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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public's Health and National Security: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25203.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public's Health and National Security: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25203.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public's Health and National Security: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25203.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public's Health and National Security: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25203.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public's Health and National Security: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25203.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public's Health and National Security: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25203.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public's Health and National Security: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25203.
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Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public's Health and National Security: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25203.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public's Health and National Security: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25203.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public's Health and National Security: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25203.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public's Health and National Security: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25203.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public's Health and National Security: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25203.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public’s Health and National Security PROCEEDINGS OF A WORKSHOP Joe Alper, Rapporteur Forum on Medical and Public Health Preparedness for Disasters and Emergencies Board on Health Sciences Policy Health and Medicine Division PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by a contract between the National Academy of Sciences and the Department of Health and Human Services (#10003836). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25203 Additional copies of this publication are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2018 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Engaging the private-sector health care system in building capacity to respond to threats to the public’s health and national security: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25203. PREPUBLICATION COPY: UNCORRECTED PROOFS

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY: UNCORRECTED PROOFS

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY: UNCORRECTED PROOFS

PLANNING COMMITTEE ON ENGAGING THE PRIVATE-SECTOR HEALTH CARE SYSTEM IN BUILDING CAPACITY TO RESPOND TO THREATS TO THE PUBLIC’S HEALTH AND NATIONAL SECURITY1 HELEN BURSTIN (Co-Chair), Executive Vice President and Chief Executive Officer, Council of Medical Specialty Societies ARTHUR L. KELLERMANN (Co-Chair), Professor and Dean, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences MICHAEL ANDERSON, President, UCSF Benioff Children’s Hospital and Senior Vice President, Children’s Services, UCSF Health, University of California, San Francisco ANGELA BRICE-SMITH, Deputy Consortium Administrator for Quality Improvement and Survey & Certification Operations, Centers for Medicare & Medicaid Services ERIC EPLEY, Executive Director, Southwest Texas Regional Advisory Council PAUL HINCHEY, Assistant Medical Director, Wake County EMS THOMAS KIRSCH, Director, National Center for Disaster Medicine and Public Health and Professor of Military and Emergency Medicine, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences JON KROHMER, Director, Office of Emergency Medical Services, National Highway Traffic Safety Administration, U.S. Department of Transportation NICOLETTE LOUISSAINT, Executive Director, Healthcare Ready RICARDO MARTINEZ, Chief Medical Officer, Adeptus Health CARTER MECHER, Senior Medical Advisor, Office of Public Health, Department of Veterans Affairs JOHN OSBORN, Operations Manager and Assistant Professor, Health Care Systems Engineering, Department of Surgery, Mayo Clinic College of Medicine TODD RASMUSSEN, Associate Dean for Research and Harris B. Schumaker, Jr. Professor of Surgery, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences ROSLYNE SCHULMAN, Director for Policy Development, American Hospital Association SKIP SKIVINGTON, Vice President of Healthcare Continuity Management and Support Services, Kaiser Permanente JEFFREY UPPERMAN, Director, Trauma Program and Director, Pediatric Disaster Resource and Training Center, Children’s Hospital of Los Angeles MICHAEL WARGO, Assistant Vice President, Enterprise Preparedness & Emergency Operations, Hospital Corporation of America Health and Medicine Division Staff SCOTT WOLLEK, Senior Program Officer CLAIRE GIAMMARIA, Associate Program Officer BEN KAHN, Research Associate MARIA BABIRYE, Senior Program Assistant ANDREW POPE, Director, Board on Health Sciences Policy Consultants JOE ALPER, Writer, LSN Consulting LAURA RUNNELS, LAR Consulting 1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteur and the institution. PREPUBLICATION COPY: UNCORRECTED PROOFS v

FORUM ON MEDICAL AND PUBLIC HEALTH PREPAREDNESS FOR DISASTERS AND EMERGENCIES1 DAN HANFLING (Co-Chair), Johns Hopkins Center for Health Security SUZET MCKINNEY (Co-Chair), Illinois Medical District STACEY ARNESEN, National Library of Medicine, National Institutes of Health ERIC BLANK, Association of Public Health Laboratories MARY CASEY-LOCKYER, American Red Cross BROOKE COURTNEY, Office of Counterterrorism and Emerging Threats, U.S. Food and Drug Administration JOHN DREYZEHNER, Association of State and Territorial Health Officials DAVID EISENMAN, University of California, Los Angeles BRUCE EVANS, National Association of Emergency Medical Technicians LARRY FLUTY, Office of Health Affairs, Department of Homeland Security JOHN HICK, Hennepin County Medical Center ROBERT KADLEC, Assistant Secretary for Preparedness and Response, Department of Health and Human Services CLAUDIA KELLY, Seqirus THOMAS KIRSCH, Uniformed Services University of the Health Sciences, Department of Defense DREW LEWIS, Meridian Medical Technologies NICOLETTE A. LOUISSAINT, Healthcare Ready FREDA LYON, Emergency Nurses Association CAROLYN MEIER, Administration for Children and Families, Department of Health and Human Services AUBREY MILLER, National Institute of Environmental Health Sciences, National Institutes of Health JOHN OSBORN, Mayo Clinic College of Medicine TARA O’TOOLE, In-Q-Tel ANDREW PAVIA, Infectious Diseases Society of America ALONZO PLOUGH, Robert Wood Johnson Foundation TERRY RAUCH, Defense Health Agency, Department of Defense STEPHEN REDD, Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention SARA ROSZAK, National Association of Chain Drug Stores ROSLYNE SCHULMAN, American Hospital Association RICHARD SERINO, Harvard University School of Public Health ALAN SINISCALCHI, Council of State and Territorial Epidemiologists CRAIG VANDERWAGEN, East West Protection, LLC JENNIFER WARD, Trauma Center Association of America GAMUNU WIJETUNGE, National Highway Traffic Safety Administration, Department of Transportation MATTHEW WYNIA, University of Colorado Denver 1 The National Academies of Sciences, Engineering, and Medicine’s forums do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution. PREPUBLICATION COPY: UNCORRECTED PROOFS vi

REVIEWERS This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: MAHSHID ABIR, University of Michigan MICHAEL J. CONSUELOS, The Hospital & Healthsystem Association of Pennsylvania JORIE KLEIN, Parkman Memorial Hospital JEFFREY UPPERMAN, Children’s Hospital Los Angeles Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by SARA ROSENBAUM, George Washington University. She was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteur and the National Academies. PREPUBLICATION COPY: UNCORRECTED PROOFS vii

CONTENTS ACRONYMS AND ABBREVIATIONS xiii 1 INTRODUCTION AND OVERVIEW 1-1 Sponsor’s Charge, 1-2 Organization of the Proceedings, 1-4 2 PERSPECTIVES ON THE NATION’S CAPACITY TO RESPOND TO THREATS TO HEALTH, SAFETY, AND SECURITY 2-1 Private Health System Perspectives, 2-1 Discussion, 2-5 Federal Perspectives, 2-8 Discussion, 2-12 3 LEARNING FROM EXPERIENCE 3-1 Case Studies in Cross-Sector Collaboration from Past Disruptions, 3-1 Discussion, 3-8 4 ASPR’S NEW VISION FOR A REGIONAL DISASTER HEALTH RESPONSE SYSTEM 4-1 5 LOOKING TO THE FUTURE 5-1 Cultivating Best Practices, 5-2 Discussion, 5-10 Leading Change Across the Field, 5-12 Discussion, 5-15 Leading Change at the Local Level, 5-17 Discussion, 5-20 6 OPPORTUNITIES TO IMPROVE PRIVATE-SECTOR INVESTMENT IN CAPACITY BUILDING 6-1 Examining Regulatory Barriers and Facilitators, 6-1 Discussion, 6-3 Examining Financial Barriers and Facilitators, 6-4 Discussion, 6-6 7 FINAL THOUGHTS 7-1 Discussion, 7-2 REFERENCES R-1 APPENDIXES A Workshop Agenda A-1 B Statement of Task B-1 C Speaker Biographies C-1 PREPUBLICATION COPY: UNCORRECTED PROOFS ix

Acronyms and Abbreviations AMR American Medical Response ASPR Assistant Secretary for Preparedness and Response BARDA Biomedical Advanced Research and Development Authority CBRN chemical, biological, radiological, and nuclear CDC Centers for Disease Control and Prevention CMOC Catastrophic Medical Operations Center CMS Centers for Medicare & Medicaid Services DHS Department of Homeland Security DMAT Disaster medical assistance team DoD Department of Defense EMS emergency medical services FAA Federal Aviation Administration FEMA Federal Emergency Management Agency GIS geographical information system HCA Hospital Corporation of America HHS Department of Health and Human Services HIPAA Health Insurance Portability and Accountability Act HPP Hospital Preparedness Program NDMS National Disaster Medical System NERC North American Electric Reliability Corporation NGO nongovernmental organization NORAD North American Aerospace Defense Command NTSB National Transportation Safety Board PREPUBLICATION COPY: UNCORRECTED PROOFS xi

xii ACRONYMS AND ABBREVIATIONS PAHO Pan American Health Organization REPLICA Recognition of EMS Personnel Licensure Interstate CompAct SETRAC SouthEast Texas Regional Advisory Council SNS Strategic National Stockpile STRAC Southwest Texas Regional Advisory Council USNORTHCOM U.S. Northern Command USUHS Uniformed Services University of the Health Sciences VA Department of Veterans Affairs PREPUBLICATION COPY: UNCORRECTED PROOFS

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Disasters tend to cross political, jurisdictional, functional, and geographic boundaries. As a result, disasters often require responses from multiple levels of government and multiple organizations in the public and private sectors. This means that public and private organizations that normally operate independently must work together to mount an effective disaster response. To identify and understand approaches to aligning health care system incentives with the American public’s need for a health care system that is prepared to manage acutely ill and injured patients during a disaster, public health emergency, or other mass casualty event, the National Academies of Sciences, Engineering, and Medicine hosted a 2-day public workshop on March 20 and 21, 2018. This publication summarizes the presentations and discussions from the workshop.

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