Telecommunications:

FCC's Performance Management Weaknesses Could Jeopardize Proposed Reforms of the Rural Health Care Program

GAO-11-27: Published: Nov 17, 2010. Publicly Released: Dec 17, 2010.

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Telemedicine offers a way to improve health care access for patients in rural areas. The Federal Communications Commission's (FCC) Rural Health Care Program, established in 1997, provides discounts on rural health care providers' telecommunications and information services (primary program) and funds broadband infrastructure and services (pilot program). GAO was asked to review (1) how FCC has managed the primary program to meet the needs of rural health care providers, and how well the program has addressed those needs; (2) how FCC's design and implementation of the pilot program affected participants; and (3) FCC's performance goals and measures for both the primary program and the pilot program, and how these goals compare with the key characteristics of successful performance goals and measures. GAO reviewed program documents and data, interviewed program staff and relevant stakeholders, and surveyed all 61 pilot program participants with recent participation in the program.

FCC has not conducted an assessment of the telecommunications needs of rural health care providers as it has managed the primary Rural Health Care Program, which limits FCC's ability to determine how well the program has addressed those needs. Participation in the primary program has increased, and some rural health care providers report that they are dependent on the support received from the program. For example, a provider in Alaska has used program funds to increase the use of telemedicine, which has reduced patient wait times and travel costs. FCC has been successful in disbursing over 86 percent of all committed funds. However, FCC has disbursed only $327 million in total over the 12 years of the primary program's operation-- less than any single year's $400 million funding cap. FCC has frequently stated that the primary program is underutilized and has made a number of changes to the program, including the creation of the pilot program. Currently, FCC is proposing to replace portions of the primary program with a new broadband services program. However, without a needs assessment, FCC cannot determine how well the current program is targeting those needs--and whether the program is, in fact, underutilized--or ensure that a new program will target needs any better. FCC's poor planning and communication during the design and implementation of the pilot program caused delays and difficulties for pilot program participants. FCC did not consult with the program's administrator, other federal agencies, or relevant stakeholders prior to announcing the program, nor did it request public comment on its design. In addition, FCC called for applications to participate in the pilot program before it fully established pilot program requirements. FCC added additional program requirements after the pilot program began, and survey respondents indicated that program guidance was not provided in an effective manner. Despite these difficulties, most participants were positive about the assistance provided by program officials and reported that the benefits they anticipate receiving from the pilot program outweigh the costs of participating. However, the entire program has been delayed and projects have struggled to meet requirements that were not clearly defined at the beginning of the program. FCC has not developed specific performance goals for the Rural Health Care Program and has developed ineffective performance measures. The performance measures are limited for a number of reasons, the most important of which is that FCC has set no specific performance goals to which to link them. In addition, FCC has not evaluated the performance of the primary Rural Health Care Program and has no evaluation plan for the pilot program. Without reliable performance information, FCC does not have the data that it needs to make critical policy decisions about the overall Rural Health Care Program. If FCC does not correct these deficits in performance management, it may perpetuate the same performance management weaknesses in its stewardship of the new rural health care programs that it has proposed. GAO recommends that the FCC Chairman assess rural health care providers' needs, consult with knowledgeable stakeholders, develop performance goals and measures, and develop and execute sound performance evaluation plans. In its comments, FCC did not agree or disagree with the recommendations, but discussed planned and ongoing actions to address them.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In 2010, we reported that the Federal Communications Commission (FCC) had not conducted an assessment of the telecommunications needs of rural health care providers as it managed the primary Rural Health Care Program, which limited FCC's ability to determine how well the program was addressing those needs. Participation in the primary program had increased, and some rural health care providers reported that they were dependent on the support received from the program. Although FCC had been successful in disbursing over 86 percent of all committed funds, FCC had disbursed over the 12 years of the primary program's operation only $327 million -- less than the funding cap for a single year of program operation -- to rural health care providers to assist them in purchasing telecommunications and information services. At the time of our audit, FCC was proposing to replace portions of the primary program with a new broadband services program. However, without a needs assessment, FCC could neither determine how well the current program was targeting the needs or rural health care providers nor ensure that a new program would target needs any better. Therefore, we recommended that FCC conduct an assessment of the current telecommunications needs of rural health care providers. In response, in December 2012, FCC adopted a Report and Order for the Rural Health Care Program that included an "Assessment of Broadband Needs of Health Care Providers." FCC's needs assessment included consideration of various bandwidth-intensive telemedicine applications and was based upon information gathered through FCC's programs, outreach meetings with health care organizations and government entities, and information in FCC's record and from public sources. As a result of undertaking a needs assessment, FCC has information to be able to manage the Rural Health Care program in a more proactive fashion, as it can better determine which services the program should support, understand what proper utilization of the program by health care providers should look like, and ensure that programmatic changes are achieving the intended results.

    Recommendation: To improve its performance management of the Rural Health Care Program, the Chairman of the FCC should conduct an assessment of the current telecommunications needs of rural health care providers. If FCC does develop any new rural health care programs under the Universal Service Fund--such as the proposed Health Care Broadband Access Fund and the Health Care Broadband Infrastructure Fund--this step should be taken before implementing any new programs or starting any new data collection efforts.

    Agency Affected: Federal Communications Commission

  2. Status: Closed - Implemented

    Comments: In 2010, we reported that the Federal Communications Commission (FCC) missed multiple opportunities to collaborate with the Universal Service Administrative Company (USAC) (the third party administrator of the Rural Health Care Program), federal agencies, and other knowledgeable stakeholders when FCC designed its Rural Health Care Pilot Program. These stakeholders could have provided useful insights into FCC's design of the pilot program. We had reported in previous work on the importance of involving stakeholders when designing, implementing, and evaluating programs. Such consultations could have helped FCC better identify potential pitfalls in program design as well as meaningful opportunities to leverage federal resources and ensure that the pilot program targeted rural health care providers' needs in the most efficient way. We found that USAC's experience with the primary program could have yielded valuable insights for FCC, particularly regarding the administrative processes and forms, as we found that pilot program participants often reported difficulties in completing forms and attachments. In addition, although a number of federal agencies were involved in telemedicine efforts, FCC did not contact other federal agencies prior to announcing the pilot program, except for USDA. Although FCC met with USDA, it was unclear how FCC used the information that USDA provided. Lastly, we found that FCC did not request public comment on its proposed design for the pilot program. We have previously reported that providing the public with advance notice of proposed changes and an opportunity to comment on them is desirable in that it allows agencies to find out earlier rather than later about views and information adverse to the agency's proposal or bearing on its practicality. Therefore, we recommended that FCC consult with USAC, other federal agencies that serve rural health care providers (or with expertise related to telemedicine), and associations representing rural health care providers to incorporate their knowledge and experience into improving current and future programs. In response, in April 2014, FCC staff traveled to Alaska (the state that receives almost 55 percent of program funding) to meet with the Alaska Native Tribal Health Consortium, which consists of more than 200 tribes, to consult with them about the administration of the Rural Health Care Program. In June 2014, FCC issued a public notice seeking comment from stakeholders on how best to collect data that can help it measure program performance while minimizing any burden on program participants. In the fall of 2014, FCC worked with USAC to conduct a webinar and workshop to solicit feedback and answer inquiries from program participants. According to FCC, this has led to USAC improving its application processes and response times. In May 2015, FCC and USAC staff participated in the American Telemedicine Association's annual meeting, including manning a booth and conducting a roundtable discussion with program participants, consultants, and service providers to solicit their feedback about how to improve the program and minimize administrative burdens. Also in May 2015, FCC and USAC staff consulted with staff from the Department of Health and Human Services about the Health Resources and Services Administration's (HRSA) Telehealth Network Grant Program. According to FCC, the agency plans to incorporate some of HRSA's best practices into its annual reporting requirements and plans to conduct additional outreach with other federal agencies to better refine its plans for collecting program data. As a result of these various collaborative efforts, FCC has obtained knowledge and insights about the Rural Health Care Program, as well as stakeholders' needs and concerns, that should help inform the agency's decision making and help it to proactively address issues that could arise with the Rural Health Care Program.

    Recommendation: To improve its performance management of the Rural Health Care Program, the Chairman of the FCC should consult with Universal Service Administrative Company (USAC), other federal agencies that serve rural health care providers (or with expertise related to telemedicine), and associations representing rural health care providers to incorporate their knowledge and experience into improving current and future programs. If FCC does develop any new rural health care programs under the Universal Service Fund--such as the proposed Health Care Broadband Access Fund and the Health Care Broadband Infrastructure Fund--this step should be taken before implementing any new programs or starting any new data collection efforts.

    Agency Affected: Federal Communications Commission

  3. Status: Closed - Implemented

    Comments: In 2010, we reported that the Federal Communications Commission (FCC) had not developed specific performance goals for the Rural Health Care Program and had developed ineffective performance measures. Previously, we reported that results-oriented organizations set performance goals to clearly define desired outcomes. However, FCC had been operating the Rural Health Care Program under broad, overarching goals, including the statutory goal of ensuring that rural health care providers receive telecommunications services at rates comparable to the same services in urban areas. While FCC had established some performance measures for the program, those measures fell short when compared with key characteristics of successful performance measures. Therefore, we recommended that FCC develop effective goals, and performance measures linked to those goals, for all current and future rural health care programs. In response, FCC adopted a Report and Order in December 2012 that established three specific performance goals for the program: (1) increase access to broadband for health care providers, (2) foster the development of broadband health care networks, and (3) maximize the cost-effectiveness of the program's support mechanism. For each goal, FCC also adopted linked performance measures. As a result, FCC has provided the program with a more solid performance management foundation. These goals and performance measures should better inform FCC's decision making and improve its stewardship of the Rural Health Care Program.

    Recommendation: To improve its performance management of the Rural Health Care Program, the Chairman of the FCC should develop effective goals, and performance measures linked to those goals, for all current and future programs. If FCC does develop any new rural health care programs under the Universal Service Fund--such as the proposed Health Care Broadband Access Fund and the Health Care Broadband Infrastructure Fund--this step should be taken before implementing any new programs or starting any new data collection efforts.

    Agency Affected: Federal Communications Commission

  4. Status: Closed - Implemented

    Comments: In 2010, we reported that FCC had not formally evaluated the performance of the primary Rural Health Care Program to determine whether it was meeting the needs of rural health care providers. At the time, FCC stated that it intended to evaluate its rural health care pilot program after its completion, but we found that it was unclear if FCC had effective evaluation tools for conducting a pilot program evaluation, such as an effective evaluation plan or an effective progress reporting mechanism. We concluded that if FCC did not institute better performance management tools--including planning and conducting effective program evaluations--the agency's management weaknesses would likely continue to affect the primary and pilot Rural Health Care Programs and would likely carry forward into the design and operation of any future rural health care programs. Therefore, we recommended that FCC develop and execute a sound performance evaluation plan for the current programs, and develop sound evaluation plans as part of the design of any new programs before implementation begins. In 2015, we confirmed that--in August 2012--in response, FCC's Wireline Competition Bureau released its Evaluation of Rural Health Care Pilot Program Staff Report. The bureau stated that its evaluation was to assist FCC in considering reforms to the Rural Health Care Program and assist in developing sound evaluation plans for any new programs. The bureau's evaluation provided information on the experiences of the pilot project participants, data about the pilot projects, and the bureau staff's observations about the pilot program. As a result of conducting a program evaluation, FCC obtained critical information about program performance that can help it better reform and manage the Rural Health Care Program and gained knowledge relevant to developing future program evaluation plans, which substantially addressed the intent of our recommendation.

    Recommendation: To improve its performance management of the Rural Health Care Program, the Chairman of the FCC should develop and execute a sound performance evaluation plan for the current programs, and develop sound evaluation plans as part of the design of any new programs before implementation begins. If FCC does develop any new rural health care programs under the Universal Service Fund--such as the proposed Health Care Broadband Access Fund and the Health Care Broadband Infrastructure Fund--this step should be taken before implementing any new programs or starting any new data collection efforts.

    Agency Affected: Federal Communications Commission

  5. Status: Closed - Not Implemented

    Comments: In February 2014, FCC announced the deferral of its Skilled Nursing Facility pilot program under its Rural Healthcare program. The Commission had set aside $50 million for the proposed Skilled Nursing Facility pilot program. FCC deferred the implementation of the pilot program until it determines whether some of the funds set aside for that program should be used instead to conduct consumer-oriented rural broadband experiments intended to improve patient access to health care, noting a growing demand for telemedicine and remote monitoring.

    Recommendation: To improve its performance management of the Rural Health Care Program, the Chairman of the FCC should, for any new program, ensure that FCC's request for applications to the program clearly (1) articulates all criteria for participating in the program and any weighting of that criteria, (2) details the program's rules and procedures, (3) outlines the program's performance goals and measures, and (4) explains how participants' progress will be evaluated. If FCC does develop any new rural health care programs under the Universal Service Fund--such as the proposed Health Care Broadband Access Fund and the Health Care Broadband Infrastructure Fund--this step should be taken before implementing any new programs or starting any new data collection efforts.

    Agency Affected: Federal Communications Commission

 

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