INTRODUCTION AND EXECUTIVE SUMMARY
BACKGROUND
The Current Rural Health Care Support Mechanism
Pursuant to Congressional directive, the Commission established the RHC Telecommunications Program in 1997 to ensure that rural HCPs do not pay more than their urban counterparts. To date, over $410 million has been disbursed through the RHC telecommunications and Internet access programs.24 Annual disbursements to these programs have grown over time, from $3.375 million in 1998 (the first year of funding), to $25 million in 2003, and over 80 million dollars. in 2011/25.
The Rural Health Care Pilot Program
The Commission allocated a total of USD 417 million in funding for the pilot projects over a three-year period. In an order issued on July 9, 2012, the Commission extended pilot program funding on a temporary basis for individual pilot HCP sites that will exhaust pilot funding by the end of this funding year (before June) to maintain the status quo while the Commission completes this procedure. 32.
The Notice of Proposed Rulemaking
They range in size from 4 HCPs to 477 HCPs.30 As of November 15, 2012, USAC had awarded $364.4 million in funding to approximately 3,822 individual HCP sites.31 The pilot projects are in various stages of implementing their networks, with some nearing the end of their Pilot Program funding. On July 19, 2012, the Commission's Bureau of Wireline Competition (the Bureau) issued a Public Notice requesting more focused comments on several issues in order to create a stronger and.
The Staff Evaluation of the Pilot Program
Benefits and Cost Savings Flowing from Broadband Connectivity
- Telemedicine
- Exchange of Electronic Health Records
- Dissemination of Medical and Technical Expertise
- Cost Savings
- Enhancing Revenues for Health Care Providers
Geisinger PN Commentary at 7 (finding that one-third of patients transferred from rural hospitals to tertiary care centers can be treated in situ through telemedicine and other resources); IRHN PN Comment at 26 (predicting that training for nursing staff and medical technicians will be provided by increasingly interactive applications); IRHN PN Comment at 27 (estimating that the network will allow providers to see more patients, diagnose faster, eliminate much patient transport, and provide telepsychology/psychiatry and cloud-based medical services). SWTAG PN Comments at 15 (emphasizing that providers will need higher bandwidth and HIE participation to meet the meaningful use requirements and benefit from the incentives); WNYRAHEC PN Comments at 8 (stating that the increased use of EHRs will only increase the bandwidth needed at each facility).
Health Care Provider Broadband Needs Assessment
PERFORMANCE GOALS AND MEASURES
Clear performance targets and measures will enable the Commission to determine whether the universal service support mechanism in the health sector is being used for its intended purpose and whether this funding is achieving the intended results. Using the agreed targets and measures, the Commission will, as required by the GPRA, monitor the performance of the universal health support mechanism.91 If the program does not meet the performance targets, we will consider corrective actions.
Increase Access to Broadband for Health Care Providers, Particularly Those Serving
We also direct the Bureau to engage with HHS on whether and how to include broader health care outcomes, including providers'. Finally, to advance our progress toward this goal, we also recommend that USAC, together with the Bureau and with other agencies, conduct outreach regarding the Healthcare Connect Fund with the HCPs most in need of broadband to achieve "meaningful use" of EHRs and for other health care purposes.103.
Foster Development and Deployment of Broadband Health Care Networks
Department of Health and Human Services (HHS), including the Indian Health Service (IHS) and other relevant federal agencies to ensure meaningful and non-burdensome collection of broadband data by HCP.101 We expect to follow the trends of health care (such as the use of EHRs and telemedicine) and to coordinate, to the extent possible, our monitoring efforts with other federal agencies. We will also measure how program participants are using their broadband connections to healthcare networks, including whether and to what extent HCPs engage in telemedicine, sharing EHRs, participating in an information exchange health, distance training and other telehealth applications.106 As discussed in the Needs Assessment, access to high-speed broadband healthcare networks should help facilitate the adoption of such applications by HCPs, including those HCPs serving patients in rural areas.107 We direct the Bureau to work with USAC to implement the reporting requirements related to these telehealth applications in a manner that imposes the least possible burden on participants while allowing us to measure progress toward this goal.108 We also direct the Bureau to coordinate with other Federal agencies to ensure that data collection minimizes the burden on HCPs, which may already be required to track similar data for purposes of other regulatory health care.109 To the extent possible, we will also attempt to compare the extent to which participants in the new program use telehealth applications with that of non-participants, relying on public sources of information.
Maximize Cost-Effectiveness of Program
SUPPORT FOR BROADBAND CONNECTIVITY
Overview
The new program will replace the current Internet Access Program and provide continued support to pilot program consortia as they exhaust remaining funding already committed under the pilot program.119 As discussed below in the Implementation Timeline section, rural health care providers may continue to participate for administrative convenience to the Internet Access Program during funding year 2013.120. The Commission relied on this legal authority when it established the 2006 pilot program to support infrastructure and services owned by healthcare professionals, including internet access services,125 and the Commission has broad discretion in how to implement this legal mandate. to fulfill.
A Consortium Approach to Creation of Broadband Health Care Networks
Key Benefits of a Consortium Approach
Network design was in many cases more efficient and less expensive in the pilot program than in the telecommunications program because the pilot program funds all public and nonprofit health care providers, including those located in non-rural areas. The Commission's experience with the pilot program shows that consortium applications reduce costs and enable health professionals to purchase services of greater capacity.
Eligibility to Participate in Consortia
The pilot program provided support to rural and non-rural health care providers under section 254(h)(2)(A), which directs the Commission to “improve . 173 On average, non-rural and rural health workers in the pilot program are allocated roughly the same amount of funding per health worker.
Eligibility of Grandfathered Formerly “Rural” Sites
In light of the limitations adopted above, we do not expect that our decision to allow both rural and non-rural HCPs to receive support through the Healthcare Connect Fund will cause program demand to exceed the $400 limit in the foreseeable future million, particularly in light of our decision to require a 35 percent participant contribution and our adoption of a $150 million annual cap on support for prepayments and multi-year commitments.
A Hybrid Infrastructure and Services Approach
We are taking precautions to ensure that the self-build option will only be exercised where it is absolutely necessary to enable the HCPs to obtain the necessary broadband connectivity. Furthermore, experience under the pilot program suggests that a self-build option for HCPs could provide incentives for commercial service providers to partner with HCPs to build new broadband networks in rural areas, with each party building a portion of the network.
Health Care Provider Contribution
Use of a Uniform Contribution Percentage
The analysis compared rural HCPs in the Pilot Program to rural HCPs receiving funding from the Telecommunications Program. 258 Administrative costs will be lower in the Healthcare Connect Fund due to the flat fee discount, consortium application process and exemptions from competitive bidding.
Limits on Eligible Sources of HCP Contribution
The facility surcharge for excess capacity cannot be part of the participant's 35 percent contribution and cannot be funded by any health care university endowment funds. An eligible HCP (typically the consortium, although it can be an individual HCP participating in the consortium) must retain ownership of the excess capacity facilities.
ELIGIBLE SERVICES AND EQUIPMENT
Eligible Services
Definition of Eligible Services
Minimum Bandwidth and Service Quality Requirements
311ATA Comments at 13 (noting that telemedicine networks in Arizona and Virginia have been able to operate with sites connecting at 1.5 to 3 Mbps and a 45 Mbps and 10 Mbps backbone, respectively); Marshfield Reply at 5 (stating that Marshfield's network consists primarily of 10 Mbps fiber links, but some sites are . connected to a 1.5 Mbps T-1 connection and run voice, video and data simultaneously). 314HHS Comments at 10 (questioning the need for a minimum speed); AHA Comments at 5 (also stating that the Commission need not set a "high bar" on the minimum level of broadband capability); RNHN Response at 13 (disputing the minimum speed requirement and stating that HCPs are in the best position to know their needs and what makes economic sense for themselves and their patients); CHCC/RMHN PN Comments at 3 (“No minimum bandwidth standards are required, as the healthcare provider market will set these de facto as services and needs continue to evolve”).
Dark and Lit Fiber
However, to further ensure that dark fiber is the most cost-effective solution, we will limit support for dark fiber in two ways. In accordance with that standard, we find that HCPs can receive support for the modulating electronics and other equipment needed to light dark fiber.
Connections to Internet2 or National LambdaRail
If the equipment is leased for a recurring monthly (or annual) fee, healthcare professionals may receive support for these recurring costs. The NPRM proposed support for membership fees through the Health Infrastructure Program and for broadband services through the Broadband Services Program.
Off-Site Data Centers and Off-Site Administrative Offices
Because we are not following the definitional approach proposed in the NPRM, support for these additional connections and network equipment associated with off-site data centers and administrative offices is limited to the Healthcare Connect Fund. The adopted approach also accommodates a variety of arrangements for operating off-site administrative offices and/or off-site data centers.
Reasonable and Customary Installation Charges up to $5,000
For example, one commenter was concerned that the NPRM proposal unreasonably excluded support for the off-site administrative offices and off-site data centers owned by a public or nonprofit health care system rather than by one or more eligible HCP locations.401 Under the rule we have in place today, the network equipment and connections associated with these remote facilities owned by public or nonprofit health care systems are eligible for support to the extent they meet the conditions and limitations above. 402 All network equipment and connections shared between a system's eligible and non-eligible HCP locations may receive support only to the extent that costs are allocated according to the guidelines discussed in section V.C.4 of this decision.403 We believe that this approach is consistent with the intent of the statute and best balances the goals of fiscal responsibility and increasing access to broadband connectivity for eligible HCPs. Upfront costs for the deployment of new or improved facilities by service providers for the benefit of eligible health care providers.
Upfront Charges for Service Provider Deployment of New or Upgraded Facilities to
415IRHN PN Comments at 12 (recommending that the latitude allowed in the Pilot Program be continued in the Broadband Services Program (eg, purchase/own or lease equipment, IRU, bandwidth purchase of prepaid, non-traditional and traditional service providers); allowing non-recurring costs are a critical tool for obtaining cost-effective pricing); Geisinger PN Comments at 2. 418See UTN PN Comments at 4 (noting that leased utilities often have non-recurring installation costs, including boundary-to-building installation fees); CTN PN Comments at 10-12 ("CTN recommends that the Broadband Services Program allow funding to include field wiring and technical assistance ... just as circuits and routers are covered in the Pilot Program.
Eligible Equipment
We will provide support for network equipment necessary to make a broadband service functional, in combination with providing support for the broadband service.433 In addition, for consortium applicants, we will provide support for equipment necessary to manage, monitor or maintain a broadband service or a dedicated healthcare broadband network.434 Equipment support is not available for non-healthcare networks. Second, support for the equipment needed to operate and manage dedicated broadband healthcare networks can facilitate efficient network design.
Ineligible Costs
- Equipment or Services Not Directly Associated with Broadband Services
- Inside Wiring/ Internal Connections
- Administrative Expenses
- Cost Allocation for Ineligible Entities, Sites, Services, or Equipment
Consistent with the goals of streamlining program oversight and ensuring fiscal responsibility, we decline to fund administrative expenses associated with participation in the Healthcare Connect Fund. 478 See RWHC Commentary at 5; see also AHA Comment at 2 (suggesting that "heavy administrative burdens limit participation" in the current Rural Health Care programs); RNHN PN Reply Comments at 6 (stating that the exclusion of administrative expenses "is a material failure of the program and was a material problem for the pilot program").
Limitations on Upfront Payments
We do not believe it is an efficient use of the Healthcare Connect Fund to support prepayments for speed which may become increasingly inadequate for HCP needs in the near future. For example, if a consortium has four countries, initial payments to the consortium must be prorated over at least three years if the amount of initial support requested is more than x 4).
Eligible Service Providers
FUNDING PROCESS
USAC, in cooperation with the Bureau, will develop the necessary application requirements, competitive bids, contracts, and reporting for participants to implement the requirements listed below to ensure that program objectives are met.
Pre-Application Steps
- Creation of Consortia
- Determination of Health Care Provider Eligibility
- Technology Planning
- Preparation for Competitive Bidding
- Source(s) for Undiscounted Portion of Costs
- FCC Registration Number (FRN)
The Consortium Manager is responsible for ensuring that the competitive bidding process is fair and open and is otherwise compliant. The Consortium Leader will need to provide this information to USAC to request program support.
Competitive Bidding
- Requests for Proposals
- USAC Posting of Request for Services
- Selection of the Most “Cost-Effective” Bid and Contract Negotiation
- Competitive Bidding Exemptions
Unless they qualify for one of the competitive bidding exemptions described below, all entities participating in the Healthcare Connect Fund must conduct a fair and open competitive bidding process before submitting a Form 462 request for funding. Certain applicants must use an RFP in the competitive bidding process. , and any applicant may use an RFP.
Funding Commitment From USA
- Requirements for Service Providers
- Filing Timeline for Applicants
- Required Documentation for Applicants
- Requests for Multi-Year Commitments
- USAC Processing and Issuance of Funding Commitment Letters
Each selected service provider is, to the best of the applicant's knowledge, information and belief, the most cost-effective service provider available as defined in the Commission's rules. Similarly, if the contract ends in the middle of the funding year, the funding commitment can only be extended until the contract end date.
Invoicing and Payment Process
Contract Modifications
The fourth Universal Service Reconsideration Order also addressed cases where state and local procurement laws are silent or otherwise inapplicable as to whether a proposed contract modification must be resubmitted under state or local competitive bidding processes. Please note that although minor changes will be exempt from the competitive bidding requirement, customers are not guaranteed support in relation to such changed services.
Site and Service Substitutions
An eligible HCP seeking to modify a contract without undertaking a competitive bidding process must, within 30 calendar days of signing or otherwise entering into the contract modification, submit a revised funding commitment request indicating the value of the contract modification proposed so that USAC can track the performance contract. We note that program participants make contract modifications without competing offers at their own risk.
Data Collection and Reporting Requirements
ADDITIONAL MEASURES TO PREVENT WASTE, FRAUD, AND ABUSE
The provisions we adopt here also take into account the comments we received in response to the NPRM. In addition to the requirements below, we remind participants in the Healthcare Connect Fund that they will be subject to existing Commission rules governing the exclusion of certain persons from activities related to or connected with USF support mechanisms (the Rules for suspension and exclusion). ).763 We also remind participants that all entities in arrears on debts owed to the Commission are prohibited from receiving aid until full payment or a satisfactory arrangement for the payment of the overdue debt has been made, in accordance with the Commission “red light” rule implementing the Collections Improvement Act of 1996.764.
Recordkeeping, Audits, and Certifications
These safeguards are in addition to many of the requirements described above for the Healthcare Connect Fund that are also designed to protect against waste, fraud and abuse. USAC may not knowingly accept certifications signed by a person who is not an officer, director or other authorized employee of HCP or.
Duplicative Support and Relationship to Other RHC Programs
For individual HCP applicants, the required certificates must be provided and signed by an officer or director of HCP, or other authorized HCP employee (electronic signatures are permitted .). However, we do not believe it is necessary for the Healthcare Connect Fund to prohibit the use of federal funds from non-universal service program sources to be part of the HCP's 35 percent contribution requirement.780 Here, the HCP contribution amount is significantly higher than in the Pilot Program (35 percent compared to 15 percent in the Pilot Program).
Recovery of Funds, Enforcement, and Debarment
TELECOMMUNICATIONS PROGRAM REFORM
For all of these reasons, we expect a significant migration of healthcare workers from the Telecommunications Program to the Healthcare Connect Fund over time. As the new Healthcare Connect fund is implemented, we expect to examine whether the telecommunications program is still necessary and, if so, whether reforms to the program are needed.
PILOT PROGRAM FOR SKILLED NURSING FACILITY CONNECTIONS
See e.g. ELGSS Comments at 1-2 (stating that hospitals and post-acute providers must work very closely together to provide great care at the lowest possible cost, but attempting to use definitions of skilled nursing and custodial services to determine eligibility is not consistent with the rapidly changing health care environment, and the post-acute census of Medicare residents may vary widely from facility to facility or even time of year). 799 See e.g. ELGSS Comments at 3 (“One of the best ways to improve health care for rural residents and for rural residents in skilled nursing facilities who transfer to a rural or urban hospital is to ensure that their medical records are submitted electronically from the skilled nursing facility to the hospital, and conversely Errors in prescription drugs, medical examinations that have already been run and many other necessary information can be resolved if skilled nursing facilities also have electronic medical records.”).
MISCELLANEOUS
Implementation Timeline
In the meantime, individual HCPs may still receive support through the Telecommunications or Internet Access Programs until they are eligible to apply for funding under the Healthcare Connect Fund. Telecommunications or Internet Access Programs and then to the Healthcare Connect Fund.811 Without an orderly transition to the new program, some individual HCPs of the Pilot project may be at risk.
Pilot Program Transition Process and Requests for Additional Funds
In light of our creation of the new Healthcare Connect Fund, we are denying these requests for additional Pilot Program funding. Instead, we direct USAC to use unused Pilot Program funds for the request related to the Healthcare Connect Fund.
Prioritization of Funding
In the meantime, we will continue to rely on the approach codified in our existing rules as a back-up tool in cases where funding requests reach the $400 million threshold before we have established other prioritization procedures.828. For this reason, we anticipate that growth in the combined universal health care fund will remain below the $400 million mark over the next five years.
Offset Rule
Our action here is not the first time the Commission has acknowledged the deficiencies of the offset rule. 02-60 (filed June. Comment Sought on Richmond Connections, Inc., Request for Waiver of Commission Rules on Rural Health Care Program and Petition for Emergency Stay for Expedited Review Pending Commission Review, WC Docket No.
Delegation to Revise Rules
PROCEDURAL MATTERS
Paperwork Reduction Act
Congressional Review Act
Final Regulatory Flexibility Analysis
ORDERING CLAUSES
A "rural health care provider" is a qualified health care provider site located in a rural area. Under the Telecommunications Program, rural health care providers can choose one of the following two support options. iv).