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 (Auf der Heide and Scanlon, 2007). 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. Titled Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public’s Health and National Security, this workshop had the following objectives as developed by an ad hoc planning committee:
1 The planning committee’s role was limited to planning the workshop, and the Proceedings of a Workshop was prepared by the workshop rapporteur and staff as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus.
- Explore the degree to which the public and private health care systems self-identify as key components of the U.S. disasters and national security infrastructure;
- Discuss interest among health care institutions in developing collaborations across public and private sectors with the aim of strengthening capacity to respond to disasters and public health emergencies;
- Consider possible key levers that would motivate private-sector investment in system capacity building for disaster and public health emergency response, including those levers that already exist, but are not currently used as incentives to expand this capacity (quality measurement, grant programs, alternative payment models, tax benefits, etc.);
- Explore possible strategies to overcome key challenges to applying existing incentives to improve the quality, effectiveness, and efficiency of the management of critically ill and injured patients on a day-to-day basis and during emergency response scenarios;
- Review possible key sources of information and data elements that could be used to improve situational awareness of public- and private-sector health care facility capacity and capabilities to respond to disasters and public health emergencies; and
- Understand the degree to which Department of Defense (DoD) or Department of Veterans Affairs (VA) hospitals could be used as a part of the U.S. response to disasters and public health emergencies requiring a health care response.
To begin the workshop, Kevin Yeskey from the Office of the Assistant Secretary for Preparedness and Response (ASPR) of the Department of Health and Human Services (HHS) provided some background on ASPR.2 ASPR’s mission, he said, is to save lives and protect Americans from 21st-century threats, many of which have the possibility of causing unimaginable health consequences. ASPR’s charge includes planning for and responding to seasonal threats such as hurricanes, tornadoes, and debilitating snowstorms; infrequent threats, such as earthquakes; and new threats, including
2 For the purposes of this publication, unless otherwise stated, ASPR refers to the Office of the Assistant Secretary for Preparedness and Response rather than the Assistant Secretary himself.
state-sponsored terrorism, mass shootings, and bombings. The new threats, noted Yeskey, were not a big part of the public consciousness when ASPR was established in 2007; they cause injuries that most hospitals and trauma centers do not see at a frequency that enables them to handle such events with optimal efficiency. “We need to not only act stronger and with more capacity, we need to act smarter,” said Yeskey. “We need to build smartness and efficiencies into the way we respond and recover as well as prepare.”
The question ASPR gets regularly is, “Are we ready?” The 2017 hurricane season, with three significant hurricanes in a 4-week period, tested the nation’s emergency response and health care system capacity. Yeskey noted that HHS can call on the National Disaster Medical System (NDMS) at times of great need, but the volunteer force of federal employees that is part of NDMS was stretched to its limit by the time Maria struck Puerto Rico and the U.S. Virgin Islands. What Yeskey found alarming was that these were relatively straightforward events for which there were warnings and time to prepare, but some 21st-century threats do not have that fidelity as far as when and where they are going to strike. “We are going to have to look at how we can improve that system and improve our response capabilities,” said Yeskey.
Beyond that, the events in the fall of 2017 illustrated and amplified the health care system’s dependence on its supporting infrastructure. Hospitals, for example, depend on electricity, but the supplemental generators meant to keep hospitals with power during an outage are not built to run for days on end. In addition, as Yeskey noted, generators require fuel, and if roads are impassible, fuel may also be in short supply. “Those dependencies were very much thought about and discussed during the hurricanes, and we need a way to work through understanding those dependencies, whether it is in the supply chain or the electrical grid, and how to better get our health care facilities and our clinics back online and staffed and equipped and supplied,” he said.
Moreover, emergencies of that scale need the entire community—businesses, faith-based organizations, nongovernmental organizations (NGOs), and local government—to be involved, which calls for all sectors to be engaged in planning, response, and recovery activities. Speaking from ASPR’s perspective, Yeskey said, “We do not know people [in the community] and have not engaged in trusted relationships that will help us work through the complex problems associated with response and recovery.” That realization was one of the main reasons that ASPR asked the Forum on Medical and Public Health Preparedness for Disasters and Emergencies to hold this workshop. “Our emphasis today and tomorrow is to talk about public–private partnerships, how to develop those and not engage in those transactional onesies and twosies kind of relationships, but have ongoing,
credible, trusting relationships where you know the people you are dealing with, and can plan together and work together,” said Yeskey.
As an example of the work ASPR is doing to develop better relationships in communities, Yeskey described the Critical Infrastructure Protection Program. This initiative works with private industry to address problems and identify solutions from the private sector for infrastructure protection. He also mentioned a coordinating council, consisting of representatives from the private sector, that works with ASPR staff on issues such as pharmaceutical shortages and supply chain needs. ASPR also runs the public–private Hospital Preparedness Program (HPP) that was started by the Health Resources and Services Administration in 2002. This program provides states with money to fund efforts by hospitals and local coalitions to prepare for disasters and develop surge capacity, hardened communication infrastructure, and relationships. To receive money from this program, hospital coalitions must work with their community response partners, such as emergency management, emergency medical services, and public health, on community preparedness. As the 2017 hurricane season showed, some of these coalitions are quite capable, while others have room for improvement, said Yeskey.
He then mentioned several other programs that aim to improve preparedness on a community or regional basis. In September 2016, the Centers for Medicare & Medicaid Services (CMS) finalized a rule to establish consistent emergency preparedness requirements for health care providers participating in Medicare and Medicaid, increase patient safety during emergencies, and establish a more coordinated response to natural and human-made disasters.3 ASPR’s Biomedical Advanced Research and Development Authority (BARDA), another public–private partnership, advances medical countermeasure candidates through the later stages of preclinical development and the initial stages of clinical development. Over 10 years, BARDA’s efforts have helped develop 34 new countermeasures that have been approved by the Food and Drug Administration and are now included in the national stockpile for responding to chemical, biological, radiological, and nuclear (CBRN) threats.4
The NDMS that Yeskey mentioned earlier is a unique partnership among ASPR, DoD, the VA, Department of Homeland Security (DHS), and private-sector hospitals to create the capability of providing field care and moving patients out of harm’s way to hospitals that the VA coordinates with DoD. This network includes some 1,900 hospitals out of the 5,000 U.S. hospitals. ASPR would like more hospitals to join the network and
3 See https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Pressreleases-items/2016-09-08.html (accessed April 18, 2018).
4 See https://www.phe.gov/about/BARDA/Pages/default.aspx (accessed May 1, 2018).
is looking at ways of getting more hospitals to engage with the program. Yeskey noted that during Hurricane Maria, the VA provided personnel to staff federal medical stations, made its clinics and hospital in Puerto Rico available to anyone, and opened its supply chain and offered logistical support to response efforts on the island. “That was new ground, and we look to strengthen those relationships and work with the VA on how to better do that,” he said.
ASPR’s priorities going forward, said Yeskey, are to provide strong leadership, enhance public health security, improve the medical countermeasure enterprise, and create a regional disaster health response system. In each case, ASPR will depend on strong, ongoing public–private partnerships. As an example of strong local leadership, he noted Texas’s response to Hurricane Harvey in providing resources to move patients and establish situational awareness and support at the local level. He also singled out the nation’s response to the 2017–2018 influenza outbreak and the way in which hospitals stepped up to take care of patients even when emergency departments were overwhelmed with cases.
In conclusion, he charged the workshop participants with helping to identify the respective roles of government and the private sector in preparedness and response and to call out best practices in places where public–private partnerships are having success. He also asked the participants to consider cases where the response was not optimal and to identify the barriers that prevented effective working relationships between government and the private sector. “We hear sometimes in ASPR that the federal government is not a good partner and that we do not hold up our end of the bargain sometimes,” said Yeskey. “We want to know about those, and we want to understand what the challenges are so that we can get better at it.” His hope for the workshop was that it would help define a clear, actionable path forward in the short and intermediate terms that will enable ASPR and the nation to address the challenges associated with 21st-century threats.
This Proceedings of a Workshop summarizes the discussions and panel presentations that took place during the workshop. Chapter 2 provides private health system and federal perspectives on the nation’s capacity to respond to threats to health, safety, and security. Chapter 3 presents several examples of cross-sector collaboration from past disasters. Chapter 4 recounts small-group discussions about ASPR’s new vision for a regional disaster health response system. Chapter 5 takes up the subject of how to cultivate best practices in disaster response at both the ground level and across the entire health care enterprise. Chapter 6 discusses regulatory and financial barriers and facilitators for engaging the private sector in building
capacity to respond to disasters. Chapter 7 summarizes the closing keynote presentation by the Assistant Secretary for Preparedness and Response and the subsequent discussion with the workshop participants.
In accordance with the policies of the National Academies, the workshop did not attempt to establish any conclusions or recommendations about needs and future directions, focusing instead on issues identified by the speakers and workshop participants. In addition, the organizing committee’s role was limited to planning the workshop. This Proceedings of a Workshop was prepared by the workshop rapporteur as a factual summary of what occurred at the workshop.