1997 Partnerships for Networked Consumer Health Information Conference
Response to FCC Public Notice on
Universal Service
CC Docket 96-45
U.S. Department of Health and Human Services
December 19, 1996
1. Advisory Committee Recommendations.
The U.S. Department of Health and Human Services (HHS) believes that the recommendations of the FCC's Advisory Committee on Telecommunications and Health Care which are particularly important are: supporting Internet access at local calling rates for rural health care providers; support for bandwidths high enough for a wide range of activities, including accessing the Internet, transmitting high-quality images, and delivering fully interactive video; allowing providers to choose telecommunications services up to the 1.544 Mbps ceiling for any health-related application the provider determines necessary; and supporting infrastructure upgrades, where necessary, to provide the desired services.
We do not think that the FCC need worry that the inclusion of these provisions will generate tremendous demand for sophisticated telecommunications services. Rural health providers and health departments have very limited budgets. They are likely to be extremely cost conscious about what services they order. On the other hand, we would like to see the ceiling set high enough so that those who can benefit from more advanced telecommunications services will be able to obtain whatever services they feel are needed at rates comparable to those in urban areas.
2. Review Cycle
We prefer the two-year review cycle recommended by the Committee rather than the year 2001 review recommended by the Joint Board. The health sector is evolving as rapidly as telecommunications. The focus is moving away from acute, specialty care toward primary and preventive care; and away from hospitals to out-patient and extended care facilities--and, most dramatically, toward the home. With the goal of reducing unnecessary utilization of medical services, greater emphasis also is placed on the public health infrastructure to support personal and community health and on the role of the well informed individual and family in sound health decision-making. It will be important to reassess the "market basket" of essential applications in light of these developments and concurrent improvements in telecommunications.
We would suggest that the review take into account information that will be available in approximately 18 months from an evaluation of rural telemedicine by the HHS Office of Rural Health Policy. This data can inform FCC policy so that the most cost-effective decisions can be made regarding the subsidies. To wait until 2001 for revisions of FCC policies could risk keeping in place provisions that do not reflect the current reality of rural activities.
Another reason we support the shorter review cycle is that we would like it to be completed before the end of a new three-year telemedicine demonstration sponsored by the Health Care Financing Administration. A major goal of this demonstration is to determine if or how Medicare should cover such services. It would be very helpful if the nature and extent of a subsidy for health-related telecommunications were reviewed and any changes made before the end of HCFA's demonstration,allowing for appropriate data to be gathered and reviewed as HCFA develops a telemedicine coverage policy. Such a subsidy could affect not only what HCFA may determine as appropriate compensation for telemedicine providers, but also the scope of coverage and determination of when or how telemedicine is cost-effective for Medicare or Medicaid.
3. Inadequacy of Public Notice Comment Period.
It is impossible to obtain comprehensive, generalizable telehealth cost data in the time allowed. While HHS is pleased to provide some data from its own grantee networks and has encouraged other health agencies and organizations to submit available data, we feel that additional data gathering efforts should be undertaken during the review cycle. We would be happy to work with FCC staff on this.
4. Definition of Scope of Services
The Act specifically addresses telecommunications services that "are essential to...public health...," and public health departments are included in the definition of health care provider in the Rural section. However, the Advisory Committee report seems to focus on "Telemedicine." This is a term applied to telecommunications services related to the delivery of medical care and especially to consultative services by subspecialists. As noted in our attachments, rural health departments and agencies engage in a wide array of non-medical activities in support of health care. HHS would therefore ask that the FCC's Final Order include a specific finding that defines "rural health care provider...[including] public health departments" as including all sites of rural health departments and agencies, not only those that deliver medical care on the premises. We interpret the Act to allow support for "telecommunications services necessary for the provision of health care" to include services linking these public health departments and agencies not only to urban medical centers but with each other and other health care providers, schools of medicine and public health, and also public schools. We would also like the Final Order to include a specific finding that defines "telecommunications services necessary for the provision of health care services in a state (including instruction)" as including the transmission of preventive health data, reports of epidemiological investigations, guidelines for the delivery of preventive services, training materials, and emergency notices; professional teleconsultation with two-way interactive audio and video; access to health data and information via the Internet; and multi-point consultation for health emergencies. HHS suggests that FCC adopt the broader term "telehealth" to indicate inclusion of these applications as well as telemedicine applications, which can be viewed as a subset of telehealth.
5. Distance Insensitive Rates
HHS urges the FCC to establish rates that address the impact of distance. Telecommunications carriers frequently set rates based on a per mile basis. So even when the per mile charges are the same, rural providers may be paying 10-20 times more for the same services because of the great distances involved.
6. Gaps in 1996 Legislation
HHS is concerned that low income, urban populations also lack access to the benefits of advanced telecommunications. These people have disproportionate levels of illness, injury, and premature death. We support the Advisory Committee's recommendation that FCC and Congress investigate whether incentives for the development of telehealth applications in underserved urban areas would be appropriate.
HHS also notes that most rural health care is provided by small for-profit institutions and individuals. If they do not utilize telehealth applications, rural areas will not gain the desired benefits. While we understand that the intent of Congress was clearly not to subsidize for-profit providers, we encourage the FCC to explore this issue further.
List of Enclosed Materials
- Detailed Response to Public Notice
- Value of Telecommunications Services for Health Priorities
- The Role of Public Health in Prevention and Medical Care
- Making a Powerful Connection: The Health of the Public and the National Information Infrastructure
- Illustrative Examples from a Selection of [HHS Centers for Disease Control and Prevention] INPHO Grant States: Report on 12 Question Survey on Telecommunications
- Data from HHS Office of Rural Health Policy Telemedicine Grantees
