Broadband internet access comes to Lake District Hospital along a single line, a fiber-optic cable that stretches up from Klamath Falls and dead-ends in Lakeview. At least once a year, that line gets severed accidentally, cutting off the 24-bed critical access hospital from an increasingly virtual world.
“All of our X-rays, they’re now all digital — they’re not on a film,” said Charles Tveit, CEO of the Lake Health District. “If that line gets cut, we can’t transmit, and therefore we can’t have our X-rays read.”
More and more, rural hospitals and clinics rely on high-speed internet access to bridge the urban-rural gap and provide their patients with services that are often found only in much larger cities. But a federal program to help subsidize the cost of broadband for rural health care facilities has hit its funding cap, which may jeopardize the push to connect more rural health facilities.
“We’re moving into a virtual care world. We have continued provider shortages, and looking at behavioral telehealth, addiction services, telepsychiatry, teledermatology, teleopthalmology, multiple specialty services, all of this is requiring higher broadband speeds,” said Jennifer Stoll, vice president of government affairs and public relations for OCHIN, a nonprofit health care innovation center based in Portland. “But it needs to be able to be supported, otherwise we will continue to have this urban-rural divide.”
OCHIN operates a consortia of rural safety net clinics and hospitals, drawing down federal broadband subsidies through the Federal Communications Commission’s Rural Health Program. The program was created in 1997 and helps rural facilities pay for high-speed connectivity. Administered by the Universal Service Administrative Company, the program provides 65 percent funding for broadband costs, up to an annual cap of $400 million.
Spending over the first 12 years never reached that amount combined. But the cap did not grow with inflation, and the growing importance of connectivity has greatly increased demand. As a result, requests for subsidies hit the cap for the first time in fiscal year 2016.
That prompted the administrator to reduce subsidies in fiscal year 2017 by 15 percent for individual participants and by 25 percent for consortia members. The American Hospital Association has urged the FCC to increase funding to fully meet demands. The FCC has proposed increasing the cap to account for inflation over the 20 years of the program. That would bring the cap to about $571 million, enough to cover all of the $521 million in subsidy requests received in fiscal 2017. But the FCC has not finalized that change and so the subsidies are still being cut.
St. Charles Health System stands to lose some $120,000 in subsidies if the cuts are not reversed.
“We’ll have to juggle our books to figure out where we’re going to find the money, what’s not going to happen,” said Don Stupfel, St. Charles’ director of infrastructure and operations.
In 2015, more than half of rural residents had no access to broadband, and the divide between urban and rural areas is widening. One study found that from 2010 to 2014, the percentage of urban health care facilities with broadband grew from 14 percent to 55 percent, while in rural areas, connectivity grew from 5 percent to 12 percent.
“Just like in any other aspect of life, connectivity is everything,” said Brian Whitacre, a broadband researcher with Oklahoma State University, who authored the study. “But for health care, it’s vital.”
That digital divide has a real impact on patients. Lake District Hospital, for example, opted for a less robust electronic health record that could be housed on computers within the hospital, rather than the cloud-based record system that most larger hospitals are adopting.
OCHIN supports a clinic in Eastern Oregon that once had to wait all day to upload a mammogram to a radiologist to read, and another day to download the results.
“That’s for a woman who is on pins and needles all day,” Stoll said. “Now they can do it in a matter of hours because they have access to proper communications.”
State and federal lawmakers and health authorities regularly suggest the use of telehealth, which connects patients in rural areas with specialists in urban areas through a video feed, to address the shortfall in addiction, mental health and pediatric specialists. But those connections require broadband access; in some cases, all the way to the patient’s home.
“I think we in urban areas take for granted how important it is, and the lack of infrastructure support throughout the state,” Stoll said. “The more rural, the less infrastructure.”
Broadband service providers say bringing the connections to rural areas is costly. Stringing fiber-optic cable above ground costs in the range of $3 to $5 per foot, says Carey Cahill, director of business development for Hunter Communications, a broadband provider serving southern Oregon and northern California. “Underground is where it gets crazy.”
Typically, connecting a rural hospital or clinic from the nearest existing broadband line involves a mix of overhead and underground cables. That connection must often cover great distances with few customers on the other end to help pay for the connection. Service providers often spread the cost of the connection over many years, allowing the facility to pay for it in monthly payments. The federal subsidies help hospitals and clinics pay those monthly fees, so even facilities that are already connected could feel the pinch of the cuts.
“It’s kind of the old adage: Once you get used to something, you kind of get dependent on it,” Cahill said. “Either they’re going to have to get us to lower their services or lower their rates.”
That’s something the company would be willing to do, he said, once the initial cost of the connection has been paid off.
“We’re committed to keep our pricing low for health and education, and medical has always been a priority,” he said. “There’s still a lot of rural health care clinics and hospitals that are underserved.”
Connecting a community hospital or clinic can also benefit the rest of the community. Whitacre has found that connectivity increases access to jobs and raises incomes.
Tveit, the Lake Health District CEO, says his hospital has little choice but to find the money to pay for connectivity even if that means cutting back on spending elsewhere.
“We still have to deliver the service,” he said, “even if we have to rob Peter to pay Paul.”
Tveit has been talking with Oregon’s congressional delegation as well as state lawmakers in Salem, trying to boost support for rural health connectivity. Last week, a group of 31 U.S. senators co-signed a letter urging the FCC to increase the funding cap.
“Building out rural broadband in Oregon and nationwide is vital to helping healthcare providers and telemedicine technology connect residents of rural communities to the care they need,” U.S. Sen. Ron Wyden said in a statement emailed to The Bulletin. “That’s exactly why I stand with my Senate colleagues in urging the FCC to increase the annual cap for the Rural Health Care Program, an essential piece to support access to care and quality of life in rural communities in our state and throughout the country.”
Lakeview officials have also been trying to find money to connect the town to a broadband line coming down to Silver Lake. They have found funding to connect the town of Paisley, about 45 miles to the north, but would still need to bridge the extra 50 miles to Silver Lake.
That would put the Lakeview hospital on a broadband loop rather than a spur, decreasing the likelihood of an interruption.
“If we don’t have internet, we do what doctors have always done: We go to paper,” Tveit said. “We can manage. We can take care of our patients. But it’s highly inconvenient.”
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