The Impacts of the Affordable Care Act on Preparedness Resources and Programs: Workshop Summary (2014)

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1 Introduction1 Many of the elements of the Affordable Care Act (ACA) went into effect in 2014, and with the establishment of many new rules and regulations, there will continue to be significant changes to the U.S. health care system. It is not clear what impact these changes will have on medical and public health preparedness programs around the country. Although there has been tremendous progress since 2005 and Hurricane Katrina, there is still a long way to go to ensure the health security of the country, said Gregg Margolis, director of the Division of Health Systems and Health Care Policy in the Office of the Assistant Secretary for Preparedness and Response (ASPR) at the U.S. Department of Health and Human Services. There is a commonly held notion that preparedness is separate and distinct from everyday operations and that it only affects emergency departments. But time and time again, he said, catastrophic events challenge the entire health care system, from acute care and emergency medical services down to the public health and community clinic level, and the lack of preparedness of one part of the system places preventable stress on other components. The implementation of the ACA provides the opportunity to consider how to incorporate preparedness into all aspects of the health care system. For example, how will the provisions of the ACA, such as coverage expansion, payment reform, 1 The planning committee’s role was limited to planning the workshop. The workshop summary has been prepared by the rapporteurs and staff as a factual account of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the Institute of Medicine. They should not be construed as reflecting any group consensus. 1 

2 IMPACTS OF THE ACA ON PREPAREDNESS workforce issues, health information technology (IT), and telehealth2 impact preparedness? How do investments in preparedness and national health security improve everyday health care? We have the opportunity to bridge two worlds, Margolis said, and bring the health care policy and emergency preparedness communities together to think about how to achieve Berwick’s Triple Aim3 of higher-quality care, better population health across the country, and lower cost, with an added focus on making our nation more prepared. WORKSHOP OBJECTIVES On November 18 and 19, 2013, the Institute of Medicine’s (IOM’s) Forum on Medical and Public Health Preparedness for Catastrophic Events convened a workshop in Washington, DC, to discuss how changes to the health system as a result of the ACA might impact medical and public health preparedness programs across the nation. Workshop objectives are highlighted below (see Box 1-1).4 BOX 1-1 Meeting Objectives • Explore opportunities to leverage benefits of health care reform and develop action steps that the preparedness community can take to mit- igate identified challenges. • Discuss challenges and benefits of the Affordable Care Act to disaster preparedness and response efforts around the country. • Consider how changes to payment and reimbursement models will present opportunities and challenges to strengthen disaster prepared- ness and response capacities. 2 Telehealth refers to “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health- related education, public health and health administration.” Telehealth is broader than telemedicine, which generally refers to remote clinical services. See http://www.healthit.gov/ providers-professionals/faqs/what-telehealth-how-telehealth-different-telemedicine (accessed June 8, 2014). 3 Former President and CEO of the Institute for Healthcare Improvement (IHI) and former Centers for Medicare & Medicaid Services (CMS) Administrator, Donald Berwick, described his vision for health care as a “triple aim,” consisting of improving population health, improving the experience of care, and reducing per capita costs (Berwick et al., 2008). 4 The full Statement of Task can be found in Appendix C. 

INTRODUCTION 3  Explore potential impacts that changing health care delivery infrastruc- ture may have on disaster preparedness and response.  Consider how impacts on the health system workforce may impact resilience, emergency preparedness, response, mitigation, and recovery.  Explore how changes to data collected through health information technology may be used to strengthen community resilience. BACKGROUND AND OVERVIEW This summary discusses only the relevant preparedness impacts of the ACA that were discussed at the workshop, and may not be entirely comprehensive. However, it should cut across several issues. These include cost changes, access to care, quality of care, and a shifting mindset of the health care system to focus on value-based purchasing, patient-centered medical homes, and overall population health—both in daily life and in disaster settings. Some elements that were not discussed, but are worth mentioning, are the creation of the Ready Reserve Corps through the U.S. Public Health Service and the increased support of epidemiology and laboratory capacity for infectious diseases.5 The Ready Reserve Corps was formed under Section 5210 and creates additional Commissioned U.S. Public Health Service Corps volunteer members who can be available on short notice to assist in emergency or routine public health missions. Section 4304 establishes an epidemiology- laboratory capacity grant program to award funding to states and local and tribal jurisdictions to improve surveillance and threat detection and build laboratory capacity. These, and all the provisions mentioned throughout the report are compiled in Table 1-1 for ease of reference. It is important to note that all of these provisions are in various stages of implementation, so the impacts are limited to “potential.” 5 The full text of the bill, Patient Protection and Affordable Care Act, 42 U.S.C. §18001 (2010), can be found at https://www.govtrack.us/congress/bills/111/hr3590/text (accessed June 8, 2014). 

4 IMPACTS OF THE ACA ON PREPAREDNESS TABLE 1-1 ACA Provisions That Could Potentially Affect Medical and Public Health Preparedness Activitiesa Potential Impact on Preparedness as Title/Subtitle Presented by (Section) Topic Area Summary of Provisionb Individual Speakers A percentage of hospital Greater emphasis on payment would be tied to overall health of patient, hospital performance on prevention and well- Hospital quality measures related to ness; greater need to Title 3. A. I Value-Based common and high-cost condi- demonstrate value; (3001) Purchasing tions, such as cardiac, surgi- ensuring patient needs cal, and pneumonia care. are met before and after hospital visit.1 Provides funding to the Assis- Improved everyday care tant Secretary for Prepared- and emergency response ness and Response (ASPR) to at a regional level can support pilot projects that improve response in a design, implement, and eval- disaster;2,5 housing uate innovative models of under ASPR also can regionalized, comprehensive, allow for better coordi- and accountable emergency nation between prepar- care and trauma systems edness and daily Title 3. F (3504- Regional (3504); Reauthorizes and emergency programs.3 3505) Trauma Care improves the trauma care program, providing grants administered by the Health and Human Services (HHS) Secretary to states and trauma centers to strengthen the nation’s trauma system (3505). Reduction in federal Medi- For those states that do caid Disproportionate Share not expand their medi- Hospital Allotments at the caid program, the cov- state level, based on the as- erage increase will not Disproportion- sumption of increased cover- occur. But, their Title 3. G age and reduced uncompen- “safety-net” hospitals ate Share Hos- (2551); Title 3. sated care costs. While the will still lose this allot- pital (DSH) B (3133) statute sets forth reductions ment and correspond- Allotments through fiscal year (FY) ingly, they may have 2020, the final rule applies less resources to bear in only to reductions in FY 2014 a disaster.1,16,17 and 2015. Grant program to award fund- Increased funding and ing to states and local and capacity at the state and Epidemiology- Title 4. D tribal jurisdictions to improve local levels for threat Laboratory (4304) surveillance and threat detec- detection and bio- Capacity Grants tion and build laboratory surveillance.4 capacity. 

INTRODUCTION 5 Potential Impact on Preparedness as Title/Subtitle Presented by (Section) Topic Area Summary of Provisionb Individual Speakers Ready Reserve Corps mem- Building a network of bers may be called to active trained professionals duty to respond to national ready to respond in emergencies and public health disasters who can be Title 5. C Ready Reserve crises and to fill critical pub- deployed to assist in any (5210) Corps lic health positions left vacant public health emergency by members of the Regular and augment response.6 Corps who have been called to duty elsewhere. Increased emphasis on team- Potential for increased based service and merging of and better educated clinical and public health workforce within public U.S. Public Title 5. D training. Public health re- health field.6 Health Sciences (5314-5315) cruitment and retention pro- Track grams are also being expanded. Federally Expansion of Medicare- Could take the burden Qualified Covered Preventive Services of surge off of commu- Title 5. F (5502) Health Center at FQHCs; Increased spend- nity hospitals (and DSH (FQHC) Im- ing for FQHCs. payments) if patients provements shift routine care visits throughout FQHC net- Title 5. G FQHC work.7 (5601) Improvements Establishes private, nonprofit Increased data infra- institute to identify priorities structure and dissemina- for and provide for the con- tion of research findings Patient- duct of comparative outcomes focused on improved Centered Out- Title 6. D research. patient outcomes could comes Research (6301) contribute to more Institute standardized sharing of (PCORI) best practices to in- form.8 Imposes new requirements on Better awareness of 501(c)(3) organizations that community needs in an operate one or more hospital emergency and a more Community facilities to conduct a CHNA accurate population Title 9. A Health Needs and adopt an implementation picture; Opportunity for (9007, 6033(b), Assessment strategy at least once every 3 hospitals to partner 4959) (CHNA) years (9007); Also added a more with public health tax penalty for failing to meet departments to meet and report this requirement these requirements.7,9 (6033(b), 4959). 

6 IMPACTS OF THE ACA ON PREPAREDNESS Potential Impact on Preparedness as Title/Subtitle Presented by (Section) Topic Area Summary of Provisionb Individual Speakers Development of data collec- More data and infor- tion standards for five differ- mation will be available ent demographic factors and for improved awareness calls for them to be collected of community needs and in all national population resources; more infor- Data Collec- health surveys (4302); Re- mation will be available tion, Public quires the Secretary to collect for surveillance and Title 3. A. II Reporting; and aggregate consistent data predictive modeling (3015) Title 4. Understanding on quality and resource use potential.4,10,11,12 D (4302) Disparities, measures from information Data Collection systems used to support and Analysis health care delivery to im- plement the public reporting of performance information (3015). (1) By including mental Individuals can have health and substance use better coverage for daily disorder benefits in the Essen- mental health and sub- tial Health Benefits; (2) by stance abuse issues and applying federal parity pro- after a disaster may tections to mental health and have better access to substance use disorder bene- services because they Title 1. D. I Mental Health fits in the individual and are already familiar with (1302, 1311) small group markets; and (3) care and providers.9 by providing more Americans with access to quality health care that includes coverage for mental health and sub- stance use disorder services. Requires the development of While everyone is col- standards and protocols to lecting data, the data promote the interoperability of may not reach potential systems for enrollment of indi- unless they can be viduals in federal and state shared across county, health and human services state, and agency lines; programs (1561); Requires the standards and interoper- Health Director of the Centers for ability are key to build Title 1. G Information Disease Control and Prevention on HITECH Act and (1561); Title Technology, (CDC) to issue national stand- Meaningful Use stand- IV. D (4304) Interoperability, ards on information exchange ards.8,13,14 and Standards systems to public health entities for the reporting of infectious diseases and other conditions of public health importance in consultation with the National Coordinator for Health Infor- mation Technology (4304). 

INTRODUCTION 7 Potential Impact on Preparedness as Title/Subtitle Presented by (Section) Topic Area Summary of Provisionb Individual Speakers Patient navigator program Patient navigator pro- (3510); Funding outreach and gram can assist patients assistance for low-income in continuity of care and programs (3306); Clinical and staying healthy between Community Preventive Ser- disasters; Opportunity Title 3. F vices (4003); Community for improved care and (3510); Title 3. Transformation Grants overall health at the D (3306); Title Community (4201); Healthy Aging, Liv- community level 4. A (4003); Resilience ing Well: evaluation of through transformation Title 4. C community-based prevention grants and preventive (4201, 4202) and wellness programs for services; Evaluation of Medicaid beneficiaries community-based pro- (4202). grams could allow for improvements and ability to share lessons across cities and states.15 a The information presented in this table was compiled by the rapporteurs based on the presen- tations made by workshop speakers and highlighted through this workshop summary. Each poten- tial impact has been referenced to the workshop speaker or speakers who discussed the relevant topic. b Summary items garnered from https://www.govtrack.us/congress/bills/111/hr3590/text# (accessed June 8, 2014). 1 9 Speakers: Lisa Tofil Nicole Lurie 2 10 Norman Miller Gus Birkhead 3 11 Gregg Margolis Nathaniel Hupert 4 12 Georges Benjamin Brandon Dean 5 13 Charles Cairns Kevin Larsen 6 14 Ellen Embrey Roland Gamache 7 15 Karen DeSalvo Connie Chan 8 16 Justin Barnes Xiaoyi Huang 17 Jack Ebeler In a keynote address to open the workshop, Assistant Secretary for Preparedness and Response, Nicole Lurie, shared her perspective that health care delivery system reform will have tremendous benefits for preparedness, response, and recovery. For example, people with untreated chronic health conditions, including mental and behavioral health conditions, must deal with both the impact of the disaster and their ongoing condition. Often times, disaster settings can exacerbate under- lying illnesses, whether physical or mental. In addition, every disaster is accompanied by substantial impacts to individual and population mental health, and it is very hard to recover if one cannot access necessary care 

8 IMPACTS OF THE ACA ON PREPAREDNESS post-event. Together, through the ACA and the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), mental health and substance abuse benefits are being extended to more than 60 million people who did not previously have access to mental health care. The ACA and its implementing regulations, building on the MHPAEA, will expand coverage of mental health and substance use disorder benefits and federal parity protections in three distinct ways: (1) by including mental health and substance use disorder benefits in the Essential Health Benefits; (2) by applying federal parity protections to mental health and substance use disorder benefits in the individual and small-group markets; and (3) by providing more Americans with access to quality health care that includes coverage for mental health and substance use disorder services.6 Another benefit of the ACA is improved access to medications, both as a result of expanded insurance coverage and because health IT systems will support the prescribing process, regardless of where a patient may be transported to receive care. The loss of medications or the inability to refill needed medications during a disaster is a current challenge. Additionally, insurance expansion and delivery system reform will also address the issues of coverage of out-of-network care and the prohibitive co-pays often faced by people who need to evacuate an area post-event. In terms of preparedness and resilience, Lurie said, with health reform people will be better able to care for themselves pre-event, and have access to needed services post-event. Over time, she said, improved access to care in general will lead to substantial improvements in population health, which will in turn lead to greater resilience. The term resilience has been used more often in recent disaster planning and can have several definitions. According to a 2012 National Research Council report modified definition, “individual, community, and national resilience is the ability to prepare and plan for, absorb, respond, recover from, and more successfully adapt to adverse events. No person or place is immune from disasters or disaster-related losses. Infectious disease outbreaks, acts of terrorism, social unrest, or financial disasters as well as natural hazards can all lead to large-scale consequences for the nation and its communities. Enhanced resilience allows better anticipation of disasters and better planning to reduce disaster losses, rather than waiting for an event to occur and paying for it afterward” (NRC, 2012, p.16). Individuals and communities that are more resilient fare better in 6 See http://aspe.hhs.gov/health/reports/2013/mental/rb_mental.cfm (accessed June 8, 2014). 

INTRODUCTION 9 disasters (NRC, 2012; Plough et al., 2013). Lurie also pointed out that under the ACA, in order to maintain not-for-profit status, under Sections 9007, 6033, and 4959 of the law, a hospital must conduct a community health needs assessment and demonstrate a community benefit or be subject to a tax penalty. Preparedness and resilience are important community benefits, she said. Examples of how care organizations could have an impact on preparedness and simultaneously provide community benefit could include identifying vulnerable populations in the community; increasing public awareness and individual readiness; planning for the health facility’s role in the community post-event; and redesigning health care facilities to be resilient during and after an event. This is an opportunity for coalitions to further integrate and connect hospitals with public health departments. Provisions in the ACA can be leveraged to integrate preparedness into daily health care and to help create stronger routine and emergency health care delivery systems that can surge to respond to disasters (Lurie et al., 2013). While many hospitals and acute care centers often run close to capacity levels on a daily basis, being able to surge in a disaster and increase staffing, beds, and other equipment to accommodate an increase in patients can be critical in any disaster response. However, while the ACA may provide opportunities and incentives for health systems to prepare, it cannot ensure that entire communities are prepared, and there is still a strong role for medical and public health preparedness programs. ORGANIZATION OF THE REPORT The following report summarizes the presentations from expert speakers and discussions among workshop participants. Chapter 2 provides a brief overview of how the health system is changing under the ACA. The potential impacts of ACA implementation on preparedness, response, and recovery are presented in the report relative to three main areas: the health care delivery infrastructure and financing reforms (Chapter 3), the health care workforce (Chapter 4), and opportunities through health IT (Chapters 5 through 7). Finally, the ongoing role for public health in preparedness, response, and recovery is discussed in Chapter 8. 

10 IMPACTS OF THE ACA ON PREPAREDNESS TOPICS HIGHLIGHTED DURING PRESENTATIONS AND DISCUSSIONS7 Throughout the 2-day workshop, several participants highlighted many important opportunities provided by the ACA: • the impact of coverage expansion on preparedness and how the changing reimbursement systems and incentives will affect preparedness activities; • the use of data to help preparedness, response, and recovery; • how existing resources can be used to improve both day-to-day operations and response during public health emergencies; • workforce transformation and training needs; and • opportunities for collaboration, coalition building, and rel- ationships among health care delivery systems that may not have been involved in preparedness activities in the past. A number of themes emerged across multiple workshop presentations and discussions on the topics above. The following themes are discussed further in the report that follows. • Bridging the health care and public health preparedness communities. Many participants pointed out that the imp- lementation of the ACA provides the opportunity to incorporate preparedness into all aspects of the health care system. Pro- visions in the ACA can be leveraged to integrate preparedness into daily health care and to help create stronger routine and emergency health care delivery systems that can surge in response to disasters. It was repeated throughout the workshop that preparedness should not be thought of as separate and distinct from everyday operations. • Fostering resilience through improved access to health care. It was noted by many participants that with expanded coverage, people will be able to receive needed routine and chronic care so they will not already be in a compromised state in the event of a disaster. Improved access to care in general will lead to sub- 7 This list is the rapporteurs’ summary of main topics and recurring themes from the presentations, discussions, and summary remarks by the meeting and session chairs. Items on this list should not be construed as reflecting any consensus of the workshop participants or any endorsement by the IOM or the Forum. 

INTRODUCTION 11 stantial improvements in population health, which will in turn lead to greater individual and community resilience.  Continuing to care for the most vulnerable. Although the ACA and Medicaid expansion is improving access to health insurance coverage to all population segments, millions of persons will remain uninsured or underinsured. For those who are insured, plans will vary with regard to what is covered. However, 10 Essential Health Benefits are mandated to be covered in the individual and small-group marketplace.8 With regard to impacts of the ACA on health system finances, individual participants expressed concerns about planned reductions and eventual elimination of disproportionate share hospital (DSH) payments9 to hospitals that serve large numbers of uninsured or underinsured. If these community members cannot receive everyday care, their general health may decline and overall community resilience could decline as well. As revenues dwindle, the ability of these safety net institutions to serve the most vulnerable people during disasters will also be impacted.  Proposing preparedness and resilience as community benefits under the ACA. The ACA has a requirement for non- profit hospitals to engage in and allocate funds to activities that have a community benefit10 (discussed further in Chapter 2). Many participants discussed how public health could leverage this requirement to improve system capacity. For example, health information exchange platforms provide a real community benefit, both directly, to the individuals whose data are housed in them, and at a population level, to public health and health care systems for preparedness. 8 Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; laboratory services; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; pediatric services, including oral and vision care; prescription drugs; preventive and wellness services and chronic disease management; and rehabilitative and habilitative services and devices. 9 DSH payments are federal funds awarded to qualified hospitals that serve a large number (i.e., disproportionate share) of uninsured and underinsured patients and provide high levels of uncompensated care. 10 See http://www.irs.gov/Charities-&-Non-Profits/Charitable-Organizations/New- Requirements-for-501(c)(3)-Hospitals-Under-the-Affordable-Care-Act (accessed May 10, 2014). 

12 IMPACTS OF THE ACA ON PREPAREDNESS • Enhancing preparedness through public–private partner- ships. A few participants discussed examples of the value of public–private partnerships in achieving preparedness goals. Many collaborations that already exist for routine care could, for example, enhance public health capacity in threat assessment, immunization tracking, and medical countermeasures disp- ensing. Additionally, mission-critical vendor agreements could provide for the vendor’s assistance in planning for and resp- onding to an emergency. Given the emphasis of the ACA on integrated and coordinated care, the importance of engaging other members of the community, including organizations, disaster responders, and mental and behavioral health service providers was also noted by many participants. • The evolving health care workforce. Various participants discussed the predicted physician shortage in the face of increased access through coverage expansion and the importance of team-based care and expanded roles for mid-level prac- titioners (e.g., nurse practitioners, physician assistants, mid- wives, pharmacists) to meet the growing demand. Examples were given of how care is increasingly being provided outside of the hospital setting (e.g., community paramedicine) and of how allowing more flexibility in providing care can increase access to care and reduce the burden and costs to the health care system (e.g., through reduction of unnecessary transports to the hospital). A few participants also discussed training needs relative to the provisions in the ACA. • Preparedness opportunities through health IT. There was significant discussion about health IT, its impact on everyday care, and opportunities to bring technologies such as predictive analytics and telemedicine to advance public health preparedness and response. Several speakers drew comparisons between Hurricane Katrina and Hurricane Sandy to illustrate the benefits of health IT for preparedness, planning, response, and recovery. Participants stressed that health IT should become something everyone is accustomed to using every day, not a special device or portal that is used only in a disaster. o Using health data to develop a better understanding of the community. Participation in the health care system as a result of expanded coverage through the ACA means that more people are now visible to the system, and more data are 

INTRODUCTION 13 available to better understand the potential vulnerabilities of the community, plan for those with specific or complex health needs, and foster individual and community resiliency. o Health information exchanges. Many participants discussed the potential to improve preparedness and response by increasing the exchange of health information among health care systems, public health, and other stakeholders. Some exchanges have functionality for patients to access and enter their own health data. Participants also discussed a model of a social-health information exchange, which includes community-based service organizations, enabling providers to focus on the whole person during a disaster response and addressing acute medical needs as well as housing, shelter, and other needs that impact health. Also noted is that there is an ongoing struggle to sustain health information exchanges and that identifying sustainable revenue streams is critical. o Standards-based interoperability of data systems. A major topic of discussion was the need for standards-based interoperability so that health information exchanges and other databases can communicate useful information. The concept of a national patient identifier was also raised. A challenge for interoperability is the diversity of privacy and security rules across the country. o Modeling and predictive analytics. Participants described several examples of how data from electronic health records, syndromic surveillance, and other sources can facilitate modeling, predictive analytics, and real-time situational awareness that can aid effective planning and execution before an event and can provide decision support during an event. o Public health preparedness uses for telemedicine. Telemedicine was highlighted as an important tool to enable the sharing of information and expertise remotely in real- time, extending workforce capacity and increasing quality of care. Individual speakers noted that telemedicine can help reduce disparities in care due to geography, improve triage and transport decisions, and in the case of toxins and 

14 IMPACTS OF THE ACA ON PREPAREDNESS infectious agents, reduce the number of providers being directly exposed at the scene. • Continuing role for public health. Although the ACA provides opportunities and incentives for health systems to prepare, several participants stressed that it cannot ensure that entire communities are prepared, and there is still a strong role for coordinating and collaborating across the entire spectrum of medical and public health preparedness programs.