If the U.S. is ever to improve rural America's access to quality healthcare, the one thing it must provide—just about everyone agrees—is broadband Internet access. Connections are needed from clinics to hospitals and to physician offices, to specialists who read images in faraway places, and even to patients' homes so their conditions can be remotely monitored and managed.
So when the Federal Communications Commission last month released its "Notice of Proposed Rulemaking" seeking comments on its plan to spend up to $400 million a year to improve rural health connectivity, I jumped in to read the 30-page tome. The money would come from the Universal Service Fund, the charge appearing on phone bills, which is administered by the FCC.
"This greater broadband connectivity has the potential to revolutionize healthcare delivery by providing access to state-of-the-art Health IT solutions to over 12,000 hospitals and clinics across the nation," the proposal begins.
"Greater use of broadband will allow patients in medically underserved communities to receive healthcare locally and have access to state of the art diagnostic tools typically available only in the largest and most sophisticated medical centers. Use of health-related applications delivered over broadband will not only save lives, but also cut costs by shortening average hospital stays, reducing the need for tests, and increasing administrative efficiencies."
For example, the proposal says, "remote patient monitoring for heart failure can save up to $6.4 billion annually through reduced hospital admissions. The monetary benefits of remote monitoring of other medical conditions could be exponentially larger."
But for a variety of reasons the entire program and proposed rulemaking has become extremely controversial. Many rural health experts I spoke with insist that the FCC's current plan falls far short of being able to deliver its promises. There are problems with whether it will help providers qualify for meaningful use requirements, but that's not even their main issue.
As background, FCC officials admit that they are trying to correct the follies that have crippled, and some say doomed to failure, most of the 62 Rural Health Care Pilot projects that were approved in 2007, which would have spent $417 million by June of this year, the deadline for completion. Only recently were the stymied projects given another year to comply with all the requirements.
These 62 grants funded demonstration or pilot projects from Puerto Rico to Western New York to the mountains of Utah and Alaska.
An FCC spokesman said, "The Rural Health Care Pilot Program has provided the FCC with valuable insight on how to provide much-needed connectivity for broadband-enabled health care technology in areas where it is lacking. Over half of the 62 projects have received sign-off from the FCC to link hundreds of hospitals in 30 states, and 20 projects have submitted invoices for work already performed. As we seek comment on designing a new Rural Health Care Program, we are using lessons learned in the Pilot to create a flexible program that will provide rural health providers the networks and support they need, where they need them, while still protecting the universal service fund from waste, fraud and abuse."
Unfortunately, most of them have yet to get off the ground for a variety of complicated reasons.
Massive amounts of paperwork were required to be submitted quarterly and in some cases monthly by the grantees, who in many cases didn't have the resources or the acumen to accomplish the task. As of last week, only $24.9 million of the money has been spent, and only $69.2 million, or about 15%, has been committed for only 32 of the 62 projects.
A major part of the problem is that the federal funds required a 15% match, which the applying entities can't come up with, said Dale Alverson, MD, full time medical director for the Center for Telehealth in Albuquerque, NM, a region that is still waiting to receive the first penny of its $15,931,111 award for the Southwest Telehealth Access Grid, which was to receive one of the top 10 highest amounts.
The money was supposed to support a network of networks that would distribute telemedicine clinical services to about 60 healthcare facilities in Arizona, and New Mexico, said Alverson, who also is the newly elected president of the American Telemedicine Association.
Alverson describes a series of paperwork bottlenecks of lengthy forms, formulas that kept changing. "It was like filling out a complex tax return."
And a lot of the sites that might have benefitted didn't have the infrastructure in place—to use an analogy, the on and off ramps from the main networks to the provider's clinics and hospitals—that was needed to even start the projects.
Rural Native American tribes, as strange as it might sound, Alverson explained, "had to confirm that they really existed. And it proved to be much more complicated for these rural smaller clinics."
"We had to hire a full time program manager to manage this full time, But (the grant) wouldn't pay for that."
There were also discouraging restrictions on what types of providers qualified for the money. Skilled nursing facilities or renal dialysis centers did not, and if the provider's administrative offices were in a different building, those offices weren't eligible. The money also couldn't assist a clinic's data centers, its routers, or servers, he said.
With the new rulemaking, the FCC is trying to be more lenient. With future projects, the proposal would allow skilled nursing facilities, dialysis centers, and administrative offices to benefit from the funding. Additionally, monthly recurring costs for broadband services, funded at 25% for the pilot projects, would be increased to 50%.
Eligibility would be expanded from roughly 9,800 entities today to roughly 12,000 rural health care providers, the FCC said in a statement.
But the American Telemedicine Association is unconvinced the FCC proposal will work.
"At this point, with my first read of it, I don't see it as an improvement," said John Linkous, CEO of the American Telemedicine Association, which has followed the issue closely. "I haven't seen that it will do anything to accelerate the payments or streamline the process. Those are the two biggest concerns."
He acknowledges that the FCC proposal relaxes some other troublesome provisions, "but it's not going to be any less complex than the current program."
And rather than allowing 85% federal funding to be a ceiling, Linkous says it should be a floor.
He listed six changes the ATA would like the FCC to fix in its current proposal before going forward with more $400 million annual broadband connectivity projects.
- Streamline the process for project approval and refrain from additional last-minute requirements so as to accelerate the full funding of all eligible projects.
- Reduce red tape, eliminating required quarterly progress reports until funding is dispensed and the project started.
- Eliminate the proviso allowing participants to sell excess broadband capacity to entities that don't provide healthcare.
- Allow funding to support project management and administration, including salaries and travel, which the current FCC rules do not allow.
- Remove cash only requirement for matching funds or adopt a more liberal position for grantees to accept in-kind services.
- Quickly reevaluate the costs per site of each approved project to ensure the efficient use of federal funds.
According to an FCC report released July 20, between 14 million and 24 million Americans do not have access to broadband today, and most of these individuals are disproportionately lower income and/or rural residents.
It is well known that rural areas lag behind urban and suburban regions in having commercially available broadband access. According to the Pew Internet & American Life Project, only 47% of Americans in rural areas have access to broadband connections at home, whereas 61% of urban adults and 64% of suburban adults have such access.
"The FCC's rulemaking comment period began Aug. 9 with publication in the Federal Register, and will end in Sept. 8, with the deadline for comments in reply to those comments Sept. 23. I have no doubt that many affected rural health providers will make the strongest arguments they can to expand rural broadband access.