areas with multiple large health systems ad health care professioals. For residets i the rural areas, this is ot the case. This is why statewide collaboratios are imperative. These collaboratios also allow i-state providers to remai competitive, serve as the stewards of quality, ad move toward equitable distributio of care for all South Caroliias. As SCTA headquarters, MUSC provides operatioal fudig to a umber of health care providers ad support etities icludig the Greeville Health System, Palmetto Health/USC, McLeod Health, the Departmet of Metal Health, the SC Area Health Educatio Cosortium, the rural-focused o-profit Palmetto Care Coectios, ad SC Educatioal Televisio (ETV). KEY INITIATIVES School-Based Telehealth School-based telehealth is a iovative program that overcomes barriers ad provides high-quality care to childre while decreasig abseteeism ad missed work time for parets. This program has bee successful i several commuities alog the I-95 corridor. The school-based telehealth team at MUSC has collaborated with the parters i the SC Telehealth Alliace ad the SC Departmet of Educatio to idetify regios of highest eed i the state to expad this program. This pla particularly focuses o addressig childhood asthma ad behavioral health eeds i order to improve health ad educatioal attaimet while decreasig overall costs. Direct-to-Patiet Telehealth Direct-to-cosumer or patiet techologies are showig promise i the delivery of care to patiets i the most appropriate settigs for certai coditios ad levels of acuity. Some of these techologies are providig efficiet care to low acuity coditios such as sius problems ad eczema, while remote patiet moitorig ad direct-to-cosumer applicatios are essetial to maagig chroic coditios. Oe of the more recet remote patiet moitorig programs lauched at MUSC is the heart valve program that moitors patiets after heart valve replacemet. Patiets egage i self-care by takig their vital sigs, icludig their heart rate ad oxyge 11

saturatio. This iformatio is trasmitted directly ito their electroic medical records, allowig the attedig physicia to set parameters to be otified if the patiet is ot withi the accepted rage. Whe appropriately applied, these direct-to-patiet techologies ca reduce readmissios, emergecy room visits, ad hospital legths of stay, all while improvig patiet satisfactio. FEDERAL BUDGET AND POLICY RECOMMENDATIONS As telehealth is rapidly becomig more widely itegrated ito the South Carolia health care delivery system, reimbursemet rates through Medicare ad Medicaid should be at a sufficiet level to support the growth of this importat health care model. Expadig federal fudig through HRSA to ehace ad match state-level ivestmets would allow academic medical ceters such as MUSC to cotiue to build this effective etwork, thus makig the overall health care delivery system more efficiet ad focused o quality care for all. This is especially importat i the rural areas of South Carolia ad other states where access to specialized medicie is limited. I additio, we propose that Cogress address how CMS reimburses providers of care through telemedicie to esure that ecoomic icetives are i place, so that telemedicie lives up to its potetial as a essetial part of America s health delivery system. REMOVE GEOGRAPHIC RESTRICTIONS Medicare rurality rules remai a barrier to expadig telemedicie services. While they attempt to address geographical barriers, they do ot address socioecoomic barriers i our commuities. To receive telemedicie services, curret Medicare laws dictate patiets be located i a rural area that is desigated as: a rural health professioal shortage area uder sectio 332(a)(1)(A) of the Public Health Service Act (42 U.S. C. 254e(a)(1)(A)) i a couty that is ot icluded i a Metropolita Statistical Area (MSA); OR from a etity that participates i a Federal telemedicie demostratio project that has bee approved by (or receives fudig from) the Secretary of Health ad Huma Services as of December 31, 2000. As i may states, i South Carolia the telehealth policies of some private payers ad Medicaid do ot have geographic restrictios. I additio, restrictig the developmet of telehealth programs to those that oly serve rural areas creates barriers to efficiecy ad scalability. Therefore, MUSC recommeds removig all geographic restrictios. PROVIDER TYPE RESTRICTIONS Provider types covered by curret Medicare telemedicie reimbursemet laws iclude oly a limited list of practitioers: physicias, urse practitioers, physicia assistats, urse midwives, cliical urse specialists, cliical psychologists, ad cliical social workers. There is a serious shortage of qualified health care providers, ad expadig the list of telemedicie-eligible providers to iclude additioal practitioers will address this shortage ad assist i lowerig the cost of treatmet while maitaiig a high quality of care. MUSC recommeds expadig the list of curretly eligible providers to iclude certified diabetes educators, audiologists, occupatioal therapists, physical therapists, ad speech laguage pathologists. May cliical applicatios ca be performed with the same quality via telehealth. Rules that are based upo adequate documetatio of quality care should apply to telehealth i the same maer as that of i-perso care. For this reaso, MUSC recommeds that provider-type restrictios be lifted for Medicare reimbursemet. 12

PATIENT LOCATION RESTRICTIONS Curret origiatig sites (patiet sites) may receive a facility fee uder the Medicare program: Office of a physicia or practitioer Critical access hospital Rural health cliic (RHC) Federally qualified health ceter (FQHC) (as defied i sectio 1861(aa)(4)) Hospital Hospital-based or critical access hospital-based real dialysis ceter (icludig satellites) Skilled ursig facility Commuity metal health ceter Expadig origiatig sites, or the types of sites where patiets may receive care, will help address access to care ad health care disparity cocers while facilitatig cost savigs. The Ceter for Telehealth has developed programs to effectively brig care to patiets i schools, jails, work places, ad homes. MUSC recommeds elimiatig the restrictio o origiatig sites i order to brig care to expaded health care facilities ad directly to places where patiets live, work, ad lear. Orga Doatio Legislatio The Uited Network for Orga Sharig (UNOS) is charged with maagig orga trasplatatio uder a cotract with HRSA/HHS. For more tha a decade, UNOS has focused o allocatio policy: how to distribute a fiite umber of orgas to a growig umber of patiets waitig o orga trasplat lists aroud the coutry. Not surprisigly, each attempt to redistribute this fiite supply created wiers ad losers, resultig i fierce resistace from withi the trasplat commuity. This historical ad cotiuig focus o allocatio from HRSA/UNOS wastes time ad resources ad detracts from the primary problem facig patiets with life-threateig orga failure: the scarcity of doors. Trasplat surgeos across the coutry, icludig those at MUSC, believe it is time to explicitly direct HRSA/UNOS to shift their focus away from allocatio ad toward geeratig more doors ad savig more lives. The Natioal Orga Trasplat Act (NOTA), which became law i 1984, outlied 15 objectives for the Orga Procuremet ad Trasplatatio Network. Oly three eve metio orga doatio: (K) (H) (N) work actively to icrease the supply of doated orgas, provide iformatio to physicias ad other health professioals regardig orga doatio, carry out studies ad demostratio projects for the purpose of improvig procedures for orga doatio procuremet ad allocatio, icludig but ot limited to projects to examie ad attempt to icrease trasplatatio amog populatios with special eeds, icludig childre ad idividuals who are members of racial or ethic miority groups, ad amog populatios with limited access to trasportatio The remaider cocer allocatio, logistics, data collectio, ad studies. Sice NOTA is the legal basis upo which HRSA/UNOS decides policy, it is ot surprisig that there has bee a misaligmet of emphasis by HRSA/UNOS o orga allocatio rather tha doatio. 13

Each day thousads of people suffer o trasplat waitig lists, may of whom will die. It is imperative the NOTA be updated to prioritize icreasig orga doatio ad makig the best use of doated orgas. Over the 13-year period from 2003 to 2015, the umber of orga doors ufortuately icreased by oly 13%, from 13,285 to 15,068. Much of this icrease was due to advaces i trasplat sciece that allowed more margial doors to be utilized by trasplat programs. Efforts to improve doatio over this time ca therefore oly be thought of as a failure. Review of curret doatio rates reveal a threefold differece across commuities, suggestig implemetatio of ew techiques, policy adjustmets, ad best practices across the coutry could dramatically icrease the umber of orgas trasplated. I order to icrease the umber of orga doors ad the umber of orgas available for trasplat, the objectives of the NOTA should be reordered ad ameded. These ew rules reflect four importat priciples. 1) Doatio is a local effort ad local commuities must be prioritized to beefit from these efforts. 2) Orga procuremet orgaizatios (OPO) ad ceters must have support to icrease doatio ad use ad be held accoutable for performace. 3) Vulerable ad rural populatios must be assured access to trasplatatio services. 4) Federal regulatio of trasplatatio must be coordiated betwee HRSA ad CMS to maximize orga use. MUSC trasplat surgeos have worked with colleagues aroud the coutry to draft amedmets to the NOTA desiged to icrease the umber of orgas available for trasplat, ad we would appreciate the South Carolia delegatio s cosideratio of this legislatio. MUSC-Clemso State Health Extesio MUSC is workig with Clemso Uiversity to help fill health care eeds i Aderso, Barwell, ad Williamsburg couties. The MUSC-Clemso State Health Extesio will address the followig priorities i order to close the gap o key health disparities that these rural ad uderserved commuities face: 1. Childre s Welless a. MUSC will establish a school-based program, Docs Adopt School Health Iitiative (DASHI), which is housed uder the MUSC Boeig Ceter for Childre s Welless. DASHI uses a approach to lead schools to assess their curret welless efforts ad the address the eeds they have idetified by selectig from evidece-based strategies listed o the School Welless Checklist, while competig i a welless competitio with other schools. So far, this program has bee deployed i 260 schools i 12 school districts across South Carolia, affectig approximately 160,000 studets. The state s rakig for obesity has improved for every age category, but there is still work to do that could be accomplished with additioal reach. b. MUSC will establish SC Farm to School. Farm to School uses local produce, hads-o utritio educatio, ad school gardes i its program. MUSC will utilize the DASHI program to deploy Farm to School ad to stregthe the relatioship betwee existig agricultural/utritio services ad schools. Educatig childre i a hads-o approach about utritio ad where their food comes from helps promote healthy livig. 2. Ifat Mortality a. MUSC will cotiue to establish Mother s Milk Bak of South Carolia (MMBSC) Door Milk Depots (collectio sites). South Carolia has set a iovative stadard of care that whe mother s milk is ot available, all preterm ifats receive door huma milk durig birth hospitalizatio. I that way, there will be o racial or socioecoomic disparity i preterm ifats receivig door milk. However, South Carolia does have a disparity i who ca be a milk door due to the lack of milk depots i rural couties. I fact, despite Aderso Couty ot havig a milk depot, at least three wome have drive over a hour to the MMBSC milk depot i Greeville. Establishig door depots i these couties will allow ursig 14

mothers to cotribute to the milk baks ad help save lives. b. MUSC will establish Safe Sleep Messagig i hospitals ad physicias offices. Over 70 South Carolia ifats aually die i sleep-related deaths. Additioally, 17 South Carolia couties experiece ifat mortality rates well above the state average. We believe that South Carolia families eed to kow the high risk of usafe sleep. This program seeks to trai health care professioals ad advocates o safe sleep methods so they ca educate expectig ad ew parets o best practices that ca save lives. Safe sleep methods should be as stadard as car seat safety, but educatio is essetial to achievig that level of awareess. c. MUSC will establish iovative ifat health care support ad perform a eeds assessmet to idetify the barriers ad facilitators to sustai breast-feedig ad improve ifat survival i racially, socioecoomically, ad geographically diverse South Carolia. We will respod to the eeds assessmet by implemetig tailored iovatios i these couties such as commuity-based Baby Cafes (breast-feedig drop-i ceters to support moms), revisio of ifat medical care with health care providers, ad telehealth lactatio support. 3. Cacer/Prevetative Care This iitiative will icrease the Holligs Cacer Ceter Mobile Health Uit service sites to iclude Aderso ad Barwell couties. The mobile uit is a MUSC/Clemso/DHEC partership that already serves Williamsburg Couty. The uit works to reach adults livig i target areas of South Carolia who have difficulties accessig health care ad who are at risk of developig cacer. Curret screeig services iclude breast health, ski cacer, ad cervical health. Prevetio ad early detectio of cacer saves lives ad decreases costs of treatmet. 4. Opioid Addictio We will establish the MUSC Itesive Program for Pai ad Opioid Rehabilitatio (IPPOR), directed toward patiets who are o high-dose opioid pai medicatios ad do ot have a addictio, yet are at high-risk for addictio, ad rehabilitate them over three weeks while discotiuig their opioids. This will prevet them from developig addictio. This program is a itesive outpatiet program that icorporates psychology ad physical ad occupatioal therapy. It is differet from all other state iitiatives, as all other iitiatives are treatig patiets who have already progressed to opioid addictio. Already, there is a huge umet eed for this populatio, which will icrease as we decrease opioid prescribig across the state. Clemso Uiversity ad MUSC have already committed to a robust collaboratio to ehace the health ad welfare of South Carolia s citizes, icludig uderserved rural commuities. As a lad-grat uiversity, Clemso leds the support of its agriculture extesio etwork ad mobile cliic outreach programs ad assets. Clemso Extesio has existig persoel ad physical ifrastructure i the served couties. Most importatly, Clemso Extesio has existig commuity relatioships i these couties, which provide a meas to immediately itroduce these health care programs ito the served commuities. We believe that this collaboratio provides a excellet opportuity to alig the Cooperative Agriculture Extesio s atioal framework for health ad welless with the health care expertise ad iovative health care delivery systems at MUSC to improve the health of the citizes of South Carolia. By utilizig the existig trusted relatioships of Clemso ad MUSC, the health iovatio pla will be more effective i a reduced amout of time. Usig the Cooperative Agricultural Extesios i Aderso, Barwell, ad Williamsburg couties as a focal poit, MUSC ad Clemso will lauch collaborative efforts to promote health, prevet chroic disease, elimiate disparities, ad build a culture of health i these commuities. 15

State/Regioal Surgery Demostratio The South Carolia Surgical Quality Collaborative is fuded through a grat from the BlueCross BlueShield Foudatio. The collaborative combies the kowledge, skills, ad resources of multiple diverse hospitals, BCBS, Health Scieces South Carolia, SC Hospital Associatio, ad MUSC. The primary goal of the collaborative is to improve surgical outcomes ad improve health care value (quality/cost). This uique partership supports the quality improvemet efforts of surgical ad ursig leaders across the state. Sice its iceptio, outcomes data o over 14,000 surgical cases has bee etered ito the collaborative database. These cases represet a wide swath of surgical cases from basic to extremely complex, from small rural critical access hospital, to large academic medical ceters. The collaborative is a web-based system that allows idividual surgeos to look at their outcomes very soo after the episode of care. Providers ca dissect the data to focus o ay area of iterest such as readmissio, woud ifectio, trasfusio rate, legth of stay, ad may others. I additio to the web portal for surgeos, SCSQC s focus o quality ad value egages patiets ad surgical traiees i quality improvemet efforts. This aspect is uique to the South Carolia collaborative effort. The goal of the collaborative is to lear from patiets about what o-cliical factors may cotribute to quality outcomes. It will also address disparities i care across the state. SCSQC strives to egage the ext geeratio of surgical leaders ad help them develop cotiuous quality improvemet skills that will serve them ad residets of SC for may years. The hospitals ivolved i this iovative iitiative represet a sigificat portio of the state ad are diverse i terms of geography ad type of facility. There are critical access facilities, midsize facilities, ad large academic medical ceters ivolved. Easley ad Spartaburg represet the Upstate; the Midlads are represeted through Greewood, Camde, ad Florece; ad the Lowcoutry with Georgetow, Orageburg, ad Charlesto. Mothly calls ad quarterly faceto-face meetigs take place so each facility ca share its kowledge ad quality improvemet efforts. Each hospital has started projects across a wide rage: Examples of targets iclude lower surgical site ifectios after colo surgery, reductio i blood trasfusios, reductio i hospital admissios, ad reductio i reoperatios. The iitial data has bee promisig, ad its impact o the Medicare populatio ad low socioecoomic status patiets is impressive ad has bee submitted to atioal meetigs for cosideratio for presetatios. While the collaborative is focused o geeral surgery, the overall improvemets i care will be felt throughout each hospital. As the collaborative matures, we hope to obtai additioal fudig through HHS/CMS. Additioal fuds would allow us to: add more hospitals to the collaborative which will allow more South Caroliias to be impacted by this quality improvemet work; lear ways to icorporate telehealth ad mobile health solutios ito higher value care; develop ad implemet pre-habilitatio programs which help patiets prepare for elective surgery (stop smokig, lose weight, improve utritio); expad ehaced recovery efforts to multiple surgical procedures; improve post-discharge recovery by supportig recovery efforts of patiets at home; improve patiet educatio ad expectatios so patiets kow how to pla for ad recover from surgical procedures. BlueCross BlueShield Foudatio of South Carolia provided $4 millio over three years to help support this iitiative, ad give this state-level support, MUSC would welcome matchig fudig opportuities to expad this program i South Carolia. 16

South Carolia Opioid Reductio Program (SCORP) Opioid misuse ad abuse is a atioal epidemic. The umber of deaths from prescriptio opioid pai relievers i the Uited States has quadrupled sice 1999, with 16,000 deaths occurrig i 2013. Sice 1999, the aual umber of South Carolia drug-related deaths has icreased by 250%. Five hudred ad fifty South Caroliias died of heroi ad opioid poisoigs i 2015 aloe. I 2016, 4,641,302 opioid prescriptios were writte i SC (populatio = 4,900,000). Surgery plays a sigificat role i the developmet of opioid addictio ad poisoig with a estimated 5-19% of opioidaïve patiets cotiuig to use opioids beyod 30 days after commo surgeries. Medicaid is importat to addressig the crisis because vulerable populatios are particularly affected. Three i 10 people with opioid addictio were covered by Medicaid i 2015. Medicaid recipiets represet approximately 17% of the surgical patiets but represet 20-30% of the patiets to develop opioid depedece followig surgery. Opioid depedece correlates with illegal heroi use ad death. Existig public health measures curretly focus o palliative strategies that target chroic opioid use ad prescriptio opioid diversio ito the commuities. A strategy that focuses o the prevetio of opioid depedece requires targetig opioid-aïve patiets prior to opioid depedece. The vast majority of idividuals who become opioid-depedet receive their first dose of opioids followig surgical care (elective surgery, emerget surgery, ad trauma). Betwee 5 ad 20% of opioid-aïve patiets who have successful surgery remai opioid-depedet followig surgery. This is likely related to the fact that surgeos prescribe early 40% of opioids, but there are o guidelies to direct postoperative pai maagemet, ad the degree to which prescribig is drive by coveiece, kowledge, or evidece is ukow. Therefore, chagig cliical care amog opioid-aïve patiets i the settigs has the greatest potetial to reduce the umber of chroic opioid users ad miimize diversio of prescriptio opioids from patiets ito the commuities. THE SOUTH CAROLINA OPIOID REDUCTION PROGRAM The state of South Carolia is uiquely poised to implemet ovel itervetios to reduce uwarrated opioid use, give the robust etwork of Cotiuous Quality Improvemet (CQI) programs. The South Carolia Surgical Quality Learig Collaborative is a uique collaboratio betwee HSSC, SC Hospital Associatio (SCHA), BlueCross BlueShield of SC (BCBS, SC) curretly fuded by the BlueCross ad BlueShield (BCBS) Foudatio. Surgeo-led etworks are devoted to improvig the care of patiets i South Carolia ad represet major health systems i urba ad rural SC. This itegrated etwork of relatioships, data ifrastructure, ad platform for chage is uique ad has positioed our state as the gold stadard for high-quality surgical care. The goals of this iitiative are to reduce the amout of opioids prescribed to surgical patiets by 50%; reduce ew chroic postoperative opioid use by 50%; ad reduce opioid diversio ito our commuities. Over five years, we will leverage the South Carolia CQIs to trasform statewide practices. We will build upo a data ifrastructure that eables detailed cliical data collectio, best practice idetificatio, ad rapid dissemiatio. We will create a patiet-cetered care budle that provides iformatio regardig opioid use ad alteratives ad will examie opioid prescribig treds, health outcomes, ad care utilizatio usig BCBS SC, CMS, ad Medicaid claims of patiets udergoig surgery across the state of South Carolia. The CQI etwork i South Carolia has a established culture of trust ad cooperatio that will eable trasformatioal chage i opioid abuse itervetio ad reductio. 17

DSH ad CHIP DISPROPORTIONATE SHARE HOSPITAL (DSH) PAYMENTS Oe of the biggest challeges faced by MUSC is the budget cuts that are required by the ACA for importat programs like Disproportioate Share Hospital (DSH) paymets. Presidet Roald Reaga ad Cogress created Medicaid DSH paymets to sustai hospitals like MUSC that serve a disproportioate umber of low-icome ad uisured patiets. I treatig those who have owhere else to tur, we icur substatial ucompesated costs ad operate o very arrow margis. Uder the ACA, Cogress established a schedule for reducig federal DSH allotmets to accout for a aticipated decrease i ucompesated care expected to occur as a result of the icreased umber of people with isurace due to Medicaid expasios ad the availability of subsidized exchaged coverage. These reductios have sice bee delayed five times. Origially set to take effect begiig i FY 2014, the reductios bega i FY 2018 i the followig aual amouts: $2.0 billio i FY 2018 $3.0 billio i FY 2019 $4.0 billio i FY 2020 $5.0 billio i FY 2021 $6.0 billio i FY 2022 South Carolia receives about $350 millio i DSH fuds per year. A delay i Medicaid DSH cuts through at least FY2020 will allow hospitals like MUSC to cotiue servig vulerable patiets util a more sustaiable, permaet solutio is reached. CHILDREN S HEALTH INSURANCE PROGRAM (CHIP) The CHIP program was created by Cogress with bipartisa support as part of the Balaced Budget Act of 1997. The program exteds health coverage uder the Medicaid program for childre ad pregat wome who do ot qualify for Medicaid but have o health isurace. Natiowide, CHIP has cut the umber of uisured childre by 50% sice its iceptio. Betwee 73,00 ad 80,000 childre i South Carolia are erolled i CHIP. CHIP, just like Medicaid, is a joit federal-state program i which the federal govermet matches state dollars to fud the program. States maage the program with federal oversight ad CHIP beefits vary by state. The federal govermet provides a ehaced match (efmap) which is higher that the match (FMAP) for the regular Medicaid program. I Jauary 2018, Cogress re-authorized the CHIP program for six years as part of its deliberatios over the cotiuig resolutio. Uder this ew provisio, the FMAP for CHIP is scheduled to be reduced over a period of years from the curret rate of 100% to the pre-aca rate of 80%. Give the budget costraits we face i South Carolia, it will be icreasigly difficult for the state to provide the icreased fuds to match the federal CHIP fudig. We appreciate the South Carolia delegatio s support of this importat program ad hope that Cogress will revisit this policy i the future, so that childre do ot lose their coverage due to icreased match requiremets. 18

Health Care Reform MUSC uderstads the eed to reduce the deficit ad spedig; we have take steps to reach the same goals withi our istitutio. However, withi those parameters, we must maitai our ability to provide health services to South Caroliias, particularly through the special programs oly available through MUSC. As a academic medical ceter, MUSC provides advaced care for the sickest patiets i the state who would otherwise have to seek treatmet out of state. MUSC provides South Carolia with access to advaced cliical trials for the most difficult diseases, so that treatmet ca be provided close to home. MUSC is the oly Level 1 trauma ceter i the state ad has oe of the oly eoatal itesive care uit for sick babies. MUSC also provides South Carolia with a first-class orga trasplat program. All of this advaced care is costly ad is oly available through a academic medical ceter like MUSC. May of the budget proposals reviewed by MUSC ted to focus o cuts to the very programs that allow MUSC to exist as a highly regarded medical ceter i South Carolia. There are 5,000 hospitals i the Uited States, but oly 10% are academic medical ceters/teachig hospitals. MUSC asks that academic medical ceters ot be sigled out to carry a disproportioate share of the deficit-reductio burde. MEDICAID REFORM At MUSC, we cotiue to believe that ay health care legislatio must first be measured by the umber of people that will gai or lose access to care. A Medicaid block grat or per-beeficiary capitated paymet system alterative to the curret Medicaid program would eed to take ito accout the fact that Medicaid operates differetly i almost every state. If the block grat formula is based o the umber of Medicaid erollees i each state, the states that have expaded Medicaid uder the ACA would have a great advatage over o-expasio states. States with more selective eligibility requiremets would also be treated ufairly compared to states with a more liberal eligibility stadard. I order for South Carolia to be treated fairly uder ay Medicaid reform proposals, Cogress eeds to look closely at how each state coducts its Medicaid program to esure every state is treated equally. REGULATORY REFORM We believe that Cogress should look at ways the admiistrative burde of providig health care ca be reduced to make the system more efficiet while maitaiig the same high stadards of care for our patiets. Medicare ad Medicaid regulatios grow every year without ay look-back requiremets to determie if the ew regulatios icrease the quality ad efficiecy of the health care delivery system or simply add more layers of admiistratio ad costs. This burde has become particularly excessive due to the Ceters for Medicare ad Medicaid ad other agecies of the Departmet of Health ad Huma Services releasig 21,000 pages of proposed ad fial rules affectig hospitals ad health systems. Adherig to these regulatios meas less time for MUSC physicias ad care team members to focus o their primary purpose of carig for patiets. As experieced providers, we ca tell you firsthad that excessive red tape is a barrier to more patiet-cetered care. Reducig admiistrative complexity i health care would save billios of dollars. We eed to cotiue to spur iovatio so that we ca do more with fewer dollars, but iovatio should also create a more streamlied system for approvig patiet treatmet ad reimbursemet for services of providers. We uderstad that the admiistratio ad may members of Cogress are aware of the admiistrative complexity imposed by the govermet o health care ad that iitial steps have bee take to begi to relieve some of those burdes. We wat to thak the South Carolia delegatio for your focus o this critical issue, ad we look forward to cotiuig to work with you to deliver the best patiet-cetered care possible. 19

20 Research Priorities

Health Equity Despite the availability of more effective strategies for early detectio, prevetio, ad treatmet, racial ad ethic miorities ad idividuals from other medically uderserved groups, cotiue to experiece sigificat disparities i morbidity ad mortality from chroic ad acute diseases. MUSC has ivested i the reductio of disparities i health care ad outcomes by promotig populatio, commuity, ad patiet health through iitiatives i commuity ad public health parterships, quality improvemet strategies, ad workforce diversity. We are ow at a critical jucture where coordiated efforts are eeded at a istitutioal level to esure that previous ad ew ivestmets that are made across the cliical, educatioal, ad research missios at MUSC are leveraged effectively to maitai the progress that has bee made i deliverig quality health care to all patiets, families, ad commuities ad to cotiue to advace health equity. The Ceter for the Advacemet of Health Equity, Traiig, ad Diversity (AHEAD) will be established uder the leadership of Dr. Chaita Hughes-Halbert to promote ad advace health equity across the MUSC Health eterprise. The AHEAD Ceter will advace health equity i patiet care ad outcomes by providig strategic directio of efforts i miority health ad health disparities across cliical, research, ad educatioal etities. We will coordiate health disparities research, workforce developmet ad traiig, ad commuity ad cliical egagemet across scietific, cliical, ad educatioal etities i the MUSC Health eterprise ad i the state of South Carolia. MUSC will moitor ad track the outcomes of research, cliical, ad commuity-based efforts i miority health ad health disparities at MUSC Health. This iitiative will further facilitate trasdiscipliary research i miority health ad health disparities through the developmet of competitive applicatios for extramural fudig, ad the idetificatio of foudatios ad philathropic resources to support iitiatives i health care equity. We will idetify opportuities for extramural fudig i miority health ad health disparities, develop resources, coordiate submissio of applicatios, ad evaluate the effects of this research to demostrate the cumulative beefits to populatio health ad health care outcomes. We believe that the work of the AHEAD Ceter will icrease the diversity of the health disparity workforce (e.g., researchers, cliicias, studets) through educatio ad traiig i disparities research, methods, ad culturally competet care. We aim to icrease access to professioal traiig i medicie, ursig, health professios, graduate studies, ad detistry by ehacig the developmet, dissemiatio, ad implemetatio of evidece-based pipelie programs to uderrepreseted miority studets at MUSC ad i South Carolia. We will also establish a Health Equity Certificate Program to provide traiig i disparities research ad methods ad culturally competet cliical care. Lastly, the AHEAD Ceter will support the egagemet of diverse stakeholders i research, health care delivery systems, ad educatioal efforts to promote the developmet of best practices ad ehace the traslatio of evidecebased itervetios ito cliical ad public health practice ad commuity advocacy. It will provide oversight of the egagemet of commuity, cliical, ad public health stakeholders i iitiatives for miority health ad health equity at MUSC Health ad will allow us to work collaboratively with commuity, cliical, ad public health parters to develop, implemet, ad evaluate health equity iitiatives. There has bee sigificat growth i the amout of research fudig at MUSC that addresses miority health ad health care disparities; cliical programs that target icreasig access to quality health care services; educatioal efforts that focus o traiig the ext geeratio of health care providers i social determiats ad cultural competecy; ad strategies that are desiged to icrease the diversity of the cliical, research, ad educatioal workforce. The AHEAD Ceter will coordiate trasdicispliary, research, ad cliical iitiatives to improve miority health ad reduce health disparities. 21

Sickle Cell Disease Sickle cell disease is the most commo iherited blood disorder i the Uited States. The disease affects all ethicities, although i the U.S., it is most ofte see i Africa-Americas. Due to red blood cell breakdow, iflammatio, ad blood vessel occlusio, this disablig disease causes extesive boe ad orga damage. Frequet, chroic, ad progressive pai crises, alog with other medical complicatios of the disease, make livig a ormal existece for afflicted idividuals very difficult. Despite improvemets i disease maagemet, may idividuals with sickle cell disease have difficulty completig schoolig or maitaiig employmet. I additio to ecoomic disparities created by sickle cell, the disease itself is life-limitig. Advaces i medical care have icreased the average life expectacy to 45 years, but may idividuals succumb to the disease log before. There are may pediatric providers for idividuals with sickle cell disease; however, affected adults ofte have difficulty fidig a medical home or disease specialist. May adults are oly seeig primary care doctors because there is a isufficiet umber of adult SCD providers. To meet this eed withi the commuity, we have established the Lifespa Comprehesive Sickle Cell Ceter at MUSC to care for persos of all ages. The ceter is focused o providig cotiuity of care to all idividuals with SCD ad offerig cuttig-edge research therapies as well as curative optios. We are also workig closely with our local sickle cell foudatio, COBRA, to cotiue raisig awareess for this disease. I 2014, we opeed the Sickle Cell Ceter o the secod floor of Rutledge Tower that icludes exam rooms ad a ifusio ceter for idividuals eedig trasfusios, pai medicatios, or other therapies. We expaded the ceter to iclude four urses, three physicias, a med-peds physicia, three-advaced care providers, ad a social worker. We also have a psychologist who specializes i developmetal assessmets of our youg patiets. We have assembled a large research team to esure our patiets have access to cuttig-edge research therapies ad the opportuity to improve disease outcomes. With a focus o studyig ew therapies ad improvig access to care for patiets, our sickle cell team has successfully participated i over 10 multiceter trials. To help esure all adults with sickle cell disease have access to a specialist, Dr. Julie Kater (Director of the Lifespa Ceter) applied for ad received fudig from the Duke Edowmet i 2015 to establish SC2 (Sickle Cell South Carolia) to help improve access to care for idividuals throughout the state. Sice SC2 was fuded, we have had a large umber of referrals for idividuals eedig adult SCD care from all over the state. This ovel statewide sickle cell etwork is a hub ad spokes model to brig disease-modifyig therapy ad idividual treatmet plas closer to patiets. I additio to the fudig above, Dr. Kater created a iterprofessioal team from throughout MUSC, icludig the colleges of Nursig, Medicie, ad Health Professios ad the Departmet of Public Health to desig a implemetatio pla to ehace the outreach ad success of SC2. This team, co-led by Dr. Kater ad Dr. Cathy Melvi, recetly received NIH fudig as oe of the eight Sickle Cell Disease Implemetatio Ceters i the U.S. Through this collaborative, we hope to idetify optimal ways of esurig all patiets have equal access to quality care for SCD. I additio to this excitig project, Dr. Kater ad Dr. Melvi also received a multiceter R01 grat from the NHLBI to better evaluate barriers to stroke screeig i childre with sickle cell disease. MUSC remais committed to a atioal effort to raise awareess of sickle cell disease ad brig together private ad govermet sources to focus more fudig o research ad treatmet. Support is eeded at the atioal level to: prevet the loss of isurace coverage o reachig age 18. Optios could iclude givig states the optio to expad Medicaid eligibility for adults with sickle cell or through the creatio of a waiver program to allow states to develop demostratio projects. Prevetative care will mea better quality ad more savigs. support sickle cell disease as a research priority for the Natioal Istitutes of Health, Agecy for Health Care Research ad Quality (AHRQ), ad Patiet Cetered Outcomes Research Istitute (PCORI). support FDA efforts i their Patiet-Focused Drug Developmet Iitiative for sickle cell disease therapies. 22

icrease awareess of sickle cell disease. facilitate through public policy ad public forums the sharig ad developmet of evidece-based care maagemet protocols for medical ad other professioals ivolved i the cotiuum of care for sickle cell disease. support the Sickle Cell Treatmet Act to ehace federal fudig for specialized sickle cell disease ceters. Resources for sickle cell disease remai extremely limited for affected idividuals, ad we hope to work together to icrease awareess ad decrease these iequalities. Opioids Research ad Traiig Ceter of Excellece MUSC faculty have tremedous expertise i research, treatmet, ad educatio cocerig opioid-use disorders (OUDs) ad other addictios. This is reflected i the fact that MUSC is the oly istitutio i the Southeast that has bee raked i the Top 10 i the atio for excellece i traiig i addictios i the US News & World Report rakigs for the last 10 years. The opioid epidemic has bee recogized as a public health emergecy i the Uited States. I respose to this public health crisis i South Carolia, MUSC partered with the South Carolia Departmet of Alcohol ad Other Drug Addictio Services (DAODAS) i a statewide effort to educate physicias across the state about best practices i opioid prescribig, pai maagemet, ad screeig ad likage to care for idividuals with OUDs ad other addictios. I additio, the MUSC/DAODAS partership has focused o icreasig access to medicatio-assisted treatmet (MAT) for OUDs i South Carolia by providig traiigs to providers statewide ad likig local ophysicia addictio treatmet providers with cliicias traied to prescribe MAT. Aother iitiative has bee the provisio of MAT ad likage to care for idividuals with opioid overdose who preset to emergecy rooms throughout the state. All of these iitiatives have bee eabled by the South Carolia Telehealth Alliace, headquartered at MUSC, which was recetly awarded a Ceter of Excellece i Telehealth from the Health Resources ad Services Admiistratio. The South Carolia Telehealth Alliace has facilitated expasio of traiig, coachig, ad treatmet of OUDs to rural parts of the state where there is iadequate access to medical providers. Researchers at MUSC have also partered with SC DHEC, Bureau of Drug Cotrol, ad the CDC s Prescriptio Drug Overdose Prevetio for States Program to aalyze a variety of state data to help defie hot spots for opiate prescribig for targeted itervetio. As such, MUSC has become a valuable resource for the state of South Carolia ad the atio i addressig the opioid crisis. MUSC will create a regioal Ceter of Excellece i Opioid Research ad Traiig to assist other states throughout the Southeast. The use of telehealth ad other olie resources we have developed (www.scmataccess.com) makes may of our ogoig efforts easily scalable. Addictios are a chroic problem i the Uited States ad have ever bee adequately addressed i U.S. medical schools ad residecy traiig programs. This lack of attetio is, i part, resposible for the curret opioid crisis. A Ceter of Excellece could help the Southeaster medical commuity deal with addictio-related issues i a more proactive maer by developig ad promotig traiig materials for health care providers ad traiees i the area of OUDs ad other addictive disorders. 23

Mass Violece ad Victimizatio Resource Ceter The Natioal Crime Victims Research & Treatmet Ceter (NCVC) at MUSC was established i 1977 ad has achieved a iteratioal reputatio for its iovative research, educatio, ad traiig; evidece-based metal health treatmet; prevetio services; collaboratio with victim service agecies; ad cosultatio with public policy makers. The NCVC was recetly awarded a prestigious $18 millio grat to establish the Departmet of Justice Mass Violece ad Victimizatio Resource Ceter. The Mass Violece ad Victimizatio Resource Ceter will support the comprehesive eeds of victims of mass violece ad domestic terrorism ad assess the eeds of victims of other large-scale crimial icidets that are ot ecessarily mass violece or domestic terrorism but result i a large umber of victims. The goal of this project is to develop a atioal victim-cetric framework that addresses best practices i preparig for ad respodig to icidets of mass violece ad domestic terrorism with timely, diverse, ad comprehesive approaches from plaig to log-term recovery. The MV Ceter, workig closely with the DoJ Office for Victims of Crime, will develop tools ad strategies, egage commuities ad the atio, ad build the capacity to support victims, their families, ad commuities affected by mass violece ad domestic terrorism through traiig ad techical assistace, idetifyig ad creatig best practices, ad expadig expertise i the field. MUSC will be parterig with may orgaizatios ad experts to establish the ew ceter. Its academic parters iclude the Bosto Uiversity School of Public Health ad the Uiversity of Califoria, Los Ageles. Several professioal orgaizatios will be ivolved, such as the Uited States Coferece of Mayors ad Natioal Associatio of Attoreys Geeral, as well as other major atioal ogovermetal orgaizatios. MUSC asks the delegatio to cotiue to support fudig for the DOJ Victims of Crime Program i order to cotiue the importat work of the ewly established Mass Violece ad Victimizatio Resource Ceter. Post-Traumatic Stress Disorder Cliical Research Ceter The faculty of the Medical Uiversity of South Carolia are iteratioally respected leaders i research o posttraumatic stress disorder ad its treatmet, both with respect to the impact of their work o treatmet of this disorder, ad i terms of the umber ad breadth of grats fuded by the Natioal Istitutes of Health, Departmet of Defese, Departmet of Veteras Affairs, Office for Victims of Crime, Natioal Istitute of Justice, ad a variety of private foudatios. MUSC faculty have coducted more treatmet outcome studies o PTSD i the past decade tha ay other academic istitutio or research etity, icludig the VA s Natioal Ceters o PTSD. This is because MUSC researchers are ot limited to oe type of PTSD victim, but istead, study PTSD across the populatio spectrum, icludig PTSD i Active Duty ad Vetera populatios (e.g., combat-related PTSD), as well as PTSD i civilias related to severe accidets (e.g., automobile crashes), iterpersoal violece (both domestic violece ad strager violece), atural disasters (icludig hurricaes, earthquakes, ad tidal waves), ad terrorism (icludig that perpetrated by both citizes ad foreig agets). No other research etity has such deep expertise ad research fudig i each of these areas of PTSD, ad o other etity has bee able to maximize cross fertilizatio of research fidigs across trauma type ad ito cliical settigs with the speed of MUSC, a accomplishmet due both to our itegratio of research ito cliical services ad the collaborative ature of our faculty ad Uiversity admiistratio (e.g., cross-college sharig of idirect cost fuds). To date, this extesive etwork of iterrelated research ad researchers has fuctioed without a formal orgaizig etity or ifrastructure, like the proposed PTSD Cliical Research Ceter. As such, collaboratios, while may i umber, are seredipitously formed without a overarchig visio or strategic pla, ad the potetial collective power of research is ot realized. If MUSC is to cotiue its leadership i terms of overall umber of PTSD treatmet outcome grats ad impact of its research fidigs, a orgaizig ifrastructure will be essetial to coordiate recruitmet of participats, so that idividual projects are ot competig with oe aother for the same subjects. 24

A orgaizig etity i the form of a PTSD Cliical Research Ceter will also be essetial to the strategic commuicatio of fidigs to the geeral public. MUSC is seekig fudig for a PTSD Cliical Research Ceter for the followig reasos: largest umber of PTSD treatmet outcome projects of ay istitutio or etity i the past decade; oly etity to coduct research i all types of PTSD (combat, military sexual trauma, iterpersoal violece, disaster, terrorism, child abuse, elder abuse, domestic violece); first etity to demostrate effective delivery of evidece-based psychotherapy for PTSD via telehealth directly ito veteras homes; techology applicatios for Healthful Lifestyles Ceter is itimately ivolved i itegratig techology ito best practices PTSD treatmets (Co-Director is amog the Top PTSD researchers); first etity to study Trascraial Magetic Stimulatio i treatmet of PTSD highly itegrated research collaboratios with VA PTSD researchers ext door, usig dual appoitmets to strategically achieve research force multiplicatio; research spas bech-to-bedside-to-dissemiatio sciece. To summarize, MUSC PTSD research is uique, i terms of its high volume ad more importatly because it focuses o all types of PTSD, represetig research i the areas of civilia trauma (icludig domestic violece, strager violece, sexual violece, elder abuse, ad child abuse), combat trauma (icludig combat, military sexual trauma, ad deploymetrelated accidets), atural disaster, ad terrorism (both domestic ad foreig). No other sigle site comes close to MUSC i terms of such ecompassig PTSD work. Moreover, MUSC PTSD research is ed-user focused ad cuttig edge, i that we have spet the last decade focused o coductig more best-practices treatmet-outcome research, icludig deliverig itervetios via mhealth, telehealth, ad the web. We are at a stage where we have the critical mass to justify a itegrated PTSD ceter, that would allow us to maximize syergy across researchers ad studies. It will also allow us to compete for ad successfully coduct large-scale ceter grats that have previously eluded us. Support for the Natioal Istitutes of Health MUSC appreciates the successful efforts i Cogress to provide steady icreases to the Natioal Istitutes of Health budget over the past several years. The NIH budget icreased by $2 billio i FY2016, $2 billio i FY2017, ad the Seate LHHS appropriatios bill icludes a additioal $2 billio for NIH i FY2018. The House FY2018 LHHS appropriatios bill icludes a $1.1 billio icrease for NIH. MUSC received $112 millio i fudig from the NIH i FY2017. NIH s budget averages $30+ billio a year ad is the primary support for our atio s medical research programs. NIH fudig impacts the basic research that is the foudatio of medical sciece ad supports the developmet of ew drugs to fight deadly diseases like cacer. Cliical trials that are part of the drug developmet ad approval process give South Caroliias access to the most curret sciece that medicie has to offer, ad i may cases, ca save lives that would otherwise be lost to advaced disease. Sice 2015, the HCC has opeed 95 NIH/NCI fuded cliical trials. I September 2015, MUSC was awarded the Natioal Ceter for Advacig Traslatioal Scieces coveted Cliical ad Traslatioal Sciece Awards (CTSA) the largest grat mechaism at the Natioal Istitutes of Health (NIH). The CTSA atioal etwork works together to reduce the time it takes to tur research discoveries ito ew treatmets for patiets, to egage commuity stakeholders to take active roles i all phases of research, ad to trai the ext geeratio of researchers ad support staff. The South Carolia Ceter for Traslatioal Research (SCTR) is led by 25

MUSC ad has robust collaboratios with affiliate members across the state, icludig the Uiversity of South Carolia, Clemso Uiversity, South Carolia State Uiversity, Clafli Uiversity, Greewood Geetics Ceter, South Carolia Research Authority, ad V. A. medical ceters to expad iovative research ad traiig activities across the state. I additio to the discovery of ew therapies ad developmet of ew medical devices, this research fudig is a importat cotributor to the regioal ecoomy, as it is estimated that each NIH dollar geerates $2.21 i ew state busiess activity. South Carolia is home to 1,153 biosciece busiess establishmets. I 2012, residets held 13,603 biosciece idustry jobs, ad the average aual wage i the biosciece sector was $21,873 higher tha the private sector overall. NIH dollars also serve to power the SC ecoomy i producig ew compaies ad ew jobs. MUSC iovatio led to the formatio of more tha 50 startup compaies over the past several years. NIH fudig also results i ew licesig agreemets ad patets for South Carolia. This fudig should cotiue to be prioritized as it will affect may thousads of Americas ad their families who are affected by health problems ad disease. Support for the Holligs Cacer Ceter The MUSC Holligs Cacer Ceter (HCC) is oe of oly 69 Natioal Cacer Istitute (NCI)-desigated cacer ceters i the atio ad is the oly oe i the state. The more tha 4,800 patiets treated at HCC yearly have access to the latest cacer treatmets through a extesive etwork of cliical trials. Cliical trials offer HCC patiets the opportuity to beefit from itervetioal ad o-itervetioal therapies ot available elsewhere i South Carolia. HCC is curretly erollig patiets i 117 therapeutic ad 76 o-therapeutic studies, icludig phase I trials. HCC has bee a NCI-desigated cacer ceter sice 2009 ad is curretly udergoig a reewal for NCI-desigatio, a rigorous, highly competitive process that occurs every five years. As part of this process, HCC is required to demostrate how it is reducig the cacer burde i the state ad providig public outreach o cacer prevetio ad screeig. The ceter also is dedicated to developig ad implemetig strategies targetig cacer health disparities ad extedig care to uderserved ad high-risk populatios, such as the Sea Islad commuities. I 2018, a estimated 30,450 South Caroliias will be diagosed with cacer. HCC offers these patiets the optio to be treated close to home while still receivig the most advaced cacer care that is guided by a multi-discipliary team of cliicias ad backed by world-class researchers. Cacer researchers at HCC held more tha $42 millio i research fudig i 2017. Some of HCC s special objectives iclude: providig traiig opportuities to better support cacer research, such as the HCC Fellowship Program to icrease traiig ad educatio of graduates ad post-doctoral studets. advocatig for cacer cotrol iitiatives supportig the prevetio of cacer ad importace of cacer screeig. Oe such push icludes efforts to icrease HPV vacciatio rates through the educatio ad traiig of health care providers, parets ad commuity health workers ad legislators, who ca impact the state s policy o vacciatios. developig ew stadards of care i smokig cessatio ad addictio services, areas of atioal expertise for MUSC. A example of this is HCC s Tobacco Cessatio Program ad ipatiet smokig cessatio couselig program. expadig HCC s research portfolio dedicated to addressig health disparities ad supportig itervetioal programs targetig cacer health disparities ad uderserved populatios. offerig commuity outreach to make cacer prevetio screeigs ad cacer awareess more accessible to the public. These efforts iclude the HCC Mobile Health Uit that provides screeig for oral, breast, ad ski cacers to rural commuities. The work doe at Holligs Cacer Ceter has a tremedous impact o South Caroliias, as will cotiued fudig for Natioal Cacer Istitute iitiatives. 26

EPSCoR/IDeA Program MUSC asks the delegatio to cotiue to support robust fudig for the Established Program to Stimulate Competitive Research (EPSCoR) ad the Istitutioal Developmet Award (IDeA) programs. EPSCoR/IDeA programs have become the ceterpieces of the federal govermet s efforts to esure that all states ad regios beefit from its sciece ad egieerig (S&E) research ad educatio activities. I September 2017, South Carolia was awarded a $20 millio five-year NSF RII Track-1 grat, which will ivolve collaboratio betwee 10 research istitutios, icludig MUSC. The Natioal Sciece Foudatio established EPSCoR i 1979 because Cogress was troubled by the ueve distributio of federal research ad developmet grats. Grats gravitated toward the few states ad istitutios that had historically beefited. This status quo igored the dramatic growth i regioal educatioal ad research istitutios, so the atio was t profitig fully from the wealth of igeuity ad skill embedded across the coutry. Four other federal agecies have followed the Natioal Sciece Foudatio i creatig EPSCoR programs: the Natioal Istitutes of Health, the Natioal Aeroautics ad Space Admiistratio, the Departmet of Eergy, ad the Departmet of Agriculture. The Natioal Istitutes of Health Istitutioal Developmet Award (IDeA) program is the largest. MUSC is pleased that Cogress has cotiued to recogize the value of the IDeA program, with the House Appropriatios Committee icludig $373.6 millio ad the Seate Appropriatios Committee icludig $344.3 millio for the program i FY2018. Last year, Cogress icreased fudig for the NIH IDeA program by $13 millio over FY2016 i fial egotiatios of the Omibus Appropriatios Bill. Research uiversities i South Carolia receive substatial fudig from the EPSCoR ad IDeA programs, which is used to icrease research ifrastructure ad trai ew geeratios of researchers. South Carolia research istitutios curretly hold 10 active IDeA awards. I July 2014, the MUSC College of Health Professios received ews that it was the recipiet of a $10.8 millio COBRE grat from the NIH/IDeA program, the largest such grat awarded to MUSC to date. The grat established the South Carolia Research Ceter for Recovery from Stroke. The COBRE grat allows a team of seior ivestigators with differet skills to work together to trai ad metor the cadre of juior scietists ivolved i the grat, who will become skilled i multiple areas, providig them the multidiscipliary toolbox ecessary to become the ext geeratio of leaders i the field. They will be developig ad traslatig ew mechaism-based itervetioal strategies i a effort to improve fuctioal recovery from stroke, which is a leadig killer i South Carolia. Without the IDeA program, our ability to address this importat health care problem would be hidered sigificatly. 27

28 Educatioal Priorities

Graduate Medical Educatio Various deficit reductio proposals have focused o reducig fudig for Graduate Medical Educatio (GME), the atio s primary source of fudig for the educatio of ew doctors. GME fuds are provided through Medicare to help offset some of the costs associated with educatig residets, carig for patiets who require more itese ad complex care, ad other special missios of teachig hospitals. Ay deficit reductio plas that reduce fudig for GME will ievitably make the physicia shortage worse ad will be especially harmful to rural commuities that are already desigated as physicia-shortage areas. Medicare pays supplemets to teachig hospitals for Direct Graduate Medical Educatio (DGME) ad for Idirect Graduate Medical Educatio (IME). IME provides a small icrease over ormal Medicare reimbursemet rates for services provided at teachig hospitals. DGME pays hospitals o a per-residet basis based o how may residecy slots they are allocated. All medical school graduates must complete a residecy traiig program, ad each year, graduates participate i a residecy match which assigs them to a residecy slot at a particular hospital. The Balaced Budget Act of 1997 essetially froze the umber of slots Medicare would pay for o a atioal basis. Sice that time, a hospital that decides to icrease the umber of residets traiig at their facility above what Medicare pays for has to cover the etire cost from hospital reveues. Each year, several hudred seiors i MD programs i the Uited States are left without a positio at the coclusio of the match, which does ot iclude iteratioal medical graduates, previous graduates, or other o-traditioal applicats. 2017-2018 RESIDENT DATA Total umber of filled residecy slots 713 Federally fuded 365 MUSC fuded 237 VA fuded 102 Departmetal/Grat/Other fuded 7 Air Force fuded 2 As hospitals across the atio, icludig MUSC, have come uder icreasig budget pressure from reductios i Medicare ad Medicaid paymets ad icreasig lost reveue from providig ucompesated care to the poor ad uisured, hospitals have limited their expasio of residecy slots. I fact, as budget reductios required by the Affordable Care Act for programs like Disproportioate Share Hospital (DSH) Paymets cotiue to be implemeted, hospitals are expected to further cut the umber of residecy slots they ca afford. While medical schools are doig their part by erollig more medical studets to meet the eeds of a growig ad agig populatio, the cost of traiig ew doctors through residecy programs, a resposibility that was oce primarily supported by federal reveues, has ow falle to each of the 500 teachig hospitals. Accordig to the AAMC, the Uited States faces a shortage of somewhere betwee 40,800 ad 104,900 physicias by 2030. South Carolia is raked 37th i the umber of doctors per 100,000 people, accordig to the AAMC. As of 2016, there were more tha 435 total medical school graduates (allopathic ad osteopathic) i the state with oly aroud 300 firs-year residecy slots i the etire state. Several bills have bee itroduced i Cogress by Republicas ad Democrats to address the shortage of residecy slots. MUSC ecourages the South Carolia delegatio to review the merits of these bills that provide for a icrease i residecy slots to address a atioal physicia shortage that is especially troublig i South Carolia. 29

Rural Studet Loa Repaymet MUSC has idetified a eed to expad the Natioal Health Service Corps Studet Loa Repaymet Program to iclude physical therapists ad occupatioal therapists. Additioally, the program curretly serves detal studets who opt to serve rural commuities, but loa repaymet fuds should be applied to the frot ed of debt, so as to reduce paymet amouts, rather tha its curret form, which oly reduces the loa terms. The Natioal Health Service Corps (NHSC) is a Health Resources ad Services Admiistratio (HRSA) program that addresses the health eeds of more tha 9.7 millio uderserved idividuals across the atio. The program offers fiacial ad other support to primary care providers ad sites i uderserved commuities, with the goal of buildig healthy commuities i areas with limited access to care. The program has show icreases i retetio, meaig that NHSC members choose to remai i uderserved commuities after their service commitmet has eded. The NHSC program provides a opportuity for participats to pay off studet loas through cotiued service, as well as access to educatioal, traiig, ad etworkig opportuities. The NHSC Loa Repaymet Program allows licesed health care providers to ear up to $50,000 toward studet loas i exchage for a two-year commitmet at a NHSCapproved site. Curretly, accepted participats iclude primary care medical, detal, or metal/behavioral health cliicias, ad they ca choose to serve loger for additioal loa repaymet support. MUSC supports the additio of rehabilitatio professioals, icludig physical ad occupatioal therapists, to the loa repaymet program. Based o curret treds i the physical therapist workforce, the shortage of physical therapists could potetially reach over 27,000 i the Uited States by 2020, greater tha other primary care disciplies recogized by the Natioal Health Service Corps. May physical therapists live i urba ad suburba areas, creatig maldistributio of physical therapists throughout the coutry. The iclusio of physical ad occupatioal therapists i the NHSC Loa Repaymet Program will help to esure that rehabilitatio services are available to uderserved commuities i South Carolia ad atioally. Addig professios to the NHSC program will ot icrease the moey eeded for the program but will allow our commuities to determie their most pressig eeds. Natioal AHEC Program Though the Area Health Educatio Ceter (AHEC) program was ot i the presidet s budget for FY2018, the FY 2018 House LHHS-Ed Appropriatios bills icludes $30,250,000 ad the Seate LHHS-Ed bill icludes $32,750,000 for the program. MUSC appreciates that Cogress recogizes the value of the AHEC program ad asks the South Carolia delegatio to lead the federal effort i assurig sustaiable fudig for the AHEC program. The AHEC program should be fuded i FY2019 ad beyod, at least at the level provided i FY2017 ad FY2018 appropriatios bills. The AHEC program improves the health of rural ad uderserved populatios i South Carolia through the developmet ad expasio of pipelie programs i medicie, ursig, detistry, ad other health professios; by creatig ad expadig primary care rotatios for residets ad studets; ad by providig educatio ad support for physicias, detists, urse practitioers, physicia assistats, urses, ad other providers i rural ad uderserved areas of South Carolia. America s health care system is beig challeged to make chages that will achieve the ambitious triple aim of better health, better care, ad lower costs. AHEC ceters ad programs based i widely diverse commuities across the atio are actively respodig to this challege with services ad programs which directly address the chagig health care eviromet. 30

THE SOUTH CAROLINA AHEC PROGRAM: helps meet the icreasig demads o the primary care health care workforce. improves the distributio of the health professios workforce i rural ad uderserved areas. fosters a diverse health professios workforce that reflects the state s populatio. prepares health professioals to expad collaborative practices ad team models of care. AHEC is buildig ad supportig the health care workforce that South Carolia eeds through the followig iitiatives: telehealth educatio provides ew access for studets, providers, patiets, ad commuities through techologyeabled services. Telehealth exteds AHEC s statewide reach ad parterships to address rural health care delivery ad health care workforce developmet eeds. health careers programs address the eed to icrease the umber of youg people, especially those from uderserved populatios, who aspire to become health care professioals by promotig academic preparatio ad motivatio for high school ad college studets through year-log ad summer programs. health professios studet programs provide opportuities for studets to work ad lear i rural ad uderserved commuities i South Carolia by gaiig real-world experiece i patiet care settigs. These experieces icrease the likelihood they will choose to practice i commuities i eed of health care services. graduate Medical Educatio provides support for Family Medicie residecy traiig programs i eight South Carolia commuities. More tha 50% of all family doctors i South Carolia are traied i AHEC-affiliated residecies. recruitmet ad retetio programs address the state s health care workforce eeds through recruitmet activities, the Locum Tees Program ad grats that provide fiacial icetives to physicias, detists, ad advaced practice providers to practice i rural ad uderserved commuities. professioal educatio programs idetify the eeds of health care professioals ad provide educatio programs desiged to ehace cliical skills ad maitai professioal certificatios. Programs are delivered through traditioal methods ad iovative techologies. the Office for Health Care Workforce Aalysis ad Plaig geerates iformatio about health care workforce characteristics ad eeds i South Carolia to iform idividuals, commuities, educatioal systems, state agecies, health systems, ad others i order to assist with iformatio-based plaig ad decisio makig. 31

AHECs are providig services that respod to key eeds of the chagig health care ladscape. AHEC programs: itegrate public health ad primary care ad address the icreased eed for the placemet of studets i commuitybased primary care settigs. participate i efforts to icrease access to ad coverage by health isurace. provide iterprofessioal educatio iitiatives to develop team-based care ad focus o traiig for improved patiet safety ad cliical outcomes. AHECs have a excellet track record of recruitig, metorig, ad traiig studets from uderrepreseted miority, rural, ad disadvataged populatios. With more tha 40 years of experiece, AHECs are uiquely positioed to play a sigificat role i buildig a health care workforce to serve commuities i South Carolia ad succeed withi the health care system of the future. Providers eed to uderstad how to work with a icreasig diverse group of patiets, ad AHECs have the access, diversity, capability, ad capacity to help make this happe. 32

Health Professios Chagig What's Possible