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

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.

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.

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.

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.