Source: http://www.fcc.gov/document/wcb-seeks-further-comment-rural-health-care-reform-proceeding?contrast=
Timestamp: 2013-12-20 23:51:21
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Matched Legal Cases: ['§ 254', '§ 254', 'art 54', '§ 54', '§ 254', '§ 254']

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WCB Seeks Further Comment in Rural Health Care Reform Proceeding
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DA 12-1166
WIRELINE COMPETITION BUREAU SEEKS FURTHER COMMENT ON ISSUES IN THE RURAL HEALTH CARE REFORM PROCEEDING
Comment Date: August 23, 2012Reply Comment Date: September 7, 2012
1. In this Public Notice, the Wireline Competition Bureau seeks to develop a more robust record in the pending Rural Health Care reform rulemaking proceeding, particularly with regard to the proposed Broadband Services Program.1 The Commission’s Rural Health Care Pilot Program has helped foster the creation and growth of numerous state and regional broadband networks of health care providers (HCPs) throughout the country.2 These Pilot project networks have enabled health care providers in rural areas to tap into the medical and technical expertise of other health care providers on their networks, using telemedicine and other telehealth applications to improve the quality and lower the cost of health care for their patients in rural areas.3 As the Commission moves forward with reform of the Rural Health Care (RHC) program, it can benefit greatly from the experience of the Pilot projects and the lessons learned in the Pilot Program. A more focused and comprehensive record will help the Commission craft an efficient permanent program that will help health care providers exploit the potential of broadband to make health care better, more widely available, and less expensive for patients in rural areas. 2. In its March 16, 2010, Joint Statement on Broadband, the Commission said that “ubiquitous and affordable broadband can unlock vast new opportunities for Americans, in communities large and small, with respect to . . . health care delivery.”4 The National Broadband Plan issued that same day 1 Rural Health Care Support Mechanism, WC Docket No. 02-60, Notice of Proposed Rulemaking, 25 FCC Rcd 9371, 9407-9415, paras. 90-113 (2010) (NPRM).
2 See Rural Health Care Support Mechanism, WC Docket No. 02-60, Order, 21 FCC Rcd 1111 (2006) (2006 Pilot Program Order); Rural Health Care Support Mechanism, WC Docket No. 02-60, Report and Order, 22 FCC Rcd 20360 (2007) (2007 Pilot Program Selection Order). 3 See, e.g., USAC Apr. 27 Site Visit Reports; USAC Mar. 16 Site Visit Reports. A list of recent ex parte filings and associated short cites used throughout this Public Notice is attached in the Appendix. 4 Joint Statement on Broadband, GN Docket No. 10-66, FCC 10-42, para. 3 (rel. Mar. 16, 2010).
recommended, among other things, that the Commission reform its Rural Health Care program in two ways: (1) by replacing the existing Internet Access Fund with a Health Care Broadband Access Fund, and (2) by establishing a Health Care Broadband Infrastructure Fund to subsidize network deployment for HCPs where existing networks are insufficient.5 Later that year, the Commission issued a Notice of Proposed Rulemaking in this docket proposing, consistent with the National Broadband Plan recommendations, both a Health Infrastructure Program, which would support the construction of new broadband HCP networks in areas of the country where broadband is unavailable or insufficient, and a Health Broadband Services Program, which would support the monthly recurring costs of broadband services for rural HCPs.6 3. Since the Commission issued the NPRM in 2010, the rural health care Pilot projects have made additional progress toward full implementation of their health care broadband networks.7 Although the Commission allowed Pilot projects to receive support to construct and own broadband network facilities, many Pilot projects chose to lease broadband services from commercial service providers as a way to implement broadband networks connecting HCPs.8 Projects chose to lease services instead of building networks because HCPs did not want to own or manage the networks and could more easily obtain needed broadband without owning the facilities or incurring administrative and other costs associated with network ownership. In light of the number of successful projects that elected to lease services instead of constructing networks, this Public Notice focuses on deepening the record regarding the Commission’s proposed Broadband Services Program and the participation by consortia, including Pilot projects, in such a program.
4. In recent months, Commission staff has engaged in outreach calls and meetings with many Pilot projects, as well as with other entities knowledgeable about rural health care, telemedicine, and Health IT.9 Based on what we have learned from the Pilot projects, and in light of the comments and other information filed in this Docket, we have identified several areas relating to the Broadband Services Program proposed in the NPRM that would benefit from further development of the record: (1) use of consortium applications; (2) inclusion of urban health care providers in funded consortia; (3) services and equipment to be supported; (4) use of competitive bidding processes and multi-year contracts; and (5) broadband needs of rural health care providers. We are especially interested in obtaining input that reflects the experience of participants in the Commission’s current Rural Health Care programs, particularly that of the Pilot Program participants. To the extent possible, parties should identify 5 Federal Communications Commission, Connecting America: The National Broadband Plan, at 215-16 (rel. March 16, 2010) (National Broadband Plan). 6 See NPRM, 25 FCC Rcd at 9373, para. 3.
7 The Commission recently issued an order maintaining support on a transitional basis for those Pilot project health care provider sites that will exhaust their Pilot funds before the end of the coming funding year (before June 30, 2013), while the Commission considers potential reforms that would enable Pilot recipients to transition to a permanent support mechanism. Rural Health Care Support Mechanism, WC Docket No. 02-60, Order, FCC 12-74 (rel. July 6, 2012).
8 See infra para. 9 and note 32.
9 See Appendix. As defined in the National Broadband Plan, Health IT includes “information-driven health practices and the technologies that enable them” such as “billing and scheduling systems, e-care, EHRs [electronic health records], telehealth and mobile health.” National Broadband Plan at 200.
throughout their comments the particular Public Notice questions to which they are responding, by using the relevant section numbers and letters (for example, “Section I.a. -- Consortium application process”).
CONSORTIA 5. Section 254(h)(7)(B)(vii) of the Communications Act specifically authorizes funding for consortia of eligible health care providers.10 Commenters suggest that the consortium approach has many benefits, especially for rural HCPs that have limited administrative, financial, and technical resources.11 Although a health care provider may apply for funding under the existing Rural Health Care telecommunications program or Internet access program (collectively, “Primary Program”) as a member of a consortium, in practice consortium applicants in the Primary Program must still file a separate form for every HCP site, and thus the consortium process has not been as widely used in that program as it has in the Pilot Program.12
6. In the NPRM, the Commission recognized that many Pilot projects, which are consortia of HCPs, may wish to transition to the permanent Broadband Services Program, if adopted, and sought 10 47 U.S.C. § 254(h)(7)(B)(vii).
11 See USAC Observations Letter at 2-4 (discussing benefits of the consortium approach); Comments of Virginia Telehealth Network, WC Docket No. 02-60, at 34-35 (filed Sept. 8, 2010) (VTN Comments) (recommending that the Commission consider the use of a consortium application, by which a single party could apply for and receive funding on behalf of a group of eligible entities and then administer that funding for their benefit); Comments of Internet2 Ad Hoc Health Group, WC Docket No. 02-60, at 20 (filed Sept. 8, 2010) (Internet2 Comments) (stating that Pilot program participants, including consortia, should be allowed to transition to the Broadband Services Program); PSPN Feb. 23 Ex Parte Letter at 2 (stating that individual HCPs often do not have the capacity to negotiate the processes of the RHC program and that the ability to bill as a consortium is more efficient than requiring hundreds of members to submit invoices each month); Colorado Feb. 28 Ex Parte Letter at 1-2 (stating that the joint purchasing power of a consortium has led to a cost-effective contract and financial benefits to member HCPs, and that the consortium mechanism has increased Colorado’s participation in the RHC program from 10 to 15 participants in the Primary Program to over 200 participants in the Pilot Program); Pilot Conference Call Mar. 13 Ex Parte Letter (PMHA et al.) at 3 (noting the view of five Pilot projects that a reformed RHC program should provide opportunities for networks to file as consortia, which takes the administrative burden off of small HCPs that do not have the time or personnel to apply for funds through the RHC program, and that the ability to bill service providers as a consortium in the Pilot Program was very helpful); Pilot Conference Call Mar. 26 Ex Parte Letter (AEN et al.) at 4 (noting the view of six Pilot projects that the consortium-based approach in the Pilot Program is much easier than the process in the Primary Program).
12 The Commission’s traditional rural health care programs (the telecommunications program and the Internet access program) are together commonly referred to as the “Primary Program.” The telecommunications program ensures that rural HCPs pay no more than their urban counterparts for their telecommunications needs in the provision of health care services. See 47 U.S.C. § 254(h)(1)(A); Federal-State Joint Board on Universal Service, CC Docket No. 96-45, Report and Order, 12 FCC Rcd 8776, 9093-9161, paras. 608-749 (1997) (Universal Service First Report and Order); 47 C.F.R. Part 54, Subpart G. The Internet access program provides a 25 percent discount off the cost of monthly Internet access for eligible rural HCPs. See 47 C.F.R. § 54.621; Rural Health Care Support Mechanism, WC Docket No. 02-60, Report and Order, Order on Reconsideration, and Further Notice of Proposed Rulemaking, 18 FCC Rcd 24546, 24557, para. 22 (2003) (2003 Order and Further Notice).
comment on that transition.13 We now seek to further develop the record on issues relating to the use of consortium applications in the proposed Broadband Services Program: a.
Consortium application process. We seek comment on specific procedures for the application process for consortia in the proposed Broadband Services Program and ask commenters to focus on how to streamline the application process while protecting against waste, fraud and abuse. What specific information should the Commission require from the consortium leader regarding each consortium member on the application forms? Should letters of authorization (LOAs) from participating members of the consortium be required? If so, should LOAs be submitted at the request-for-funding-commitment stage (with the filing of the Form 466-A), rather than at the request-for-services stage (with the filing of the Form 465), as is now the case under the Pilot Program? Submitting the LOAs later in the process, with the Form 466-A, would appear to be more administratively efficient for the consortium, because the consortium could wait until it had completed competitive bidding and knew the pricing before soliciting the LOAs. Before they know the pricing, health care providers are likely to be less certain about whether they will want to participate. This approach also would be administratively simpler for USAC, as USAC would only have to confirm eligibility for that smaller group of HCPs that already know the pricing and are therefore more sure that they want to participate. We also seek comment on the alternative of requiring HCP LOAs to be submitted at the earlier (Form 465) stage, as in the Pilot Program. Should the Commission require consortium applicants to provide details in the consortium’s request for services (the Form 465) regarding the services to be purchased, such as the desired bandwidth, sites to be served, and general type of service, as is currently required in the Pilot Program? Should the Commission require the lead entity and selected vendor to certify that the support provided will be used only for eligible purposes, as it does in the Pilot Program in connection with Form 466-A? Should the Commission require applicants to submit a “declaration of assistance,” as is required with the Form 465 in the Pilot Program? We encourage commenters to draw on their experience with the Pilot and Primary programs in supporting any recommendations for streamlined application procedures.
Post-award reporting requirements. What is the least burdensome way to collect information necessary to evaluate compliance with the statute and other relevant regulations, and to monitor how funding is being used? Should the Commission require consortium applicants to submit Quarterly Reports, as in the Pilot Program?14 Would the same information that is required for single HCP applicants be required for each HCP in a consortium application, or should the Commission permit consortium applicants to submit a reduced amount of information for each HCP, as it did in the Pilot Program? We encourage commenters to draw on their experience with the Pilot and Primary Program in supporting any recommendations for streamlined reporting procedures. c.
Site and service substitution. The Pilot Program permits site and service substitutions within a project in certain specified circumstances, in order to provide some amount of flexibility to project participants. Under the Pilot Program, a site or service substitution 13 NPRM, 25 FCC Rcd at 9415, para. 113.
14 See 2007 Pilot Program Selection Order, 22 FCC Rcd at 20423-24, paras. 126-127.
may be approved if (i) the substitution is determined to be provided for in the contract, be within the change clause, or constitute a minor modification, (ii) the site is an eligible health care provider or the service is an eligible service under the Pilot Program, (iii) the substitution does not violate any contract provision or state or local procurement laws, and (iv) the requested change is within the scope of the controlling FCC Form 465, including any applicable Request for Proposal.15 Should the Commission adopt a similar policy for consortia that participate in the Broadband Services Program, if adopted? Would any modifications to that policy be warranted for the Broadband Services Program? II.
INCLUSION OF URBAN SITES IN CONSORTIA
7. One of the benefits of facilitating the establishment and operation of health care networks that serve providers in rural America is improved access to specialized care that typically is more available in urban areas. Historically, support under the Primary Program has only been provided to health care providers that meet the rural health care mechanism’s definition of “rural.”16 In the Pilot Program, however, the Commission permitted non-rural health care providers to participate as part of consortia that include health care providers serving rural areas.17 8. In response to the NPRM, a number of commenters and USAC identify many benefits from including public and not-for-profit urban (or “non-rural”) health care providers in rural broadband health care networks.18 Urban providers have taken the lead in many of the Pilot projects, and commenters note 15 USAC Site and Service Substitution Policy, at 1, 3, available athttp://www.universalservice.org/_res/documents/rhc-pilot-program/pdf/Site-and-Service-Substitution.pdf (last visited June 29, 2012); see also Federal-State Joint Board on Universal Service; Access Charge Reform, Price Cap Performance Review for Local Exchange Carriers, Transport Rate Structure and Pricing, End User Common Line Charge, CC Docket No. 96-45 et al., Fourth Order on Reconsideration & Report and Order, 13 FCC Rcd 5318, 5448-51, paras. 224-229 (1997) (Universal Service Fourth Order on Reconsideration) (outlining the circumstances under which rural health care program participants can make modifications to a contract that USAC has previously approved for funding without completing an additional competitive bidding process).
16 Whether an HCP is “rural” depends on where it is located in relationship to any Core Based Statistical Area (CBSA). An area located outside of any CBSA is rural. However, an area within a CBSA can be rural, depending on the characteristics of the particular census tract. See Rural Health Care Support Mechanism, WC Docket No. 02-60, Second Report and Order, Order on Reconsideration, and Further Notice of Proposed Rulemaking, 19 FCC Rcd 24613, 24619, para. 9 (2004) (Second Report and Order and Further Notice).
17 2006 Pilot Program Order, 21 FCC Rcd at 11111, 11114, paras. 3, 10. The Pilot Program was established under section 254(h)(2)(A) of the Act, which provides the Commission broad discretionary authority to provide universal service support for “advanced services” for all health care providers. See 47 U.S.C. § 254(h)(2)(A) (“The Commission shall establish competitively neutral rules to enhance, to the extent technically feasible and economically reasonable, access to advanced telecommunications and information services for all public and nonprofit . . . health care providers . . . .”); Texas Office of Public Utility Counsel v. FCC, 18 F.3d 393, 446 (5th Cir. 1999) (concluding that “the language in § 254(h)(2)(A) demonstrates Congress’s intent to authorize expanding support to ‘advanced services,’ when possible, for non-rural health providers”).
18 USAC Observations Letter at 4-5 (stating that urban participation in Pilot projects was beneficial from a network design perspective, provided necessary leadership to bring disparate stakeholders together, provided IT expertise and (continued…)
that many urban HCPs also provide technical, financial, and administrative support that otherwise might be unavailable to rural HCPs.19 Commenters have also noted that urban locations typically have medical specialists and other resources that rural HCPs need to access, through telemedicine and other telehealth applications.20 To further develop the record in the rulemaking docket, we now seek more focused comment on issues relating to the participation of urban HCPs in consortia that serve rural health care needs as part of the Broadband Services Program, if adopted.
Proportion of urban or rural sites in consortia. The 2007 Pilot Program Selection Orderallowed urban HCPs to receive support under the Pilot Program as long as they were part of networks that had more than a de minimis number of rural HCPs on the network.21 If the Commission were to provide support for broadband services to urban HCPs that are members of consortia that serve rural areas, should it adopt specific rules to ensure that the major benefit of the program flows to rural HCPs and/or to rural patients? For example, should the Commission require that more than a de minimis number of rural HCPs be included in such consortia, as in the Pilot program, and if so, what specific metrics should be used to determine whether a sufficient number of rural (Continued from previous page)technology to rural HCPs, and facilitated access for rural patients to health care specialists in urban areas); Comments of the Nebraska Statewide Telehealth Network, WC Docket No. 02-60, at 5 (filed Sept. 8, 2010) (stating that specialty urban providers serve not only as rural health safety nets through provision of health care, but also provide leadership in collaborative ventures, education, training, and information technology support to small rural health facilities and practitioners) (NSTN Comments); Colorado Feb. 28 Ex Parte Letter at 2 (stating that Colorado has created a 60 percent rural, 40 percent urban statewide health care network that “undergirds, complements, and strength