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Net neutrality repeal may diminish telemedicine access, harm small practices

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The repeal of net neutrality as voted on by the Federal Communications Commission could lead to unintended and devastating consequences for physicians in small practices, as well as telemedicine and patients in rural areas that receive state-of-the-art medical care through telecommunications, according to experts.

“One of the biggest concerns around the net neutrality issue is that larger business entities with more resources would be able to create market environments where there is a higher cost to operate, such as having to pay for outgoing bandwidth,” Steven Waldren, MD, director of the American Academy of Family Physicians’ Alliance for eHealth Innovation, told Healio.com in an interview. “Larger entities would be able to subsidize these higher costs with capital or other revenues, while smaller competitors would not be able to subsidize and therefore exit the market. In this way, practices are the smaller business organizations. Most medical practices do not have the expertise or resources to manage network connectivity issues; they are struggling to have the resources to manage care delivery and medical payment.”

Net neutrality — a regulation passed by former President Barack Obama’s administration in 2015 — prohibits internet service providers from interfering with the content that flows over their networks or charging extra for more reliable access. The FCC voted to repeal this regulation by a vote of 3 to 2, after Chairman Ajit Pai previously argued that net neutrality “depressed investment in building and expanding broadband networks and deterred innovation.”

Healio.com spoke with several experts about the possible consequences various areas of health care could experience with net neutrality repealed.

Limited resources

Physicians are inundated with new requirements and regulations and change due to the transformation to value-based payment in health care, according to Waldren. Coupled with the continuously-growing body of medical knowledge and direct patient care consuming physicians’ attention, most physicians are unaware of what net neutrality means, Waldren said.

“Their core business is too demanding for them to be concerned about this issue at this time,” he said. “The only physicians potentially digging into this issue are those with a heavy telemedicine practice, those with interest in a diagnostic imaging service or those working in a data-intensive start-up, such as genomics.”

However, a lack of awareness could be putting physicians — in particular, physicians with small practices — in a precarious position because medical practices could see higher prices for appropriate bandwidth to source networks, to conduct telemedicine and to access data-intensive services such as diagnostic image retrieval and genomics.

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“With the move to value-based payments, the revenue for a practice becomes more and more uncoupled from expenses,” Waldren said.

Those business entities that can amortize their fixed costs over larger numbers of patients will have an advantage. Without net neutrality, there is a risk of smaller practices being disadvantaged, likely leading to higher overall medical costs.”

Additionally, net neutrality’s repeal could lead to further consolidation of medical practices and integrated delivery networks, “which allow for greater bargaining power, and therefore higher medical costs.”

Telemedicine, rural patients suffer

Approximately 60 million people live in areas that are considered rural and not within a designated urban area, according to 2016 data from the Census Bureau.

Many patients in those areas live more than an hour away from major metropolitan areas and significantly rely on telemedicine to gain easy access to state-of-the-art care.

The problem, as Laurence J. Heifetz, MD, FACP, medical director of Gene Upshaw Memorial Tahoe Forest Cancer Center, told Healio.com, is that most patients in rural areas only have one or two internet service providers (ISPs).

“Those people are already experiencing no choice as to who their ISP is,” he said.

With net neutrality repealed, there’s a possibility that major ISPs would implement blanket charges that cover a range of services, Heifetz added.

“My feeling is that they probably will not pay attention to it,” he said. “They’re not going to consciously say we’re going to [hurt] patients, but they might as an unintended consequence. These are potentially very poor, underinsured patients with very poor rural health care facilities with limited resources.”

Advances in technology have allowed physicians to graph patients’ information such as blood tests, weight and blood pressure and present the information through telemedicine in an easy-to-understand manner in a face-to-face environment while being more than an hour away from a patient.

“Whether it’s diabetic management or cancer management, whatever you measure, it is nice to be able to share that visually with a patient,” he said.

“In the future, I’d like to be able to say, ‘OK, look at the CAT scan,’ and the patient is sitting at home. Well, that's going to require a ton of bandwidth, because these diagnostic images are very bandwidth sensitive.”

Currently, smaller hospitals in rural areas have agreements with other major hospitals to share all necessary patient information through picture archiving and communication systems, Heifetz said. The goal would be to use all that information in the future in a similar manner to have a patient consult through telemedicine portals, according to Heifetz.

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“If I can do that, that would be a very healing experience,” he said. “Well, repealing net neutrality may screw that up. They may charge those patients a zillion dollars for the necessary bandwidth I need to communicate and to do my job better.”

Cyber protection, competition

Another hurdle to telemedicine if net neutrality is repealed involves encryption. Everything that is transmitted through telemedicine portals must be encrypted to meet HIPAA laws.

“Say an ISP decides they no longer want encrypted traffic to go across their network because they want visibility into everything that goes across their line. At that point we’re just hoping that they’re going to continue to pass that traffic,” Greg Hall, IT director for the Center for Telehealth at the University of Mississippi Medical Center, told Healio.com. “If they decide they don't want to or want us to pay them additional fees to have the traffic that is encrypted then suddenly we’re stuck. They could very easily block it all and we can no longer do a telehealth encounter because we can’t pass our traffic over our networks. Our business is completely stopped because one ISP somewhere on the chain has decided that they don't like that kind of traffic.”

Even if major ISP providers such as AT&T, Verizon and Sprint continue to operate under the guidelines of net neutrality and do not restrict access, there still could be hurdles to telemedicine, Hall said.

“You have a small rural ISP that decides, ‘Hey, no we don’t want to play all those games, we want to charge a certain fee for certain traffic’ and say that happens to be the video traffic that we push across the internet at some point. All of the sudden, that small little provider, just because we happen to pass some traffic across their network, could very easily cripple access at that point.

“The main concern is not even just, ‘Hey, our bill comes from AT&T every month.’ It doesn't always just go over AT&T lines, so we have to worry about every ISP that our traffic happens to go across to get from one location to another.”

And although major ISPs might say there will be no changes, Hall said there are examples where that has not been the case. Previously, he said, larger providers blocked video applications from going across their network because they competed with another service the provider already offered.

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The ramifications could present dangerous situations to patients in rural areas if net neutrality is repealed, according to Heifetz.

“They’re just going to have to get in the car and drive to the hospital an hour away in inclement weather possibly. It’s crazy,” he said.

Patients might need to get some type of insurance coverage that would insure telemedicine technology if prices became significantly high.

“Someone is going to have to pay for this,” Heifetz said. “My sense is that the ISPs aren’t even thinking about this. It’s not even on their radar. If they decide to stick it to everyone else for buying more bandwidth, they should be willing to provide free bandwidth [but] ... that would require the legislation that demonstrated patients in need who have active telemedicine relationships with their health care providers ... to get their bandwidth for free.”

Heifetz said that health care facilities, providers and most importantly patients, should not suffer from a repeal of net neutrality.

“I don't care if they want to charge the person for watching a movie, but I do care if they interfere with an essential service which is increasing in acceptance around the country — and around the world,” he said. – by Ryan McDonald

Disclosures: Hall, Heifetz and Waldren report no relevant financial relationships.

Editor's note: This article was updated with the result of the FCC's vote.