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Forum on Medical and Public Health Preparedness for Catastrophic Events Board on Health Sciences Policy Board on Health Care Services Megan Reeve, Theresa Wizemann, Bradley Eckert, and Bruce Altevogt, Rapporteurs PREPUBLICATION COPY: UNCORRECTED PROOFS

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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, NW • Washington, DC 20001 NOTICE: The workshop that is the subject of this summary was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This activity was supported by contracts between the National Academy of Sciences and the American College of Emergency Physicians; American Hospital Association; Association of State and Territorial Health Officials; Centers for Disease Control and Prevention (Contract No. 200-2011-38807, TO #19); Department of Defense (Contract No. HT0011-11-P-0186); Department of Defense, Uniformed Services University of the Health Sciences (Contract No. HT9404-12-1-0022); Department of Health and Human Services’ National Institutes of Health: National Institute of Allergy and Infectious Diseases, National Institute of Environmental Sciences, National Library of Medicine (Contract No. HHSN26300007 [Under Base 1 #HHSN263201200074I]); Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response (Contract No. HHSO100201000021P); Department of Homeland Security’s Federal Emergency Management Agency (Contract No. HSFE20-13-P-0212); Department of Homeland Security, Office of Health Affairs (Contract No. HSHQDC-13-J-00384 [Under Base 1 #HSHQDC-11-D-00009]); Department of Transportation’s National Highway Traffic Safety Administration (Contract No. DTNH22-10- H-00287); Department of Veterans Affairs (Contract No. 101-G09041); Emergency Nurses Association; Food and Drug Administration (Contract No. HHSF22301027T [Under Base Contract DHHS-8598]); Infectious Diseases Society of America; Martin, Blanck & Associates; Mayo Clinic; Merck Research Laboratories (Contract No. 2391); National Association of Chain Drug Stores; National Association of County and City Health Officials; National Association of Emergency Medical Technicians; Pharmaceutical Research and Manufacturers of America; Target Corporation; Trauma Center Association of America; and United Health Foundation. The views presented in this publication do not necessarily reflect the views of the organizations or agencies that provided support for the activity. International Standard Book Number-13 0-309-0XXXX-X International Standard Book Number-10 97-XXXXX Additional copies of this workshop summary are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2014 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: IOM (Institute of Medicine). 2014. The impacts of the affordable care act on preparedness resources and programs: Workshop summary. Washington, DC: The National Academies Press. PREPUBLICATION COPY: UNCORRECTED PROOFS

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org PREPUBLICATION COPY: UNCORRECTED PROOFS

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WORKSHOP PLANNING COMMITTEE1 GEORGES BENJAMIN (Co-chair), American Public Health Association, Washington, DC GREGG MARGOLIS (Co-chair), Division of Healthcare Systems and Health Policy, Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services, Washington, DC TERRY ADIRIM, Health Resources and Services Administration, U.S. Department of Health and Human Services, Washington, DC JACK EBELER, Health Policy Alternatives, Inc., Washington, DC DEBORAH LEVY, Division of Strategic National Stockpile, Centers for Disease Control and Prevention, Atlanta, GA PURVA RAWAL, Avalere Health, LLC, Washington, DC JEANNE RINGEL, RAND, Santa Monica, CA LISA TOFIL, Holland & Knight, LLP, Washington, DC KATHARINE WITGERT, National Academy for State Health Policy, Washington, DC MATTHEW ZAVADSKY, Medstar Mobile, Fort Worth, TX IOM Staff BRUCE M. ALTEVOGT, Project Director MEGAN REEVE, Associate Program Officer BRADLEY ECKERT, Research Associate ALEX REPACE, Senior Program Assistant 1 Institute of Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. v PREPUBLICATION COPY: UNCORRECTED PROOFS

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FORUM ON MEDICAL AND PUBLIC HEALTH PREPAREDNESS FOR CATASTROPHIC EVENTS1 ROBERT P. KADLEC (Co-chair), RPK Consulting, LLC, Alexandria, VA LYNNE R. KIDDER (Co-chair), Consultant, Boulder, CO ALEX J. ADAMS, National Association of Chain Drug Stores, Alexandria, VA ROY L. ALSON, American College of Emergency Physicians, Winston-Salem, NC WYNDOLYN BELL, UnitedHealthcare, Atlanta, GA DAVID R. BIBO, The White House, Washington, DC KATHRYN BRINSFIELD, Office of Health Affairs, Department of Homeland Security, Washington, DC CAPT. D. W. CHEN, Office of the Assistant Secretary of Defense for Health Affairs, Department of Defense, Washington, DC SUSAN COOPER, Regional Medical Center, Memphis, TN BROOKE COURTNEY, Office of Counterterrorism and Emerging Threats, U.S. Food and Drug Administration, Washington, DC BRUCE EVANS, National Association of Emergency Medical Technicians, Upper Pine River Fire Protection District, Bayfield, CO JULIE L. GERBERDING, Merck Vaccines, Merck & Co., Inc., West Point, PA LEWIS R. GOLDFRANK, New York University School of Medicine, New York City DAN HANFLING, INOVA Health System, Falls Church, VA JACK HERRMANN, National Association of County and City Health Officials, Washington, DC JAMES J. JAMES, Disaster Medicine and Public Health Preparedness, Onancock, VA PAUL E. JARRIS, Association of State and Territorial Health Officials, Arlington, VA LISA G. KAPLOWITZ, Office of the Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services, Washington, DC ALI S. KHAN, Centers for Disease Control and Prevention, Atlanta, GA 1 Institute of Medicine forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. vi PREPUBLICATION COPY: UNCORRECTED PROOFS

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MICHAEL G. KURILLA, National Institute of Allergy and Infectious Diseases, Washington, DC JAYNE LUX, National Business Group on Health, Washington, DC LINDA M. MACINTYRE, American Red Cross, San Rafael, CA SUZET M. MCKINNEY, Chicago Department of Public Health, Chicago, IL NICOLE MCKOIN, Target Corporation, Furlong, PA MARGARET M. MCMAHON, Emergency Nurses Association, Williamstown, NJ AUBREY K. MILLER, National Institute of Environmental Health Sciences, Bethesda, MD MATTHEW MINSON, Texas A&M University, College Station ERIN MULLEN, Pharmaceutical Research and Manufacturers of America, Washington, DC JOHN OSBORN, Mayo Clinic, Rochester, MN ANDREW T. PAVIA, Infectious Disease Society of America, Salt Lake City, UT STEVEN J. PHILLIPS, National Library of Medicine, Bethesda, MD LEWIS J. RADONOVICH, Department of Veterans Affairs, Washington, DC MARY J. RILEY, Administration for Children and Families, Department of Health and Human Services, Washington, DC KENNETH W. SCHOR, Uniformed Services University of the Health Sciences, Bethesda, MD ROSLYNE SCHULMAN, American Hospital Association, Washington, DC RICHARD SERINO, Federal Emergency Management Agency, Department of Homeland Security, Washington, DC MARGARET VANAMRINGE, The Joint Commission, Washington, DC W. CRAIG VANDERWAGEN, Martin, Blanck & Associates, Alexandria, VA JENNIFER WARD, Trauma Center Association of America, Las Cruces, NM JOHN M. WIESMAN, Washington State Department of Health, Tumwater GAMUNU WIJETUNGE, National Highway Traffic Safety Administration, Washington, DC vii PREPUBLICATION COPY: UNCORRECTED PROOFS

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IOM Staff BRUCE M. ALTEVOGT, Forum Director MEGAN REEVE, Associate Program Officer BRADLEY ECKERT, Research Associate ALEX REPACE, Senior Program Assistant ANDREW M. POPE, Director, Board on Health Sciences Policy ROGER HERDMAN, Director, Board on Health Care Services viii PREPUBLICATION COPY: UNCORRECTED PROOFS

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Reviewers This workshop summary has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published workshop summary as sound as possible and to ensure that the workshop summary meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this workshop summary: Elisabeth Belmont, Mainehealth Diane Pilkey, U.S. Department of Health and Human Services Arlene Stanton, Substance Abuse and Mental Health Services Administration Jolene Whitney, Utah Department of Health Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the workshop summary before its release. The review of this workshop summary was overseen by Kristine Gebbie, Flinders University School of Nursing and Midwifery. Appointed by the IOM, she was responsible for making certain that an independent examination of this workshop summary was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this workshop summary rests entirely with the author(s) and the institution. ix PREPUBLICATION COPY: UNCORRECTED PROOFS

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Contents 1 INTRODUCTION 1 Workshop Objectives, 2 Background and Overview, 3 Organization of the Report, 9 Topics Highlighted During Presentations and Discussions, 10 2 HOW THE ACA WILL CHANGE THE HEALTH CARE DELIVERY SYSTEM 15 Coverage Expansion, 18 Financing and Delivery Reform, 19 3 PREPAREDNESS IMPACTS OF THE CHANGES TO HEALTH CARE SYSTEM FINANCING AND DELIVERY INFRASTRUCTURE 23 Integrated Care and Opportunities for Preparedness, 24 Preparing to Meet the Needs of the Most Vulnerable, 28 Distributed Networks of Care, 30 Financing Preparedness, 33 4 THE EVOLVING HEALTH WORKFORCE 37 Workforce Implications of New Care Settings, 38 Changes in Hospital Operations Impacting Workforce, 41 Opportunities for New Provider Roles in Health Care and Preparedness, 42 Training, 47 xi PREPUBLICATION COPY: UNCORRECTED PROOFS

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5 NEEDS AND LOGISTICS OF DATA SHARING AND HEALTH INFORMATION TECHNOLOGY 51 Understanding the Needs of the Population: Turning Data into Information, 52 Transforming the Health Information Infrastructure, 53 Standards and Interoperability, 55 6 POTENTIAL OPPORTUNITIES TO ENHANCE PREPAREDNESS THROUGH HEALTH INFORMATION EXCHANGES AND PREDICTIVE ANALYTICS 61 Health Information Exchanges, 62 Predictive Analytics in Public Health Preparedness, 67 7 LEVERAGING THE AFFORDABLE CARE ACT AND INFORMATION TECHNOLOGY TO INNOVATE 75 PCCI: Layering Technologies for Information Exchange, Analytics, and Continuity of Care, 76 Integrating Telemedicine into Disaster Plans, 80 Incorporating Health Information Technology into Everyday Use, 82 8 THE CONTINUING ROLE FOR PUBLIC HEALTH PREPAREDNESS AND RESPONSE 85 Insurance: Not a Replacement for Public Health, 86 Expanding Public Health Capacity and Reach through Public–Private Collaborations, 88 Looking Forward, 97 APPENDIXES A REFERENCES 99 B ACRONYMS 103 C STATEMENT OF TASK 105 D AGENDA 107 E BIOGRAPHICAL SKETCHES OF INVITED SPEAKERS AND PANELISTS 117 F KEY FEATURES OF THE AFFORDABLE CARE ACT BY YEAR 135 xii PREPUBLICATION COPY: UNCORRECTED PROOFS