Improving Rural Mass Casualty Response in the United States
“There is not one healthcare discipline that is solely and completely responsible for preparing and responding to mass casualty incidents (MCIs), nor is there one government entity that is solely responsible for helping to support these activities,” said session chair Jon Krohmer of the Office of Health Affairs in the Department of Homeland Security (DHS). In describing preparedness and response to rural MCIs, the theme of the absence of a centralized and dedicated federal office to support emergency medical services (EMS), and the impact this has on rural preparedness and response efforts recurred throughout the discussion. Several participants highlighted the importance of leveraging partnerships between the government and the private sector to improve the capacity and effectiveness of responding to large-scale rural incidents, and these partnerships are needed to strengthen workforce, education and training, and technology.
ADDRESSING THE ISSUE OF FUNDING
A major theme throughout the workshop was the absence of dedicated and coordinated funding for integrated rural MCI planning and response, commented workshop chair Robert Bass. EMS is critical to supporting the response to any MCI, rural or urban. There are numerous needs for the EMS community to ensure they are an equal partner in the health systems capacity to respond to an MCI. While the National Highway Traffic Safety Administration (NHTSA), DHS’ Office of Health Affairs, and the Assistant Secretary for Preparedness and Response (ASPR) all play important roles, there is currently no federal agency that has specific responsibility
in setting national policy for EMS. Instead there is a patchwork of available resources, commented Bass, that do not meet the complete needs of the health care sector due to an absence of directed federal guidance and policy. This absence of a specific federal advocate results in an inability of EMS, at both the federal and state level, to attain the same priority as other components of the health system in terms of having the necessary guidance and resources to prepare for and respond to an MCI. In addition, although EMS is a critical component of the emergency response system other first responder communities, such as police and fire, receive a significantly larger portion of federal grant dollars compared to EMS. This was highlighted in 2007 congressional testimony by the Department of Homeland Security to the House Appropriations Committee: less than 4 percent of DHS grants to state and local agencies is directed towards EMS functions (DHS to Committees on Appropriations, 2007).
Granting agencies such as the DHS, ASPR, NHTSA, the Health Resources and Services Administration (HRSA), the Federal Emergency Management Agency (FEMA), and others need to review their grant guidance and how funding is directed and distributed to ensure appropriate resources are provided to EMS and for rural MCI planning. Strong federal direction of this kind can help ensure EMS is a fully integrated component of the emergency response system. This could have the affect of stabilizing EMS funding within federal and state budgets so that it is less vulnerable to economic stability trends (receiving more funding in “boom” years, and seeing that funding drastically cut during recessions). To this end it is important to similarly include public and private healthcare insurers in discussions of sustained funding. Specific suggestions for integrating the funding provided by the Medicare and Medicaid payer, the Centers for Medicare and Medicaid Services (CMS), are discussed below.
When engaging an entity on the issue of funding, noted associate chief medical officer at the Office of Health Affairs at DHS Mike Zanker, emphasis should not only be given to urban centers. In addition to the need for rural EMS to respond to an MCI in their community, in the event of a major urban incident urban communities will be reliant on their rural neighbors to help support response efforts, especially if the urban center is incapacitated.
HRSA Rural Health Grants
Eileen Holloran, a public health analyst in the Office of Rural Health Policy at HRSA described four current grant programs that support im-
Applicable HRSA Office of Rural Health Policy Grant Programs
Rural Health Network Planning Grant
Rural Health Network Development Grant
Rural Health Care Services Outreach Grant
Rural Access to Emergency Devices
provement of rural mass casualty response (Box 7-1).1 The purpose of the grants is to foster collaboration among rural health providers. The main eligibility requirement for the first three programs (Planning, Development, Outreach) is that primary applicants must be rural and not-for-profit. The applicant’s headquarters must be rural, Holloran clarified, they cannot simply be the rural subsidiary of an urban entity. They can, however, partner with urban and for-profit organizations. The subject of the application can be any health-related goal. In the Outreach program, for example, HRSA has funded projects ranging from mental health to transportation to rural addressing.
Following the workshop, Health and Human Services (HHS) Secretary Sebelius on August 23, 2010, announced the awarding of over $32 million in funding to support rural health priorities. The FY2010 funds are administered by the Office of Rural Health Policy at HRSA and span seven programs: Rural Hospital Flexibility Program, Rural Health Workforce Development Grant Awards, Telehealth Network Grant Program, Telehealth Resource Center Grant Program, Flex Rural Veterans Health Access Program, Frontier Community Health Integration Demonstration Program, and the Rural Training Track Technical Assistance Demonstration Program. See the press release at http://www.hhs.gov/news/press/2010pres/08/20100823a.html.
Benefits and Limitations of Medicare Reimbursements
Mercedes Benitez-McCrary, director of the Division of Emergency Preparedness at the Centers for Medicare & Medicaid Services (CMS), said that this central Medicare/Medicaid agency is attempting to respond to the gap through the establishment of collaborative partnerships and open lines of communication with the rural medical community. The Medicare program is identifying resources that could better serve the needs of beneficiaries, and one of those is transportation. Benitez-McCrary clarified some of the aspects of Medicare coverage for reimbursing transportation costs. Transportation, whether in a rural setting or not, must meet the requirements of the law.2 For example, Medicare does not pay for multiple trips, and the beneficiary must be on board for each leg of the ambulance journey. Benitez-McCrary further explained that while ambulances can provide treatment, they will not be paid by Medicare unless the patient is in the ambulance. There must be a medical necessity for the use of an ambulance, and transportation must be to an approved destination (i.e., the beneficiary cannot use the ambulance for personal transport to an appointment). Ambulance transport must also meet “medical reasonableness” requirements. In that regard, Medicare has defined the situations that qualify for air transportation (e.g., cardiogenic shock, severe burns, conditions requiring hyperbaric oxygen, multiple severe life-threatening injuries). Some workshop participants suggested that these constraints present a major policy issue for sustainability of EMS systems, particularly critical care transport.
Medicare requirements are not flexible. Only when there is a declaration of a disaster or emergency by the President and a public health emergency declaration by the HHS secretary, can temporary waivers or modifications to requirements be made.3 Once an “1135 Waiver” is authorized, healthcare providers submit requests to file Medicare claims under that waiver (i.e., it is not a blanket or group waiver, requests are individually considered). Some examples of requirements that might be waived in a declared disaster include the need for preapproval of care, or the requirement that doctors hold a license in the state where they are giving care. Waivers terminate after 60 to 90 days.
Funding Sources Dedicated to Transportation Improvements
One funding program specific to rural roads is the High-Risk Rural Road Program. These are federal funds administered by state departments of transportation (DOTs) specifically for improvements to high-risk rural
roads. A related funding opportunity is the Highway Safety Improvement Program (HSIP), which is umbrella funding under which the High-Risk Rural Roads Program is funded. All public roads are eligible for HSIP funds. States are required to have Strategic Highway Safety Plans (SHSP) developed by the state DOT to qualify. Kelly Hardy, safety program manager for the American Association of State Highway and Transportation Officials (AASHTO), noted if a state can certify that its infrastructure needs per its SHSP have been met for that year, they can redirect 10 percent of the state’s HSIP funds to other public safety projects. Therefore she suggested that there may be an opportunity to direct those funds to support EMS needs. She also noted that there is an opportunity for involvement of EMS as states evaluate their progress in implementing their SHSPs and update their plans. In most cases, EMS has not been at the table for development of these plans.
Inequalities in Funding and the Impact of Cost Containment
The absence of a consistent federal EMS funding source was specifically noted as a major obstacle by Ken Knipper, director of the State National Volunteer Fire Council in Kentucky and a retired emergency manager. EMS receives some fire grant money, some HRSA funding, some Medicare reimbursements, but no dedicated singular source exists. This lack of reliable funding has led to a concomitant absence of fellowship funds in rural areas noted session chair Dia Gainor. She explained that fellowship programs are generally in cities with disaster medical assistance teams (DMATs). In rural states without DMATs or other disaster-centered groups for the fellowship programs to affiliate with, there is really no home for them. Overall there is a dearth of new doctors going into the emergency medicine specialty. Winchell added that these kinds of programs are part of preparedness and thus vital to an MCI response.
Questions were raised about how the current emphasis on cost containment in health care affects the surge capacity component of emergency preparedness. There is enormous pressure on hospitals to avoid additional capacity because of the associated additional costs. If a hospital is not 100 percent full, they look to close the additional beds. This leaves the recovery room, hallways, or wherever else as the surge capacity. Many hospitals also have a backlog of surgical cases that further limit potential surge capacity. Knipper added that insurance companies are starting to deny some claims for what they deem are unnecessary transportation charges (e.g., helicopter transport of a patient with minimal injuries who is treated and released), under the banner of cost containment. These factors together can produce a cultural opposition to preparedness strategies among hospital and EMS
administrators. Therefore, it is very important that the preparedness and EMS communities actively engage health care providers and insurers.
THE ROLE OF GOVERNMENT
James DeTienne, supervisor of EMS and Trauma Systems in the Montana Department of Public Health and Human Services, said that the role of government in response to rural MCIs encompasses leadership, workforce, training, and technology. A balance needs to be struck between providing structured support and maintaining command sovereignty with local leaders.
While all responses are ultimately local, leadership from federal and state governments is urgently needed in rural response and EMS, DeTienne said. From the federal perspective, this means adjudicating across interstate, regional, and national jurisdictions to provide broad guidance to communities. Similarly, states must assume responsibility for ensuring the needs of local emergency responders and health care providers are measured and adequately met. A leadership role for government at all levels is to facilitate a realistic public perception of what emergency services are available and what they are capable of doing with their current resources.
Drew Dawson, director of the Office of Emergency Medical Services at the NHTSA, further detailed potential roles the federal government could play productively. The responsibility of the federal government, first and foremost, Dawson said, is communication and collaboration with all stakeholders in the system. There needs to be a coordinated federal vision of where rural emergency medical services should be. That vision must be developed in concert with state and local areas, and with federal leadership. One participant suggested that this vision might best come to fruition by strengthening EMS within the federal government, recognizing that EMS is a critical component of the everyday health system and disaster response. This strengthened role could in part be tasked with elevating the priority of EMS preparedness, guiding better allocation of grants and alignment of grants with federal policy, and removing barriers to communicating best practices solutions across state and regional jurisdictions.
In fact, Dawson commented that the federal government is in a key position to develop and share best practices, by sponsoring forums such as this IOM workshop and others that bring rural communities together with state and local partners. He suggested that there is also a need for federal support of additional research into rural emergency medical services, not just with respect to patient care, but with respect to systems. Development
of common metrics that could predict the success of emergency response in rural communities is another area with which the federal government can assist. There is a need for increased consistency of metrics on a nationwide basis to be able to identify needs and manage resources effectively.
Dawson said that an important leadership role for the federal government is to conduct and facilitate an assessment, based on solid data, of where we are in the nation with respect to emergency medical services. Such an assessment should identify if there are barriers nationally to improving rural emergency medical services and rural mass casualty care, and what can be done to eliminate such barriers. Dawson noted that addressing some of these challenges may require changes in policy or changes in laws or rules.
An emergency care system encompasses many components, not just EMS. DeTienne cited a NHTSA report on rural workforce that found that the absence of data makes workforce characterization impossible (NHTSA, 2008). One of the first charges to government is to collect the necessary data to characterize the current workforce. Without this baseline it will be difficult to apply any metrics and assess the impact of new strategies. Community paramedicine is another workforce issue where the EMS system has evolved out of necessity. Also, as discussed in Chapter 5, an all volunteer responder system is not sustainable, and there needs to be serious discussion of transitioning to paid systems.
In response to presentations by panelists, a participant suggested that the federal government, through the Department of Defense (DoD), determine the feasibility of training experienced combat medics returning from active duty as rural EMTs and paramedics to address the aforementioned gaps in personnel resources. Another participant underscored the importance of military aid to the extent possible during an MCI, as the military already has personnel specially trained to fill gaps in rural provider care. Benitez-McCrary’s concurred, noting that wounded pets in need of care during the aftermath of Hurricane Katrina, a significant issue, could have been best treated by the U.S. Army’s dedicated Veterinary Corps. Often traveling with the troops, a participant noted their work as an essential component of Army response to natural disasters.
There are many opportunities for government to be involved with training, DeTienne said. EMS needs specific education in incident command systems (ICS). However, DeTienne described an ICS course he was aware
of that was simply the course for firefighters, retitled for EMS, ensuring most of the scenarios did not adequately describe EMS-centered response. Therefore, the use of dedicated education by the professional field cannot be understated in its importance to preparing responders to deal with an MCI. In addition, time lost at a job is a significant consideration for volunteers, who make up a large part of rural responders (described in Chapter 4). Government needs to find ways to use distance learning and technology to provide ICS training to EMS. DeTienne also reiterated the point that the workforce and infrastructure must be able to adequately handle the everyday emergency response if it is to ever be able to handle mass casualties. Dawson brought the point further to bear insisting that invention, evaluation, and deployment of new technologies is another area where the federal government can play an important role.
Zanker concurred, commenting that as important as technology is, without the proper training it is of limited use (the government’s role in technology was discussed in Chapter 3). Zanker advocated funding programs that broaden the basic skills of responders who are not paramedics, such that their training in combination with guided instructions from onboard telemedicine technologies, for instance, could increase a whole response unit’s ability to save lives quickly. As stated by participants in previous chapters, skill retention should be considered a crucial aspect of any authority’s education responsibilities.
THEMES IDENTIFIED BY WORKSHOP PARTICIPANTS
Participants discussed the roles of local, state, and federal governments, the private sector, and other organizations in improving rural MCI response capabilities. In the noted absence of a single dedicated federal agency, the responsibility falls to a coordinated effort across multiple agencies, all sectors, and involving all stakeholders.
Addressing the pervasive communications challenges is a priority, posited workshop chair Robert Bass. A variety of telecommunications technologies and initiatives were discussed, such as Next Generation 9-1-1, satellite communications, broadband, and telemedicine. Several participants suggested that a way to bring these technologies to rural and frontier areas and increase connectivity is needed. Incentivizing and engaging the private sector were suggested as possible approaches.
Although funding is essential, and a variety of available grants and funding sources were discussed, funding is not the only issue and is not exclusively the responsibility of agencies of the federal government. Bass emphasized that a coordinated federal vision for the role of EMS in rural environments should be developed, aligning funding and activities at the federal level across the various agencies (e.g., HHS, DOT, DHS).
Some participants said that coordinated and consolidated federal guidance is needed for EMS and rural preparedness. This would help facilitate increased resources at the local and state levels for rural EMS. The federal government also has a role in facilitating the sharing of best practices, supporting research and data collection (e.g., for technology development, accurate characterization of the workforce), increasing awareness and coordination, and the development of consistent, nationwide metrics and assessment strategies.