December
1999
The
Office
for
the
Advancement
of
Telehealth
recently
filed
comments
on
underserved
insular
areas
with
the
FCC.
These
comments
were
in
response
to
the
FCC's
Further
Notice
of
Proposed
Rulemaking
on
Universal
Service:
Promoting
Deployment
and
Subscribership
in
Unserved
and
Underserved
Areas,
Including
Tribal
and
Insular
Areas,
CC
Docket
No.
(96-45),
which
can
be
downloaded
from
the
FCC
Web
site
at
http://www.fcc.gov/Bureaus/Common_Carrier/Notices/1999/fcc99204.txt.
Office of the Secretary
Federal Communications Commission
445 12th Street, SW, Room TW-A325
Washington, DC 20554
Dear Chairman Kennard:
This letter is in response to the Federal
Communication Commissions (FCC)
Further Notice of Proposed Rulemaking,
(NPRM) CC Docket No. (96-45) which seeks
comment on, among other things, the "possible
impediments to deployment and subscribership
in unserved and underserved areas of the
Nation."
The Office for the Advancement of Telehealth
(OAT), Health Resources and Services Administration
(HRSA) of the US Department of Health
and Human Services (DHHS) welcomes this
FCC NPRM, which seeks to promote Universal
Service in tribal lands and other insular
areas. OATs mission is to promote
the wider adoption of effective telecommunications
and information technologies to provide
our Nations underserved with greater
access to health care services and training.
Health care issues in the Pacific ihttp://telehealth.hrsa.gov/grants/04/grantee.htm
nsular jurisdictions are in many ways
related to the areas unique demographics,
geographic setting, and lack of sophisticated
telecommunications and other relevant
infrastructures. Our comments on Section
VII of the NRPM are limited to the problems
facing rural health care providers in
the Pacific insular jurisdictions. Our
general comments address infrastructure
issues that affect tribal, insular and
other rural areas in the Nation.
(Section VII) Insular Areas
Background
To understand the Pacific insular areas
special needs, one must comprehend the
challenges posed by the areas demographics,
geographic setting and poverty. The U.S.
Associated Pacific Basin consists of six
jurisdictions: American Samoa, Guam, Commonwealth
of the Northern Mariana Islands (CNMI),
Republic of the Marshall Islands (RMI),
Federated States of Micronesia (FSM),
and Republic of Palau (ROP). American
Samoa and Guam, unincorporated territories,
and CNMI, a commonwealth Convenant, are
officially part of the United States and also called flag territories. The latter three jurisdictions are freely associated
with the United States, meaning they are
politically independent but have each
signed Compacts of Free Association with
the United States establishing specific
rights and responsibilities.1
The total population of all six jurisdictions
is about 454,000.2
That population is spread across 104 inhabited
islands covering an expanse of ocean larger
than the continental United States.
As shown in the table below, in 1995,
more than 50% of the population of American
Samoa, Palau and FS Micronesia lived below
the poverty line. According to the Department
of the Interior "Poverty levels use
the US standards, even when they are not
comparable to the insular areas
situations." Based on US standards,
about 25% on Guam were living below the
poverty line compared to about 29% in
the Virgin Islands and 33% in the CNMI.
For other areas, which live partly on
subsistence which is not considered in
poverty determinations, the levels were
much higher about 63% of the people
in Palau were below poverty, 68% in American
Samoa, and more than 91% in the Federated
States of Micronesia.3
Insular Areas' Per Capita Income for
1995
Name |
Per
capita income |
%
below poverty line |
11.6 |
Puerto
Rico |
NA |
NA |
29.1 |
CNMI |
$6,984 |
33.3 |
67.7 |
Palau |
$3,508 |
62.8 |
91.0 |
Marshall
Islands |
NA |
NA |
Source: Department
of the Interior, Office of Insular Affairs,
"A Report of the Islands", 1997;
Appendix A, Table 1
Given these statistics, it is not surprising
that almost all health indicators for
islanders are worse than those in the
United States, particularly in the freely
associated states (FAS). For example,
average life expectancy in the jurisdictions
is 69.1 years compared with 76.0 years
in the U.S. Infant mortality (deaths per
1,000 births) is very high in the FAS,
ranging from 46.0 in the Federated States
of Micronesia to 26.0 in Palau compared
with 7.2 in the U.S. Diabetes, cancer,
tuberculosis, tobacco use, alcohol abuse,
and suicide are serious health problems
in many of the jurisdictions.4
Contributing to these poor health outcomes
are unique challenges in the jurisdictions
health care delivery system. Because the
population is scattered over such a wide
area, in most jurisdictions, over 20%
of residents must travel over one hour
to a health facility. Since most of the
jurisdictions do not have many paved roads,
land travel can be slow. In addition,
except for Guam5
, each jurisdiction consists of multiple
islands, thus necessitating travel by
boat or plane, which adds to the cost
and time.
Sometimes, patients must be referred
out of the region for treatment, which
creates a serious drain on the jurisdictions
health budgets. In some years, American
Samoa, the Marshall Islands, and the Federated
States of Micronesia have spent between
20 and 30% of their health care budget
on off-island referrals. Round-trip plane
tickets to Hawaii cost from $700 in American
Samoa to $1,600 in Palau.6
Trips often involve multiple stops, long
layovers, and over ten hours in the air.
Telemedicine is one strategy for reducing
these expensive off-island referrals,
but high telecommunications costs and
limited infrastructure prevents telemedicine
from proliferating. Long-distance phone
rates can be from $2.50 to $5 a minute,
and phone or Internet service is often
unavailable, unreliable, or low quality.
Many outer islands do not have access
to phones but rather communicate using
radiophones to the main islands. For example,
most of the inhabited outer islands located
near Palau communicate with their main
island via radiophones.
Comments
(#138) What areas should be included
in the FCCs Insular Area Definition?
The Office for the Advancement of Telehealth
agrees with the FCCs tentative conclusion
that Puerto Rico, American Samoa, CNMI,
Guam, and the US Virgin Islands should
be included in the definition of insular
areas. These areas have historical, treaty
and economic ties with the United States
and should be included in the definition.
In both 1996 and 1997, DHHS provided approximately
$56.6 million in funding for health care
in the three Pacific jurisdictions named
above.
(# 139) Should the FCC include
the Freely Associated States in the definition
of insular areas?
Consistent with other Federal health
policies, OAT urges the FCC to include
the Freely Associated States (FAS)7
in its definition of insular areas. Historically,
the United States was designated the United
Nations trustee for this area after
World War II. More recently, the Freely
Associated States have each negotiated
an independent compact with the United
States. A key component of these compacts
has been agreements about health care
services. DHHS has had a long-standing
commitment to support health services
and training in the FAS. For example,
DHHS provided approximately $13.5 million
in funding for health care in the Freely
Associated States in 1996 and again in
1997.
(#141) What are the differences
between the needs and opportunities of
rural health care providers in insular
areas and those located on mainland USA?
Important characteristics that set insular
areas apart from other rural areas in
the USA include:
1. The enormous costs involved with
sending patients off island for tertiary
or specialized care.
- In some years, 30% of a jurisdictions
health care budget is used for off-island
care. Although these referrals consume
a large part of the health budget, they
benefit only a small number of patients.
- Plane travel to Hawaii costs from
$700 in American Samoa to $1,600 in
Palau and flights are infrequent. For
example, Hawaiian Airlines only flies
to American Samoa on Monday and Friday.
2. Extreme isolation of the region.
- American Samoa, the closest jurisdiction,
is a five-hour plane trip to Hawaii.
Palau, the furthermost jurisdiction,
is a 16-hour trip to Hawaii, including
the required stopover.
- Only one airline carrier serves this
region
- There are only two flights per week
between Hawaii and American Samoa.
- The region spans five time zones and
crosses the international dateline.
3. Shortages of adequately trained
health care personnel.
- None of the jurisdictions have enough
health professionals to adequately serve
its population. American Samoa, Palau,
and the Federated States of Micronesia
are designated Health Professional Shortage
Areas (HPSAs) in primary care, dental
care, and mental health care, according
to the U.S. Department of Health and
Human Services. The Marshall Islands
are shortage areas in primary care and
dental care. The remaining jurisdictions
(Guam and the Mariana Islands) are a
combination of whole and partial shortage
areas in these categories.
- American Samoa, the Marshall Islands,
and the Federated States of Micronesia
have significantly higher ratios of
population to primary care physicians
than the United States average.8
- There are no medical schools located
in the U.S. Associated Pacific Basin
jurisdictions. Moreover, the Pacific Basin Medical Officers
Training Program, a regional Medical
Officers training program based in Pohnpei
and instituted in 1986 to address an
imminent physician
shortage, was closed after 10 years.
It has trained indigenous individuals
as primary care providers, who can function
as Medical Officers (M.O.s) only within
the jurisdictions. Seventy students
graduated and are now practicing in
the region. However, to maintain and
improve skills, these M.O.s need access
to continuing education and training.
- There is an extreme shortage and uneven
distribution of dentists in the jurisdictions.
Half of the regions dentists are
on Guam, with the other half scattered
throughout the entire region. Excluding
Guam, ratios of dentists to people range
from 1 per 4,306 in Palau to 1 per 14,811
in the Marshall Islands. In the US,
the ratio is 1 dentist per 1,785 people.
- The University of Guam has the only
four-year, BSN nursing program in the
region.
- Several of the other jurisdictions
have two-year nursing programs at their
community colleges. However, many of
the programs have had difficulty recruiting
and retaining faculty, affecting the
quality of the programs. Many of the
graduates from these programs have failed
to pass U.S. RN licensing exams.
4. Difficulty in recruiting and retaining
health care providers in such an isolated
area.
- With the exception of Palau, between
60% and 100% of the medical doctors
with M.D.s or M.B.B.S.s degrees9
in the jurisdictions are expatriate
physicians, and are often hired on two-year
contracts. Thus, there is great turnover
with these types of physicians.
- Faculty recruitment and retention
in the nursing programs and other allied
health science programs is difficult.
5. Poorly maintained and equipped
health care facilities.
- There are no tertiary hospitals with
specialty care located in the jurisdictions.
- Hospitals in Guam, American Samoa
and CNMI are certified by the Health
Care Finance Administration (HCFA) to
receive Medicare and Medicaid payments,
however, maintaining HCFA standards
has been difficult.
- There are no hospitals in the jurisdictions
accredited by the Joint Commission on
Accreditation of Health Care Organizations
(JCAHO)10
. In contrast, all 50 states have several
facilities accredited by JCAHO.
- In American Samoa, the Marshall Islands,
and parts of the Federated States of
Micronesia, the hospitals are built
of wood or coated cardboard, or have
major safety problems. Equipment and
supplies for CT scans, X-rays, and MRIs
are unavailable in most of the jurisdictions.
- Primary care sites (called "dispensaries")
may lack basic supplies such as aspirin.
These sites are usually staffed solely
by health assistants who receive only
limited training. Communication with
higher trained personnel is usually
available only by phone or radio.
(#143) Do the rules concerning
calculation of rural health care support
need modifications to address the geographic
or demographic situation in insular areas?
Propose specific revisions.
Urban Benchmarks
- Using an urban rate based on rates
charged in the "nearest large city
in the state" as a benchmark to
calculate rural health discount rates
for telecommunications services is not
appropriate in the Pacific insular areas.
None of the Pacific jurisdictions have
urban populations of 50,000 nor tertiary
hospitals with specialty care. Part
of the FCCs rational for choosing
a city of 50,000 as "urban"
for calculating subsidy rates was that
"an MSA, as defined by OMB, is
based in part on counties with cities
having a population of 50,000 or more
and every state has at least one MSA
with a city that size." However,
insular areas lack cities with a population
that size and lack counties or county
equivalents. When the FCCs Universal
Service Order was implemented, the decision
was made to designate the largest community
in each jurisdiction as "urban".
Given that in many of the Pacific jurisdictions,
all calls are local calls, there is
no differential between what the largest
communities and smallest communities
pay for services. Thus, the flag territories,
which pay into the universal service
fund and are most in need of specialty
services, receive no benefits from the
FCCs Rural Health Care Program
(RHCP). In part, this is because there
are no cities of 50,000 and the large
communities that do exist do not have
the needed specialists that could provide
services via telemedicine.
- Normally, teleconsultations are made
between an urban specialist or subspecialist
and a primary care provider in a rural
setting. The Advisory Committee on Telecommunications
and Health Care, established by the
FCC to guide the implementation of the
Universal Service Order, described in
the report issued prior to the Joint
Boards Recommended Decision, what
it called its "market basket"
of "essential telemedicine applications."
The Advisory Committee developed the
market basket as a guide to the level
of telecommunication services "necessary
to support rural telemedicine efforts."
One of the tenets was that applications
in the market basket include a comprehensive
set of specialty services such
as radiology, dermatology, selected
cardiology, pathology, obstetrics (fetal
monitoring), pediatric, and mental health/psychiatric
services. However, even in the largest
communities in the Pacific jurisdictions,
these health specialists typically dont
exist.11
Therefore, classifying these communities
"urban" for the purpose of
the FCC Rural Health Care Program, defeats
the overall intent of the legislation
and provides no assistance for the areas
of greatest need.
OAT's Recommended Revision
OAT recommends that the FCC calculate
the discount rate for rural health care
providers in insular areas using the urban
rate of the closest tertiary hospital
with specialists, such as in Hawaii or
the West Coast of mainland United States.
Some Estimated Costs
- The cost of using Hawaii or the West
Coast of the United States to calculate
the difference between the urban and
rural rate is difficult to estimate
because there are no links in place
between and among these jurisdictions.
The lowest bid based on a competitive
bid for a T-1 between American Samoa
and Hawaii was $780,000 and included
Internet Service Provider charges. The
American Samoa Telecommunications Authority
won the bid.
- The second lowest bid submitted by
ISDI and GTE was $840,000. The approximate
costs of a T-1 between Guam and Hawaii
and CNMI and Hawaii would probably be
about $30,000-40,000 a month. If and
when this comes out to bid, a direct
earth station may yield a lower price
if the long distance carriers were to
examine other options, such as a wireless
direct between sites.
- The estimated cost of a 384-Kbps link
is about $8,000-$12,000 USD per month
or about $64,000 per year. This does
not include ISP services. Guam has on-island
ISDN, but not off-island yet. CNMI and
American Samoa do not have ISDN capabilities.12
Other Comments
(# 133) To what extent should
improvements to the telecommunications
network, required to meet the telecommunications
needs of rural health care providers,
be supported by federal universal service
mechanisms?
Given the rapid advances in telecommunications
and information technology, it is not
difficult to imagine how many areas in
the US that had previously lacked infrastructure
may soon be served by wireless or other
advanced technologies that may be cheaper
and faster to deploy than wireline technology.
However, there are other areas where the
likelihood of developing the advanced
telecommunications services required for
telehealth services within the next two
to five years is slim. The Pacific insular
jurisdictions fall into this category.
Since we have already commented on these
areas, we limit these comments to some
of the challenges facing our grantees
in largely rural states in the continental
US and Alaska.
Many rural states do not have state funding
or programs supporting telecom infrastructure
development for rural telehealth purposes.
Moreover, most of the federal telehealth
programs, cited in the FCCs NPRM
footnote 245, do not provide funds for
telecom infrastructure development costs.
For example, the largest Department of
Health and Human Services (DHHS) telehealth
grant programs including OATs Rural
Telemedicine Network Grant Program13
and the Office of Rural Health Policys
Rural Health Outreach Grant Program do
not give grants for telecommunications
infrastructure development or telecom
transmission costs. In fact, their legislative
authority specifically prohibits the use
of federal funds for the purchase or installation
of transmission equipment.
The Commerce Departments Telecommunications
and Information Infrastructure Program
(TIIAP)14
also does not provide funds for telecommunication
infrastructure build-out or telecom transmission
costs. The Department of Agricultures
Rural Utility Services (RUS) Distance
Learning and Telemedicine Program does
provide grants and long-term loans to
improve rural telecommunications infrastructure.
However, few have applied for the loan
program and the grant program is small.
In FY 1998, 60 awards were made totaling
$16 million ($12.5 in grants and $3.5
in loans combined with grants). Only 25
of the 60 awards in FY 1998 were for telemedicine
projects; the rest were for K-12 distance education. Moreover, although the
RUS dollars may be used for transmission
equipment, the majority of the health-oriented
projects purchase telemedicine equipment,
not transmission/telecommunications equipment
with their funds. (In the FY 1999 cycle,
RUS did award a grant of $269,360 for
a spread spectrum microwave system that
will provide telecommunications linkages
among rural health agencies in Maine.)
This type of application tends to be the
exception, not the rule. Last, the maximum
grants award amount is $350,000. Generally,
this would not be a sufficient amount
of money to undertake a major build-out
of telecom capacity.
The Federal Communication Commissions
Rural Health Care Program is the only
Federal program with funding specifically
designed to address rural telehealths
high transmission costs. Moreover, this
FCC Program is one of the few federal
programs that do not
involve a competitive process.
All the above-mentioned programs, are
competitive grant programs that have limited
coverage and may by-pass some of the neediest
communities.
Based on experience with our grantees,
we believe that some form of telecom infrastructure
development funding would greatly assist
rural health care providers in areas with
limited telecommunications services. In
Alaska, our rural telehealth grantees
are limited to expensive satellite communications
services to reach their far-flung clients
because other telecommunications services
are not yet available. Even in states
such as the Dakotas, advanced, broadband
telecommunication services are not always
available. And, given the heavy debt load
of many of the small rural cooperative
telcos that serve these communities, it
is not feasible for these telecos to take
on additional debt to improve the infrastructure.
These are also areas unlikely to profit
from competition because their population
bases are so small. That is, many of these
areas are classified as frontier because
they have fewer than six people per square
mile. There is simply an inadequate population
base over which to spread the costs of
major telecommunication upgrades, making
it difficult for the telco serving the
area to make such improvements, and making
it an unlikely place for a competitor
to enter the market.
We therefore believe there may be areas
that may only gain access to the needed
telecommunication services through an
infrastructure enhancement program. We
are in the process of gathering additional
information to determine which areas fit
this category and will provide such data
to the FCC once it is available. A possible
vehicle for this type of program might
be the Telecommunications Development
Fund. Congress created the Fund through
the Telecommunications Act of 1996 to
"promote access to capital for small
businesses in the telecommunications industry,
to stimulate the development of new technologies,
and to support the delivery of universal
service and telecommunications services
to underserved rural and urban areas."15
OAT strongly urges the FCC to explore
the use of this program for upgrading
telecommunications infrastructure capacity
of Americans chronically underserved,
rural communities.
Dena S. Puskin, ScD.
Director, Office for the Advancement of
Telehealth
Health Resources and Services Administration
U.S. Department of Health and Human Services
Footnotes
1The FSM and
RMI signed their compacts in 1986, Palau
in 1994. Prior to that time, the United
States had administrative control over these
islands. Each compact provides for developmental
assistance and cedes full authority and
responsibility for the jurisdictions
defense to the United States.
2Information
in this introduction is drawn heavily
from Pacific Partnerships for Health:
Charting a New Course (1998) by the Institute
of Medicine.
3Source: Department
of the Interior, Office of Insular Affairs,
A Report of the Islands, 1997, Appendix
A, Table 1.
4In the Republic
of Marshall Islands, 30 percent of the
population over age 15 suffers from diabetes.
In Guam, the prevalence of middle-age-onset
diabetes is seven times that of the United
States. Cancer is one of the top three
causes of death in all the jurisdictions.
5Travel is
especially difficult in the Federated
States of Micronesia, which includes 62
separate islands crossing three time zones.
At the other extreme is American Samoa
with only three islands, but even here,
travel can take several hours on a regular
plane or eight hours by boat.
6Based on
phone calls made in Spring 1999.
7The Freely
Associated States consist of Republic
of the Marshall Islands, Federated States
of Micronesia, and Republic of Palau.
8Ratios for
Pacific jurisdictions are based on data
from the 1996 Report of the HRSA Pacific
Basin Intra-Agency Workgroup, the 1998
book Pacific Partnerships for Health,
and the 1998 World Health Organization
Information Profiles. Jurisdictions are
listed as below the U.S. primary care
physician ratio if they were listed as
such in all three reports.
9The British
equivalent to the US M.D.
10The Joint
Commission evaluates and accredits more
than 19,500 health care organizations
in the United States, including hospitals,
health care networks, managed care organizations,
and health care organizations that provide
home care, long term care, behavioral
health care, laboratory, and ambulatory
care services.
11In Guam,
there are a limited number of specialists,
but not subspecialists.
12Based on
conversations and emails with Norman H.
Okamura, Ph.D. Associate Specialist, Social
Science Research Institute, University
of Hawaii.
13Under OATs
program, not more than 40% of the total
grant award may be used to purchase or
lease and install equipment. Grant dollars
may not be used for construction or renovation,
except for minor renovations related to
the installation of equipment.
14TIIAP grant
funds can be used to purchase equipment
for connection to networks, including
computers, videoconferencing systems,
network routers, and telephones; to buy
software for organizing and processing
all kinds of information, including computer
graphics and databases; to train staff,
users, and others in the use of equipment
and software; and to purchase communications
services, such as telephone links and
access to commercial online services.
15FCC Public
Notice, October 1, 1999
|