Workshop Summary1

INTRODUCTION

In June 2009 the Institute of Medicine’s (IOM’s) Forum on Medical and Public Health Preparedness for Catastrophic Events held a workshop with the goal of convening many of the best minds in health preparedness for a wide-ranging update on preparations for a major public health threat.

For the health community, a primary issue at hand before and during a catastrophic incident is how to provide care to thousands or tens of thousands of individuals through a health system that will go beyond capacity. Much work on this subject has been done, but responses to incidents continue to show that gaps in the system remain and further refinement is required. Some of the work is as simple as creating common language: defining medical surge capacity, and creating standards and metrics to guide planning so that the highest priority requirements can be addressed in a timely manner. Some of the work is blisteringly complex, such as developing data systems that reach across the boundaries of states and regions, public and private healthcare systems, and outside the healthcare environment into the work of emergency management organizations. How do the medical system, public health system, and emergency management system provide care to those who need it with limited resources and staff? How can facilities prepare to meet the surge

1

The planning committee’s role was limited to planning the workshop. The workshop summary has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop.



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Workshop Summary 1 INTRODUCTION In June 2009 the Institute of Medicine’s (IOM’s) Forum on Medical and Public Health Preparedness for Catastrophic Events held a workshop with the goal of convening many of the best minds in health prepared- ness for a wide-ranging update on preparations for a major public health threat. For the health community, a primary issue at hand before and during a catastrophic incident is how to provide care to thousands or tens of thousands of individuals through a health system that will go beyond ca- pacity. Much work on this subject has been done, but responses to inci- dents continue to show that gaps in the system remain and further refinement is required. Some of the work is as simple as creating com- mon language: defining medical surge capacity, and creating standards and metrics to guide planning so that the highest priority requirements can be addressed in a timely manner. Some of the work is blisteringly complex, such as developing data systems that reach across the bounda- ries of states and regions, public and private healthcare systems, and out- side the healthcare environment into the work of emergency management organizations. How do the medical system, public health system, and emergency management system provide care to those who need it with limited resources and staff? How can facilities prepare to meet the surge 1 The planning committee’s role was limited to planning the workshop. The workshop summary has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. 1

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2 MEDICAL SURGE CAPACITY and, simultaneously, what procedures, policies, and planning can be done to reduce the requirement to surge? Coincident with the second day of the workshop, the World Health Organization officially declared the H1N1 virus to be pandemic, based on viral activity in the Southern hemisphere. The United States had al- ready recorded 27 deaths and 13,217 confirmed cases of H1N1 influenza by June 5, and was beginning to gear up for many more in cases in fall 2009. Emergency departments in certain parts of the country were over- loaded with patients either ill with virus, or concerned they were. Schools in cities such as New York City (NYC) were closing in response to massive absenteeism, either due to illness or anxious parents keeping their children home. As Gerry Parker, principal deputy assistant secretary for Office of the Assistant Secretary for Preparedness and Response (ASPR) in the Department of Health and Human Services (HHS), explained to work- shop attendees: “The country stands at a moment in history in which we face continued and complex challenges, but also ample opportunities. As we address the issues of healthcare reform, the creation of the first na- tional health security strategy and the realities of a potential pandemic influenza, we must also continue our efforts to seek solutions and mitiga- tion efforts for all health threats of natural disasters, emerging effects of diseases, bioterrorism, and terrorism.” GOALS AND OBJECTIVES The Hospital Preparedness Program (HPP) in HHS’s ASPR spon- sored the workshop on medical surge capacity. HPP’s mission is to help prepare the nation’s healthcare system to respond appropriately to mass- casualty incidents, whether due to bioterrorism, natural disaster, or other public health emergencies. Ultimately, this effort comes down to prepar- edness and efficiency—health systems must develop a disaster medical capability that is rapid, flexible, sustainable, integrated, and coordinated, and that can deliver appropriate treatment in the most ethical manner with the resources and capabilities available. The workshop, held in Washington, DC, on June 10–11, 2009, fea- tured presentations and discussions on the following topics, including the role of HPP in facilitating each of these efforts:

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3 WORKSHOP SUMMARY • Definitions of medical surge, standards, and metrics; • Creating an integrated approach to an alternate care system, and establishing alternate care facilities; • The capability and tools available to local, state, territorial, tribal, and federal government entities to provide situational awareness during operations, and to assess the current status of preparedness for medical surge operations; • Strategies to facilitate public- and private-sector work to improve surge capability for victims and the distressed, including vulner- able populations; and • Issues related to financing surge and preparedness. The forum brought together leaders in the medical and public health preparedness fields, including policy makers from federal agencies and state and local public health departments, providers from the healthcare community (including representatives from nursing, emergency medical services [EMS], mortuary services, and other providers), and healthcare and hospital administrators. About This Summary This document highlights and summarizes the work that was pre- sented at the workshop with the hope that this information will encour- age cooperation across regions, illuminate best practices, and prevent the need to “reinvent the wheel.” Whenever possible, unique ideas or con- cepts presented at the meetings are attributed in this report to the individ- ual who first advanced those concepts. In situations where many attendees made similar points, the recurring themes are identified. In ad- dition, the chairs from most of the panels were commissioned to draft white papers that were distributed at the workshop and served as a start- ing point for the panel discussions (see Appendixes D-I). Authors were asked to highlight some of the on-the-ground successes and address questions such as: • What is the state of the art? • What short- and long-term goals should be identified? • What will it take to get there? • What are the research needs? • How can the HPP program help facilitate advancement?

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4 MEDICAL SURGE CAPACITY THE COMMUNICATIONS CHALLENGE: DEFINITIONS, STANDARDS, AND METRICS During an emergency—be it a mass-casualty event or pandemic— communication is critical to providing quality healthcare and relief ser- vices. If those involved in disaster planning and response do not speak the same language, use common terminology, and work with compatible technologies (both literal and figurative), the ability to cope with a crisis is hampered. “The old adage goes, ‘Every plan survives only the first minutes of a disaster,’” said Jeffrey Runge, who served as the first chief medical offi- cer and assistant secretary for the Department of Homeland Security (DHS) Office of Health Affairs and is now president of Biologue, Inc. “But at least the confusion is reduced when people understand what the definitions and terminologies are.” One of the first workshop sessions addressed the importance of de- veloping consistent definitions, terminology, and metrics. Standardizing the terminology used to prepare and respond to a crisis is a critical step in the development of both high-quality, fundamental research, as well as metrics and practical standards to guide future work, Runge explained. If the healthcare system can not measure its preparedness and judge the effectiveness of different practices, it is unlikely to be able to appro- priately compete for funding. “We can’t grant our way into success here,” said Runge. “We absolutely have got to find ways for sustainable funding to fund preparedness. It is not going to happen without definable metrics that the funding agencies can actually say ‘Yes, you have done this.’” Medical Surge Capacity: Conventional, Contingency, and Crisis Capacity The term “medical surge capacity” has many different meanings to many different people. This can cause confusion and even an inability to have a meaningful discussion about the issues. Does spare capacity mean the number of free beds a hospital has at this moment? Does it mean the number of beds that can be vacated in the next hour through early discharge or the transfer of patients to other fa- cilities? Is it the number of cots an off-hospital facility has in the base- ment that can be set up in a cafeteria somewhere?

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5 WORKSHOP SUMMARY “Unfortunately there has been quite a bit of variability in the use of the term ‘surge capacity,’” explained John Hick, medical director for emergency preparedness at Hennepin County Medical Center, MN. “It has become a little bit of a wastebasket” term. Hick presented a conceptual framework from the Medical Surge Ca- pacity and Capability project at HHS. Grossly defined for the work- shop’s purposes, surge capacity is the ability to rapidly accommodate a large number of patients from a defined mass-casualty incident or pan- demic. Hick’s work looks at surge capacity on a continuum with three distinct stages: 1. Conventional capacity: Traditional and normal patient-care fa- cilities and staff meet their normal goals in providing care. Status quo. 2. Contingency capacity: Minor adaptations are made that may have minor consequences for standards of care, but adaptations are not enough to result in significant changes to standards of care. 3. Crisis capacity: A fundamental, systematic change into a system in which standards of care are significantly altered. When crisis capacity is reached, Hick noted, the institutional focus should shift: “It should prompt the institution to either get the right re- sources in, transfer the excess patients out, or look for additional relief.” These definitions and distinctions do not just relate to the beds or equipment available, but also to the staff needed to provide care and the tasks that staff will be required to perform. This same continuum can be extended into EMS and the public health planning sector. Establishing a common continuum provides the opportunity to define the triggers associated with movement from one stage to the next. How- ever, many organizations are unclear about what sequence of events an- nounces the move from one phase to the next. “Perhaps we have an opportunity here to build off of this Conventional–Contingency–Crisis [Capacity] framework to do exactly that,” Hick said. An example of one easy trigger to define is when circumstances re- quire the use of staff in a capability outside of their usual training, or the use of facilities for unintended purposes. When these situations occur, they should be automatic triggers for the institution to recognize the

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6 MEDICAL SURGE CAPACITY severity of the situation and attempt to take actions that would enable the institution to return to conventional operation. A common terminology around “surge” can also facilitate informa- tion sharing and create an opportunity to efficiently share resources throughout a region. If all of the facilities in a region use an agreed-on set of terms and triggers, resource gatekeepers can make much more co- gent decisions about what resources belong where and when. Quite often, the resources to respond to a crisis are available—they are just not in the right place at the right time. A common framework helps to ease the movement of these resources. “If my hospital is asking for five nurses and the hospital next door is asking for five nurses, if I’m asking for them in a crisis situation and they are asking for them in a contingency situation, our needs get filled first,” explained Hick. “This is, otherwise, a very difficult prioritization.” The Problem of (and Need for) Standards and Metrics As discussed in further detail in Runge’s white paper (Appendix D), there are distinct advantages to having standards to which the healthcare sector should aspire. First and foremost, achieving appropriate standards increases the chances of actually being prepared when the time comes. There are system advantages as well. Planning aimed at achieving stan- dards will drive more concrete requirements, which in turn leads to more exacting and efficient use of funding. Healthcare systems can better compete with other sectors for homeland security grant funding when specific requirements are known. However, where should standards originate? Who should set the definitions? What metrics should be developed? Should these ideas come from the federal government, be left to individual states, or filter up or- ganically from local healthcare systems? All of these questions were dis- cussed throughout the workshop. But although it is premature to determine who should set standards or how strict they should be, many participants commented on the need for additional guidance, metrics, and benchmarks. “In order to move forward in the field of emergency and disaster preparedness, we do need quantitative parameters,” said Jamil Bayram, a workshop attendee. “We need metrics, after we agree on definitions.” Unfortunately, many at the workshop believed much of the current research in the area of emergency and disaster preparedness is fundamen-

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7 WORKSHOP SUMMARY tally qualitative, not quantitative. “It seems that what we are doing now is putting out resources and papers and literature and documents and waiting for some sort of magical process of spontaneous combustion or the big bang to happen,” suggested Jeffrey Duchin, chief of communica- ble disease control in the Epidemiology and Immunization Section for Public Health in Seattle and King County, WA. “I am wondering where the leadership is going to come from to actually pull us as far down the road as we can get with the currently available information, as quickly as possible.” However, some cautioned that although this work is critical, care needs to be taken to ensure the standards are not too rigid and prescrip- tive to be valuable. Evidence-based standards are notoriously difficult to establish even in the most mathematically precise fields of medicine. When dealing with people and organizations, getting quantitative and definitive information is a challenge. Workshop participants suggested the best way forward may lie with organizations that already touch most components of the nation’s healthcare system—for example, the Joint Commission and the Centers for Medicare & Medicaid Services (CMS)—to partner with stakeholders and begin setting evidence-based standards for the health system. LEGAL AUTHORITIES AND GOVERNMENT SUPPORT Large-scale, catastrophic mass-casualty events and pandemics are by definition beyond the capacity of the normal healthcare system. That sys- tem has been designed to provide the best possible care to every patient, and an elaborate system of checks and balances has been put in place to ensure quality care, patients’ rights, and accountability. When a crisis occurs, the processes, standards of care, and resources require change, and so must the laws governing these actions (IOM, 2009a). Since the passage of the Pandemic and All-Hazards Preparedness Act of 2006, the Secretary of HHS has been responsible for all federal public health and medical responses to public health emergencies cov- ered by the National Response Framework. HHS has broad authority to reshape critical parts of the legal landscape to enable an effective response during a disaster. In order for HHS and others to act, however, a public declaration of a disaster or of a public health emergency is required.

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8 MEDICAL SURGE CAPACITY Declaring Federal Disasters: Implications for Public Health Emergencies Declaration of a major disaster by the President of the United States under the Stafford Act grants the HHS Secretary the authority to imple- ment various public health actions to respond to the emergency. The HHS Secretary also has the ability to declare a public health emergency, independent of the President’s authority, should the situation require it. Once a public health emergency has been declared, Susan Sherman the general council at ASPR, noted, “The Secretary can also consider whether or not to waive certain Medicare/Medicaid and CHIP [Chil- dren’s Health Insurance Program] requirements.” Other waivers can also come into play, as long as HHS has declared a public health emergency and the President has declared an emergency under the Stafford Act or the National Emergencies Act. These so-called 1135 waivers (named after Section 1135 of the Social Security Act) ap- ply only within the emergency area during the emergency period. These waivers include: • Waiver of Emergency Medical Treatment and Labor Act (EMTALA) sanctions for 72 hours, except in the case of pan- demic infectious disease; • Waivers concerning various conditions of participation, program participation requirements, certification requirements, and Stark self-referral sanctions for 72 hours; • Waiver of deadlines and timetables for the performance of re- quired activities; and • Waiver of the requirements that healthcare providers hold li- censes in the state where they provide services (for the purposes of Medicare, Medicaid, and SCHIP only). The HHS Secretary can also work with and mobilize various groups during a public health emergency, including the following: • The National Disaster Medical System is a coordinated effort of DHS, the Department of Defense (DoD), the Veterans Admini- stration (VA), and HHS collaborating with states and public and private entities to provide health and related services to victims of a public health emergency;

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9 WORKSHOP SUMMARY • The Commissioned Corps of the U.S. Public Health Service led by the Surgeon General was founded to pursue public health through health promotion and disease prevention. In addition, there are emergency response teams that are trained and equipped to respond to disaster situations; • The Medical Reserve Corps is made up of practicing and retired healthcare personnel (physicians, nurses, and others) who come together at a local or state level to assist with public health needs during large-scale emergencies; and • The Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) is a national system of state- based programs that include recruitment, advanced registration, licensure and credential verification, assignment of standardized credential levels, and mobilization of volunteers. Licensing and Interstate Credentialing During a catastrophic health event, the need for staff may go far be- yond what is available within the local healthcare system, and volunteers may need to be used. In the wake of Hurricane Katrina, for instance, vol- unteers came from across the country and around the world. Each indi- vidual arrives on the scene with different skills and experience. For a crisis coordinator on the scene, it is critical to know who can be involved, how they can be used, and what liability protections are in place to protect both the volunteers and the facilities in which they will be working, explained James Hodge from Johns Hopkins University’s Center for Law and the Public’s Health. Ultimately, these are questions of licensing, credentialing, and privileging. To better understand these issues, the following definitions were provided: • Licensing—The authority that comes from a state government, allowing an individual to practice a specific medical profession based on state-specific requirements. • Credentialing—A general assessment of the qualifications of a specific, state-licensed healthcare practitioner to provide services within a given entity or organization. • Privileging—A step added to credentialing; this means the abil- ity to provide specific health services within a given organiza-

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10 MEDICAL SURGE CAPACITY tion. This is not dictated by the state, but is related to how a spe- cific organization operates. In the practice of non-crisis medicine, these steps are sequential and pedestrian: A physician gets a state license, attains credentials in a cer- tain organization, and is granted privileges to practice within a certain hospital system. But in a crisis, how these steps interact depends on who a volunteer is working for, and what types of emergency declarations have been made. In situations when the federal government uses out-of- state volunteers and authorizes them to provide services, everything is set. “Federal authority allows for anyone licensed in the state, working for the Feds, to go to any other facility authorized by the feds to provide services,” said Johns Hopkins’ Hodge. Beyond that scenario, five situations can provide certain portability in licenses and credentials—and the liability coverage that goes with them—to out-of-state volunteers. Which one, or more, of the following applies in a particular location or crisis is entirely situational. 1. Certain states explicitly note in law that license reciprocity exists for the duration of a state of emergency, state of disaster, or state of public health emergency, as long as the license is in good standing in another jurisdiction. 2. A given jurisdiction may participate in interjurisdictional com- pacts such as the Emergency Management Assistance Compact (EMAC). 3. Mutual Aid agreements may exist among jurisdictions at local, state, and even unnecessary tribal levels that recognize the li- censes of healthcare practitioners across those jurisdictions. For example, the Mid-America Alliance allows for the provision of services even outside of any declared emergency. 4. During an emergency, governors may issue orders formally rec- ognizing out-of-state licenses, which happened in the aftermath of Hurricane Katrina. 5. Good Samaritan Laws in some jurisdictions may explicitly rec- ognize out-of-state licensure in specific circumstances, such as the practice of emergency medicine. Understanding what does and does not apply in a crisis is ultimately the responsibility of each organization participating. “In fact,” explained Hodge, “The Joint Commission [the primary certifying organization for

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11 WORKSHOP SUMMARY hospitals] requires hospitals to be prepared and ready to do fast, rapid credentialing and/or privileging as needed to ensure that they can provide emergency patient care.” Although mechanisms may be in place to ensure a volunteer is legally licensed to practice, challenges remain. With an eager, legally licensed physician standing in front of you, how do you decide the scope of care that the physician will be given? This scope of practice is state- specific: A practitioner in one state may be authorized to provide a specific service that is provided by someone else in the neighboring state. Additionally, many volunteers are concerned with the liability issue: Will they be protected while they provide services out of their regular jurisdiction? Even with a legal liability framework in place, a key factor in both answering this question and ensuring a smooth allocation of personnel is the advanced registration of volunteers. Many of the various protections and guidelines for license reciprocity are actually dependent on using volunteers who have registered in advance, been approved, and are ready to provide services. As Hodge noted, “Spontaneity is out. Spontaneous volunteers are disdained.” The problems don’t go away with paid staff, either. Workshop par- ticipants noted that plans must be in place to suspend certain staffing rules in order for the group to function optimally in an emergency situa- tion. One way to prepare for this is to have staffing waivers for union, Medicare, or other rules in place before an incident occurs. Leslee Stein-Spencer, manager of quality improvement at the Chi- cago Fire Department, shared her experience. “We wrote a letter now requesting a staffing waiver in case of declared emergency. We need that for our unions and for our other response systems in place.” With these triggered agreements in place, it means staff can focus on performing the necessary tasks in a time of crisis, not just the paperwork. “The letter is already written … in case an incident occurs, we will be able to move forward.” Most of the measures described above cannot be taken without for- mal declaration that an emergency exists. Generally speaking, this re- quires the official action of a state’s governor or the federal government. Federal agencies cannot legally respond within a state unless they are requested or authorized by the state’s government. This delayed some federal assets, including DMAT teams, from moving into affected areas in the chaotic days following Hurricane Katrina.

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56 MEDICAL SURGE CAPACITY Staff Considerations One of the hardest challenges to manage in shifting from response to recovery is the role of staff. Some entities have taken the approach of defining what each employee’s role is during an emergency—who are the first responders and who are responsible for keeping operations going while others respond. Critically, some roles may change once a declared disaster is officially over. In the Department of State Health Services in Texas, each employee’s job description details his or her role in a disas- ter. In Florida, the Martin Memorial Health Systems employs storm teams, with one team staying onsite at facilities for the duration of the event, and the second team relieving them after the storm. Even more important is to develop programs that support personal and family preparedness. The healthcare workers should all have a plan for how their families will respond to an incident, such as those promoted by the Red Cross, address evacuation, emergency planning, supply kits, and communications. Staff also require personal support during and after an incident. They need to know that they and their families are safe and supported. For ex- ample, they will be more likely to report for work if a childcare plan is in place and lasts through recovery efforts. “We mobilize our daycare fa- cilities immediately,” said Robitaille of Martin Memorial Health Sys- tems. “We have a very comprehensive associate-assistance program to facilitate their ability to get back to normal—whether it’s housing, food, shelter, or childcare,” he explained. “We found that has been extremely valuable in being able to help our associates, but to also make sure they’re available to be able to come back and perform their duties.” Repatriation Just as good discharge planning begins when the patient is admitted, planning for repatriation occurs before a disaster begins. “Getting people back home in many ways is more difficult than getting them out of harm’s way,” said David Lakey, commissioner of the Texas Department of State Health Services. He noted that after a disaster standards of care return to normal, and what was appropriate during the emergency is no longer appropriate—which changes the resources you use. “Individuals that were evacuated by buses or by airplane may now need to be sent back home by ambulances.”

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57 WORKSHOP SUMMARY Patient-tracking needs after a disaster are similar to those during one—names, addresses, and shelter identification are all important. But when it comes to thinking about getting people home, it is important to understand their medical needs and the type of environment to which they will return. Essential infrastructure such as electricity and sanitation services need to be in place before evacuees can be returned to the com- munity. After the 2008 Galveston Hurricane, officials used the media to inform the public that, until such basic services were available, they could not return. Once the basics were up and running, the public health infrastructure and basic medical infrastructure had to be back in place before the general public could return. Beyond that, “Additional infra- structure … had to be up in place before medical special needs individu- als could safely return,” said Lakey. For example, if a person is on dialysis, it is important that they are not returned to the community until the local outpatient dialysis center is open and ready for patients. Depending on a disaster’s scale and scope, repatriation will always be a local, intrastate, and possible interstate or national issue that corre- lates to the dynamics of the population evacuated. Factors include desti- nation(s); acuity; evacuee type (general, special-needs; hospital, etc.), infrastructure status, ground transportation including EMS units, coordi- nation and communication, and others. Because of this, Lakey suggested unifying transportation standards-of-care and electronic tracking into cohesive, national standards. He noted, “We need a unified tracking sys- tem instead of a collection of systems. We need to consider how some of the federal assets might be used in this repatriation process.” Repatriation is an essential part of recovering from a mass-casualty incident, but it is complicated by the fact that recovery of communities is less predictable than the recovery of a single individual or a single hospi- tal. Moving patients and other evacuees out-of-state, adds to the compli- cations for repatriation. It is a long-term process that can drain organizational resources as care is provided for evacuees for extended periods of time. Workshop participants noted that this broad, long-term resource drain is an area that needs further research, discussion, and funding. FINANCING SURGE CAPACITY AND PREPAREDNESS A continued theme throughout the workshop was that current financ- ing strategies have not and will not be able to support efforts to plan,

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58 MEDICAL SURGE CAPACITY prepare, and respond to catastrophic health incidents. For example, one gap discussed in detail was the need to appropriately finance training. As William Smith, senior director for emergency preparedness at University of Pittsburgh Medical Center, said, “We have lots of stuff, but we don’t have the money to pay people to learn how to use it properly and how to deploy it properly.” The need to fund training exists at all levels of medi- cal surge, from front-line emergency workers, clinic staff, nurses, and physicians to non-medical staff who will be called on in a crisis. The old adage “form follows finance” was brought up many times throughout the workshop, and participants noted that the existing finance system is not helping. “Everything we do about how we finance and en- gineer healthcare delivery in the United States is designed to thwart pre- paredness,” suggested Emory University’s Kellerman. To set the stage for discussions, workshop participants examined the various ways health care is paid for in the United States and how each can contribute to emergency preparedness planning and medical surge. Centers for Medicare & Medicaid Services Medicare can represent 30 percent or more of an average physician’s revenues. Hospital revenue is often even more heavily dependent on Medicare, with as much as 50 percent of operating revenue coming from inpatient and outpatient services to Medicare patients. Because of this, the continued flow of Medicare payments during a mass-casualty inci- dent is financially critical for healthcare systems. One of CMS’s roles is to ensure the continuity of healthcare services to its beneficiaries by paying for services rendered to individual patients. “We assist when there is a disaster, in trying to ensure that our payments flow more easily,” said Marc Hartstein, deputy director of the CMS Hos- pital and Ambulatory Policy Group. CMS has created an emergency pre- paredness website that is updated with various resources such as links and answers to payment and billing policy questions. During an emergency, CMS has some limited flexibility in the rules that can be waived. If a public health emergency has been declared, an 1135 waiver can be made. An 1135 waiver allows CMS to waive some rules and regulations—but not all of them.3 Hartstein explained, “Most of 3 Of note, since the workshop took place President Obama declared a public health emergency (October 24, 2009), which among other things provided HHS Secretary Kath- leen Sebelius the authority to permit CMS to waive a number of its requirements.

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59 WORKSHOP SUMMARY the rules and regulations that we’ll waive will be related to things like conditions or participation, certification requirements, requirements that physicians and other healthcare professionals hold licenses in states where they provide services, sanctions under the Emergency Medical Treatment and Labor Act—[those] would be some examples— and sanctions and penalties arising from noncompliance with certain HIPAA [Health Insurance Portability and Accountability Act] privacy regulations.” But some things cannot be waived. “One of the things that we can’t wave is payment regulations,” Hartstein said. This means that rules about fee-for-service payments or about transferring patients between acute care facilities cannot be abridged. This issue was particularly important in Arkansas when patients were evacuated from Louisiana after Hurri- cane Katrina. CMS worked with the Arkansas hospitals to help them un- derstand how the transfer policy regulations work in those situations— what to do when the patients were there for a length of time that caused them to go into “outlier” status. In short, the rules and regulations of CMS remain functionally intact from a payment perspective regardless of the crises. The 1135 waivers serve primarily to ensure that patients receive care, not to provide addi- tional, alternative, or streamlined funding for healthcare providers. Private Insurance Plans Although there is no insurance code that physicians can use to bill for disaster-training activities, the private insurance companies do play a part in preparing and responding to catastrophic incidents. The most important factor for the healthcare system is that insurance companies are up and running and paying for services. Private insurers, just like Medicare and Medicaid, need to be prepared for the payment issues that arise from mass-casualty events, especially when patients may be seeking treatment at facilities that are not part of their insurer’s net- work. “We have asked our plans to look at rules that actually need to be waived,” said Diana Dennett of America’s Health Insurance Plans. “For example: cost sharing, out of network, those kinds of rules.” Straighten- ing out problems can become quite complicated, especially when a disas- ter is focused in a certain geographical area and waivers are requested for people in those areas, but not in others. For example, during Hurricane Katrina waiver requests were coming in based on what parish (Louisi-

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60 MEDICAL SURGE CAPACITY ana’s equivalent of a county) people lived in, but the insurance plans don’t organize their members that way. Dennett noted that thinking about regional approaches would reduce these types of complications. Ultimately, it is in insurance plans’ best interest that their members be prepared for emergencies, and some use existing nurse hotlines to supply their members with access to medical information or advice with- out requiring an office visit during a crisis. It makes good business sense from the insurers’ point of view to reduce the need for office visits if a member can be safely and effectively treated at home. If they need to enter the healthcare system, private insurers need to know where their patients are, so patient tracking is important to them as well. Unfortu- nately, large-scale funding of preparedness programs by private insur- ance companies is absent. Funding EMS Surge—A Gap in Planning? “In the fee-for-service world, you really don’t fund surge, you fund what exists,” said Kurt Krumperman, clinical assistant professor at the Department of Emergency Health Services at the University of Maryland–Baltimore County. In the EMS world, that means a fee-for- service model that is tied to transports with no money for readiness costs. Funding is based on day-to-day patient care needs, and even then it may not be adequate. A Government Accountability Office report on Medi- care funding showed that on average, Medicare pays 6 percent below the average cost of service for EMS (GAO, 2007). In urban areas, Krumper- man explained, there may not be adequate resources to meet response time standards of 8 minutes or less for 90 percent of calls received. Workshop participants noted that local EMS surge ability currently comes through local or regional mutual-aid relationships. Nationally, there are two systems for mutual aid in a disaster—the Emergency Man- agement Assistance Compact and the FEMA ambulance contract. Under EMAC, states provide mutual aid to other states using resources drawn from their local communities. With FEMA ambulance contracts, the agency contracts directly with EMS companies to provide resources to an affected community. Both systems have their problems. “There are a lot of issues that re- late to the EMAC response,” Krumperman said. “It has to do with the lack of set rates, the issue of low bid, lack of consistent standards, delays in payments or no payments, different rate structure between the FEMA

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61 WORKSHOP SUMMARY ambulance contract and what EMAC reimbursement is, not being able to backfill overtime on EMAC responses, and also, finally, who assumes the risk?” Despite the problems mentioned above, the nation has demonstrated the ability to field a large national response after Hurricane Katrina and other hurricanes. Still, Krumperman asked, what kind of capacity is ex- pected for a community to have at a local level if federal response is not available? Funding Alternatives “The point has been made before—the IOM report on EMS made it—that the funding for training and for equipment related to disaster re- sponse from the first responder grant program, it’s only been 4 percent for EMS and it’s been that way since the inception of the program,” ex- plained Krumperman. This makes funding anything not immediately put to use on the street—spare capacity—problematic. Biologue’s Runge proposed a shift away from straightforward payments for capacity to a plan-driven, requirement-defined system that pays for capabilities instead. “The bigger issue is how do we get the people, how do we provide enough people on the ground to provide that surge that we want?” asked Krumperman. “If we don’t figure that out, the equipment’s just going to sit there.” The solution is to create spare personnel capacity within the EMS system, and fund it through community-based funding, rather than on a pure fee-for-service basis. Krumperman outlined an example of how such a system might work. He suggested starting by calculating the costs to provide basic emer- gency medical services to the community—ambulance, first response, and medical communications—all of the components that the community wants to include. The community can then determine what amount of surge capacity the community wants above that, realizing that those re- sources would be idle on a day-to-day basis specifically so they could be available when needed. EMS would then be funded to maintain those capabilities. The question becomes: How should those capabilities be used for the public good? What activities can those providers offer given their skills as EMS responders? “Is it in public health? Is it in immunizations?” asked Krumperman. “EMS providers play a lot of different healthcare

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62 MEDICAL SURGE CAPACITY roles in disasters, and perhaps they could be done on a regular basis in a community” to prepare ahead of time. Instead of funding on a fee-for-service basis, Krumperman suggested funding on a per-capita basis, a monthly fee that all insurers pay into— including Medicare and Medicaid. At the time of the workshop, the draft bill on healthcare reform from the Senate Committee on Health, Educa- tion, Labor, and Pensions committee contained a component relating to a pilot project for regional EMS systems that dealt with, among other con- cerns, surge and the development of adequate surge funding. Looking Ahead Throughout the workshop, participants noted that the way we fund medical surge capacity and emergency preparedness in this country does not work. There is no sustained funding to plan for or prepare for medi- cal disasters, and it is only after a disaster has occurred that money is available through the Stafford Act. As Runge asked rhetorically, “Where’s the Stafford Act for predisaster?” Where does the money come from to do the planning, run the simulations, or train and drill providers on how to handle disasters that may be looming ahead? It doesn’t come from fee-for-service funding; it is only marginally addressed by grants, and possibly not all that well. The Maryland Insti- tute for Emergency Medical Services System’s Bass said, “As a state EMS director, my personal experience is that federal efforts to drive planning and response through grants are overly prescriptive and too compartmentalized, hampering state and local efforts to address the com- plex issues and unique needs of state-level planning and coordination, and in the end are counterproductive.” Any discussion of the “how” in financing preparedness quickly devolves to a discussion of “who,” and while opinions varied, workshop participants agreed national leadership was needed. “One of the few good reasons to have a federal government is to provide for the common defense,” suggested Runge. “There is a pre-event phase that has to enter into this common defense ethic. It is a shared responsibility” that flows from the federal government to the state level and down into each community. In this line, William Smith, senior director of emergency prepared- ness at the University of Pittsburgh Medical Center, joined other work- shop participants in suggesting that going forward, federal funding

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63 WORKSHOP SUMMARY should emphasize regional capabilities. “My idea for future funding is to emphasize regional planning,” said Smith. “Maybe even mandate that in terms of the utilization of the money, so it’s most effective for the popu- lations served, not necessarily for the individual institutions.” CONCLUSIONS The IOM’s workshops exist to bring together a diverse set of view- points to tackle major problems—in the case of this workshop, the issue of medical surge planning. This program certainly did that, bringing to- gether nearly 100 people from 21 states, representing many segments of the health system, from doctors to public health officials to service mem- bers, EMS directors, morticians, and more. Workshop discussions highlighted that the HHP program should consider the following in the development of their grant guidance: (1) planning must be regional, (2) funding must be identified and sus- tained for pre-disaster as well as post-disaster, and (3) unique needs and constraints of the private healthcare system must be identified and acknowledged. This unique gathering served a unique purpose: Perhaps the single most important lesson drawn from the workshop was that, in order for surge planning to work, each of these parties must work with the others, efficiently and according to plans. It goes far beyond the hospital, but includes coordination among all components of the health system. The picture that emerged of a successful medical surge was a plan- ning and response system that goes beyond just hospital and that has the following features: politicians who rapidly issue disaster proclamations, and legal teams who work immediately on credentialing and authoriza- tions; contingency staffing plans that snap into place, and hospital triage teams that are ready to function; activation of contingency plans throughout the health system including alternate care facilities that are staffed, and funeral directors that have local-language translators on hand, ready to help; hospital daycare facilities that are activated, payers who keep the necessary funds flowing, EMS who are ready, and an en- gaged public. It is a web of support, and failures at any one point lead to lost lives and lost opportunity. But the nature of disaster response extends beyond individual re- sponsibilities, and indeed, beyond individual jurisdictions. One message that was hammered home throughout the workshop was that disasters do

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64 MEDICAL SURGE CAPACITY not strike inside the political lines drawn on a map. There is a need to think regionally, and to figure out how to leverage all of the healthcare resources in a community for the good of the whole community. As Gerry Parker, principle deputy secretary at ASPR said during the work- shop’s closing remarks, “Regionalization is a theme that is really starting to resonate, and we need to think about what that really means … how we can break down those barriers to regional planning, and how we can find those incentives that will enable regional planning in a more mean- ingful, constructive way.” Discussions at the workshop presented numerous examples of what has worked—and what has not—in various communities around the na- tion during various disaster events. But participants clearly saw the need for clear and concise definitions, standards, and metrics in order to facili- tate further advances. To do this, more solid, evidence-based research needs to be done in the field of emergency preparedness. Additional re- search should be quantitative, not just qualitative, in nature, according to participants, to make it possible to start putting hard numbers on what has been traditionally a soft science. A key theme from the workshop was the need to involve the public in some of these difficult issues. Communication and education before an event occurs will go a long way in helping the population understand what will need to be done. Just as school children are taught “stay low and go” they also need to understand the basic steps of protecting them- selves in an emergency or pandemic situation. Another key to emergency preparedness and meeting medical surge demand is the staff that are in the trenches, doing the work. Are they adequately trained and drilled? Do they know the procedures? Are there enough staff to do what needs to be done? If not, how can you get more? This lack of staff and training for staff was mentioned in every session of the workshop. Participants also emphasized that it is important to have support in place for the caregivers and healthcare providers that are re- sponding during an event. Even caregivers need food, sleep, and emo- tional support. One issue that was seen as missing from the workshop’s discussions was the fact that in many places, healthcare workforces are downsizing and hospitals are closing. Sally Phillips from HHS said, “We’ve got lay- offs going on all over the place, even hospitals doing layoffs. And in that light, though, we still have a responsibility when the balloon goes up to provide that care, somehow.”

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65 WORKSHOP SUMMARY Finally, there are huge financing challenges, both in terms of the amount of money available for preparedness and how those funds are made available. As HHS’s Parker said, “Grants are necessary and we do need to do a better job, particularly with the lessons we have learned, so we can more intelligently target our grant programs in the future.” But he cautioned that grants alone aren’t sufficient for preparing the nation for mass-casualty events. Many workshop participants believe that preparedness is fundamentally a national security issue, and suggested that funding can come from that arena. As the University of Pittsburgh Medical Center’s Toner said, “We always find ways to pay for national security projects. We have to find a way to pay for this.” Inova Health Systems’ Hanfling put preparedness efforts in perspec- tive. “The dual luxuries that we have, right now before us, of time and available resources: They should be taken advantage of, because once we hit scarcity and fear, we’re not going to be able to innovate. Now is the time for innovation.” Through the HPP program and other federal funding mechanisms, the health system can continue to make the progress necessary to reach these difficult, but important, goals.

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