Prepared for Members and Committees of Congress

 



Lawmakers incorporated the Health Information Technology for Economic and Clinical Health (HITECH) Act as part of the American Recovery and Reinvestment Act of 2009 (H.R. 1), the economic stimulus bill that the President signed into law on February 17, 2009 (P.L. 111-5). The HITECH Act is intended to promote the widespread adoption of health information technology (HIT) to support the electronic sharing of clinical data among hospitals, physicians, and other health care stakeholders. HIT is widely viewed as a necessary and vital component of health care reform. It encompasses interoperable electronic health records (EHRs)including computerized systems to order tests and medications, and support systems to aid clinical decision makingand the development of a national health information network to permit the secure exchange of electronic health information among providers. The HITECH Act builds on existing federal efforts to encourage HIT adoption and use. It codifies the Office of the National Coordinator for Health Information Technology (ONCHIT) within the Department of Health and Human Services. ONCHIT was created by Executive Order in 2004 and charged with developing and implementing a strategic plan to guide the nationwide implementation of health information technology (HIT) in the public and private health care sectors. ONCHIT has focused on developing standards necessary to achieve interoperability among varying HIT applications; establishing criteria for certifying that HIT products meet those standards; ensuring the privacy and security of electronic health information; and helping facilitate the creation of prototype health information networks. The HITECH Act provides financial incentives for HIT use among health care practitioners. It establishes several grant programs to provide funding for investing in HIT infrastructure, purchasing certified EHRs, training, and the dissemination of best practices. It also authorizes grants to states for low-interest loans to help providers finance HIT. Beginning in 2011, the legislation authorizes Medicare incentive payments to encourage doctors and hospitals to adopt and use certified EHRs. Those incentive payments are phased out over time and replaced by financial penalties for physicians and hospitals that are not using certified EHRs. The legislation further authorizes a 100% federal match for payments to certain qualifying Medicaid providers who acquire and use certified EHR technology. Finally, the HITECH Act includes a series of privacy and security provisions that expand the current requirements under the Health Insurance Portability and Accountability Act (HIPAA). Among other things, the legislation strengthens enforcement of the HIPAA privacy rule and creates a right to be notified in the event of a breach of identifiable health information. The Congressional Budget Office (CBO) estimates that Medicare and Medicaid spending under the HITECH Act will total $32.7 billion over the 2009-2019 period. CBO anticipates, however, that widespread HIT adoption will reduce total spending on health care. Through 2019, CBO estimates that the HITECH Act will save the Medicare and Medicaid programs a total of about $12.5 billion. Under current law, CBO predicts that about 45% of hospitals and 65% of physicians will have adopted HIT by 2019. CBO estimates that the incentive mechanisms in the HITECH Act will boost those adoption rates to about 70% for hospitals and about 90% for physicians.



 
  


Introduction ..................................................................................................................................... 1 Federal Efforts to Promote HIT....................................................................................................... 2 HIPAA Administrative Simplification: Electronic Transactions, Security & Privacy Standards................................................................................................................................ 2 Electronic Transactions and Code Sets ............................................................................... 3 Unique Health Identifiers.................................................................................................... 3 Health Information Security ............................................................................................... 3 Health Information Privacy................................................................................................. 4 Medicare Part D: E-Prescribing ................................................................................................ 5 Anti-Kickback Statute, Stark Law............................................................................................. 6 CMS Grants, Demonstrations and Pay-for-Performance .......................................................... 6 Office of the National Coordinator for Health Information Technology .................................. 7 Agency for Healthcare Research and Quality ........................................................................... 8 Other Federal Agencies ............................................................................................................. 9 HIT Legislation in the 109th and 110th Congresses.......................................................................... 9 109th Congress........................................................................................................................... 9 110th Congress ......................................................................................................................... 10 HITECH Act: Explanation of Provisions ...................................................................................... 10 HIT Appropriations in ARRA.........................................................................................................11


Table 1. HITECH Act: Standards Development and Adoption; Grants and Loans; Privacy and Security................................................................................................................................ 12 Table 2. HITECH Act: Medicare and Medicaid Payments............................................................ 24

Author Contact Information .......................................................................................................... 28 Acknowledgments ......................................................................................................................... 28 Key Policy Staff ............................................................................................................................ 28



 
  


The American Recovery and Reinvestment Act of 2009 (ARRA; H.R. 1), which the President signed into law on February 17, 2009 (P.L. 111-5), incorporated the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act, based on legislation introduced in the 110th Congress, is intended to promote the widespread adoption of health information technology (HIT) for the electronic sharing of clinical data among hospitals, physicians, and other health care stakeholders. HIT, which generally refers to the use of computer applications in medical practice, is widely viewed as a necessary and vital component of health care reform. It encompasses interoperable electronic health records (EHRs)including computerized systems to order tests and medications, and support systems to aid clinical decision makingand the development of a national health information network to permit the secure exchange of electronic health information among providers. The promise of HIT comes not from automating existing practices, but rather as a tool to help overhaul the delivery of care. HIT enables providers to render care more efficiently, for example, by eliminating the use of paper-based records and reducing the duplication of diagnostic tests. It can also improve the quality of care by identifying harmful drug interactions and helping physicians manage patients with multiple conditions. Moreover, the widespread use of HIT would provide large amounts of clinical data for comparative effectiveness research, performance measurement, and other activities aimed at improving health care quality. Relatively few health care providers have adopted HIT. The most recent estimate suggests that only about 5% of physicians have a fully functional EHR that incorporates all or most of the recommended capabilities, including electronic documentation of physicians notes, electronic viewing of lab test results and radiological images, electronic prescribing, clinical decision support, and interoperability with other systems.1 The most important barriers to HIT adoption include the high implementation and maintenance costs, the limited financial incentives for using HIT, and the lack of interoperability.2 The HITECH Act includes three sets of provisions to promote HIT adoption. First, it codifies the Office of the National Coordinator for Health Information Technology (ONCHIT) within the Department of Health and Human Services (HHS). Created by Executive Order in 2004, ONCHIT was charged with developing and implementing a strategic plan to guide the nationwide implementation of HIT in the public and private health care sectors. ONCHIT has focused its activities in the following areas: (1) developing vocabulary, messaging, and functional standards necessary to achieve interoperability among varying HIT applications; (2) establishing criteria for certifying that HIT products meet those standards; (3) ensuring the privacy and security of electronic health information; and (4) helping facilitate the creation of prototype health information networks. The goal is to develop a national capability to exchange standards-based health care data in a secure computer environment.

Catherine M. DesRoches et al., Electronic Health Records in Ambulatory CareA National Survey of Physicians, New England Journal of Medicine, 2008, vol. 359, no. 1, pp. 50-60. 2 Interoperability refers to the ability of IT systems to share and use electronic information. Sharing clinical data across different HIT applications depends on the use of a standardized format for communicating the information electronically.



 
  

Second, the HITECH Act through a number of mechanisms provides financial incentives for HIT use among health care practitioners. It establishes several grant programs to provide funding for investing in HIT infrastructure, purchasing certified EHRs, training, and the dissemination of best practices. It also authorizes grants to states for low-interest loans to help providers finance HIT. Beginning in 2011, the legislation provides Medicare incentive payments to encourage doctors and hospitals to adopt and use certified EHRs. Those incentive payments are phased out over time and replaced by financial penalties for physicians and hospitals that are not using certified EHRs. In addition to the Medicare incentives, the legislation authorizes a 100% federal match for payments to certain qualifying Medicaid providers for the acquisition and use of certified EHR technology. Finally, the HITECH Act includes a series of privacy and security provisions that amend and expand the current HIPAA requirements. Among other things, the legislation strengthens enforcement of the HIPAA privacy rule and creates a right to be notified in the event of a breach of identifiable health information. The Congressional Budget Office (CBO) estimates that the HITECH Act payment incentives (and penalties) will increase spending for the Medicare and Medicaid programs by a total of $32.7 billion over the 2009-2019 period. CBO anticipates, however, that widespread adoption of interoperable EHRs will reduce total spending on health care by decreasing the number of duplicate and inappropriate tests and procedures, reducing paperwork and administrative overhead, and eliminating medical errors. Over the 2009-2019 period, it estimates that the HITECH Act will save the Medicare and Medicaid programs a total of $12.5 billion. When savings to the Federal Employees Health Benefits program and CMSs administrative costs are factored in, CBO estimates overall that the HITECT Act will increase direct federal spending by $20.8 million.3 Under current law, CBO predicts that about 45% of hospitals and 65% of physicians will have adopted HIT by 2019. CBO estimates that the incentive mechanisms in the HITECH Act will boost those adoption rates to about 70% for hospitals and about 90% for physicians. This report provides a summary and explanation of the provisions in the HITECH Act. In order to provide some context for that discussion, the report first gives an overview of prior actions taken by Congress and the Administrations to promote HIT, and briefly describes efforts by the 109th and 110th Congresses to enact comprehensive HIT legislation. The report will continue to be updated to reflect administrative actions related to the implementation of the HITECH Act.




     

Congress took an important first step towards promoting HIT when it enacted the Health Insurance Portability and Accountability Act of 1996 (HIPAA; P.L. 104-191). HIPAA imposed new federal requirements on health insurance plans offered by public and private employers,
3

The CBO cost estimate for the H.R. 1 conference agreement is at http://www.cbo.gov/ftpdocs/99xx/doc9989/hr1conference.pdf.



 
  

guaranteeing the availability and renewability of health insurance coverage for certain employees and individuals, and limited the use of preexisting condition restrictions. But while HIPAA was primarily concerned with giving consumers greater access to health insurance, the legislation also contained a section, subtitled Administrative Simplification, that included provisions to promote more standardization and efficiency in the health care industry and safeguard personal health information. Under HIPAA Administrative Simplification, the HHS Secretary was required to develop standards to support the growth of electronic record keeping and claims processing in the health care system and to safeguard the privacy of patient records. The standards apply to health care providers (who transmit any health information in electronic form in connection with a HIPAA-specified transaction), heath plans, and health care clearinghouses.

 
HIPAA instructed the Secretary to issue electronic format and data standards for nine routine administrative and financial transactions between health care providers and health plan/payers. Those transactions include claims and encounter information, payment and remittance advice, and claims status inquiry and response. The electronic transactions standards include several Accredited Standards Committee X12 (ASC X12) standards, as well as a number of code sets (e.g., International Classification of Diseases, 9th Edition, Clinical Modification, or ICD-9CM) used to identify specific diagnoses and clinical procedures that pertain to a patient encounter. HIPAA does not mandate that providers submit transactions electronically, though health plans/payers increasingly require it. However, if a health care provider chooses to submit one or more of the HIPAA-specified transactions electronically, then he or she must comply with the standard for that transaction. In 2001, Congress enacted the Administrative Simplification Compliance (P.L. 107-105), which, among other things, requires Medicare providers to submit claims electronically.



HIPAA further required the Secretary to issue national identification numbers for health care providers, health plans, employers, and individuals (i.e., patients) for use in standard transactions. Unique identifiers for providers and employers have been adopted, while the health plan identifier is still under review. The requirement that HHS develop a unique patient identifier has proven too controversial because of privacy concerns and is on hold. Beginning in FY1999, Congress each year has included language in the annual appropriations bill for the Departments of Labor, HHS, and Education prohibiting the use of funds for the development of a unique individual identifier.

 
HIPAAs Administrative Simplification provisions also instructed the Secretary to issue security standards to safeguard individually identifiable health information in electronic form against unauthorized access, use, and disclosure. The security rule (45 CFR Parts 160, 164) specifies a series of administrative, technical, and physical security procedures for providers and plans to use to ensure the confidentiality of electronic health information. Administrative safeguards include such functions as assigning or delegating security responsibilities to employees, as well as security training requirements. Physical safeguards are intended to protect electronic systems and data from threats, environmental hazards, and unauthorized access. They include restricting access to computers and off-site backups. Technical safeguards are primarily IT functions used to



 
  

protect and control access to data. They include using authentication and password controls, and encrypting data for storage and transmission. The HIPAA security standards are flexible and scalable, allowing covered entities (i.e., health plans, health care providers, and health care clearinghouses) to take into account their size, capabilities, and the costs of specific security measures. The standards are also technology neutral. They do not prescribe the use of specific technologies, so that covered entities will not be bound by particular systems and/or software.

 
Finally, HIPAA set a three-year deadline for Congress to enact health information privacy legislation. If, as turned out to be the case, lawmakers were unable to pass such legislation before the deadline, the HHS Secretary was instructed to promulgate regulations containing standards to protect the privacy of individually identifiable health information. The HIPAA privacy rule (45 CFR Parts 160, 164) established several individual privacy rights with respect to such protected health information (PHI). First, it established a right of access. Individuals have the right to see and obtain a copy of their own PHI in the form or format they request, provided the information is readily producible in such form or format. If not, then the information must be provided in hard copy or such form or format as agreed to by the covered entity and the individual. The covered entity can impose reasonable, cost-based fees for providing the information. Second, the privacy rule gives individuals the right to amend or supplement their own PHI. Third, individuals have the right to request that a covered entity restrict the use and disclosure of their PHI for the purposes of treatment, payment, or other routine health care operations. However, the covered entity is not required to agree to such a restriction unless it has entered into an agreement to restrict, in which case it must abide by the agreement. Finally, individuals have the right to an accounting of disclosures of their PHI by a covered entity during the previous six years, with certain exceptions. For example, a covered entity is not required to provide an accounting of disclosures that have been made to carry out treatment, payment, and health care operations. In addition to patient privacy rights, the HIPAA privacy rule placed certain limitations on when and how covered entities may use and disclose PHI. Generally, health plans and health care providers may use and disclose health information for the purpose of treatment, payment, and health care operations without the individuals authorization and with few restrictions. In certain other circumstances (e.g., disclosures to family members and friends), the rule requires plans and providers to give the individual the opportunity to object to the disclosure. The rule also permits the use and disclosure of health information without the individuals permission for various specified activities (e.g., public health oversight, law enforcement) that are not directly connected to the treatment of the individual. For all uses and disclosures of health information that are not otherwise required or permitted by the rule, plans and providers must obtain a patients written authorization. The privacy rule incorporates a minimum necessary standard. Whenever a covered entity uses or discloses PHI or requests such information from another covered entity, it must make reasonable efforts to limit the information to the minimum necessary to accomplish the intended purpose of the use or disclosure. There are a number of circumstances in which the minimum necessary standard does not apply; for example, disclosures to or requests by a health care provider for treatment purposes. The rule also permits the disclosure of a limited data set for certain specified purposes (e.g., research), pursuant to a data use agreement with the recipient. A limited data set, while not meeting the rules definition of de-identified information (to which the privacy



 
  

protections do not apply), has most direct identifiers removed and is considered by HHS to pose a low privacy risk. Under the HIPAA privacy and security standards, health plans and health care providers may share PHI with their business associates who provide a wide variety of functions for them, including legal, actuarial, accounting, data aggregation, management, administrative, accreditation, and financial services. A covered entity is permitted to disclose health information to a business associate or to allow a business associate to create or receive health information on its behalf, provided the covered entity receives satisfactory assurance in the form of a written contract that the business associate will not use or disclose the information other than as permitted or required by the contract or as required by law, and that the business associate will implement appropriate administrative, technical, and physical safeguards to prevent unauthorized uses and disclosures. Covered entities are not liable for, or required to monitor, the actions of their business associates. If a covered entity finds out about a material breach or violation of the contract by a business associate, it must take reasonable steps to remedy the situation, and, if unsuccessful, terminate the contract. If termination is not feasible, the covered entity must notify HHS. HIPAA authorized the Secretary to impose civil monetary penalties on any person failing to comply with the privacy and security standards. The maximum civil penalty is $100 per violation and up to $25,000 for all violations of an identical requirement or prohibition during a calendar year. The HHS Office of Civil Rights (OCR) is responsible for enforcing the privacy rule. For certain wrongful disclosures of PHI, OCR may refer the case to the Department of Justice for criminal prosecution. HIPAAs criminal penalties include fines of up to $250,000 and up to 10 years in prison for disclosing or obtaining health information with the intent to sell, transfer or use it for commercial advantage, personal gain, or malicious harm. Together, the HIPAA privacy and security standards have helped lay the groundwork for the development of a National Health Information Network and the widespread adoption of interoperable EHRs. Information on the HIPAA privacy rule and links to information on the other HIPAA Administrative Simplification standards is at [http://www.hhs.gov/ocr/hipaa].

 

Besides HIPAA, the other significant legislative action taken by Congress to promote HIT was the inclusion of electronic prescribing provisions in the Medicare Modernization Act of 2003 (MMA; P.L. 108-173), which created the Part D prescription drug benefit. The MMA established a timetable for the Centers for Medicare and Medicaid Services (CMS) to develop e-prescribing standards, which provide for the transmittal of such information as eligibility and benefits (including formulary drugs), information on the drug being prescribed and other drugs listed in the patients medication history (including drug-drug interactions), and information on the availability of lower-cost, therapeutically appropriate alternative drugs. CMS issued a set of foundation standards in 2005, then piloted and tested additional standards in 2006. The final Medicare e-prescribing standards, which become effective on April 1, 2009, apply to all Part D sponsors, as well as to prescribers and dispensers that electronically transmit prescriptions and prescription-related information about Part D drugs prescribed for Part D eligible individuals. The MMA did not require Part D drug prescribers and dispensers to e-prescribe. Under its provisions, only those who choose to e-prescribe must comply with the new standards. However, the recently enacted Medicare Improvement for Patients and Providers Act of 2008 (MIPPA; P.L. 110-275) includes an e-prescribing mandate and authorizes incentive bonus payment for e-prescribers



 
  

between 2009 and 2013. Beginning in 2012, payments would be reduced for those who fail to eprescribe. Information on the CMS e-prescribing standards is at [http://www.cms.hhs.gov/ EPrescribing].

  
The MMA also instructed the Secretary to establish a safe harbor from penalties under the antikickback statute (42 U.S.C. 1320a-7b) and an exception to the Medicare physician self-referral (Stark) law (42 U.S.C. 1395nn) for the provision of HIT and training services used in eprescribing. The anti-kickback statute prohibits an individual or entity from knowingly or willfully offering or accepting remuneration of any kind to induce a patient referral for, or purchase of, an item or service covered by any federal health care program. The Stark law prohibits physicians from referring patients to any entity for certain health services if the physician (or an immediate family member) has a financial relationship with the entity, and prohibits entities from billing for any services resulting from such referrals, unless an exception applies. Both statutes, which are intended to fight fraud and abuse, are seen as impediments to the dissemination of HIT among health care entities. In 2006, the Secretary announced final regulations creating new safe harbors and Stark exceptions for certain arrangements involving the donation of electronic prescribing and EHR technologies and training services.4 That would allow, for example, a hospital to provide such technologies and services to its medical staff, and Medicare Advantage plans to provide such technologies and services to pharmacies and prescribing health care providers.



 

CMS is administering a number of additional programs to promote HIT adoption. The MMA mandated a three-year pay-for-performance demonstration in four states to encourage physicians to adopt and use HIT to improve the treatment of chronically ill Medicare patients. Physicians participating in the Medicare Care Management Performance (MCMP) demonstration receive bonus payments for reporting clinical quality data and meeting clinical performance standards for treating patients with certain chronic conditions. They are eligible for an additional incentive payment for using a certified EHR and reporting the clinical performance data electronically. CMS has developed a second demonstration to promote EHR adoption using its Medicare waiver authority. The five-year Medicare EHR demonstration is intended to build on the foundation created by the MCMP program. It will provide financial incentives to as many as 1,200 small- to medium-sized physician practices in 12 communities across the country for using certified EHRs to improve quality, as measured by their performance on specific clinical quality measures. Additional bonus payments will be made based on the number of EHR functionalities a physician group has incorporated into its practice.

U.S. Dept. of Health and Human Services, Office of Inspector General, Medicare and State Health Programs: Fraud and Abuse; Safe Harbors for Certain Electronic Prescribing and Electronic Health Records Arrangements Under the Anti-Kickback Statute, 71 Federal Register 45110, Aug. 8, 2006. U.S. Dept. of Health and Human Services, Centers for Medicare and Medicaid Services, Medicare Program: Physicians Referrals to Health Care Entities With Which They Have Financial Relationships; Exceptions for Certain Electronic Prescribing and Electronic Health Records Arrangements, 71 Federal Register 45140, Aug. 8, 2006.



 
  

The Tax Relief and Health Care Act of 2006 (P.L. 109-432) established a voluntary physician quality reporting system, including an incentive payment for Medicare providers who report data on quality measures. The Medicare Physician Quality Reporting Initiative (PQRI) was expanded by the Medicare, Medicaid, and SCHIP Extension Act of 2007 (P.L. 110-173) and by MIPPA, which authorized the program indefinitely and increased the incentive that eligible physicians can receive for satisfactorily reporting quality measures. In 2009, eligible physicians may earn a bonus payment equivalent to 2.0 percent of their total allowed charges for covered Medicare physician fee schedule services. The PQRI quality measures include a structural measure that conveys whether a physician has and uses an EHR. The Deficit Reduction Act of 2005 (P.L. 109-171) authorized Medicaid Transformation Grants to states totaling $150 million over two years. The purpose of the grants is to support adoption of innovative methods to improve effectiveness and efficiency in providing medical assistance under Medicaid. In 2007, CMS awarded Medicaid Transformation Grants to 33 states, the District of Columbia, and Puerto Rico. Most of the funds are being used for HIT-related initiatives.

 
 
On April 27, 2004, President Bush announced a commitment to the promotion of HIT by calling for the widespread adoption of interoperable EHRs within 10 years. That same day he signed Executive Order 13335 creating ONCHIT to develop, maintain, and direct a strategic plan to guide the nationwide implementation of HIT in the public and private health care sectors. Within three months, ONCHIT published a strategic framework in which it outlined four major goals for HIT: (1) informing clinical practice by accelerating the use of EHRs; (2) interconnecting clinicians allowing them to exchange health information in a secure environment; (3) personalizing health care by enabling consumers to participate more actively in their own care; and (4) improving population health through improved public health surveillance and by accelerating research and its translation into clinical practice. In fall 2004, ONCHIT solicited public input on a series of questions on whether and how a National Health Information Network should be developed. The questions addressed such topics as organization and business framework, legal and regulatory issues, management and operational considerations, interoperability standards, and privacy and security. Based on the detailed and coordinated responses that it received from a broad array of stakeholders in the health care sector, ONCHIT has undertaken a series of activities to address several important challenges to the nationwide implementation of a HIT infrastructure. In 2005, the Secretary created the American Health Information Community (AHIC), a publicprivate advisory body, to make recommendations to the Secretary on how to accelerate the development and adoption of interoperable HIT using a market-driven approach. AHIC and its workgroups have proven to be extremely important in creating a forum to seek input and guidance from a broad range of stakeholders on key HIT issues and policy implications. The AHIC charter required it to provide the Secretary with recommendations to create a successor entity based in the private sector. AHIC Successor, Inc. was established in July 2008 to transition AHICs accomplishments into a new public-private partnership. That partnership, the National eHealth Collaborative (NeHC), was launched on January 8, 2009.



 
  

Developing standards and a process to certify HIT products and services as meeting those standards is a key priority. ONCHIT awarded a contract to the American National Standards Institute (ANSI) to establish a public-private collaborative, known as the Healthcare Information Technology Standards Panel (HITSP), to harmonize existing HIT standards and identify and establish standards to fill gaps. To date, the Secretary has recognized over 100 harmonized standards, including many that need to be used for interoperable EHRs. To ensure that these standards are incorporated into products, a second contract was awarded to the Certification Commission for Healthcare Information Technology (CCHIT), a private, nonprofit organization created by HIT industry associations, which establishes criteria for certifying products that use recognized standards. CCHIT has certified over 150 ambulatory and inpatient EHR products. In August 2006, the President issued Executive Order 13410 committing federal agencies that purchase and deliver health care to require the use of HIT that is based on interoperability standards recognized by the Secretary. The National Health Information Network (NHIN) is envisioned as a network of networks; that is, a nationwide, Internet-based architecture that interconnects state and regional health information exchanges (and other networks). It will be built on a secure platform using a shared set of standards and policies to permit interoperable health information exchange among providers, consumers, and others involved in supporting health care. To facilitate the development of the NHIN, ONCHIT awarded several contracts to develop models of how nationwide electronic health information might work. Each contractor was asked to develop a prototype architecture for the NHIN and to interconnect three communities as a demonstration of the architecture. The initial phase of the project has since been expanded and now involves health information exchanges across the country working cooperatively to identify and implement best practices for health information exchange. Ensuring the privacy and security of electronic health information is critical to the success of the NHIN and the widespread adoption of interoperable EHRs. ONCHIT has undertaken the development of a national privacy and security framework, using HIPAA as its foundation, to incorporate the needs of health care consumers and build public trust in the new e-health environment. To this end it has awarded a contract to RTI International, which in turn has subcontracted with 33 states and one territory that make up the Health Information Security and Privacy Collaboration (HISPC). HISPC is leveraging input from a broad range of public and private stakeholders in health information exchange to assess the variations in current privacy and security practices and policies. The goal is to identify both best practices and challenges, and develop consensus-based solutions for interoperable electronic health information exchange that protect the privacy and security of health information. Information on ONCHITs activities and programs is at [http://www.hhs.gov/healthit].

 
Within HHS, the Agency for Healthcare Research and Quality (AHRQ) is the principal source of federal HIT grant money. Since 2004, AHRQ has awarded $260 million to support and stimulate investment in HIT. This translates into almost 200 projects in 48 states. AHRQ-funded projects, many of which are focused on rural and underserved populations, cover a broad range of HIT tools and systems, including EHRs, personal health records (PHRs),5 e-prescribing, privacy and
5

Unlike an EHR, which is created and controlled by one or more health care providers who populate it with clinical data, a PHR is controlled by the patient. A PHR does not contain the same depth of information as an EHR, and (continued...)



 
  

security, quality measurement, and Medicaid technical assistance. In addition, AHRQ created the online National Resource Center for Health IT to disseminate research findings and best practices, facilitate expert and peer-to-peer collaboration, and foster the growth of online communities who are planning to implement HIT. Information on AHRQs HIT activities and programs is at [http://healthit.ahrq.gov].

Other federal agencies that purchase health care are also involved in efforts to further the development and broad adoption of HIT. The Department of Defense (DOD), the Department of Veterans Affairs (VA), and the Office of Personnel Management (OPM) have worked with HHS to adopt health information standards for use by all federal health agencies. As part of the Consolidated Health Informatics Initiative, more than 20 federal agencies have agreed to endorse standards that enable information to be shared among agencies and that can serve as a model for the private sector. Over the past few years, OPM has encouraged Federal Employees Health Benefits (FEHB) health benefits plans to increase their use of HIT. The VA and DOD are both extensive users of HIT. For several years, the VA has used an EHR the Veterans Health Information Systems and Technology Architecture, or VistAin providing care to U.S. military veterans. According to the VA, VistA has improved the efficiency of its health care delivery and the quality of the care it provides. DOD has developed and is in the process of implementing an EHRknown as AHLTA (Armed Forces Health Longitudinal Technology Application)for its health care system. DOD is also working with the VA to develop a way by which health information can be transmitted seamlessly and instantaneously between the two agencies.

The 109th Congress was the first to consider comprehensive HIT legislation. On November 18, 2005, the Senate, by unanimous consent, passed the bipartisan Wired for Health Care Quality Act (S. 1418, S.Rept. 109-111). On July 27, 2006, the House passed the Health Information Technology Promotion Act (H.R. 4157, H.Rept. 109-603) on a vote of 270-148. The bills, which contained several important differences, were not conferenced. Both bills included comparable provisions establishing ONCHIT, but contained competing language addressing the responsibilities and composition of AHIC and its role in the adoption of interoperability standards. Only the Senate bill addressed certification. S. 1418 also would have authorized grants for health care providers, grants for implementing regional HIT plans, and a state loan program to facilitate HIT adoption. H.R. 4157 included a single HIT grant program for integrated health care systems. Both measures would have authorized a demonstration program, but for different
(...continued) typically includes information from multiple sources, including data on insurance claims. Individuals and other authorized clinical and wellness professionals use the PHR to help guide and make health decisions and manage the patients care. Many health plans and some employers offer PHRs. Other leading IT companies, including Google and Microsoft, also offer a PHR product.

 



 
  

purposes. The House measure also included provisions that would have established an antikickback safe harbor and Stark exception for the donation of HIT and related support or training services, as well as provisions to expedite updating and modifying the HIPAA electronic transactions and codes standards. The Senate version contained no such provisions.

The Wired for Health Care Quality Act (S. 1693) was reintroduced on June 26, 2007, and ordered reported (as amended) by the Committee on Health, Education, Labor, and Pensions (HELP) on August 1, 2007 (S.Rept. 110-187). In the House, H.R. 6357, the PRO(TECH)T Act of 2008, was introduced by Representatives Dingell and Barton on June 24, 2008, and ordered reported (as amended) by the Committee on Energy and Commerce on September 11, 2008 (H.Rept. 110837). No further legislative action was taken on either measure. Like the Senate bill, H.R. 6357 would have codified ONCHIT and authorized grants and loans to promote the adoption of EHRs and the development of health information exchange networks. Unlike S. 1693, however, the House measure also included extensive privacy and security provisions to strengthen the HIPAA rules. A second House bill, H.R. 6898, the Health-e Information Technology Act of 2008, was introduced by Representative Stark on September 15, 2008, and referred to the Committees on Energy and Commerce, Science and Technology, and Ways and Means. Broadly similar to the PRO(TECH)T Act, H.R. 6898 also included Medicare incentive payments to encourage EHR use by hospitals and physicians, as well as financial penalties for providers that failed to adopt HIT.

Lawmakers incorporated the HITECH Act in the American Recovery and Reinvestment Act of 2009 (ARRA; H.R. 1, H.Rept. 111-16), the economic stimulus bill that the President signed into law on February 17, 2009 (P.L. 111-5). The HITECH Act is an amalgam of the two House bills from the 110th Congress. It contains three sets of provisions that are expected to boost HIT adoption among health care providers in the coming years. First, it codifies ONCHIT and establishes a process for the development of interoperability standards that support the nationwide electronic exchange of health information among doctors, hospitals, patients, health plans, the federal government, and other health care stakeholders. It also establishes a voluntary certification process for HIT products. The National Institute of Standards and Technology (NIST) is to provide for the testing of such products to determine if they meet national standards that allow for secure electronic information exchange. After the adoption of an initial set of standards by the end of 2009, the National Coordinator must make an EHR available at a nominal fee, unless it is determined that the needs and demands of providers are being adequately met by the marketplace. Second, the HITECH Act authorizes funding for several grant programs to support HIT infrastructure, EHR adoption, training, dissemination of best practices, telemedicine, and inclusion of HIT in clinical education. Funds also are provided to states for low-interest loans to help health care practitioners finance HIT. In addition, the legislation provides financial incentives through the Medicare and Medicaid programs to encourage doctors, hospitals, health clinics, and other entities to adopt and use certified EHRs. Medicare incentive payments are phased out over time and replaced with financial penalties for providers that are not using EHRs.



 
  

Finally, the HITECH Act expands the HIPAA privacy and security standards. Among other things, it establishes a breach notification requirement for health information that is not encrypted, strengthens enforcement of the HIPAA standards by increasing penalties for violations and provides greater resources for enforcement and oversight activities, places new restrictions on marketing activities by health plans and providers, and creates transparency by allowing patients to request an audit trail showing all disclosures of their electronic health information. The HITECH Act appears in two separate ARRA titles, each of which is described in the tables below. Table 1 provides a summary of the HITECH Act provisions in Division A, Title XIII of the economic stimulus bill. Those provisions include ONCHIT and the development and adoption of standards, the grant and loan programs, and the privacy and security requirements. Table 2 summarizes the HITECH Acts Medicare and Medicaid provisions, which are in Division B, Title IV of the stimulus bill. For each provision, as appropriate, the tables include additional information on existing federal requirements and other relevant administrative activities. Each mention of the Secretary in the tables refers to the Secretary of Health and Human Services. Note: Table 2 does not include two miscellaneous Medicare provisions added to the HITECH Act, which are unrelated to HIT.6



In addition to the mandatory funding that would become available to health care providers under the HITECH Acts Medicare and Medicaid provisions, the emergency appropriations provisions in ARRA Division A include $2 billion in discretionary funds for ONCHIT to invest in HIT architecture; provide grants to hospitals, physicians, and other health care providers; and support training programs. In addition, $85 million is appropriated to the Indian Health Service (IHS) for HIT and telehealth, to be allocated at the discretion of the IHS Director.7

Those provisions are at the end of Division B, Title IV: (i) Section 4301, Moratoria on Certain Medicare Regulations; and (ii) Section 4302, Long-Term Care Hospital Technical Corrections. 7 For more details, see CRS Report R40181, Selected Health Funding in the American Recovery and Reinvestment Act, coordinated by C. Stephen Redhead.



 
  



.srotces erac htlaeh etavirp dna cilbup eht ni TIH elbareporetni fo noitatnemelpmi ediwnoitan eht ediug ot nalp cigetarts a tcerid dna ,niatniam ,poleved ot detcurtsni saw rotanidrooC lanoitaN ehT .4002 ,72 lirpA no hsuB tnediserP yb dengis ,53331 redrO evitucexE yb detaerc saw TIHCNO

)1 traP ,A eltitbuS( noitpodA dna tnempoleveD sdradnatS :)TIHCNO( ygolonhceT noitamrofnI htlaeH rof rotanidrooC lanoitaN eht fo eciffO seitivitcA dna stnemeriuqeR tnerruC noisivorP fo yrammuS cipoT

.pihsdrawets atad dna ,ytiruces ,ycavirp no rotanidrooC lanoitaN eht esivda ot rotanidrooC lanoitaN eht fo eciffO eht fo reciffO ycavirP feihC a tnioppa )8( dna ;krowten noitamrofni htlaeh lanoitan eht rof msinahcem ecnanrevog lanoitan a hsilbatse )7( ;ecrofkrow TIH tneiciffus a hsilbatse ot dedeen secruoser eht gnidulcni ,4102 yb sRHE fo noitpoda ediwnoitan eveihca ot yllaunna dedeen secruoser eht gnitamitse troper a dna ;saera devresrednu yllacidem ni dna seitirapsid htlaeh htiw seitinummoc no TIH fo tcapmi eht fo tnemssessa na ;noitamrofni htlaeh fo egnahcxe dna esu cinortcele eht fo stsoc dna stifeneb eht no troper a ;smetsys erac htlaeh etavirp dna cilbup rojam yb noitatnemelpmi TIH morf denrael snossel no troper a ;sdradnats TIH poleved dna etaulave ot dedeen ytirohtua ro gnidnuf lanoitidda yna no troper a gnidulcni ,stroper lareves eraperp )6( ;yraterceS eht yb detpoda airetirc noitacifitrec elbacilppa htiw ecnailpmoc ni gnieb sa TIH fo noitacifitrec yratnulov eht rof smargorp ro margorp a ezingocer ro peek ,)TSIN( ygolonhceT dna sdradnatS fo etutitsnI lanoitaN eht htiw noitatlusnoc ni )5( ;erutcurtsarfni TIH ediwnoitan a etomorp ot stroffe ot detaler krow eht tuoba noitamrofni tnaveler tsop ot etisbew a etadpu dna niatniam )4( ;sgniht rehto gnoma ,ngised ygolonhcet eht ni desserdda yletairporppa era ,nerdlihc sa hcus ,sdeen euqinu htiw snoitalupop taht gnirusne rof snalp dna ,ytilauq erac htlaeh evorpmi ot TIH gnisu rof seigetarts ,noitamrofni htlaeh s'laudividni na fo egnahcxe cinortcele eht rof snoitcetorp ytiruces dna ycavirp fo noitaroprocni eht ,4102 yb setatS detinU eht ni nosrep hcae rof RHE na fo noitazilitu eht ,noitamrofni htlaeh fo esu dna egnahcxe cinortcele eht ot tcepser htiw scirtem dna ,senotselim ,sevitcejbo cificeps edulcni ot )8002 ,3 enuJ fo sa( nalP cigetartS TI htlaeH laredeF eht hsilbuper dna etadpu )3( ;tnemnrevog laredef eht dna )woleb ees( seettimmoC sdradnatS dna yciloP TIH eht gnoma nosiail a sa tca dna seicnega laredef rehto fo esoht htiw dna SHH nihtiw smargorp dna ycilop TIH etanidrooc )2( ;)woleb ees( eettimmoC sdradnatS TIH eht yb dednemmocer airetirc noitacifitrec dna ,snoitacificeps noitatnemelpmi ,sdradnats esrodne ot rehtehw enimreted dna weiver )1( :seitud gniwollof eht htiw degrahc si rotanidrooC lanoitaN ehT .sgniht rehto gnoma ,sesaesid cinorhc fo tnemeganam dna noitneverp etomorp dna ,hcraeser etatilicaf ,htlaeh cilbup evorpmi ,seitirapsid htlaeh dna stsoc erac htlaeh ecuder ,ytilauq erac htlaeh evorpmi ot redro ni ,noitamrofni fo egnahcxe dna esu cinortcele eht swolla taht erutcurtsarfni TIH lanoitan a fo tnempoleved eht etomorp ot si esoprup sTIHCNO .yraterceS eht ot yltcerid troper dna yraterceS eht yb detnioppa si rotanidrooC lanoitaN ehT .)TIHCNO( ygolonhceT noitamrofnI htlaeH rof rotanidrooC lanoitaN eht fo eciffO eht SHH nihtiw sehsilbatse tcA ehT

seituD dna esopruP :TIHCNO

ytiruceS dna ycavirP ;snaoL dna stnarG ;noitpodA dna tnempoleveD sdradnatS :tcA HCETIH .1 elbaT

IIIX eltiT ,A noisiviD :)5-111 .L.P( 9002 fo tcA tnemtsevnieR dna yrevoceR naciremA



.9002 ,8 yraunaJ no dehcnual saw ,)CHeN( evitaroballoC htlaeHe lanoitaN eht ,pihsrentrap tahT .pihsrentrap etavirp-cilbup wen a otni stnemhsilpmocca s'CIHA noitisnart ot 8002 yluJ ni dehsilbatse saw .cnI ,rosseccuS CIHA .rotces etavirp eht ni desab ytitne rosseccus a etaerc ot snoitadnemmocer htiw yraterceS eht edivorp ot ti deriuqer retrahc CIHA ehT .hcaorppa nevird -tekram a gnisu TIH elbareporetni fo noitpoda dna tnempoleved eht etarelecca ot woh no yraterceS eht ot snoitadnemmocer ekam ot ,ydob yrosivda etavirp-cilbup a ,)CIHA( ytinummoC noitamrofnI htlaeH naciremA eht detaerc yraterceS eht ,5002 nI

.eettimmoC yciloP TIH eht ot ylppa )ACAF( tcA eettimmoC yrosivdA laredeF eht fo snoisivorp ehT .snoitadnemmocer s'eettimmoC eht fo lla enilno tsop dna retsigeR laredeF eht ni hsilbup tsum yraterceS ehT .srosivda edistuo fo noitapicitrap eht erusne tsum eettimmoC ehT .snoitadnemmocer seettimmoC eht secneulfni yludnu rotces eno on taht os srotces erac htlaeh suoirav gnoma ecnalab a tneserper tsum)tcA eht ni deificeps sa( lareneG rellortpmoC eht dna ,ssergnoC ,yraterceS eht yb detnioppa srebmem eettimmoC .eettimmoC yciloP TIH eht fo snoitarepo dna tnemhsilbatse eht ni elor gnidael a ekat tsum rotanidrooC lanoitaN ehT .enicidemelet dna ,srorre lacidem ecuder ot TIH gnisu gnidulcni ,redisnoc thgim eettimmoc eht taht saera rehto sebircsed tcA ehT .snoitalupop elbarenluv rehto dna nerdlihc fo sdeen eht sserdda taht serutaef ngised dna seigolonhcet )8( dna ;)tcA ytiruceS laicoS eht fo 9081 .ceS rednu atad seitirapsid htlaeh fo noitaulave eht htiw tnetsisnoc( atad cihpargomed tneitap tcelloc ot smetsys cinortcele fo esu eht )7( ;slaudividni dezirohtuanu ot elbarehpicedni dna ,elbadaernu ,elbasunu noitamrofni redner taht seigolonhcet noitpyrcne )6( ;ytilauq erac htlaeh evorpmi ot sRHE gnisu )5( ;serusolcsid fo gnitnuocca na rof wolla taht seigolonhcet RHE )4( ;sRHE deifitrec fo noitpoda ediwnoitan )3( ;egnahcxe noitamrofni cinortcele selbane taht erutcurtsarfni TIH ediwnoitan a )2( ;noitamrofni htlaeh cinortcele fo ytiruces dna ycavirp eht tcetorp taht seigolonhcet )1( :saera thgie gniwollof eht tsael ta ni snoitadnemmocer edivorp ot deriuqer si eettimmoC ehT .sdradnats hcus fo tnempoleved eht rof ytiroirp fo redro na gnidnemmocer dna ,noitamrofni htlaeh fo esu dna egnahcxe cinortcele eht rof dedeen era sdradnats hcihw ni saera gnidnemmocer gnidulcni ,erutcurtsarfni TIH ediwnoitan a fo noitatnemelpmi eht ot gnitaler rotanidrooC lanoitaN eht ot snoitadnemmocer ycilop ekam ot eettimmoC yciloP TIH na sehsilbatse tcA ehT

eettimmoC yciloP TIH

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

cipoT



smetsyS TIH ecruoS nepO

ygolonhceT RHE laredeF seititnE etavirP yb sdradnatS fo esU

airetirC noitacifitreC dna ,snoitacificepS noitatnemelpmI ,sdradnatS fo noitpodA

.stcudorp RHE tneitapni dna yrotalubma 051 revo deifitrec sah TIHCC .sdradnats dezingocer esu taht stcudorp gniyfitrec rof airetirc sehsilbatse hcihw ,snoitaicossa yrtsudni TIH yb detaerc noitazinagro tiforpnon ,etavirp a ,)TIHCC( ygolonhceT noitamrofnI erachtlaeH rof noissimmoC noitacifitreC eht ot dedrawa saw tcartnoc dnoces a ,stcudorp otni detaroprocni era sdradnats eseht taht erusne oT .sRHE elbareporetni rof ynam gnidulcni ,sdradnats 001 revo dezingocer sah yraterceS eht ,etad oT .spag llif ot sdradnats hsilbatse dna yfitnedi dna sdradnats TIH gnitsixe ezinomrah ot ,)PSTIH( lenaP sdradnatS ygolonhceT noitamrofnI erachtlaeH eht sa nwonk ,evitaroballoc etavirp-cilbup a hsilbatse ot )ISNA( etutitsnI sdradnatS lanoitaN naciremA eht ot tcartnoc a dedrawa TIHCNO

.derusninu eht ot erac fo tnuoma tnacifingis a edivorp taht esoht dna sredivorp larur dna rellams gnidulcni ,sredivorp ten ytefas laredef ot smetsys TIH ecruos nepo fo tsoc dna ytilibaliava eht no ,0102 ,1 rebotcO yb ssergnoC ot troper dna yduts ot ,seicnega laredef rehto htiw noitatlusnoc ni ,yraterceS eht seriuqer tcA ehT .sredivorp larur dna rellams fo secnatsmucric laicnanif eht tnuocca otni gnikat ,ygolonhcet siht esahcrup ot eef lanimon a sredivorp egrahc yam rotanidrooC lanoitaN ehT .ecalptekram eht hguorht tem yletauqeda dna yllaitnatsbus gnieb era sredivorp fo sdnamed dna sdeen eht taht senimreted yraterceS eht sselnu elbaliava ygolonhcet hcus ekam ot dna ygolonhcet RHE deifilauq fo gnitadpu enituor dna tnempoleved eht troppus ot rotanidrooC lanoitaN eht seriuqer tcA ehT .tcA eht rednu depoleved noitacificeps noitatnemelpmi ro dradnats a tpoda ot ytitne etavirp a )eriuqer ot ytirohtua wen ycnega laredef a sevig ro( seriuqer tcA eht ni gnihtoN .elur lanif miretni na sa deussi eb yam sdradnats laitini ehT .9002 ,13 rebmeceD yb sdradnats fo tes laitini na ,gnikamelur tnemmoc-dna-eciton hguorht ,tpoda tsum yraterceS ehT .eettimmoC sdradnatS TIH eht dna rotanidrooC lanoitaN eht ot gnitirw ni deyevnoc eb ot si tpoda ot ton noisiced a saerehw ,gnikamelur tnemmoc-dna-eciton hguorht dehsilpmocca eb ot si noitpodA .serusaem hcus fo noitpoda esoporp ot ton ro rehtehw enimreted ot ,airetirc noitacifitrec ro ,snoitacificeps noitatnemelpmi ,sdradnats TIH rof noitadnemmocer a rotanidrooC lanoitaN eht morf gniviecer fo syad 09 nihtiw ,yraterceS eht seriuqer tcA ehT .eettimmoC sdradnatS TIH eht ot ylppa )ACAF( tcA eettimmoC yrosivdA laredeF eht fo snoisivorp ehT .snoitadnemmocer s'eettimmoC eht fo lla enilno tsop dna retsigeR laredeF eht ni hsilbup tsum yraterceS ehT .srosivda edistuo fo noitapicitrap eht erusne tsum eettimmoC ehT .seitivitca sti gnitcudnoc rof serudecorp gnipoleved ni ecnalab ralimis a erusne tsum eettimmoC ehT .snoitadnemmocer seettimmoC eht secneulfni yludnu rotces eno on taht os srotces erac htlaeh suoirav gnoma ecnalab a tneserper tsum srebmem eettimmoC .eettimmoC sdradnatS TIH eht fo snoitarepo dna tnemhsilbatse eht ni elor gnidael a ekat tsum rotanidrooC lanoitaN ehT .eludehcs siht no tnemmoc cilbup rof wolla ot ssecorp a poleved dna sgniteem cilbup nepo tcudnoc ot si eettimmoC eht ,noitidda nI .eettimmoC yciloP TIH eht yb depoleved snoitadnemmocer ycilop eht gnissessa rof )yllaunna detadpu eb ot( eludehcs a eniltuo ot si eettimmoC sdradnatS TIH eht ,tnemtcane retfa syad 09 naht retal toN .sdradnats fo noitingocer dna ,noitazinomrah ,tnempoleved eht no tupni edivorp ot sredlohekats fo egnar daorb a fo noitapicitrap eht rof murof a sa gnivres dna ,sdradnats fo gnitset tolip dna ,noitazinomrah ,tnempoleved eht edulcni eettimmoC sdradnatS TIH eht fo seituD .noitamrofni htlaeh fo egnahcxe cinortcele eht rof airetirc noitacifitrec dna ,snoitacificeps noitatnemelpmi ,sdradnats rotanidrooC lanoitaN eht ot dnemmocer ot eettimmoC sdradnatS TIH na sehsilbatse tcA ehT

eettimmoC sdradnatS TIH

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

cipoT



.seitivitca noitacifitrec sTIHCC htiw dna ssecorp noitazinomrah sdradnats PSTIH eht htiw gnitsissa si TSIN .sdradnats TIH gnitset no TSIN htiw gnikrow si TIHCNO

.seirotarobal gnitset detidercca yb margorp gnitset yratnulov a fo tnemhsilbatse eht troppus sa llew sa ,sdradnats TIH tset ot ,eettimmoC sdradnatS TIH eht htiw noitanidrooc ni ,TSIN seriuqer tcA ehT

)B eltitbuS( ygolonhceT noitamrofnI htlaeH fo gnitseT

gnitseT TSIN

stropeR srotcartnoC laredeF

.yraterceS eht yb dezingocer sdradnats ytilibareporetni no desab si taht TIH fo esu eht eriuqer ot erac htlaeh reviled dna esahcrup taht seicnega laredef gnittimmoc 01431 redrO evitucexE deussi hsuB tnediserP ,6002 tsuguA nI

.sraey owt nihtiw ssergnoC ot troper ot dna ,ssecorp gniga eht tuohguorht srevigerac rieht dna seitilibasid htiw slaudividni ,sroines tsissa ot ygolonhcet secivres gniga wen fo esu laitnetop eht ot gnitaler srettam fo yduts a tcudnoc ot )3( dna ;sraey owt nihtiw ssergnoC ot troper ot dna ,scinilc eerf dna scinilc htlaeh larur ,sretnec htlaeh deifilauq yllaredef ni ytilauq erac htlaeh gnivorpmi rof sevitnecni tnemesrubmier tneiciffe etaerc ot sdohtem senimaxe taht yduts a tcudnoc ot )2( ;noitamrofni htlaeh fo egnahcxe cinortcele eht rof metsys ediwnoitan a fo noitpoda eht etatilicaf ot stroffe no ssergnoC ot troper ot ,retfaereht yllaunna dna sraey owt nihtiw )1( :yraterceS eht seriuqer tcA ehT .tcA siht rednu yraterceS eht yb detpoda sdradnats eht teem taht stcudorp dna smetsys TIH esu ot tnemnrevog laredef eht htiw tcartnoc taht sredivorp dna sreyap erac htlaeh seriuqer tcA ehT .noitpoda rieht fo sraey eerht nihtiw sdradnats hcus htiw tnetsisnoc era noitamrofni htlaeh fo noissimbus dna noitcelloc eht gnivlovni seitivitca laredef taht erusne tsum tnediserP ehT .tcA siht rednu yraterceS eht yb detpoda sdradnats eht teem taht stcudorp dna smetsys TIH esu ot noitamrofni htlaeh fo egnahcxe cinortcele eht rof smetsys TIH edargpu ro ,eriuqca ,tnemelpmi taht seicnega laredef seriuqer tcA ehT .wal ytiruces dna ycavirp AAPIH rednu yraterceS eht fo seitirohtua eht no tceffe yna gnivah sa deurtsnoc eb ton yam snoisivorp sti taht seificeps tcA ehT .eettimmoC sdradnatS TIH eht ro eettimmoC yciloP TIH eht sa ti ezingocer ot yraterceS eht timrep dluow taht rennam a ni eltitbus siht fo snoisivorp eht htiw tnetsisnoc eb ot snoitcnuf rehto yna dna ,pihsrebmem ,seitud ,retrahc sti gniyfidom morf ,evitaroballoC htlaeHe lanoitaN eht sa ssenisub gniod ,.cnI ,rosseccuS CIHA stibihorp tcA eht ni gnihtoN .tcA eht yb dehsilbatse TIHCNO wen eht ot derrefsnart era TIHCNO gnitsixe eht fo snoitca evitartsinimda dna ,seitilibail ,stessa ,lennosrep ,snoitcnuf lla ,tnemtcane nopU

)2 traP ,A eltitbuS( sdradnatS ygolonhceT noitamrofnI htlaeH detpodA fo esU dna noitacilppA

seicnegA laredeF

seluR ytiruceS dna ycavirP AAPIH ot snoitaleR

snoitisnarT

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

cipoT



.margorp eht rednu sretnec ot elbaliava eb ot detcepxe slevel troppus mumixam eht dna ,stnacilppa eht yb dewollof eb ot serudecorp ,margorp eht fo noitanalpxe deliated a retsigeR laredeF eht ni hsilbup tsum yraterceS eht ,tnemtcane fo syad 09 nihtiW .yllainneib detaulave eb tsum troppus laicnanif seviecer taht retnec hcaE .serutidnepxe ecnanetniam dna gnitarepo launna dna latipac rieht fo %05 ot pu revoc ot ,gnidnuf fo sraey ruof ot pu eviecer ot dettimrep era sretnec lanoigeR .slaudividni devresrednu yllacidem dna ,derusnirednu ,derusninu eht evres taht seititne dna ,secitcarp puorg llams dna laudividni ,sretnec htlaeh ytinummoc ,slatipsoh ssecca lacitirc dna ,tiforpnon ,cilbup gnitsissa ot nevig eb lliw ytiroirP .noiger eht ni sredivorp ot ecnatsissa edivorp ot ,snoitazinagro tiforpnon htiw detailiffa ,sretneC noisnetxE lanoigeR TIH fo noitarepo dna noitaerc eht dnuf tsum yraterceS eht ,yllaniF .seitinummoc devresrednu yllacidem ni TIH gnisu tuoba gninrael dna ,skrowten noitamrofni htlaeh ot ecnatsissa lacinhcet gnidivorp ,ecneirepxe dna egdelwonk gnignahcxe rof murof a sa evres ot retneC hcraeseR TIH na etaerc tsum osla yraterceS ehT .ygolonhcet RHE deifitrec gnisu dna gnitpoda ni sredivorp tsissa ot margorp noisnetxe TIH na hsilbatse ot ,TSIN htiw noitatlusnoc ni ,rotanidrooC lanoitaN eht seriuqer tcA ehT .ytilauq erac htlaeh evorpmi ot ,dnabdaorb gnidulcni ,secivres snoitacinummocelet rof sredivorp erac htlaeh larur ot noillim 714$ dedivorp sah margorP eraC htlaeH laruR ecivreS lasrevinU snoissimmoC noitacinummoC laredeF eht ,noitidda nI .ecnatsissa lacinhcet diacideM dna ,tnemerusaem ytilauq ,ytiruces dna ycavirp ,gnibircserp -e ,sRHP ,sRHE gnidulcni smetsys dna sloot TIH fo egnar daorb a revoc ,snoitalupop devresrednu dna larur no desucof era hcihw fo ynam ,stcejorp dednuf -QRHA .TIH ni tnemtsevni etalumits dna troppus ot noillim 062$ dedrawa sah QRHA ,4002 ecniS .yraterceS eht yb detpoda sdradnats elbacilppa steem taht TIH eriuqca ot desu era sdnuf taht ,elbacitcarp tnetxe tsetaerg eht ot ,erusne tsum yraterceS ehT .stnemtraped htlaeh cilbup yb esu TIH )7( dna ;noitamrofni htlaeh gnitcetorp rof secitcarp tseb dna seigolonhcet )6( ;seirotisoper atad lacinilc elbareporetni )5( ;enicidemelet )4( ;yreviled erac htlaeh otni TIH etargetni ot secitcarp tseb no noitamrofni fo noitanimessid dna gniniart )3( ;diacideM dna eracideM rednu stnemyap evitnecni TIH rof elbigile ton sredivorp rof sRHE )2( ;noitamrofni fo egnahcxe cinortcele eruces eht troppus ot erutcetihcra TIH )1( :gniwollof eht troppus ot esitrepxe tnaveler htiw seicnega SHH tnereffid eht hguorht sdnuf tsevni tsum yraterceS ehT .noitamrofni htlaeh cinortcele fo egnahcxe dna esu ediwnoitan eht etomorp ot sa os TIH ni tsevni ot yraterceS eht stcurtsni tcA ehT .TIH ot detaler smargorp tnempoleved dna hcraeser laredef edulcni tsum margorP gnitupmoC ecnamrofreP-hgiH lanoitaN ehT .TIH esu dna poleved ot sa llew sa ,erutcurtsarfni erac htlaeh lanoitan elbareporetni ylluf a fo tnempoleved eht ot sehcaorppa evitavonni etareneg ot si sretneC eht fo esoprup ehT .noitargetnI esirpretnE noitamrofnI eraC htlaeH rof sretneC yranilpicsiditlum hsilbatse ot )aitrosnoc hcraeser ro( seitisrevinu ot stnarg evititepmoc drawa ot ,seicnega laredef rehto dna )FSN( noitadnuoF ecneicS lanoitaN eht htiw noitatlusnoc ni ,TSIN seriuqer tcA ehT

ecnatsissA noitatnemelpmI TIH

)C eltitbuS( smargorP noitartsnomeD dna ,naoL ,tnarG

stnarG erutcurtsarfnI TIH

smargorP tnempoleveD dna hcraeseR

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

cipoT



stnarG noitacudE scitamrofnI lacideM

noitartsnomeD noitacudE lacinilC

.smargorp scitamrofni lacidem dnapxe ro hsilbatse ot seitisrevinu ot ecnatsissa laicnanif edivorp ot ,FSN eht htiw noitatlusnoc ni ,yraterceS eht seriuqer tcA ehT .snoitadnemmocer htiw ,snoitartsnomed eht no seettimmoC etaneS dna esuoH detangised ot troper tsum yllaunna yraterceS ehT .tnemeriuqer gnirahs-tsoc taht eviaw ot ytirohtua eht sah yraterceS eht hguoht ,dedivorp si ecnatsissa hcihw rof ytivitca yna fo stsoc eht fo %05 naht erom revoc ton yam tnarg A .nalp cigetarts a timbus tsum seetnarg ,elbigile eb oT .slanoisseforp erac htlaeh fo noitacude lacinilc eht otni TIH etargetni ot smargorp noitacude htlaeh etaudarg rehto ot dna ,sloohcs gnisrun dna ,latned ,lacidem ot stnarg evititepmoc gnidrawa rof margorp noitartsnomed a etaerc ot yraterceS eht sezirohtua tcA ehT .0102 ,1 yraunaJ erofeb dettimrep ton era sdrawA .seetnarg yb dettimbus stroper launna eht gnizirammus ssergnoC ot troper a edivorp tsum rotanidrooC lanoitaN eht ,raey hcaE .sraey 01 ot pu fo doirep a revo elbayaper era snaoL .gnidnuf laredef fo 5$ yreve rof 1$ tsael ta fo sdnuf gnihctam edivorp )3( dna ;erac fo ytilauq eht evorpmi ot noitamrofni htlaeh fo egnahcxe cinortcele eht rof naol eht yb detroppus ygolonhcet RHE deifitrec eht esu dna serusaem ytilauq no stroper deriuqer timbus taht sredivorp erac htlaeh ot nevig eb ylno lliw snaol taht secnarussa gnidivorp dna sdnuf eht fo sesu dednetni eht gnibircsed ,yllaunna detadpu ,nalp cigetarts a timbus )2( ;dnuf naol TIH deifilauq a hsilbatse )1( :tsum seetnarg ,elbigile eb oT .noitamrofni htlaeh fo egnahcxe cinortcele eruces eht evorpmi dna ,ygolonhcet hcus fo esu eht ni lennosrep niart ,ygolonhcet RHE deifitrec edargpu dna esahcrup ot sredivorp erac htlaeh rof smargorp naol hsilbatse ot sebirt naidnI ro setats ot stnarg evititepmoc drawa ot rotanidrooC lanoitaN eht sezirohtua tcA ehT .raey lacsif tneuqesbus hcae dna 3102YF ni sdnuf laredef fo 3$ hcae rof 1$ tsael ta dna ,2102YF ni sdnuf laredef fo 7$ hcae rof 1$ tsael ta ,1102YF ni sdnuf laredef fo 01$ hcae rof 1$ tsael ta fo hctam a eriuqer stnarG .egnahcxe noitamrofni cinortcele eruces dna evitceffe tsom eht dna ,stsoc ni esaerced ,ytilauq erac htlaeh ni tnemevorpmi tsetaerg eht ezilaer ot sa rennam a hcus ni sdrawa fo dnuor tneuqesbus eht ni noitaulave hcae morf denrael snossel eht tnemelpmi dna noitces siht rednu ytivitca tnarg eht etaulave tsum yllaunna yraterceS ehT .snoitacificeps noitatnemelpmi dna sdradnats dezingocer yllanoitan ot gnidrocca egnahcxe noitamrofni htlaeh cinortcele dnapxe dna etatilicaf ot tuo deirrac eb ot seitivitca eht gnibircsed nalp a timbus tsum ytitne detangised-etats deifilauq ro etats a ,tnarg noitatnemelpmi na eviecer ot redro nI .seicilop tseretni-fo-tcilfnoc dna noitanimircsidnon tpoda dna draob gninrevog sti no noitatneserper redlohekats daorb htiw noitazinagro tiforpnon a eb tsum ytitne na ,ytitne detangised-etats a sa yfilauq oT .segnahcxe noitamrofni htlaeh cinortcele dnapxe dna etatilicaf ot seititne detangised-etats deifilauq ro setats ot stnarg noitatnemelpmi dna gninnalp drawa ot dezirohtua si rotanidrooC lanoitaN ehT

smargorP naoL etatS

stnarG noitatnemelpmI dna gninnalP etatS

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

cipoT



.SHH yfiton tsum ytitne derevoc eht ,elbisaef ton si noitanimret fI .tcartnoc eht etanimret ,lufsseccusnu fi ,dna ,noitautis eht ydemer ot spets elbanosaer ekat tsum ti ,etaicossa ssenisub a yb tcartnoc eht fo noitaloiv ro hcaerb lairetam a tuoba tuo sdnif ytitne derevoc a fI .setaicossa ssenisub rieht fo snoitca eht ,rotinom ot deriuqer ro ,rof elbail ton era seititne derevoc ,dessucsid ylsuoiverp sA .seititne derevoc ot ylppa seitlanep lanimirc dna livic AAPIH ehT

.noitamrofni htlaeh cinortcele gnitcetorp rof ,eettimmoC yciloP TIH eht yb dednemmocer sdradnats noitpyrcne fo esu eht gnidulcni ,sdraugefas lacinhcet etairporppa dna evitceffe tsom eht no ecnadiug launna eussi ot ,sredlohekats yrtsudni htiw noitatlusnoc ni ,yraterceS eht seriuqer osla tI .seititne derevoc ot ylppa yeht sa rennam emas eht ni setaicossa ssenisub ot sdradnats esoht gnitaloiv rof seitlanep lanimirc dna livic eht dna sdradnats ytiruces AAPIH eht seilppa tcA ehT .noitazirohtua tuohtiw desolcsid ro ,desu ,deriuqca rehtruf ton si erusolcsid eht fo tluser a sa deviecer noitamrofni eht dedivorp ,IHP ssecca ot dezirohtua esiwrehto si ohw laudividni na morf erusolcsid tnetrevdani yna )2( dna ,desolcsid ro ,desu ,deriuqca rehtruf ton si noitamrofni eht dedivorp ,ssenisub fo ytitne derevoc a fo ytirohtua eht rednu dna htiaf doog ni gnitca laudividni na yb IHP fo esu ro ,ssecca ,noitisiuqca lanoitnetninu yna )1( edulcni ton seod tub ,noitamrofni hcus fo ycavirp dna ytiruces eht sesimorpmoc hcihw IHP fo erusolcsid ro ,esu ,ssecca ,noitisiuqca dezirohtuanu eht snaem hcaerb mret ehT .sdrocer htlaeh lanosrep fo rodnev dna ,esu ,tnemtaert ,etats ,ytiruces ,yraterceS ,)IHP( noitamrofni htlaeh detcetorp ,)RHP( drocer htlaeh lanosrep ,tnemyap ,rotanidrooC lanoitaN ,nalp htlaeh ,redivorp erac htlaeh ,snoitarepo erac htlaeh ,)RHE( drocer htlaeh cinortcele ,esolcsid ,ytitne derevoc ,etaicossa ssenisub ,hcaerb :sdradnats noitacifilpmiS evitartsinimdA AAPIH eht ni snoitinifed ot ecnerefer yb sesac tsom ni ,smret ytiruces dna ycavirp gniwollof eht senifed tcA ehT

setaicossA ssenisuB ot seitlaneP dna snoisivorP ytiruceS fo noitacilppA

)D eltitbuS( sdradnatS ytiruceS dna ycavirP AAPIH

snoitinifeD

.smargorp snoitartsnomed dna ,naol ,tnarg eht dnuf ot 3102YF hguorht 9002YF fo hcae rof yrassecen eb yam sa smus hcus fo noitairporppa eht sezirohtua tcA ehT .erac htlaeh fo ycneiciffe dna ytilauq eht ni tnemevorpmi tsetaerg eht ezilaer ot sa rennam a hcus ni sdrawa fo dnuor tneuqesbus eht ni noitaulave hcae morf denrael snossel eht tnemelpmi dna eltitbus siht rednu seitivitca tnarg eht etaulave tsum yllaunna rotanidrooC lanoitaN ehT .ytefas dna ytilauq erac htlaeh no tcejorp eht fo tcapmi eht dna dedivorp erew sdnuf eht hcihw rof seitivitca eht fo ssenevitceffe eht no troper ot ,drawa na gniviecer fo raey eno nihtiw ,seetnarg eriuqer yam yraterceS ehT

snoitairporppA fo noitazirohtuA

noitaulavE dna stropeR

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

cipoT



.serudecorp dna seicilop sti fo noitatnemelpmi dna tnempoleved eht rof laiciffo ycavirp a etangised ot ytitne derevoc hcae seriuqer elur ycavirp ehT

noitacudE ycavirP

.tcartnoc eht yb rof dedivorp ton si taht IHP fo erusolcsid ro esu yna ro tnedicni ytiruces yna fo erawa emoceb yeht fi seititne derevoc ot troper ot setaicossa ssenisub gniriuqer noisivorp a edulcni tsum stcartnoc etaicossa ssenisub ,revewoH .IHP fo ytirgetni ro ,ytiruces ,ycavirp eht fo hcaerb a fo srehto ro SHH yfiton ot seititne derevoc eriuqer ton od selur ytiruces dna ycavirp ehT

.IHP rieht fo sesu laitnetop eht dna sthgir ycavirp rieht tuoba cilbup eht etacude ot margorp noitacude lanoitan a niatniam dna poleved tsum RCO ,tnemtcane fo shtnom 21 nihtiW .setaicossa ssenisub dna seititne derevoc ot ecnadiug dna noitacude reffo ot eciffo lanoiger SHH hcae ni rosivda ycavirp a etangised ot deriuqer si yraterceS ehT .noitces siht tnemelpmi ot snoitaluger lanif miretni eussi ot deriuqer si yraterceS eht ,tnemtcane fo syad 081 nihtiW .sehcaerb fo rebmun eht ecuder ot woh no rotanidrooC lanoitaN eht yb edam snoitadnemmocer dna ,esnopser ni nekat snoitca ,sehcaerb fo epyt dna rebmun eht no ssergnoC ot troper ot yllaunna yraterceS eht seriuqer tcA ehT .ISNA yb detidercca noitazinagro tnempoleved sdradnats a yb desrodne ro depoleved saw taht slaudividni dezirohtuanu ot elbarehpicedni ro ,elbadaernu ,elbasunu ti gniredner dradnats ygolonhcet a yb deruces ton fi erucesnu deredisnoc eb lliw IHP ,senildaed esoht teem ot sliaf yraterceS eht fI .eettimmoC yciloP TIH eht yb dednemmocer sdradnats noitpyrcne fo esu eht gnidulcni ,seigolodohtem dna seigolonhcet hcus gniyficeps senilediug eussi ot deriuqer si yraterceS eht ,retfaereht yllaunna dna ,syad 06 nihtiW .slaudividni dezirohtuanu ot elbarehpicednu dna ,elbadaernu ,elbasunu noitamrofni eht gniredner sa yraterceS eht yb deifitnedi ygolodohtem ro ygolonhcet a fo esu eht hguorht deruces ton si taht noitamrofni sa IHP derucesnu senifed tcA ehT .slaudividni 005 naht erom stcapmi taht hcaerb a ni devlovni ytitne derevoc hcae etisbew SHH eht no tsil ot deriuqer si yraterceS ehT .yraterceS eht ot ti timbus yllaunna dna sehcaerb hcus fo gol a niatniam ot sah devlovni ytitne derevoc eht ,slaudividni 005 naht rewef stcapmi hcaerb eht fI .slaudividni erom ro 005 gnivlovni IHP derucesnu fo sehcaerb fo yraterceS eht yfiton yletaidemmi tsum osla seititne derevoC .detcapmi era aera taht ni slaudividni 005 naht erom fi aera ralucitrap a gnivres steltuo aidem tnenimorp ot dedivorp eb tsum hcaerb eht fo ecitoN .noitacifiton eht fo stnetnoc eht dna deifiton eb tsum slaudividni hcihw yb sdohtem eht seificeps noisivorp ehT .ytiruces lanoitan egamad ro noitagitsevni lanimirc edepmi dluow ti fi ,elur ycavirp AAPIH eht fo )2()a(825.461 noitceS ni dedivorp sa rennam emas eht ni ,deyaled eb yam noitacifitoN .yrevocsid rieht retfa syad 06 naht retal on edam eb ot evah snoitacifiton hcaerb llA .ytitne derevoc eht yfiton tsum hcaerb eht fo yrevocsid nopu etaicossa ssenisub eht ,etaicossa ssenisub a fo lortnoc eht rednu IHP derucesnu fo hcaerb a roF .hcaerb hcus fo tluser a sa desolcsid ro ,deriuqca ,dessecca ,neeb evah ot deveileb ylbanosaer si ro ,neeb sah noitamrofni esohw laudividni hcae yfiton tsum ytitne derevoc eht ,ytitne derevoc a yb derevocsid si taht IHP derucesnu fo hcaerb a fo tneve eht nI

seititnE derevoC AAPIH :hcaerB noitamrofnI fo noitacifitoN

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

cipoT



.noitazirohtua tneitap tuohtiw detibihorp si ytrap driht a ot IHP fo erusolcsid eht ,elur eht rednu deriuqer ro dettimrep ylsserpxe sselnU .ksir ycavirp wol a esop ot deredisnoc si dna devomer sreifitnedi tcerid tsom sah tes atad detimil A .tneipicer eht htiw tnemeerga esu atad a ot tnausrup ,)hcraeser ,.g.e( sesoprup deificeps niatrec rof "tes atad detimil a fo erusolcsid eht stimrep osla elur ehT .sesoprup tnemtaert rof redivorp erac htlaeh a yb stseuqer ro ot serusolcsid ,elpmaxe rof ;ylppa ton seod dradnats yrassecen muminim eht hcihw ni secnatsmucric fo rebmun a era erehT .dradnats yrassecen muminim a setaroprocni elur ycavirp eht ,dessucsid ylsuoiverp sA

.IHP fo elas eht gninrevog snoitaluger eussi tsum yraterceS eht ,tnemtcane fo shtnom 81 nihtiW .IHP reh ro sih fo ypoc a htiw laudividni eht gnidivorp )4( dna ;laudividni eht fo tnemtaert )3( ;))i(215.461 RFC 54 ni debircsed sa( hcraeser )2( ;))b(215.461 RFC 54 ni debircsed sa( seitivitca htlaeh cilbup )1( :gnidulcni ,secnatsmucric deificeps niatrec ni tpecxe noitazirohtua tneitap tuohtiw etaicossa ssenisub ro ytitne derevoc a yb IHP fo elas eht stibihorp tcA ehT

noitamrofnI tneitaP fo elaS

yrasseceN muminiM

.)noitazirohtua na ot tnausrup ro ,snoitarepo erac htlaeh ro ,tnemyap ,tnemtaert rof naht rehto( serusolcsid IHP fo gnitnuocca na ot thgir eht dna ,snoitarepo erac htlaeh rehto ro ,tnemyap ,tnemtaert fo sesoprup eht rof IHP seno fo erusolcsid dna esu eht tcirtser ytitne derevoc a taht tseuqer ot thgir eht ,IHP seno tnemelppus ro dnema ot thgir eht ,IHP nwo seno ot ssecca fo thgir eht gnidulcni ,sthgir ycavirp laredef lareves sehsilbatse elur ycavirp eht ,dessucsid ylsuoiverp sA .SHH yfiton tsum ytitne derevoc eht ,elbisaef ton si noitanimret fI .tcartnoc eht etanimret ,lufsseccusnu fi ,dna ,noitautis eht ydemer ot spets elbanosaer ekat tsum ti ,etaicossa ssenisub a yb tcartnoc eht fo noitaloiv ro hcaerb lairetam a tuoba tuo sdnif ytitne derevoc a fI .setaicossa ssenisub rieht fo snoitca eht ,rotinom ot deriuqer ro ,rof elbail ton era seititne derevoc ,dessucsid ylsuoiverp sA .seititne derevoc ot ylppa seitlanep lanimirc dna livic AAPIH ehT

.ylppa ot eunitnoc dradnats yrassecen muminim eht ot snoitpecxe selur ycavirp AAPIH ehT .noitanimreted yrassecen muminim eht sekam )retseuqer eht ot desoppo sa( IHP eht gnisolcsid ytitne eht taht seifiralc tcA eht ,noitidda nI .yrassecen muminim setutitsnoc tahw no ecnadiug seussi yraterceS eht litnu sdloh tnemeriuqer sihT .tseuqer ro ,erusolcsid ,esu hcus fo esoprup dednetni eht hsilpmocca ot yrassecen muminim eht ot ,dedeen fi ,ro tes atad detimil a ot ,elbacitcarp tnetxe eht ot ,IHP fo tseuqer ro ,erusolcsid ,esu eht timil tsum seititne derevoC .serusolcsid hcus rof gnitnuocca fo nedrub evitartsinimda eht tnuocca otni gnikat ,erusolcsid hcae tuoba detcelloc eb llahs noitamrofni tahw no snoitaluger eussi tsum yraterceS eht ,serusolcsid fo gnitnuocca no sdradnats gnitpoda fo shtnom 6 nihtiW .RHE na hguorht erew serusolcsid eht fi ,sraey eerht suoiverp eht gnirud snoitarepo erac htlaeh dna ,tnemyap ,tnemtaert rof setaicossa ssenisub rieht ro seititne derevoc yb edam serusolcsid IHP fo gnitnuocca na eviecer ot thgir eht evah slaudividni ,rehtruF .ecivres ro meti taht rof lluf ni tekcop-fo-tuo diap tneitap eht fi ,snoitarepo erac htlaeh ro tnemyap fo sesoprup rof nalp htlaeh a ot desolcsid eb ton ecivres ro meti erac htlaeh cificeps a gnidrager IHP eht taht tseuqer stneitap a ronoh ot redivorp erac htlaeh a seriuqer osla tI .laudividni eht yb detangised ylraelc nosrep ro ytitne na ot ypoc hcus timsnart ot ytitne derevoc eht tcerid dna ,RHE na ni deniatniam si ti fi ,IHP rieht fo ypoc cinortcele na eviecer ot thgir eht slaudividni sevig tcA ehT .tcartnoc eht otni detaroprocni eb ot evah dna setaicossa ssenisub ot ylppa osla seititne derevoc ot elbacilppa edam era taht eltitbus siht rednu stnemeriuqer ycavirp lanoitidda ynA .seititne derevoc ot ylppa yeht sa rennam emas eht ni etaicossa ssenisub taht ot seitlanep lanimirc dna livic eht seilppa tcA eht ,noitces siht ni stnemeriuqer tcartnoc ycavirp eht gnitaloiv etaicossa ssenisub a fo esac eht nI .egdelwonk hcus gniniag etaicossa ssenisub a ot yllauqe ylppa etaicossa ssenisub a yb noitaloiv ro hcaerb lairetam a fo egdelwonk sti no gnitca ytitne derevoc a gnidrager snoisivorp tnerruc ehT .tcartnoc eht htiw ecnailpmoc ni si noitca hcus fi IHP esolcsid ro esu ot dettimrep ylno era setaicossa ssenisuB

sthgiR ycavirP stneitaP

setaicossA ssenisuB ot seitlaneP dna snoisivorP ycavirP fo noitacilppA

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

cipoT



.elbail yllanimirc eb dluoc ytitne derevoc a ylno taht dedulcnoc dna AAPIH rednu detucesorp eb yam snosrep hcihw desserdda lesnuoC lageL fo eciffO stnemtrapeD ecitsuJ eht ,5002 yluJ nI

seitlaneP lanimirC

stcartnoC etaicossA ssenisuB

.tcartnoc eht yb rof dedivorp ton si taht IHP fo erusolcsid ro esu yna ro tnedicni ytiruces yna fo erawa emoceb yeht fi seititne derevoc ot troper ot meht gniriuqer noisivorp a edulcni tsum stcartnoc etaicossa ssenisub ,revewoH .IHP fo ytirgetni ro ,ytiruces ,ycavirp eht fo hcaerb a fo srehto ro SHH yfiton ot seititne derevoc eriuqer ton od selur ytiruces dna ycavirp eht ,revewoh ,deton ydaerla sA .setaicossa ssenisub rieht ot ,stcartnoc nettirw hguorht ,dna )sredivorp dna snalp htlaeh ,.e.i( seititne derevoc ot ylppa selur ytiruces dna ycavirp ehT

seititnE derevoC AAPIH-non rehtO dna srodneV RHP :hcaerB noitamrofnI fo noitacifitoN

.seitivitca hcus ni egagne ot ytrap driht a yb diap si ytitne derevoc eht fi neve ,noitazirohtua stneitap eht eriuqer ton od ,erofereht ,dna noitinifed siht morf dedulcxe era ecivres ro tcudorp detaler-erac htlaeh a esu ro esahcrup ot tneitap a egaruocne ot )etaicossa ssenisub sti ro( ytitne derevoc a yb edam snoitacinummoc ,revewoH .noitazirohtua tuohtiw seitivitca gnitekram nwo sti rof noitamrofni htlaeh esolcsid ro esu ton yam ytitne derevoc a ,yllareneG

.ton ro seeyolpme era yeht rehtehw ,ytitne derevoc a yb deniatniam noitamrofni hcus esolcsid ro niatbo noitazirohtua tuohtiw ohw slaudividni ot ylppa IHP fo erusolcsid lufgnorw rof seitlanep lanimirc taht yfiralc ot AAPIH sdnema tcA ehT .seititne esoht htiw stcartnoc etaicossa ssenisub evah ot )srodnev RHP dna ,)sOIHR( snoitazinagrO noitamrofnI htlaeH lanoigeR ,segnahcxE noitamrofnI htlaeH ,.g.e( IHP cinortcele gnignahcxe fo esoprup eht rof seititne derevoc htiw tcartnoc taht snoitazinagro seriuqer tcA ehT .seititne derevoc AAPIH-non rof stnemeriuqer noitacifiton hcaerb gnihsilbatse noitalsigel wen stcane ssergnoC fi ylppa regnol on lliw noitces siht ni snoisivorp ehT .noitces siht tnemelpmi ot snoitaluger lanif miretni eussi tsum CTF eht ,syad 081 nihtiW .noitamrofni htlaeh RHP derucesnu fo sehcaerb hcus gnidrager ytirohtua tnemecrofne sah dna seviecer ti seciton hcaerb yna fo SHH yfiton tsum CTF ehT .ISNA yb detidercca noitazinagro tnempoleved sdradnats a yb desrodne ro depoleved saw taht slaudividni dezirohtuanu ot elbarehpicedni ro ,elbadaernu ,elbasunu ti gniredner dradnats ygolonhcet a yb deruces ton fi erucesnu deredisnoc eb lliw noitamrofni htlaeh RHP neht ,ecnadiug eussi ot sliaf yraterceS eht fI .yraterceS eht yb deussi ecnadiug ni deificeps ygolodohtem ro ygolonhcet a fo esu eht hguorht detcetorp ton si taht noitamrofni htlaeh RHP snaem noitamrofni htlaeh RHP derucesnU .noisivorp siht ot osla ylppa snoitacifiton fo ssenilemit dna tnetnoc eht rof stnemeriuqer debircsed ylsuoiverp ehT .)CTF( noissimmoC edarT laredeF eht dna detcapmi slaudividni eht yfiton tsum ,noitamrofni htlaeh RHP derucesnu fo ytiruces fo hcaerb a fo yrevocsid nopu ,etisbew srodnev RHP a hguorht secivres dna stcudorp gnireffo seititne dna srodnev RHP .snoitacinummoc rehtruf fo tuo tpo ot tneipicer eht rof ytinutroppo na edivorp ,rennam suoucipsnoc dna raelc a ni ,tsum snoitacinummoc gnisiardnuF .tcartnoc eht htiw tnetsisnoc si noitacinummoc eht ,ytitne derevoc a fo flaheb no etaicossa ssenisub a yb edam si noitacinummoc eht tneve eht ni )3( ro ,tneipicer eht morf noitazirohtua sniatbo ytitne derevoc eht )2( ,)yraterceS eht yb denifed sa( elbanosaer si tnemyap eht dna tneipicer eht rof debircserp gnieb yltnerruc si taht cigoloib ro gurd a ylno sebircsed noitacinummoc eht )1( sselnu ,noitacinummoc eht gnikam eht rof tnemyap seviecer ytitne derevoc eht fi noitarepo erac htlaeh a deredisnoc eb ton yam ecivres ro tcudorp detaler erac-htlaeh a tuoba noitacinummoc a hcus ,rehtruF .laudividni eht fo tnemtaert eht ot setaler ro ,ecivres ro tcudorp detaler-erac htlaeh a rof si noitacinummoc eht sselnu ,noitarepo erac htlaeh a deredisnoc eb ton yam ecivres ro tcudorp eht esu ro esahcrup ot tneipicer eht segaruocne taht ecivres ro tcudorp a tuoba etaicossa ssenisub ro ytitne derevoc a yb noitacinummoc gnitekram a taht seifiralc tcA ehT

gnitekraM

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

cipoT



.tnemtcane retfa shtnom 21 tceffe ekat snoisivorp ytiruces dna ycavirp evoba eht ,dedivorp yllacificeps esiwrehto sa tpecxE .laudividni na ot elbacilppa esiwrehto egelivirp ycavirp htlaeh yna eviaw ton seod tcA ehT .snoisivorp ytiruces dna ycavirp stcA eht htiw tnetsisnoc meht ekam ot yrassecen sa sdradnats AAPIH eht dnema ot gnikamelur yb deriuqer si yraterceS ehT .stnemeriuqer esoht htiw tnetsisnoc era yeht taht tnetxe eht ot sdradnats ytiruces dna ycavirp AAPIH eht sevreserp dna stnemeriuqer ycavirp evoba eht ot snoisivorp noitpmeerp AAPIH eht seilppa tcA ehT

etaD evitceffE

.ycavirp lacidem tneitap fo evitcetorp erom si taht wal etats fo noisivorp yrartnoc a tpmeerp ton seod elur ycavirp eht ,revewoH .)gnitroper htlaeh cilbup ,.g.e( snoitpecxe deificeps niatrec htiw ,wal etats fo noisivorp yrartnoc yna tpmeerp sdradnats ytiruces AAPIH ehT .sdradnats AAPIH htiw gniylpmoc era seititne derevoc rehtehw enimreted ot sweiver ecnailpmoc tcudnoc ot dezirohtua si yraterceS ehT .mrah suoicilam ro ,niag lanosrep ,egatnavda laicremmoc rof ti esu ro refsnart ,lles ot tnetni eht htiw noitamrofni htlaeh gniniatbo ro gnisolcsid rof nosirp ni sraey 01 ot pu dna 000,052$ ot pu fo senif edulcni seitlanep lanimirc s'AAPIH .noitucesorp lanimirc rof ecitsuJ fo tnemtrapeD eht ot esac eht refer yam RCO ,IHP fo serusolcsid lufgnorw niatrec roF .noitca evitcerroc hguorht ecnailpmoc yratnulov egaruocne ot seititne derevoc htiw gnikrow no desucof sah ti ,daetsnI .ytitne derevoc-AAPIH a tsniaga ytlanep elgnis a deivel ton sah RCO .syad 03 nihtiw detcerroc saw dna ,tcelgen luflliw ot ton dna esuac elbanosaer ot eud saw ylpmoc ot eruliaf eht )3( ro ;noitaloiv eht fo egdelwonk evitcurtsnoc ro lautca evah ton did nosrep eht )2( ;snoisivorp ytlanep lanimirc sAAPIH rednu esneffo lanimirc a si noitaloiv eht )1( :fi desopmi eb ton yam seitlanep yratenom liviC .sdradnats ytiruces dna ycavirp eht htiw ylpmoc ot gniliaf nosrep yna no seitlanep yratenom livic esopmi ot yraterceS eht dezirohtua AAPIH ,evoba deton sA

waL etatS fo noitpmeerP stiduA ecnailpmoC

.eltitbus siht fo stnemeriuqer eht dna sdradnats ytiruces dna ycavirp AAPIH eht htiw ecnailpmoc erusne ot stidua cidoirep mrofrep ot deriuqer si yraterceS ehT .noitaloiv eht tuoba ,nwonk evah ton dluow ecnegilid elbanosaer gnisicrexe yb dna ,wonk ton did nosrep eht erehw sesac ni ytlanep a tuohtiw noitca evitcerroc esu ot gniunitnoc morf RCO stneverp noitces eht ni gnihtoN .sdradnats ytiruces dna ycavirp AAPIH eht etaloiv ohw slaudividni tsniaga truoc tcirtsid laredef ni noitca livic a gnirb ot dezirohtua era lareneg syenrotta etats ,yllaniF .syad 03 nihtiw detcerroc saw dna esuac elbanosaer ot eud saw noitaloiv eht fi desopmi eb ton enif livic a taht tnemeriuqer tnerruc eht sevreserp tI .raey radnelac a gnirud noitibihorp ro tnemeriuqer lacitnedi na fo snoitaloiv hcus lla rof 000,005,1$ ot pu dna noitaloiv rep 000,05$ fo enif a esopmi dluow hcihw fo tsehgih eht ,seitlanep fo sreit ruof htiw seitlanep yratenom livic gnitsixe eht gnicalper yb AAPIH sdnema rehtruf tcA ehT .slaudividni demrah ot seitlanep detcelloc yna fo egatnecrep a etubirtsid ot ygolodohtem a noitaluger yb hsilbatse tsum ,tnemtcane fo sraey eerht nihtiw ,yraterceS eht ,snoitadnemmocer esoht no desaB .demrah slaudividni eht ot detcelloc seitlanep yratenom livic yna fo egatnecrep a gnivig rof snoitadnemmocer timbus ot deriuqer si OAG ,tnemtcane fo shtnom 81 nihtiW .sdradnats ytiruces dna ycavirp AAPIH eht gnicrofne rof desu eb ot RCO ot derrefsnart eb detcelloc seitlanep yratenom livic yna taht seriuqer osla tcA ehT .stnemdnema esoht tnemelpmi ot shtnom 81 nihtiw snoitaluger eussi tsum yraterceS ehT .tcelgen luflliw ot eud snoitaloiv rof seitlanep yratenom livic fo noitisopmi eht dna stnialpmoc fo noitagitsevni lamrof a eriuqer ot AAPIH sdnema ti ,noitidda nI .laudividni eht detucesorp ton dah tnemtrapeD ecitsuJ eht fi sdradnats AAPIH eht fo noitaloiv lanimirc degella na rof laudividni yna tsniaga seitlanep yratenom livic fo noitisopmi eht dna noitagitsevni na eusrup ot RCO timrep ot AAPIH sdnema tcA ehT

seitlaneP liviC

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

cipoT



.9002 ,71 yraurbeF no tnediserP eht yb dengis ,)IIIX eltiT ,A noisiviD( 5-111 .L.P no desab ,ecivreS hcraeseR lanoissergnoC eht yb deraperp elbaT :ecruoS .noitazirohtua tneitap eriuqer noitamrofni hcus fo serusolcsid dna sesu lla tsomlA .elur ycavirp eht rednu noitcetorp laiceps dedroffa era )gnilesnuoc gnirud slanoisseforp htlaeh latnem yb dedrocer seton ,.e.i( seton yparehtohcysP .snoitarepo erac htlaeh ro ,tnemyap ,tnemtaert rof IHP esolcsid ro esu ot tnesnoc lareneg s'laudividni na niatbo ot ,deriuqer ton era tub ,yam seititne derevoC .noitazirohtua s'laudividni eht tuohtiw snoitarepo erac htlaeh rehto dna ,tnemyap ,tnemtaert fo esoprup eht rof noitamrofni htlaeh esolcsid dna esu yam sredivorp dna snalp ,yllareneG .deifitnedi eb dluoc laudividni eht taht llams yrev fi ksir eht taht senimreted ,selpicnirp detpecca gnisu ,naicitsitats deifilauq a fi ro ,devomer neeb evah )sserdda ,rebmun ytiruces laicos ,eman ,.g.e( sreifitnedi cificeps 81 fi deifitnedi-ed si noitamrofni htlaeh ,elur ycavirp eht rednU .snoitaluger eht ot tcejbus ton si noitamrofni deifitnedi -ed ;noitamrofni htlaeh elbaifitnedi yllaudividni tcetorp ot dednetni era sdradnats AAPIH ehT .snalp ro sredivorp sa gnitca era yeht sselnu ,srodnev RHP dna ,sOIHR ,segnahcxE noitamrofnI htlaeH gnidulcni ,noitamrofni htlaeh niatniam dna tcelloc taht seititne rehto ot yltcerid ylppa ton od yehT .sesuohgniraelc erac htlaeh dna ,sredivorp erac htlaeh ,snalp htlaeh ot ylppa sdradnats ytiruces dna ycavirp ehT .troper ecnailpmoc a eussi ot yraterceS eht eriuqer ton seod AAPIH .SHH htiw tnialpmoc a elif yam elur ycavirp eht htiw gniylpmoc ton si ytitne derevoc a seveileb ohw nosrep ynA

.ytilauq erac htlaeh ni tnemevorpmi dna ,noitpoda RHE ,stsoc erac htlaeh ,smuimerp ecnarusni htlaeh no tcA eht fo tcapmi eht no yraterceS eht dna ssergnoC ot troper ot ,sraey evif nihtiw ,deriuqer rehtruf si OAG .snoitarepo erac htlaeh dna ,tnemyap ,tnemtaert rof IHP gnisolcsid rof tnesnoc demrofni cinortcele fo esu eht fo noitanimaxe na sa llew sa ,erac fo ytilauq eht evorpmi secitcarp esoht woh dna ,segnahcxe noitamrofni htlaeh sa hcus ,seititne rehto dna setats yb detnemelpmi secitcarp fo noitanimaxe na edulcni tsum troper ehT .tnemtaert fo esoprup eht rof sredivorp erac htlaeh gnoma IHP fo erusolcsid eht ot detaler secitcarp tseb no troper ot ,raey eno nihtiw ,OAG seriuqer tcA ehT .noitaulave htlaeh latnem a fo trap era taht atad tset edulcni ot seton yparehtohcysp fo noitinifed eht esiver ,noitaluger yb ,yam yraterceS eht ,yllaniF .IHP gniyfitnedi-ed rof stnemeriuqer s'elur ycavirp AAPIH eht tnemelpmi ot tseb woh no ecnadiug eussi ot ,sredlohekats htiw noitatlusnoc ni dna tnemtcane fo raey eno nihtiw ,deriuqer si osla yraterceS ehT .ssergnoC ot troper dna seititne derevoc AAPIH -non ot )noitacifiton hcaerb gnidulcni( stnemeriuqer ytiruces dna ycavirp noitamrofni htlaeh fo noitacilppa eht yduts ot ,CTF htiw noitatlusnoc ni dna raey eno nihtiw ,deriuqer si yraterceS eht ,noitidda nI .eltitbus siht fo snoisivorp eht dna sdradnats AAPIH eht fo tnemecrofne dna htiw ecnailpmoc gnivorpmi rof raey gniwollof eht rof nalp syraterceS eht )4( dna ,sgnidnif rieht fo yrammus a dna demrofrep stidua fo rebmun eht )3( ,dedivorp ecnatsissa fo sepyt eht sa llew sa ,ecnailpmoc eveihca ot redro ni ecnatsissa lacinhcet gniviecer seititne derevoc fo rebmun eht )2( ,senif livic fo noitisopmi eht gnidulcni ,devloser erew yeht woh dna snoitaloiv degella fo stnialpmoc fo erutan dna rebmun eht )1( no noitamrofni gniniatnoc troper ecnailpmoc a htiw ssergnoC edivorp ot yllaunna deriuqer si yraterceS ehT

ecnadiuG ,stropeR ,seidutS

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

cipoT



.RHE na gnisu gnidulcni ,serusaem ytilauq gnitroper ylirotcafsitas rof sunob a nrae nac snaicisyhp hcihw rednu ,)IRQP( evitaitinI gnitropeR ytilauQ naicisyhP eht dna ,gnibircserp-e rof stnemyap evitnecni naicisyhp eht ,noitartsnomed RHE raey-evif eht edulcni yehT .sredivorp erac htlaeh gnoma noitpoda TIH etomorp ot smargorp fo rebmun a gniretsinimda si SMC ,dessucsid ylsuoiverp sA

.noitazinagro AM eht ot ylno edam eb ot si tnemyap eht neht ,tnemyap evitnecni mumixam eht naht ssel rof elbigile si naicisyhp eht fI .margorp SFF eht rednu ylno edam eb ot si tnemyap eht neht ,margorp )SFF( ecivres-rof-eef eht rednu tnemyap evitnecni mumixam eht rof elbigile dna redivorp detailiffa-AM na htob si naicisyhp a fi ,stnemyap fo noitacilpud diova oT .OMH na sa noitcnuf taht snoitazinagro AM htiw detailiffa snaicisyhp elbigile niatrec ot seitlanep dna stnemyap sunob RHE eht fo noitacilppa eht rof sedivorp tcA eht ,revewoH .snalp )AM( egatnavdA eracideM ot elbaliava ton era stnemyap evitnecni naicisyhp eht ,yllareneG .sraey evif naht erom rof detnarg eb ton yam snoitpmexe hcuS .pihsdrah tnacifingis ni tluser dluow resu RHE lufgninaem a gnieb taht denimreted si ti fi noitcuder tnemyap eht morf )ssecca tenretnI tneiciffus kcal taht snaicisyhp larur ,.g.e( snaicisyhp elbigile tpmexe ,sisab esac-yb-esac a no ,yam yraterceS ehT .%5 deecxe tonnac noitcuder eht hguoht ,raey suoiverp eht ni tnuoma elbacilppa eht morf tniop egatnecrep eno yb desaerced rehtruf eb lliw noitcuder tnemyap eht ,%57 naht ssel si sresu RHE lufgninaem era ohw snaicisyhp elbigile fo noitroporp eht fi ,raey tneuqesbus hcae dna 8102 roF .raey tneuqesbus hcae ni dna 7102 ni %3 ,6102 ni %2 ,5102 ni %1 :stnuoma gniwollof eht yb decuder stnemyap eracideM rieht ees lliw 5102 yb smetsys TIH deifitrec fo sresu lufgninaem ton era ohw snaicisyhp elbigilE .snaicisyhp desab-latipsoh rof elbaliava ton era stnemyap evitnecnI .6102 retfa edam eb lliw stnemyap evitnecni oN .%01 yb desaercni era stnuoma tnemyap evitnecni eht ,saera egatrohs lanoisseforp htlaeh ni gnicitcarp snaicisyhp elbigile roF .sunob on eviecer lliw 4102 retfa litnu sRHE tpoda ton od ohw esoht dna ,spac rewol ot tcejbus eb lliw 3102 retfa sresu RHE lufgninaem gnimoceb tsrif snaicisyhp elbigilE .raey taht rof )000,51$ fo daetsni( 000,81$ ot pu eviecer lliw 2102 ro 1102 si raey tnemyap tsrif esohw sretpoda RHE ylraE .raey ,lanif dna ,htfif eht ni 000,2$ dna ,raey htruof eht ni 000,4$ ,raey driht eht ni 000,8$ ,raey dnoces eht ni 000,21$ ,raey tnemyap tsrif eht ni 000,51$ ot pu eviecer lliw snaicisyhp elbigile ,1102 ni gninnigeB .emit revo sesaerced dna deppac si eviecer dluoc naicisyhp a taht tnuoma latot eht ,revewoH .raey gnitroper eht gnirud segrahc B traP dewolla eht fo %57 lauqe stnemyap evitnecni ehT .yraterceS eht yb detceles sa ,serusaem ytilauq lacinilc troper ot ygolonhcet RHE deifitrec hcus gnisu )2( dna ;ytilauq erac htlaeh evorpmi ot noitamrofni htlaeh cinortcele gnignahcxe fo esoprup eht rof gnidulcni ,)gnibircserp-e gnidulcni( rennam lufgninaem a ni ygolonhcet RHE deifitrec fo esu eht yraterceS eht fo noitcafsitas eht ot gnitartsnomed )1( :sa denifed si esu lufgninaeM .ygolonhcet RHE deifitrec fo sresu lufgninaem era ohw )tcA ytiruceS laicoS eht fo )r(1681 noitceS ni denifed sa( snaicisyhp ot B traP eracideM hguorht doirep raey-evif a revo stnemyap evitnecni sezirohtua tcA ehT

)A eltitbuS( seitlaneP dna stnemyaP evitnecnI eracideM

cipoT

snaicisyhP

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

VI eltiT ,B noisiviD :)5-111 .L.P( 9002 fo tcA tnemtsevnieR dna yrevoceR naciremA

stnemyaP diacideM dna eracideM :tcA HCETIH

.2 elba T



.seiraicifeneb eracideM ot dedivorp erac tneitapni rof tnemesrubmier desab-tsoc ,elbanosaer %101 eviecer sHAC ,yllareneG .yats fo htgnel egareva ruoh-69 a evah dna ,sdeb tneitapni erac etuca 52 naht erom on evah ,erac ycnegreme ruoh-42 reffo taht saera larur ni seitilicaf ecivres -detimil era )sHAC( slatipsoh ssecca lacitirC

.RHE fo noitpoda eht yb detceffa ton era metsys tnemyap evitcepsorp tneitapni eht rednu slatipsoh erac etuca ot stnemyap s'eracideM ,yltnerruC .stniop egatnecrep owt yb decuder egatnecrep BM elbacilppa eht evah atad ytilauq deriuqer timbus ton od taht slatipsoh ,margorp )UPADQHR( etadpU tnemyaP launnA rof ataD ytilauQ latipsoH gnitropeR eht rednU .xedni )BM( teksab tekram latipsoh eht ni esaercni detcejorp eht yb trap ni dehsilbatse si taht rotcaf etadpu na yb yllaunna desaercni era setar tnemyap esehT .egrahcsid hcae rof tnemyap denimreted ylevitcepsorp a gnisu slatipsoh erac etuca syap eracideM

.noitazinagro eht yb dereffo nalp AM na ni seellorne evres dna snoitazinagro AM gniyfilauq a htiw ecnanrevog etaroproc nommoc rednu era taht slatipsoh ot ylppa osla seitlanep dna sevitnecni tnemyap RHE ehT .slatipsoh erac-etuca sa noitpmexe pihsdrah emas eht rof elbigile era sHAC .%001 ,raey lacsif tneuqesbus hcae dna 7102YF rof dna ;%33.001 ,6102YF rof ;%66.001 ,5102YF rof :swollof sa decuder etar tnemesrubmier eracideM rieht evah dluow sresu RHE lufgninaem ton era taht sHAC ,5102YF ni gninnigeB .5102YF retfa sesunob teg tonnac HAC a taht tpecxe ,stnemyap fo sraey evitucesnoc ruof rof elbigile era yeht ,resu RHE lufgninaem a si HAC a fi ,1102YF ni gninnigeB .eludehcs noitaicerped raeyitlum a revo tnemesrubmier gniviecer naht rehtar ,stnemyap miretni tpmorp eviecer dna raey tnemyap elgnis a ni stsoc eseht esnepxe yam sresu RHE lufgninaem era taht sHAC .%001 deecxe ton yam erahs eracideM decnahne eht tpecxe ,stniop egatnecrep 02 lanoitidda na sulp ,tnemtsujda erac ytirahc eht gnidulcni ,)evoba ees( sesunob RHE rof slatipsoh erac-etuca rof detaluclac erahs eracideM eht slauqe taht erahs eracideM decnahne na no desab ,ygolonhcet hcus fo esahcrup eht rof tnemesrubmier desab-tsoc elbanosaer rof elbigile era ygolonhcet RHE deifitrec fo sresu lufgninaem era taht )sHAC( slatipsoh ssecca lacitirC .sraey evif naht erom rof detnarg eb ton yam snoitpmexe hcuS .pihsdrah tnacifingis ni tluser dluow resu RHE lufgninaem a gnieb taht denimreted si ti fi noitcuder tnemyap eht morf )ssecca tenretnI tneiciffus kcal taht slatipsoh larur ,.g.e( slatipsoh elbigile tpmexe ,sisab esac-yb-esac a no ,yam yraterceS ehT .raey lacsif tneuqesbus hcae dna 7102YF ni %001 dna ,6102YF ni %76 ,5102YF ni %33 yb decuder etadpu BM rieht fo sretrauq-eerht rehto eht ees dluow smetsys RHE deifitrec fo sresu lufgninaem ton era taht slatipsoh elbigile )2( dna ;)%52 ,.e.i( retrauq-eno yb decuder etadpu )BM( teksab tekram rieht ees dluow atad ytilauq UPADQHR deriuqer troper ot deliaf taht slatipsoh elbigile )1( :5102YF ni gninnigeB .stnemyap on eviecer lliw 5102YF retfa litnu elbigile emoceb ton od taht slatipsoH .raey lacsif ,lanif dna ,htruof eht ni %52 dna ,raey lacsif driht eht ni %05 ,raey lacsif dnoces eht ni %57 ,raey lacsif tsrif eht ni tnuoma tnemyap evitnecni lluf eht eviecer dluow slatipsoH .)eulav erahs eracideM eht rehgih eht ,erac ytirahc erom eht ,.e.i( dedivorp erac ytirahc fo level eht tnuocca otni sekat hcihw fo eulav eht ,erahs eracideM slatipsoh eht yb detsujda eb dluow stnemyap llA .egrahcsid ht000,32 eht hguorht ht051,1 eht rof egrahcsid rep 002$ lanoitidda na sulp ,)noillim 2$( tnuoma esab a eviecer dluow slatipsoh elbigile ,1102YF ni gninnigeB .yraterceS eht yb detceles sa ,serusaem ytilauq lacinilc troper ot ygolonhcet RHE deifitrec hcus gnisu )2( dna ;ytilauq erac htlaeh evorpmi ot noitamrofni htlaeh cinortcele gnignahcxe fo esoprup eht rof gnidulcni ,rennam lufgninaem a ni ygolonhcet RHE deifitrec fo esu eht yraterceS eht fo noitcafsitas eht ot gnitartsnomed )1( :sa denifed si esu lufgninaeM .ygolonhcet RHE deifitrec fo sresu lufgninaem era taht slatipsoh erac-etuca elbigile ot A traP eracideM hguorht doirep raey-ruof a revo stnemyap evitnecni sezirohtua tcA ehT

slatipsoH

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

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.sgniht rehto gnoma ,sredivorp hcus ot sevitnecni tnemyap gnikam fo stifeneb dna stsoc laitnetop eht dna ,sredivorp hcus yb ygolonhcet RHE fo ytilitu lacinilc dna setar noitpoda eht fo noitanimaxe na edulcni tsum yduts ehT .tcA siht rednu gnidnuf rehto ro sevitnecni tnemyap on ro laminim gniviecer era ohw sredivorp erac htlaeh ot elbaliava edam eb dluohs sevitnecni tnemyap RHE rehtehw no ,0102 ,03 enuJ yb ssergnoC ot troper dna ,yduts a tcudnoc ot deriuqer si yraterceS ehT ydutS tnemyaP evitnecnI TIH .dednepxe litnu elbaliava eb ot era detairporppa stnuoma ehT .snoisivorp eracideM evoba eht tnemelpmi ot ,6102YF rof noillim 54$ dna ,5102YF hguorht 9002YF fo hcae rof noillim 001$ setairporppa tcA ehT .eludehcs eef B traP eht etaluclac ot desu rotcaf noisrevnoc eht ni esaercni yna ot eud sllaftrohs detcejorp tsniaga tcetorp ot stnemyap B traP tsujda ot desu eb yam dnuF tnemevorpmI eracideM eht ni seinoM .snalp AM rof setar stnemyap ro smuimerp B traP gnitaluclac gnidnuF nehw tnuocca otni nekat eb ot ton era stnemyap evitnecni RHE eracideM ehT noitatnemelpmI ,sselmraH dloH

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

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.9002 ,71 yraurbeF no tnediserP eht yb dengis ,)VI eltiT ,B noisiviD( 5-111 .L.P no desab ,ecivreS hcraeseR lanoissergnoC eht yb deraperp elbaT :ecruoS

.margorp eracideM eht fo noitartsinimda eht ni desu smetsys laveirter noitamrofni dna gnissecorp smialc eht htiw elbitapmoc si )sgniht rehto gnoma( dnuof sah yraterceS eht taht dna stnemeriuqer deificeps steem taht SIMM na evah ot deriuqer era setatS .sSIMM devorppa -non rof elbaliava si hctam %05 A .snoitarepo SIMM devorppa rof hctam %57 a dna)sSIMM( smetsyS noitamrofnI tnemeganaM diacideM sa ot derrefersmetsys laveirter noitamrofni dna gnissecorp smialc dezinahcem fo noitallatsni ro ,tnempoleved ,ngised eht ot elbatubirtta serutidnepxe rof hctam %09 a sezirohtua etutats diacideM ehT .tnuoma rehgih a eviecer snoitcnuf niatrec tub ,%05 yllareneg si dna etats yb yrav ton seod serutidnepxe evitartsinimda rof hctam laredef ehT .noitartsinimda margorp dna secivres diacideM no gnidneps s'etats yreve fo erahs a syap tnemnrevog laredef ehT

.stnemyap ygolonhcet RHE eht gniretsinimda rof ,dednepxe litnu elbaliava niamer ot ,6102YF rof noillim 02$ dna 5102YF hguorht 9002YF fo hcae rof noillim 04$ setairporppa tcA ehT .noitarepo dna noitpoda ygolonhcet RHE rof sredivorp diacideM ot stnemyap fo thgisrevo dna ssergorp ,sutats eht no ssergnoC ot stroper timbus yllacidoirep yraterceS eht taht seriuqer rehtruf tcA ehT .stnemyap ygolonhcet RHE eht retsinimda ot setats eht ot tnemyap rof hctam laredef %09 a sezirohtua tcA ehT .gnidnuf fo noitacilpud on erussa ot ,diacideM dna eracideM rednu dedivorp stnemyap TIH eht sa llew sa ,sredivorp fo sepyt tnereffid eht rof smargorp tnemyap TIH suoirav eht fo noitanidrooc erusne tsum yraterceS ehT .sraey xis naht erom fo doirep a revo edam eb ton yam dna ,raey suoiverp eht rof tnemyap a deviecer redivorp eht sselnu ,6102 retfa edam eb ton yam stnemyap ygolonhcet RHE latipsoH .snoitacifidom emos htiw ,alumrof tnemyap evitnecni RHE eracideM eht no desab era slatipsoh erac-etuca dna slatipsoh s'nerdlihc rof stsoc elbawollA .stnuoma esoht fo sdriht-owt ot pu eviecer yam snaicirtaidep elbigilE .esu dna ecnanetniam ,noitarepo RHE fo stsoc eht revoc ot ,sraey evif ot pu fo doirep a rof ,retfaereht raey a 000,01$ )2( dna ;ygolonhcet RHE fo noitatnemelpmi laitini dna esahcrup eht revoc ot dednetni ,)6102 naht retal eb ton yam hcihw( tnemyap fo raey tsrif eht ni 000,52$ )1( :deecxe ton yam tub ,setats yb dettimbus seiduts no desab ,yraterceS eht yb denimreted eb ot era stsoc elbawolla egareva ten eht ,desab-latipsoh ton era ohw stnatsissa naicisyhp gniyfilauq dna ,srenoititcarp esrun ,seviw-dim esrun ,stsitned ,snaicisyhp roF .stnemyap evitnecni RHE eracideM ot thgir yna eviaw tsum redivorp a ,stnemyap RHE diacideM eviecer ot redro nI .noitces siht rednu esu lufgninaem sa yfilauq ot tneiciffus si stnemyap evitnecni eracideM fo esoprup eht rof esu RHE lufgninaem fo tnemhsilbatse eht taht meed yam yraterceS ehT .ygolonhcet RHE deifitrec fo esu lufgninaem setartsnomed redivorp eht ,noitatnemelpmi laitini dna esahcrup htiw detaicossa ton stsoc rof taht ,dna ;stsoc ygolonhcet RHE fo %51 rehto eht fo tnemyap rof elbisnopser si redivorp eht taht ;etaber ro noitcuded yna tuohtiw redivorp eht ot yltcerid diap era stsoc elbawolla lla taht yraterceS eht ot secnarussa edivorp tsum etats ehT .tnuoma mumixam a ot pu ,emulov tneitap diacideM %01 a tsael ta htiw slatipsoh erac-etuca rehto ot dna ,slatipsoh snerdlihc ot stnemyap detaler-RHE ot seilppa osla hctam laredef %001 ehT .elbigile eb ot emulov tneitap diacideM %02 a ylno deen snaicirtaideP .emulov tneitap diacideM %03 a tsael ta sah dna cinilc larur ro retnec htlaeh deifilauq yllaredef a ni yltnanimoderp secitcarp ohw )2( ro ;emulov tneitap diacideM %03 a tsael ta sah dna desab-latipsoh ton si ohw )1( :)tnatsissa naicisyhp a yb del retnec htaeh deifilauq yllaredef fo cinilc larur a ni gnicitcarp( tnatsissa naicisyhp ro ,renoititcarp esrun ,efiw-dim esrun ,tsitned ,naicisyhp a fo stsoc ygolonhcet RHE elbawolla egareva ten eht fo %58 ot seilppa hctam laredef %001 ehT .ygolonhcet RHE deifitrec fo esu dna noitpoda eht egaruocne ot sredivorp diacideM gniyfilauq niatrec ot stnemyap rof hctam laredef %001 a sezirohtua tcA ehT

stnemyaP noitarepO dna noitpodA RHE

seitivitcA dna stnemeriuqeR tnerruC

noisivorP fo yrammuS

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4337-7 7137-7 8637-7 4194-7 1622-7

sanukmiR drahciR nagroM .C etteluaP nosliT lybiS nhaH miJ daehdeR nehpetS .C

diacideM egatnavdA eracideM slatipsoh eracideM snaicisyhp eracideM ycavirp ,stnarg ,sdradnats ,TIHCNO ,ycilop TIH

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Jim Hahn, Sibyl Tilson, Rich Rimkunas, and Paulette Morgan contributed to this report. C. Stephen Redhead Specialist in Health Policy credhead@crs.loc.gov, 7-2261