This report originally appeared in the February 2011 issue of DOTmed Business News

It likely comes as no surprise, but the United States does not produce many neurologists.

According to recent estimates, there are about four brain specialists for every 100,000 people in the country. This is a tragic statistic for overbearing mothers who want their children to be brain doctors. But the fallout is especially heavy for stroke victims in remote, rural areas, who often don’t have ready access to stroke specialists when they really need them.

Luckily, for these patients, video conferencing with a stroke specialist hundreds of miles away might help save their lives. A 2009 report in the journal Stroke concluded that video conferencing and remote sharing of brain scans with stroke and imaging experts could help doctors determine if someone suffering an ischemic stroke was eligible for a tissue plasminogen activator (tPA). This clot-busting drug can reduce disability following a stroke, but it must be given within three hours of the appearance of symptoms. And as it only works for some conditions and can actually worsen others, only a trained specialist can decide if it’s appropriate.

And treating stroke patients is just one of the frontiers of telemedicine.

Its supporters tout numerous benefits. They claim telemedicine can save the health care system money by monitoring chronically ill patients at home, and catching problems before they would lead to a hospitalization. MRI or CT scans can also be shared with radiologists across the country or around the world. And, as with stroke patients, people living in remote areas can get face time with experts via video chat.

But for some hospitals, the glorious future of telemedicine has a sticking-point: broadband access.

“It’s definitely a problem,” says Danny Fernandez, a spokesman with the National Rural Health Association.

How big of a problem is hard to say. A report last year by the Federal Communications Commission found for some rural providers, it’s significant. About one-third of rural hospitals and one-quarter of critical access hospitals receiving federal funds lack access to affordable broadband.

As it is, some hospitals have to be crafty about using their limited bandwidth. Some hospitals wait until after-hours to upload MRI scans or other big files because they don’t have the capacity to do so during the day when other kinds of data are squeezing through their congested wires.

And wide bandwidth isn’t just needed for telemedicine. Soon, it could be required by health care providers eager to meet meaningful use requirements and qualify for financial incentives attached to them. Without affordable broadband access, later requirements, particularly those requiring hospitals to jack into health information exchanges and other bandwidth-hogging networks, could be tough to meet.

“When you think about the incentive payments and achieving meaningful use, none of that matters if you don’t have access to a broadband connection that can facilitate any type of electronic transfer,” Fernandez says.

What is broadband, anyway?
One of the main troubles of approaching the broadband problem is figuring out what everyone means by “broadband.” It’s difficult to find an answer to the problem when no one can agree on the question.

The FCC told DOTmed News it was not a “regulatory term.”

But for the purposes of benchmarking, in a report released in September, the FCC defined broadband as 4 megabytes per second downstream, and 1 mbps upstream. This definition is not agreed upon by everyone, the agency found. Under this classification, 68 percent of U.S. residential connections sold as broadband are not, in fact, broadband. And medical needs can be higher. A single-physician practice could get by with 4 mbps, the FCC said. But for diagnostic image transfer and video consultation, the agency suggests at least 10 mbps. And for large hospitals, the needs are greater: 100 mbps to 10 times that.

“Certainly a 6 mbps line would get you what you need for most applications, going upstream. But someone in our membership will say you’ll need 15 mbps. There’s a lot of debate,” Jonathan Linkous, CEO of the American Telemedicine Association, says.




It’s also a moving target. Linkous notes that 1.1 mps up and downstream used to be high-speed, but now it’s slow. Fifteen years ago, he observes, when the ATA was formed, 2 mbps would have been blisteringly fast.

“What is high speed today is not going to be high speed 20 years from now or 10 years from now,” he says.

Ease of access
For providers, improving technologies and widening adoption rates translate into lower costs. The truth is, broadband access has steadily improved over the past decade. “The cost of broadband certainly has come down considerably over the last 10 years, even the last two years,” says Linkous. “It’s not the barrier it used to be.”

This is partly the result of active policies by some states, such as Texas and California, which encourage carriers to reach their large rural populations.

“With a few limited exceptions, [broadband access] is not a huge problem in Texas,” says Don McBeath, director of advocacy and communications with the Texas Organization of Rural & Community Hospitals, or TORCH. “It’s pretty common for most rural hospitals to have multiple T1 lines going into them, at what they would consider a fairly affordable rate.”

However, T1 lines – copper or bundled glass, fiber optic lines which deliver 1.5 mbps—are often too slow for data-heavy transfers.

And nationwide, there are still obstacles. Anecdotally, the costs of broadband, even mass-market, can be three or four times higher in one part of a state (usually rural) than in another.

The reason for the higher prices is simple: the lower household density in small towns or the countryside drives up costs. The Telecommunications Industry Association, a trade group that represents telecom manufacturers, shared with DOTmed News a report it compiled last year. The report showed, among other things, costs associated with services to a rural town with about 600 people per square mile, and a completely rural area with around 60 people per square mile.

Under some estimates, for a carrier servicing a country town, the free cash flow after 10 years would be $2.7 million. But by servicing the countryside, the carrier gets hit with a negative cash flow --to the tune of minus $9.7 million.

“In rural and hard-to-reach areas, there’s not as much of an economic incentive,” says Danielle Coffey, vice president of government affairs with TIA.

But the government recognizes telecom challenges in the country, which is why the FCC runs its Universal Service Fund. Paid for by charges from long distance calls, this helps spread telephones and telecommunications to areas that otherwise wouldn’t make economic sense for carriers.

And the FCC has plans for broadband. Last spring, the agency unveiled its long-simmering National Broadband Plan, with ambitious goals: as FCC Chairman Julius Genachowski explained it, the aim is to bring 1-gigabit connections to every community nationwide. It also hopes to expand affordable 100 mbps broadband to 100 million households over the next decade.

The FCC also has worked specifically on rural health care. The results, though, have been mixed.

FCC plan, and why it struggled
Last fall, the Government Accountability Office issued a scathing report on the FCC’s 1997 Rural Health Care Program. This plan was designed to fund telecommunications for rural providers, and in 2007, noting it was underused, the agency added a pilot program, to help offset costs for broadband access between rural and urban providers.

On paper, the program seems fairly helpful: it offered to pay about a quarter of the monthly costs for Internet access for rural health providers (and a full 50 percent for the lucky residents of Guam, the U.S. Virgin Islands, the Northern Mariana Islands and Samoa). And the pilot program would cover 85 percent of the costs of laying out broadband networks in regions of the country where they didn’t exist.

Sometimes it worked -– a 2007 report found it helped increase telehealth services for some native Alaskans leading to a drop in wait times to see ear specialists from six to nine months to only two weeks. And about 86 percent of committed funds were spent, with some rural providers saying they’re now dependent on the support they receive from the fund, the GAO said.

But the GAO said overall the program was too complicated and poorly managed to really fulfill its mission. The agency never properly assessed the telecommunications needs of rural health providers, the GAO said, and they never really found out if the program was truly being underused, as they claimed. Still, the commission only disbursed $327 million over the 12 years of the program, far less than the $400 million funding cap it could spend in a single year.

One of the primary complaints was that the application process for the FCC help was too unwieldy for understaffed rural hospitals. “It was too complicated and too convoluted,” McBeath, with TORCH, says. “It equated right up there to a federal grant application.”

“The average person in Washington, D.C. who designed this stuff has sat at his desk his whole life,” he adds. “And they don’t know what it’s like for a person in a small rural community.”

Most rural hospitals can’t afford to hire a full-time grant writer, the NRHA said. And the staff they do have rarely is trained or has the time to handle the complex forms. As the American Hospital Association dryly noted in its letter commenting on the plan’s aftermath, “The structuring and management of communications services are not primary
disciplines for health care facilities.”

FCC tries again
But the FCC recognizes the problems. A spokesman told DOTmed News the rural health care program was “not as useful as it could have been.” The agency hopes its new proposals, announced last year, go some way to rectifying the earlier troubles. The agency said it wants to lift payment for monthly broadband costs from 25 percent of the costs to 50 percent for all rural providers (and not just those in Guam). It’s working with other agencies to improve and streamline communications. And it also wants to make the pilot program, sunsetting in June, permanent.

Of course, even if broadband troubles clear up for hospitals, telemedicine still has other obstacles – namely, reimbursement, which for telehealth services can still be a hassle. But some observers think with the rise of accountable care organizations and a shift toward bundled payments, these difficulties will go out the window, too.

“We feel lucky that this is not a partisan issue,” Linkous says. “This is one of the things both the conservatives and liberals agree on.”