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

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8 The Continuing Role for Public Health Preparedness and Response Highlights of Main Points Made by Individual Speakers1 • The Affordable Care Act (ACA) provides opportunities and incentives for health systems to prepare, but it cannot ensure that entire communities are prepared, and there is still a strong role for medical and public health preparedness programs. • Public–private partnerships are becoming increasingly important to achieving preparedness goals. Collaborations could, for example, enhance public health capacity in threat assessment, immunization tracking, and medical countermeasures dispensing. • The ACA focus on community-based care provides an opportunity to build more resilient communities. • Building community resilience also involves addressing social determinants of health. • To be a truly prepared nation, preparedness must not be a separate activity but rather an integral element of routine everyday care that can surge when needed. The Affordable Care Act (ACA) provides better incentives and opportunities for health systems to prepare, but it will not prepare an entire community and its facilities to deal with a disaster, Lurie stressed. Providers may still struggle with competing priorities and the allocation of scarce resources and decreased funding. However, she continued, the ACA alone will not negate the need for the National Hospital Preparedness Program or replace the need for health care facilities to 1 This list is the rapporteurs’ summary of the main points made by individual speakers and participants and does not reflect any consensus among workshop participants. 85 

86 IMPACTS OF THE ACA ON PREPAREDNESS prepare and train for public health emergencies. It will not create programs to bring partners together to drill and exercise. Changes to coverage will increase access to care and foster better individual and community health, but there is still a need for individuals and their families to prepare for how a public health emergency or disaster could impact them, not only on paper, but also in practice. INSURANCE: NOT A REPLACEMENT FOR PUBLIC HEALTH Even though the number of uninsured is projected to decline by about half, about 30 million people will remain uninsured. Ebeler reminded participants that this number includes those in states that do not expand Medicare and who will fall into the coverage gap, those who are undocumented (and cannot get coverage), and those who could get coverage but opt not to enroll. Regular and disaster care will still need to be provided for the uninsured and underinsured. Martin of the Boston Public Health Commission pointed out that health insurance plans vary and coverage does not equal access to needed care or a reduction in need for public health services. In Massachusetts, where more than 97 percent of the population is insured, Martin noted that 18 percent of those insured have had difficulty finding a provider who will see them. In addition, while much attention is paid to physical medical needs, there are also mental health, economic, and social needs during disaster response and recovery. Health care institutions do have some social services capabilities, but in a large-scale incident they are quickly overburdened. The relationship between public health and health care is very important for supporting recovery in this regard, Martin said. For example, in the weeks following the Boston Marathon bombings, the U.S. Department of Health and Human Services (HHS) provided a mental health response team of approximately 25 persons to help Boston increase its capacity to support the mental health needs of those impacted. As mentioned previously in the report, more than 200 mental health support sessions were coordinated in the city of Boston and in surrounding areas, and thousands of individuals were served, with sup- port from service providers from HHS, the Massachusetts Department of Mental Health, Red Cross, Salvation Army, and a number of other partners. A Family Assistance Center was set up within the first few days after the bombings, offering a range of services, including mental health 

THE CONTINUING ROLE FOR PUBLIC HEALTH 87 referral and support groups. As mentioned earlier in the report, many of the group visit counseling services were not covered by insurance plans. In addition, many of those injured at the marathon were not from Massachusetts and may have had national plans or other state-based plans that may have had other exclusions. This is a prime example of the continuing need for public health emergency preparedness (PHEP) and hospital preparedness programs (HPPs) to support state and local needs when routine insurance coverage does not meet the needs of the population in a disaster. Shift in Public Health Practice Public health is undergoing a lot of change simultaneously with the implementation of the ACA, DeSalvo said. As discussed in Chapter 3, health departments are moving away from providing direct clinical services and toward promoting and protecting the health of the community, including maintaining important core functions such as emergency preparedness. This transformation is resulting in a declining public health clinical workforce to handle, for example, medical special- needs shelter staffing or distribution of medicines in the event of a pandemic. On the positive side, increased access to services under the ACA means that people will likely be in better general health when they arrive at a shelter in a disaster, and they will have financial access to care wherever they may be transported. There is also investment in community health centers through the ACA, which can be leveraged to augment the emergency response infrastructure. In addition, there should be more clinical data and other information available that will inform public health preparedness and response, and help to identify those populations at risk who may have a variety of special needs. However, funding would still be needed for these efforts. Overall, many speakers noted, public health and health care entities will continue to have primary responsibility for leading the nation in preparedness, response, and recovery (see Figure 8-1). 

88 IMPACTS OF F THE ACA ON N PREPAREDNE ESS FIGUR RE 8-1 Integrrating public health h prepareedness capabiliities with heaalth care preparedness cap pabilities. SOURC CE: Martin preesentation, Nov vember 18, 20113. XPANDING PUBLIC HE EX EALTH CAPPACITY AN ND REACH THROUGH H PUBLIC–PPRIVATE CO OLLABORAATIONS Ass both public health and health h system ms transform aand strive to be more efficient an nd effective while reduucing costs, public–privaate partnerships are becoming increasingly important to achieving preparredness goals.. The health information exxchanges in K Kansas (KHIN N) 

THE CONTINUING ROLE FOR PUBLIC HEALTH 89 and New York (SHIN-NY) discussed by McGuire and Birkhead respectively (see Chapter 6) are examples of public–private partnerships in health information technology (IT) that have broad applicability to preparedness. Also as discussed in Chapter 6 relative to the use of predictive modeling, distribution of vaccines and medical counter- measures could be greatly enhanced by public–private partnerships, specifically, engaging retail pharmacies as partners. Dean and Hupert both described predictive models that were used to study the impact of additional dispensing partners. As concluded by Hupert’s model, there was hypothetically adequate retail pharmacy capacity to provide antiviral prescriptions to people at the theoretical peak of the pandemic. However, even with theoretically sufficient supply in the strategic national stockpile (SNS), a logistics model suggested problems with the timing of acquiring product from the SNS to coordinate with the demand. A pilot program described by Dean tracks prescription drug use by the most vulnerable residents and works with public and private providers to coordinate pharmaceutical care services for these individuals during a crisis. If the ACA can promote more integrated care, the ease of connecting these services in a disaster will be much greater. Individual participants discussed several other examples of public– private partnerships that are enhancing the capacity and reach of public health in the areas of threat assessment, immunizations, and countermeasures distribution, as well as the need for broad collaboration with community organizations and services. Potential in Electronic Prescriptions Surescripts began as an e-prescribing network and now processes between 5 million and 6 million prescriptions every day, or more than half of the electronic prescriptions in the country. Garrett Dawkins, director of Transitions of Care and Public Health at Surescripts, LLC, shared several examples of how Surescripts is expanding to support a range of capabilities in clinical network services. There are about 200,000 influenza-related hospitalizations every year, each costing on average $1,800. Factor in lost wages and other elements, and the typical flu season is estimated to cost $87 billion (Humer, 2013), Dawkins said. Although influenza vaccination is relatively easy, it is very hard to reach all of the population. During the 

90 IMPACTS OF THE ACA ON PREPAREDNESS 2012-2013 flu season, only 35 percent of adults and 55 percent of children received flu vaccinations.2 Dawkins described several elements that together could help to improve uptake: improving tracking of immunizations through reporting to registries; expanding reach into the community by leveraging the nation’s more than 200,000 pharmacists trained to provide imm- unizations; providing better access to patient data at the point of care; and simplifying communications within the care community. Dawkins highlighted several challenges of reporting immunizations to registries. There are 62 immunization registries in the United States, and Dawkins noted that they are not equally distributed across the country. As noted earlier in the report, a lack of standards, or implement- tation of current national and international standards, across the industry and within each individual immunization registry (including data standards, transport standards, credentialing requirements, use of a national provider identifier) makes it difficult to share information with registries. One-quarter of the registries do not provide automated notif- ication of errors. Registries are bound by local laws, regulations, and politics (e.g., there are varied approaches to patient consent, multiple immunization registries in a state). There is also a wide distribution in the levels of staffing and funding across registries. To help address this registry reporting issue and to facilitate better and more accurate data-sharing capability, Surescripts developed a simplified immunization registry reporting solution that provides one connection point to multiple local registries. The reporting solution manages local variances in messaging and field requirements, provides error message tracking and reporting, and manages the traffic loads. Working with industry stakeholders, Surescripts also developed a care coordination solution to send notifications of immunizations to primary care providers (electronically, or via secure fax or mail if needed). Dawkins noted that registries can also serve as a critical data aggregation point for public health monitoring. As more providers and pharmacies connect to registries, this monitoring could be even more granular and useful. To spur innovation in this area, Surescripts issued a challenge at Health Datapalooza 2013 for development of a tool that could provide a graphical representation of the geographic spread of flu cases, and the predictability of future outbreaks, based on sample e- 2 These figures were based on preliminary influenza data for the 2012-2013 influenza season. The final data reflect vaccination rates of 57 percent for children (6 months to 17 years) and 42 percent for adults (18 years and older) (CDC, 2013). 

THE CONTINUING ROLE FOR PUBLIC HEALTH 91 prescribing data.3 The winning application can be used to identify hotspots of influenza in real-time, based on where medications are being prescribed. In a pandemic situation, Dawkins suggested that imm- unization information could be overlaid on the top of the prescribing data and could facilitate a more targeted response. With Meaningful Use Stage 1 objectives supporting the capability to provide data to immunization registries,4 and the ACA enabling first dollar coverage to increase access to immunizations (Shortridge et al., 2011), registries similar to Surescripts could plan for future needs, provide better coordination, and lead to improved clarification of reporting in emergency scenarios. Mapping Vaccine Needs Based in Santa Barbara, California, Direct Relief is an international organization (working in 70 countries worldwide, including the United States) focused on improving the health of people living in poverty and those who are victims of natural disasters, war, and civil unrest. Direct Relief works to strengthen local health efforts and help fill critical gaps by working with private partners to donate essential material resources, including medicines, supplies, and equipment. Direct Relief is the only U.S. nonprofit that is a verified, accredited, wholesale distributor certified by the National Board of Pharmacy. Direct Relief is licensed at the same level that major pharmacies such as CVS or Walgreens are to handle pharmaceutical products in all 50 states, explained Andrew Schroeder, director of research and analysis for Direct Relief. This is important, he said, because Direct Relief works across state lines. One issue of interest to Direct Relief is patient assistance programs (PAPs), through which individuals who cannot afford essential medicines prescribed for them can apply directly to the pharmaceutical company to receive a supply. Schroeder noted that having the largest companies in the world dealing with individual patients is not particularly efficient. Thus, prior to the implementation of the ACA, Direct Relief began developing a replenishment program that hopes to increase efficiency by aggregating this process so that products are shipped to clinical units rather than to individuals. Leveraging the Direct 3 See http://surescripts.com/company-initiatives/surescripts-technology-challenge (accessed June 9, 2014) for more information on the winning application. 4 See http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ downloads/MU_Stage1_ReqOverview.pdf (accessed May 20, 2014). 

92 IMPACTS OF THE ACA ON PREPAREDNESS Relief logistics network as a communications network, the organization conducted a survey about emerging concerns for safety net providers, including their anticipated use of PAPs after implementation of the ACA. Interviews were recorded and posted on the Direct Relief website, Schroeder said, to make sure that the voices of nonprofit health care leaders are heard in the debate.5 Of the 350 nonprofit safety net facilities surveyed in 42 states, 93 percent of the respondents used PAPs to access medications, providing 43 percent of needed medications for their patients. Ninety-six percent responded that they still expect to use PAPs fairly extensively as an essential resource after the implementation of the ACA, because the coverage gaps will not be completely eliminated. Another Direct Relief activity described by Schroeder is assessing the need for charitable influenza vaccine donations for safety net health centers. Schroeder noted the value of partners such as HealthMap.org, which assesses geo-coded news sources to map emerging infectious diseases, and Google Flu Trends, which estimates rates of influenza-like illnesses (ILIs) based on Internet search queries. Direct Relief then looks at how, for example, the geographic distribution of emerging ILIs relates to the regions where Direct Relief is receiving significant requests for charitable donation of influenza vaccine from safety net health centers. This is not a commercial order, Schroeder explained, but a request for humanitarian assistance on the basis of an expectation of shortfall. Schroeder said that during the 2013 federal government shutdown, this information allowed Direct Relief to prepare for the flu season in the absence of updated information from the Centers for Disease Control and Prevention (CDC). The Right Care, at the Right Place, and at the Right Time Cairns discussed the National Collaborative for Bio-Preparedness (NCB-Prepared), for which he is a principal investigator.6 He said that the goal of emergency care regionalization is to get the right care, at the right place, at the right time. Time is of the essence in many situations (e.g., heart attack, stroke), with the best outcomes resulting from interventions that are administered within minutes of the event. Mentioned earlier in the report, the provisions in the ACA legislation related to Regionalized Systems of Emergency Care, Section 3504, that 5 Available at http://www.directrelief.org/voices (accessed April 30, 2014). 6 Cairns disclosed that the material in his presentation was based on work supported by the U.S. Department of Homeland Security grant #DHS10OHA122-001. 

THE CONTINUING ROLE FOR PUBLIC HEALTH 93 transfer ownership of trauma care grant and research programs will now be housed within the Office of the Assistant Secretary for Preparedness and Response (ASPR). Improved pre-hospital and trauma care at a regional level on a day-to-day basis may be positively affected by the ACA and could also have implications for surge management and regional disaster response. The State of North Carolina faces major challenges in terms of mortality rates for cardiovascular causes. To help address this, the state organized providers, hospitals, and emergency medical services (EMS) systems to develop a destination plan so that any paramedic rig picking up any patient with a heart attack anywhere in the state would know exactly where to take him or her (Glickman et al., 2011). For very rural areas where transport to hospital could take too long, paramedics can administer clot-busting drugs in the ambulance en route. This statewide, population-inclusive approach to emergency care of myocardial infarction has reduced mortality across the state (Glickman et al., 2012). The key, Cairns said, is having all of the systems in place, including the care providers, the data, and the ability to respond, before the actual episode of heart attack occurs (Cairns and Glickman, 2012). Following this model for regionalized emergency cardiac care, NCB- Prepared was designed to be a comprehensive state-wide system to enhance health security. NCB-Prepared is a public–private partnership including the University of North Carolina–Chapel Hill, North Carolina State University, the SAS Institute, the Department of Homeland Security (DHS) Office of Health Affairs, and the National Bio- Surveillance Integration Center. The goals of the project are to have earlier recognition of outbreaks and health threats; augment bio- surveillance; improve situational awareness; provide better information for decision makers; and provide insight into the quality of care and management systems. Cairns added that integrating data, using advanced analytics, and providing value to the data partner will all work to achieve the goals of early recognition and initiation of mitigation strategies, regardless of the threat. Cairns pointed out that typically, bio-surveillance is investigational, intended to determine the cause of an outbreak and mitigate the solution. NCB-Prepared is interventional, and action must be timely to be effective. The system has built a comprehensive set of data sources that provide a timely snapshot across geographic regions and informational layers. Data sources include, for example, Poison Center data, EMS data, 911 data, Internet search data (e.g., Google Flu), and data from the 

94 IMPACTS OF F THE ACA ON N PREPAREDNE ESS Nationnal Bio-Surveeillance Integ gration Centeer. The system m also colleccts inform mation on cu urrent hospitaal capabilitiees for Northh Carolina and surrou unding states (e.g., intenssive care uniit beds, dialyysis machinees) daily, and in the casse of the disasster this can bbe updated evvery 2 hours. Daata collected from multiplle sources muust be turned into actionabble inform mation. Cairnss described a text-analyticc approach deeveloped by tthe SAS In nstitute that can c analyze why w an event is happeningg, forecast whhat may happen h nds continue, and predict w if tren what could haappen next and what isi the best po ossible outco ome (see Figgure 8-2). Thhe system takkes millionns of records through an automated a daata quality proocess, follow wed by reall-time integraated analysis and a visualizattion. Caairns shared an example of how, by aanalyzing unnusual levels of h activity on the Google Flu search F Trends Innternet site aand alerts froom EMS data, d NCB-Prrepared was able to prediict the 2012--2013 influennza FIGUR RE 8-2 Existin ng reactive processes (greenn) and NCB-P Prepared (NCB BP) currentt and future pro oactive processses (blue) madde possible by the text-analyytic approach to data anallysis. SOURC CE: Cairns preesentation, Novvember 19, 20113. 

THE CONTINUING ROLE FOR PUBLIC HEALTH 95 outbreak 90 days before the CDC alert was issued. In the summer of 2013, an exercise was conducted in conjunction with DHS and the National Bio-Surveillance Integration Center demonstrating the system’s ability to detect an unknown respiratory agent (flu data were entered into the actual data system for the exercise and, following the same data quality, data analytic, and visualization processes that are used every day, the system was able to detect the incidence of unusual activity across North and South Carolina). This works because it is used every day, negating the need to learn how to use in an emergency situation. Community Organizations and Services as Key Partners in Resilience The ACA focus on community-based care provides an opportunity to build more resilient communities, said Priest of MESH Coalition. As mentioned by many speakers, communities that are healthier before a disaster do better after a disaster. Priest said there is an upper limit to how effective the preparedness capabilities of the health system can be. The preparedness community needs to think about surge management beyond what can be done in the hospital, for example, building community resilience, having neighbors who can help neighbors, and taking health care to where people are (e.g., community paramedicine, discussed in Chapter 4). This also means addressing the social determinants of health and thinking very broadly about what it means to be a healthy society. As the multiple provisions of the ACA work toward building a more coordinated health care delivery system, emphasizing integration of services, managing population health, and promoting value-based purchasing payment models, this could be an opportune time for building social capital and including community agencies in improving health outcomes. This is where there are very good alignments among health reform efforts, population health management, and good disaster management principles, Priest said. There will always be a need for acute care in emergencies, but there needs to be a balance with efforts toward better everyday health care. Martin said the bigger picture of resilience involves community-based organizations and larger scale institutions. All levels need to be working together toward preparedness. We need to take a holistic view of resilience, tying public health and population-based care to health care, Martin concluded. 

96 IMPACTS OF THE ACA ON PREPAREDNESS Challenges for Integrating Public and Private Health Efforts With regard to partnerships for dispensing, there was some discussion as to whether, with the integrated systems discussed, people needing a countermeasure could be electronically identified and alerted (e.g., by phone or e-mail) that a countermeasure or vaccine has been e- prescribed at their local pharmacy for them to receive. Birkhead of the New York State Department of Health pointed out that the biodefense planning thus far at state and local levels relies on government resources and open points of dispensing (PODs). People are not billed for receiving countermeasures at PODs. To e-prescribe countermeasures for people to pick up at the local pharmacy would involve many different insurance plans that may or may not cover the cost, with varying amounts of co- insurance if they do. In a true emergency situation where it is essential to try to reach everybody quickly, we do not want to stop and take insurance information unless the process can somehow become very streamlined. He added that with regard to engaging the private health care sector (pharmacies and providers) in delivering countermeasures in general, even if the vaccine was provided free of charge, there is still the issue of the fee for administration. Some insurance plans cover administration and others do not, and it would still present a barrier for persons who are uninsured or underinsured. While alternatives to mass prophylaxis in public clinics are needed, he raised a concern that the private health care system is still so complicated that even with the ACA, it will be a challenge to develop a comprehensive solution, highlighting further need for PHEP support. Birkhead said the real promise of accountable care organizations (ACOs) is that they can offer an economy of scale and a population-based focus. If a state health department can work with ACOs, vaccines can be delivered in a mass setting to a much larger group much more effectively, and perhaps lessen the need for local health departments to run vaccination clinics when they are often resource poor. However, he noted, New York State has not really engaged ACOs yet in pandemics or other emergency situations. ACOs are new partners and a promising new avenue to try to engage and integrate the clinical community as health systems around the country work to streamline care, Birkhead concluded. 

THE CONTINUING ROLE FOR PUBLIC HEALTH 97 LOOKING FORWARD While the ACA is improving access to health insurance coverage through the marketplace and Medicaid expansion, there are parts of the ACA that bear monitoring during and after implementation, especially regarding status of funding and implementation, said Terry Adirim, special consultant on maternal and child health at the Health Resources and Services Administration. The health care system is changing rapidly, and several participants discussed a variety of ways that the ACA implementation could enhance preparedness (e.g., new and expanded use of health IT) and expressed caution about the need to mitigate any negative impacts (e.g., reductions in disproportionate share hospital [DSH] payments to safety net hospitals). Benjamin asked participants to envision a future where everyone has an insurance card, where data move freely, and where all of the integrated health systems are doing individual preparedness planning for their facilities, as well as coordinated preparedness planning for their communities. The ultimate goal is to have the best health outcomes possible and to be able to return communities to full productivity after a disaster, he said. Building resilience requires a whole health care community approach, said Margolis. It is time to stop thinking about preparedness as a separate activity. In order to be a truly prepared nation and a truly prepared health care system, we need to weave the thread of preparedness into the fabric of our daily health care system, he reiterated. There is the opportunity to make this happen in the coming years as the health care infrastructure is transformed. Citing Berwick’s triple aims again, Margolis said that quality care, healthier populations, and lower cost are all interrelated, and achieving the triple aim is what leads us to be a prepared nation.