Highlights of Main Points Made by Individual Speakers1
- A key aspect of preparedness is knowing the population and preparing for its specific needs during an emergency (e.g., providing power for electricity-dependent durable medical equipment). Health information technology is highly effective in this regard.
- Increased out-of-hospital infrastructure and distributed networks of care can reduce the burden on emergency departments and on safety net hospitals and can enhance surge capacity.
- The Affordable Care Act (ACA) expands on the Mental Health Parity and Addiction Equity Act of 2008 by requiring mental health and substance abuse disorder benefits in the individual and small-group markets, increasing access to needed services every day and in a disaster.
- Accountable care organizations need to be able to address both the health (including mental health) and social needs of those most at risk.
- With the help of the ACA, health infrastructure is shifting its focus to population health management, and care systems are becoming accountable for health prior to and following health care visits.
- Broader insurance coverage leading to quicker reimbursement of hospitals could help impacted hospitals recover more quickly in a disaster.
- ACA reductions in disproportionate share payments to hospitals that provide the bulk of uncompensated or under-compensated care could compromise their ability to respond and surge when needed.
1This list is the rapporteurs’ summary of the main points made by individual speakers and participants, and does not reflect any consensus among workshop participants.
As discussed in Chapter 2, a fundamental change underlying health system reform is a shift in care management and infrastructure to a system that is more collaborative and integrated. A key element of this evolving infrastructure is the accountable care organization (ACO). ACOs are voluntary groups of health care providers (physicians, hospitals, others involved in health-related care) who work together to provide coordinated care to the patients and communities they serve, and who share collective accountability for ensuring the quality and value of that care. It will also be important during this transition to examine the effects of both the Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) on improvements in health outcomes due to greater mental health care access and attention to social needs as the patient care continuum becomes more of a central focus.
Integrated care, including ACOs, can contribute much to public health preparedness and response. Delivery system reform also has a tremendous opportunity to impact daily emergency care, said Assistant Secretary for Preparedness and Response Lurie. Questions going forward include: What is the role of an integrated care system in daily emergency care? How is the emergency care system in a community organized now that systems such as ACOs are in place? What happens to populations not covered by these types of systems? Additionally, how will refocused integrated care address the remaining mental health and social needs of patients?
Lurie also described how the health information technology (IT) aspects of health care delivery reform can enable better understanding of how many people have specific issues that will need to be addressed during a disaster, and better prepare for them. (This is discussed in further detail in Chapters 5-7.) For example, electronic health records (EHRs) can be used in the aggregate to generate a picture of a community pre-event and to facilitate real-time situational awareness during a response. She described how, during Hurricane Isaac in New
Orleans, data were mined to determine where those who had electricity-dependent durable medical equipment were located and whether they might need a battery or evacuation to a site with power. Just prior to Hurricane Sandy making landfall, dialysis centers in New Jersey and New York reached out to their patients and administered treatments to more than 5,000 people as a preparedness activity. Knowing the potential for power loss and their patients’ daily needs, the dialysis centers were incentivized to think about how to identify and take care of their vulnerable populations before the storm. As a result, many emergency department (ED) visits, hospitalizations, and deaths post-storm were avoided, reducing the strain on emergency rooms around the region. These are just a few examples of many categories of vulnerability that ACOs are poised to identify and prepare for, she said. Ideally, with more technology and partnerships at their disposal, health care providers could take a more proactive role in preparing their patients for health incidents or natural disasters and make sure they have an understanding of patients’ needs ahead of time. Additionally, through collaboration with state and local health departments, and emergency medical services (EMS)/pre-hospital care providers, there are opportunities for better real-time assessment of needs in a systematic way to help inform resource allocation. (Some possibilities are discussed at greater length in Chapter 8.)
Mental Health and Social Needs
Another area where new models of care delivery can have an impact is mental health, Lurie commented, both in the prevention of mental health crises and in delivering mental health services in novel ways after a disaster. Currently, 25 percent of uninsured Americans have a mental health condition or substance abuse disorder (Garfield et al., 2010), making them even more vulnerable in disasters than those without, because disasters would only exacerbate these types of conditions. About one-third of those covered in the individual market have no substance abuse disorder coverage, and 20 percent have no mental health coverage (ASPE Issue Brief, 2011). The MHPAEA ensures parity between coverage for medical needs and mental health and substance abuse needs, which has increased access to mental health care for many. Additionally, the ACA expands this even further, requiring mental health and substance abuse disorder benefits for Americans in the individual and small-group markets (ASPE Issue Brief, 2013). It will be important to watch as these changes take place to see what needs patients will still
have in disasters, both those with and without underlying mental health conditions, and which ones may no longer need to be accounted for in preparedness planning.
After the Boston Marathon bombings in 2013, people were eager to gather and share experiences and begin to process what they had seen. S. Atyia Martin, director of the Office of Public Health Preparedness at the Boston Public Health Commission, noted that many of these group visit counseling services were not covered by insurance plans, even though 97 percent of the population of the Commonwealth of Massachusetts is insured because of a statewide mandate in 2006. Because of this gap, she said the Boston Public Health Commission’s Medical Intelligence Center coordinated more than 600 hours of mental health services for thousands affected by the bombings, including more than 200 sessions in the following 10 days. This highlights an important point: Any kind of insurance coverage may not equal good coverage, and gaps that remain could impact preparedness and response activities for state and local authorities (see Figure 3-1). Although one agency or organization might not be entirely responsible, coordination across agencies in preparedness and response activities can still help provide needed services for the population, regardless of insurance coverage.
Karen DeSalvo, health commissioner for the City of New Orleans, asserted that social needs are also important to consider. She noted that as a result of coverage expansion, more patients will enter the private health care system, especially as the public system is increasingly privatized. This means, DeSalvo said, that people who were part of the public health care system, where there is generally a better understanding of the social needs of the patients, will now be moved into systems that may not be as accustomed to considering social issues. In times of emergency, those with limited social resources need quite a lot of help and support, but they might be isolated in their homes or might need assistance with transportation. However, if they truly become absorbed within the system, then providers would have more visibility on the needs of these patients and be more equipped to handle the correct needs of different vulnerable populations in disasters. If these patients are linked to an ACO (and that ACO is therefore financially responsible for them), DeSalvo suggested that then it is clearly in the best interest of the ACO to address both the health and social needs of those most at risk to ensure they have the best possible health outcomes.
FIGURE 3-1 Needs and services requested by those affected by the Boston Marathon bombings in 2013, many of which would not be covered by private health insurance.
SOURCE: S. Atyia Martin presentation, November 18, 2013.
Lurie noted that the National Hospital Preparedness Program has been focusing on the development of health care coalitions, including all entities in a community that are involved in disaster planning. Groups such as ACOs need to be part of these health care coalitions, she said. Lurie added that a survey by America’s Health Insurance Plans, the national trade association representing the health insurance industry, found that insurers want to learn more about their covered patients and want to be prepared for their potential needs in a disaster. From an individual perspective, preparedness plans could be part of discharge instructions for vulnerable patients (e.g., what to do if there is power loss, where to evacuate to, where to obtain medications). In the vein of coordinated care, the preparedness instructions could be followed up on
at future doctor visits, along with other discharge instructions the patient needed to follow. Additionally, wellness visits could be used to share important planning information with patients, such as maintaining a supply of medications. Again reinforcing the theme of “weaving preparedness into everyday care,” including ACOs in health care coalition building and including preparedness instructions in individual patient plans can help to raise the level of awareness and education in preparing for emergencies.
Xiaoyi Huang, assistant vice president for policy at America’s Essential Hospitals (AEH),2 discussed the role of safety net hospitals in emergency preparedness, and the post-ACA outlook for these hospitals. AEH represents more than 200 public and nonprofit safety net hospital systems that provide a disproportionate share of the uncompensated care for low-income, uninsured, and vulnerable U.S. populations. These systems also provide specialized high-acuity care (e.g., trauma, burn, and neonatal intensive care) as well as a significant amount of outpatient and community-based primary and specialty care. More than half of the member hospitals operate Level I trauma centers, and one-third of the members are the only source of Level I trauma care for their communities. Often, they are the only providers of psychiatric emergency medicine in the region. AEH members also have large ambulatory care networks, averaging about 20 off-campus clinic sites per hospital, usually located in the communities where the patients are. Their mission is to take care of everybody, regardless of their ability to pay.
Huang said that in addition to the written emergency plan required by The Joint Commission, member hospitals also ensure that their emergency plan includes provisions for the specific needs of vulnerable populations (e.g., those with limited English proficiency, the non-ambulatory, the chronically ill, the hearing impaired, the homeless). These vulnerable populations are taken into account as the hospitals consider how to ensure workforce capacity and execute effective communication plans during an emergency. As mentioned previously, providers could also work directly with the patients within these
2Known as the National Association of Public Hospitals and Health Systems prior to 2013.
populations to make sure they understand their own needs, capabilities, and resources in an emergency.
The ability to respond in an emergency or disaster depends heavily on a hospital’s ability to expand to meet this increased demand, Huang said. One key component is staffing, including enough personnel (physicians, nurses, mental health staff, emergency medical technicians, public health professionals, volunteers, and non-hospital practitioners) to treat patients needing care. Huang noted that member hospitals are prepared to identify health care practitioners during a disaster and to share pre-registered, credentialed health care professionals across state lines. In addition to staff, a hospital needs enough space and beds, as well as a plan to convert available beds into emergency and intensive care beds. Hospitals also need space to triage and manage patients and may need space for decontamination and vaccinations. Some member hospitals are increasing physical capacity to surge by using associated ambulatory care sites and by transforming nonclinical community facilities.
Changes from New Infrastructure Development
Through a myriad of factors, most notably the ACA, health care infrastructure is shifting to focus more and more on population health management and the nonmedical determinants of health that happen outside hospital walls (ACHI, 2013), but struggling with the corresponding payment changes that need to happen as well, Rueben stated. Through altering payment mechanisms, care systems are now being held accountable for the overall health of their patient population, not just services rendered while inside their institution (ACHI, 2013). Because of this, partnering with community groups, EMS, public health organizations, and others could prove a financial benefit and incentive for health care delivery. As Rueben noted, the sooner the move to population health management can occur, along with payment reform, the more coordinated health care delivery will be. If the ACA continues to encourage out-of-hospital infrastructure and is able to contribute to better coordination with community clinics and community paramedicine, then there is additional potential for easier surge increase within the hospitals themselves. Huang commented that hospitals, as well as pre-hospital care providers (e.g., EMS), also must have adequate age-appropriate supplies on hand (e.g., medication and equipment for both children and adults, electricity, water, fuel) and must be able to access patient medical
records. For example, housing the EHR system in a different building with a remote hosting process in case of a regional disaster, or contracting with the state or regional health information exchange (HIE) could be alternate sources of access when needed. This is in addition to building the overall health of the population, because acute emergencies and health needs will not disappear. Again, as more health care systems move to electronic records and mobile patient portals, this part of preparedness planning and response could be easier and more immediate. Various speakers noted the burden of medical surge could be lessened through intake at various community clinics and outpatient offices, as long as patient records are fully accessible and successful provider coordination is enabled.
Local public health departments across the country are also transforming as the Public Health Accreditation Board is pushing them away from direct service and toward a focus on population health. These system-level changes are being accelerated by the ACA, with both positive and negative implications, said DeSalvo. To illustrate, she shared some of her experiences as health commissioner for the City of New Orleans in rebuilding a more resilient, decentralized health system following Hurricane Katrina in 2005.
Hurricane Katrina affected 93,000 square miles across 4 states, killing more than 1,800 people. Eighty percent of New Orleans was flooded, 200,000 households were destroyed, and the health care infrastructure was crippled. The 911 system was shut down due to lack of staff, failure of communications technology, and other issues. Charity Hospital, the academic health center serving most of the low-income residents of the community (most of whom were uninsured or on Medicaid) was severely damaged and will not reopen. Part of the problem, DeSalvo said, was the safety net for the city’s uninsured and underinsured was geographically and financially centralized in that one hospital building downtown. Charity Hospital relied on DSH funding, and the system was not accustomed to receiving people who had insurance of any sort, public or private, and was not capable of handling traditional fee-for-service billing. When Charity Hospital closed, the large dispersion of New Orleans patients arrived at other facilities without insurance, and in most cases, without any medical records.
Although this scenario is bleak, the pieces of the ACA already discussed in this report show that DSH payments are disappearing, insurance coverage is expanding, and paper medical records are transitioning into electronic/cloud-based records that can be accessed from anywhere. With these specific ACA changes, ideally the compounded needs that Charity Hospital and its patients had could be met in future scenarios. Additionally, although Charity Hospital will not reopen, a new $1.2 billion public hospital is being built and transitioned to a private operator, which may also help to address payment issues and familiarity with insurance billing in the future.
Services Outside the Hospital
In the wake of Katrina, New Orleans has focused on building a system that is not so geographically and financially centralized and that would be much more resilient, not only for a disaster, but also for everyday care (DeSalvo and Kertesz, 2007). The city is increasing out-of-hospital infrastructure and creating a distributed network of neighborhood-based clinics that can help to decrease the dependence on safety net hospitals. DeSalvo noted that these neighborhood-based clinics, acting as patient-centered medical homes, were modeled after the team-based medical response to Hurricane Katrina. These clinics could be supported by programs such as the federally qualified health center (FQHC) program. Under various provisions,3 the ACA will also support FQHCs by adding preventative services to the Medicare payment rate and eliminating the outdated Medicare payment cap on FQHC payments, making this a viable option for distributed clinics (Riley et al., 2012). The neighborhood clinic model reduces the need for patients to travel downtown and wait in long lines to be seen in the ED, and importantly, reduces dependency on declining DSH funding at safety net hospitals.
DeSalvo also highlighted the importance of data in the event of disaster, including a registry of patients who may need attention quickly (e.g., those on blood thinners or cancer regimens). In the future, health care organizations could leverage existing cancer, trauma, stroke, joint replacement, acute myocardial infarction, and other registries to develop a new registry of patients who may need attention quickly during a man-
3Provisions include a requirement that qualified health plans reimburse FQHCs no less than the Medicaid Prospective Payment System (PPS) rate, § 10104(b)(2); addition of preventive services to FQHCs’ Medicare payment rate § 5502(a); and elimination of the Medicare payment cap on FQHC payments, § 10501(i).
made or public health emergency. There was a lot of creative work after Katrina to use claims and pharmacy data to cobble together medical records for privately and publicly funded patients, she said. This laid the foundation for the state to become much more health information technology enabled, not just through EHRs, but also through HIEs. She noted that the network of neighborhood clinics and the new public hospital will use EHRs.
In addition to a stronger, more resilient and ready health care system, it became increasingly clear that a strong local health department was also essential. DeSalvo also focused on transforming the New Orleans health department from treatment focused to prevention focused, transitioning out of direct health care service toward promoting and protecting the health of people where they live, learn, work, and play, while maintaining important core functions such as emergency preparedness. This is similar to the ACA’s recent emphasis on population health management.
DeSalvo noted several unintended consequences of public health transformation. Downsizing has meant doing the same with less, and the move away from direct service means there are less clinical staff. The new model focuses on environmental, system, and policy-level change, but it does not include safety net services. The ACA is accelerating that change because theoretically, the need for public health clinics should decline. However, there will still be people who are uninsured, and they are likely to be the ones who are most vulnerable (e.g., those with mental health issues, undocumented residents). Privatization of the local safety net also diminishes the public health work force for emergencies, including pandemics. Also on a much tighter budget, hospitals have decreased flexibility to surge in response to disaster.
However, on the contrary, as DeSalvo demonstrated in her experience, there has been investment in community health centers through the ACA, which have the potential to be part of the emergency response infrastructure. Neighborhood clinics can help to reduce the burden on EDs, making hospitals more available for true emergency cases. With expanded coverage, Lurie said, people will be able to receive needed routine and chronic care on a regular basis so they will not already be in a compromised state in the event of a disaster, and they will have financial access to care wherever they end up. In addition, participating in a health system also means more data will be available that can be used to identify those with special medical needs and move beyond response and recovery to fostering resiliency.
Health care systems are undergoing dramatic transformations at an extraordinary pace to be able to provide the right care, at the right place and right time, and at the right cost, every day, said Charles Cairns, chair of emergency medicine at the University of North Carolina–Chapel Hill. Facilities are also expected to have surge capacity to respond to disasters and mass casualty events. The challenge, he said, is maintaining efficiency and cost-effectiveness in the current setting of increased demand and limited resources.
One of the expected benefits of broader coverage is that when patients are insured, hospitals are reimbursed faster, and hospitals that are impacted by disaster can recover faster. In her remarks, Lurie pointed out as an example that the National Disaster Medical System (NDMS) pays the medical bills of uninsured patients it transfers for care when activated. Correspondingly, as the percentage of the population that is insured increases, they will have to do this less often. The cost of NDMS in disasters can be reduced, and funds within the NDMS program can be better applied to other needed response activities.
Medicaid Expansion and Disproportionate Share Hospital Payments
In her remarks, Huang noted that while limited funding is available to states and to health care providers to support emergency preparedness activities, these funds are not enough to cover the expense of being ready. Because of the amount of uncompensated care that America’s Essential Hospitals (i.e., safety net hospitals) provide, they rely heavily on programs such as DSH funding in both Medicare and Medicaid. As mentioned in Chapter 2, ACA financing reforms include cuts to funding for DSH payments (under the assumption that increased coverage will lead to less uncompensated care), and these cuts will be particularly challenging for states opting to not expand Medicaid eligibility. Federal funding for Medicaid DSH payments will be reduced by $18.1 billion by 2020 (CMS, 2013; Neuhausen et al., 2013). The formula used for Medicare DSH payments to hospitals will evolve toward distribution based on uncompensated care, but Medicare DSH payments will be reduced by about $22.1 billion over the same time period. More Medicare cuts are expected, and states continue to face fiscal pressures
on Medicaid programs. When 75 percent of the care delivered by safety net hospitals is to patients who are eligible for a government program or uninsured, Medicaid DSH is by far the largest source of support for these hospitals in terms of uncompensated care, with Medicare DSH a close second, Huang explained. State and local support are less and less reliable as many states undergo fiscal pressures, which present a difficult challenge to safety net hospitals in those states that do not expand the Medicaid program.
As hospitals face these cuts, coverage expansion under the ACA will increase demand, and the impact of adding covered lives through marketplace plans remains to be seen. As Ebeler explained, many individuals with low incomes will be eligible for tax credits to help with affordability of premiums and additional subsidies to help with cost-sharing responsibilities. However, should these patients not be able to pay the cost-sharing that is their responsibility, public hospitals will continue to incur uncompensated care, which will put them at a greater disadvantage if a disaster occurs and they cannot bill insurance companies for the care provided. Careful planning and money-saving measures based on patient populations could help hospitals and health clinics avoid these situations. However, it will demand attention from hospital administrators and emergency planners, and success will be difficult to measure until a disaster does occur. Another unknown highlighted by individual speakers is what reimbursement rates member hospitals will be paid by the qualified health plans in the insurance marketplace. Finally, even with coverage expansion as mentioned previously, millions are still expected to be uninsured. Clearly their needs will continue, and Huang assured that AEH members and safety-net hospitals will continue to treat them. However, without rational or sustainable funding, the ability to rise and serve when most needed will be compromised.
Readying Trauma Systems
Another concern, raised by Norman Miller, trauma system administrator for the Mississippi State Department of Health, is the potential impact that the penalties under the ACA Hospital Readmission Reductions Program, or the “30-day readmit rule,” may have. If, for example, a trauma, ST elevation myocardial infarction, or stroke patient is successfully discharged and then has a traffic accident or other unrelated health incident, he or she will be back at the hospital, Miller
said, and the hospital can be penalized for this readmission. An important related provision in the ACA, Sec. 3504 on Regionalized Systems for Emergency Care, would amend Sec. 1203 of the Public Health Service Act to transfer the administration of the grant program for development of trauma care systems to the Office of the Assistant Secretary for Preparedness and Response (CRS, 2010). This could help coordinate routine emergency care services even more, while potentially improving outcomes in an acute disaster requiring robust regional surge response. This section also directs the Secretary to expand and accelerate basic science, translational, and service delivery research on emergency medical care systems and emergency medicine, including pediatric emergency medical care (CRS, 2010). Taken together, individual speakers noted these provisions could have significant impacts on the trauma care that hospitals will be able to provide in the future and on the potential for regional emergency response.