The techie term “net neutrality” likely isn't in the daily
lexicon used by most senior healthcare executives. But it should be, and soon,
argue those in healthcare technology who have been following the
topic.
The wireless telecommunications industry's trade group, CTIA, for
example, has been circulating a letter to healthcare organizations, asking their
support to oppose regulation that would ensure continued net neutrality. But
others argue healthcare benefits from net neutrality and should be lobbying for
its continuance via a new Federal Communications Commission mandate.
Net
neutrality means everyone sending data is treated the same by carriers like
Verizon and others; no one can pay or be charged more for faster transmission
speeds and none can be barred from sending data. The tool that net neutrality
advocates want to use—Title II of the FCC’s authorization act—would essentially
make internet traffic into a public utility.
The FCC is expected to rule
either by year-end or early next year.
The debate on net neutrality has
intensified as the amount of data being transmitted in videos and other usages
has increased, leading some to argue that too much traffic is crossing a
too-small network, slowing down performance.
Telehealth and electronic
record data exchange are the two primary areas of healthcare that would suffer
were internet service providers allowed to charge higher prices for faster
transmission speeds, say those who back net neutrality.
“I don't think
people realize how much net neutrality can affect health services,” said Mark
Gaynor, an associate professor of health management and policy at St. Louis
University and a long-time advocate for net neutrality.
President Barack
Obama earlier this month put the spotlight on the issue when he
called on the FCC to
“implement the strongest possible rules to protect net neutrality.”
But
he muddied the debate when it comes to healthcare by saying the rule, “can have
clear, monitored exceptions for reasonable network management and for
specialized services such as dedicated, mission-critical networks serving a
hospital.”
But many critics of a net neutrality rule believe that
allowing internet service providers to charge for a “fast lane” or “paid
prioritization” would be helpful for innovation. Such pricing would allow data
from paying content providers to move more quickly to consumers. Currently, they
argue, many networks slow at peak times when everyone wants to view Netflix
videos or use other heavy bandwidth applications, like online gaming.
Charging those users more allows for more efficient usage of limited
bandwidth, and provides an incentive to internet service providers to build more
network infrastructure, which would accommodate more usage down the road. That
position is partially supported by a July 2014 draft paper produced by two FCC
officials, which use a model to show that overall market efficiency is improved
if broadband providers are allowed to charge for fast lanes.
Billionaire
internet entrepreneur Mark Cuban argued, in a
post
on his personal blog, that this debate has particular relevance to healthcare.
Hypothetically, he said, an emergency surgeon might want to access an
internet application for a surgery—and finds that she can't get enough bandwidth
for the service to work because “TV and movie services … swamp
bandwidth.”
A net neutrality rule, he suggested, encourages that
situation for two reasons: because it prevents the investment that would make a
bigger network for everyone; and because it prevents high-priority data from
jumping to the front of the line.
Cuban also doesn't believe Obama's
exception for hospitals—which might put it at the front of the queue—would do
much good, writing, “First in line in a traffic jam is still slow and
buffering.”
Also opposing neutrality, Verizon has argued in a
letter
(PDF) to the FCC, that classifying internet traffic under Title II is not
legally permissible, and an attempt to do so would invite legal challenges.
The push-and-pull over net neutrality has left the FCC's decision
uncertain. The Washington Post
reported
on Nov. 11 that FCC chair Tom Wheeler had rejected Obama's call to reclassify
internet traffic to Title II and he was looking to “split the baby” between
internet service provider and net neutrality advocate concerns.
Most
opponents of formal net neutrality believe that classifying internet traffic
under Title II would result in onerous new requirements for internet providers,
as the section was designed for older types of networked communication.
Jot Carpenter, the vice president of government affairs for CTIA, said
in an interview that the rules would slow new innovations for wireless
providers. The exception proposed by Obama, he said, would introduce confusion
for the providers.
In those instances, he said, they would have to
approach the FCC and see whether their intended idea—whether a formal
partnership with a content provider or an economic arrangement—fell under the
hospital exception. Carpenter derided that as the “Mother, may I?” approach to
governance, which he argued is bad for innovation.
It's also unclear
what might fall under the exception, Kerry McDermott, the vice president of
public policy and communications for the Center for Medical Interoperability and
a former FCC official said. Which hospital data would apply? Would other
healthcare data apply?
Because of that perspective, Carpenter and CTIA
have been circulating a letter to healthcare groups arguing that proposed
reclassification would increase regulatory uncertainty for mobile health, which
they argue is too young to withstand the shock.
While Carpenter declined
to name which stakeholder groups had been contacted, a draft copy of the letter
obtained by Modern Healthcare includes comments from the Healthcare Information
and Management Systems Society. It's not possible to attribute specific comments
on the letter to the organization. As of press time, HIMSS had not responded to
inquiries regarding the letter. And Carpenter wouldn't discuss when the letter
would be officially released, or with which signatories.
But Gaynor and
others are anxious about the negative effects of allowing providers to charge
higher prices to content providers.
“I don't want to see small companies
that are trying to innovate be locked out by bigger companies that have more
money and can pay for faster service,” Gaynor said.
Carpenter rejects
that argument. “I don't know that there's any evidence to suggest that these
startups would be prevented from reaching their customers or gaining critical
mass in the marketplace or gaining notice. Paid placement isn't always an evil,”
he said, citing Google's early history as an example.
And facing a toll
might also hurt efforts to encourage interoperability, Gaynor continued. The
healthcare system is hoping to encourage more data sharing, often through Health
Information Exchanges. A charge for faster service provides a disincentive to
sharing overall, and in particular hurts HIEs – which are non-profit and often
struggle to find the proper business model under current conditions.
Innovation might be hurt in another way, Gaynor and his co-authors
argued in a July 2013 paper in the Journal of the American Medical Informatics
Association. Some internet service providers own or are closely associated with
healthcare services; Verizon, for example, has a virtual visits telehealth
service, as well as an Apple HealthKit competitor called Converged Health
Management. If internet service providers are allowed to discriminate between
content providers, they might favor their own, Gaynor writes.
That
argument also attacks the FCC officials’ paper, which assumes that broadband
internet service providers are not vertically integrated with a content
provider.
Steve Kraus, a partner at venture capitalist firm Bessemer
Venture Partners, agrees with Gaynor’s argument. “The whole premise of
telemedicine would fall down,” he said, if startups suffer lagged performance.
He argued that the net neutrality debate is particularly relevant to
healthcare: first, patients and providers often need speed in making care; and
second, because the data being moved in healthcare – like medical records,
genomics, and video – is often so large.
Kraus's colleagues agree, and
are worried about the large telecommunications firms potentially giving
themselves an unfair advantage, noting that both Verizon and AT&T have been
investing heavily in healthcare.
Virtual visits firm American Well also
feels strongly about net neutrality. In an interview, the firm's senior vice
president of consumer markets, Mike Putnam, said that he believes paid
prioritization would decrease healthcare access and cause the firm to pass on
costs to the consumer.
Seth Ginsburg, the president of non-profit Global
Healthy Living Foundation, has been advocating for net neutrality in Capitol
Hill—and actually retained a lobbyist to do so, the only purely healthcare
entity registered in the Senate's lobbying database to list net neutrality as an
interest.
Ginsburg’s organization, which helps patients with conditions
like rheumatoid arthritis, believes that paying tolls for faster service would
harm its relationship with patients. The organization is a nonprofit, and can’t
afford to pay a toll; and yet it also communicates time-sensitive information,
concerning drug safety for example, to its patients. Allowing a fast lane would
put the organization in a bind.
Ginsburg is contemplating complementing
his firm's lobbying efforts by adding the voices of his patients, who he said
are in all 50 states. He has seen a lack of healthcare interest in the political
half of the debate. He suspects it's due to the other large healthcare IT issues
on the docket, like meaningful use and the ICD-10 code switch.
