January 18, 2008 | Special Report on Department of Homeland Security
A Resource Guide and Report of the Health Care and Homeland Security Conference, July 17-18, 2007
Health care reform is again being seriously discussed. Rapidly rising costs, problems with access to care, and questions about quality of care have made this a major issue. At the same time, the post-9/11 and post-Hurricane Katrina world has focused significant attention on improving our medical preparedness and disaster response planning. However, discussions on one issue usually do not consider the other. Homeland security clearly has many areas that involve health care, from the public health infrastructure to health-related industrial capacity. And, of course, the homeland security community relies on the health care community to respond to any disaster involving illness or injury. Health care reform will be a massive undertaking involving standard information systems, health promotion and prevention as well as acute care, access for all with an expanded emergency capacity, and the ability to "surge" hospital care. All of health care reform has homeland security implications, but emergency capability and response, hospital capacity, and public health are especially significant for both. Recognizing this, The Heritage Foundation, supported by the McCormick Tribune Foundation, convened leading health care and homeland security experts to discuss the precarious relationship between the two areas. This report, prepared with the assistance of Martin, Blanck & Associates, is the result of that conference and includes policy recommendations and additional references.
At the crossroads of health care delivery (and reform) and homeland security emergency preparedness lies the disaster. Whether the disaster is chemical, biological, nuclear, radiological or explosive, man-made or natural, the event will trigger immediate response in the affected population. The first reaction of those in need of medical attention will be to flood the local emergency care system. Our emergency response system relies on first responders (fire, police, ambulance) to treat those in need of care and transport them to first receivers (emergency departments, community hospitals, trauma centers, urgent care facilities).
9/11 and Hurricane Katrina were overwhelming regional disasters--one terrorist and one natural--that affected the entire country in their scope, difficulties of response, lack of communication, lack of preparedness, and oftentimes, lack of leadership. These will surely not be the last major disasters America will face.
What have we learned? Are we prepared for the next crisis of overwhelming proportions?
We have learned about a number of things that can go wrong in disaster response--fragmentation of responsibility, logistics problems, and poor communication channels, to name but a few. The establishment of the Department of Homeland Security (DHS) was the most significant response to 9/11, and the failure of the federal response to Hurricane Katrina four years later highlighted the weaknesses of the relatively new federal agency.
A look at the current state of readiness of the health care and emergency medical systems shows strains on capacity, budgetary constraints, and low priority given to emergency response readiness. Any surge in demand could quickly overwhelm resources. Emergency medical services received only 4 percent of the $3.38 billion distributed by the DHS for emergency preparation in 2002 and 2003. The average hospital received less than $10,000--not enough to equip a single critical care room. To make matters worse, trends in the health care sector foretell even greater constraints in the future.
Emergency planning often focuses on the first response--speed and coordination in the first days of the crisis. Practice drills are short and intense. It is easy to overlook the sustained impact of the real event. An effective plan must also deal with the later surges and continuing aftermath. When supply chains are disrupted, additional people will require care as they run out of medicines, for example. And the effectiveness of care providers can be diminished by failures of communications networks, computer systems, banking systems, transport systems and competing needs of family members.
Nearly two years have passed, yet only one of New Orleans' seven general hospitals is back to pre-Katrina capacity. Four remain closed. Hospital beds are down by two-thirds. The city's trauma center reopened in February 2007. After tourism and retail, the city's largest private employment sector had been health care. Now, the health care sector's current diminished state is considered a key factor blocking post-Katrina economic revival. Meanwhile, despite pledges of assistance and encouragement from the Secretary of the U.S. Department of Health and Human Services (HHS), Louisiana officials have yet to embark on a significant improvement of their health care system.
Disaster preparedness cannot focus solely on preventing terrorist acts. We know that at some point another disaster, man-made or natural, will come our way. An essential component of national response is the capability to respond quickly and effectively to that next crisis. For that to happen, we need to move now to strengthen the capacity and resilience of our health care delivery services, involving everything from detecting contagious disease outbreaks through organizing the public health response.
Strategic solutions are needed that can garner broad political support. Disincentives and inhibitors in our current systems must be addressed.
The good news is that many of the efforts envisioned to address overall problems in the health care system will also benefit emergency response preparedness and other elements of homeland security. These will likely take time to bring to fruition. In the interim, we need incremental and tactical solutions to provide immediate improvements and lay the groundwork for achieving strategic goals.
The Current State of First Receivers
For a variety of reasons, first receivers today are ill-prepared to treat a sudden surge in disaster victims. We will examine issues facing the emergency departments, the hospitals and other health care facilities, and the medical practitioners who comprise the first receiver community.
a. The Emergency Department Crisis
At present, our emergency rooms are at the breaking point for capacity and delivery of care. The Institute of Medicine's Future of Emergency Care report series of 2006 cites the following statistics:
Too many individuals are seeking primary or preventive care from the EDs--the National Hospital Ambulatory Care Survey classified 47 percent of all visits as emergent or non-urgent.
b. The Hospital Crisis
Throughout our nation, communities view their hospitals as a "safety net service." Our 3,000 non-profit, 1,200 state and local government-financed, and 770 for-profit hospitals command a degree of steadfast loyalty and expectation that care will always be provided.
While the emergency departments struggle with crowding, the hospitals that house them are also at the tipping point. Approximately 30 percent of hospitals today are operating in the red.
According to the American Hospital Association (AHA) the following societal and policy changes have placed additional stress on hospitals:
The closure of many mental health hospitals has forced individuals with mental health or substance abuse problems to turn to hospitals for their care. One quarter of all people seen in hospitals today have mental health and substance abuse problems according to the AHA.
In the last decade, over 700 hospitals have closed nationwide. As a result, 90 percent of Level One tertiary care hospitals are operating at 90 percent bed capacity. Over three-quarters of emergency physicians reported in the annual American College of Emergency Physicians' survey that their hospital does not have the surge capacity to respond effectively to an epidemic illness or an act of terrorism. Hospitals also lack negative-pressure units for isolating victims of airborne diseases, and personal protective equipment for their staff.
c. The Medical Practitioner Crisis
The medical practitioner (physicians, nurses, physician assistants, nurse practitioners, mental health care workers) is under siege. Costs of liability insurance, decreasing reimbursements, the "hassle factor" of increased red tape and regulation, and the increasing costs of practice are driving individuals out of the system. EDs currently have vacancies in 13 percent of their staff positions. And Community Health Centers have over 2,500 current clinical vacancies across the country.
Today, the health care sector is facing a severe shortage of nurses. Many nurses are approaching retirement age and the nursing profession faces difficulties both attracting new entrants and retaining the existing workforce. As a result, the nurse supply remains flat. This results in serious regional shortages. For example, the state of California has a 15 percent to 20 percent nursing vacancy rate at hospitals today, and there are estimates that it will reach 46 percent by 2020.
Fewer and fewer young people are entering the health care profession just as our population needs more. The 2005 Council on Graduate Medical Education report states that there will be a shortage of at least 90,000 full-time physicians in the U.S. by the year 2020. Medical schools are expected to expand enrollment by a maximum of 7 percent, leaving a shortage of 1,700 new physicians annually. At the same time, nursing schools cannot attract faculty to fill the numerous open teaching positions.
With medical practitioners stretched thin, training in emergency preparedness and disaster medicine falls to a lower priority than meeting current patient needs. There is no medical specialty that addresses disaster medicine. Without the medical professionals developing such a specialty, development and dissemination of expertise in this area will languish.
The Current State of Disaster Response
a. Emergency Management Services (EMS)
Emergency care is highly fragmented. More than 6,000 911 call centers are in operation, supporting 15,000 Emergency Management Service systems with 800,000 responders handling 16 million transport requests per year. EMS systems may be run by police departments, fire departments, city or county governments, or private companies. These are currently under state and local jurisdiction, as are the standards for the training and certification of EMS personnel.
Senior officials at DHS and HHS have communicated a national policy that puts local EMS Chiefs, Directors, and Administrators responsible for handling response to an incident in the first 24-72 hours with local and regional resources. While the local EMS officials recognize this policy, they are concerned that too many federal agencies have oversight over their activities. The local EMS community seeks one voice and consistent funding. In addition, local EMS personnel believe that they are not made aware of the larger overall emergency preparedness efforts and goals, especially at the federal level. This persistent fragmentation leaves room for confusion and wide variability of performance.
EMS systems received only 4 percent of the $3.38 billion distributed by DHS for emergency preparation in 2002 and 2003.
b. Public Health Departments
Public health departments are not typically thought of as emergency responders, yet for biologic events they fulfill this role. Public health departments are charged with early detection, epidemiologic investigations, and the application of large population measures (e.g., immunizations) to control biologic outbreaks. While funding for public health departments has increased thanks to the anthrax mailings shortly after 9/11, it is still inadequate and a national public health system with rapid communication and notification capability has not been fully developed. Public health and traditional emergency management services are not well integrated, and public health is all too often an afterthought or left out of the planning process entirely.
c. Department of Homeland Security (DHS)
The Department of Homeland Security is responsible for coordinating the overall federal response to disasters, while the Department of Health and Human Services oversees the national medical response. DHS essentially supports HHS efforts. Recently, the Office of the Chief Medical Officer within DHS was also assigned responsibilities for planning the medical response for disasters.
Within the federal organization, the challenges are crosscutting. Since the aftermath of Katrina, the office has undergone organization and scope changes in order to respond more quickly to a severe disaster. On April 1, 2007, DHS announced a new internal reorganization.
The Office of Health Affairs (OHA) was created and is led by the Chief Medical Officer, who now has the title of Assistant Secretary for Health Affairs and Chief Medical Officer. The Office of Health Affairs has three main divisions each directed by a Deputy Assistant Secretary:
As the Office of Health Affairs tackles its new mission, the following challenges have been identified:
These issues are repeated within the policy department at DHS. Officials within the department believe that the National Incident Management System (NIMS)--which consists of a nationwide template to enable federal, state, local, and tribal governments, as well as private-sector and nongovernmental organizations, to work together effectively and efficiently to prepare for, prevent, respond to, and recover from catastrophic incidents--is only a "Rolodex." The NIMS is a framework, not a solution, and communities are failing to plan or to build in self-sufficiency, flexibility, and coordination.
Another area in need of further review is the Target Capabilities List that is an internal part of the National Response Plan. The NRP establishes a comprehensive all-hazards approach to enhance the ability of the United States to manage domestic incidents. The plan incorporates best practices and procedures from incident management disciplines--homeland security, emergency management, law enforcement, firefighting, public works, public health, responder and recovery worker health and safety, emergency medical services, and the private sector--and integrates them into a unified structure. It forms the basis of how the federal government coordinates with state, local, and tribal governments and the private sector during incidents. The Target Capabilities List--a capabilities list planning tool used by local-state-regional-federal agencies to prepare their communities in the areas of public health, environmental health, triage, fatality management, surveillance, etc.--has been developed but not implemented. So far, only federal officials appear to be interested in the effort; states and local officials have not embraced the effort.
At the White House, the Office for Biodefense Policy of the White House Homeland Security Council, which is responsible for bio-surveillance, countermeasures, mass casualty planning, and community preparedness, reported the following challenges:
Progress Being Made
While the state of health care and homeland security regarding emergency preparedness appears to be somewhat dire, planning at all levels has shown significant progress.
a. Local Level
The National Association of Community Health Centers (NACHC) and the National Association of Community Health Officials (NACHO) represent Community Health Centers (CHC), which serve the most vulnerable of the U.S. population, often in more rural communities. By design, they serve all who seek care regardless of ability to pay. NACHC represents 1,100 Community Health Centers in over 3,000 communities, serving 16 million patients annually. The CHCs provide comprehensive primary and preventative health care including health screening, immunizations, dental care, pre-natal and neo-natal care, diabetes management, HIV prevention and education, mental health and substance abuse counseling, as well as health care services for migrant workers and homeless individuals. Some 71percent of patients fall at or below the federal poverty level in income.
Both organizations report that they are now included in the local, regional, and state emergency preparedness planning process. Integration has been enhanced at the local level and equipment, protocols, laboratory capacity, and transmission of results have all improved. Health departments nationwide are using the NIMS. They report that most communities have plans, live exercises and drills, mass distribution strategies, and means to integrate health affairs with law enforcement emergency response.
Established as a "safety net" in the 1960s, CHCs help alleviate the overcrowding of hospital emergency rooms by providing an alternative to high-need populations for primary care. The Bush Administration and Congress have nearly doubled annual federal spending for CHCs since 2000 to almost $2 billion. Six years ago, CHCs served 5 percent of the population; that has now grown to 10 percent.
CHCs provide additional support capabilities for local communities facing an emergency. Eighty percent of CHCs have a disaster plan, often developed in conjunction with the local health department plan. CHCs also have a historical track record in responding to past emergencies including hurricanes, wildfires, and earthquakes. Their capabilities include:
b. State Level
The National Guard has traditionally provided civilian support to governors of states. During Hurricane Katrina, the Guard provided 50,000 troops. Their goal in the medical arena is to provide triage, treatment, and transportation. In the "Lessons Learned" report after Katrina, the Guard was more fully integrated into the NRP and specifically into the state planning process by communities.
c. Regional Level
On July 19, 2007, at the Senate Committee on Homeland Security and Governmental Affairs hearing, it was reported that Department of Defense (DOD) liaison officers are stationed at all Federal Emergency Management Agency (FEMA) district offices to better coordinate the DOD and DHS response.
d. Federal Level
The National Response Plan and National Incident Management System are currently being reviewed by DHS. The Secretary of Homeland Security is conducting an interagency review to:
Federal, state, local, and tribal authorities, along with private-sector and non-governmental organizations (NGO)s are participating in the review and revision process.
Also, the Department of Health and Human Services released the National Strategy for Pandemic Planning IV on July 18, 2007. It outlines a number of initiatives and reports on their progress:
Last, on July 26, 2007, HHS issued guidance in the Federal Register for the "Emergency Use Authorization of Medical Products." This notice is defined as a "critical new tool for medical and public health communities and is applicable for both civilian and military use." The EUA allows a relevant medical product which has not yet been approved by the FDA to be used during an emergency.
Inhibitors to Progress
a. Spiraling Costs
Underlying the ED, hospital, and practitioner capacity crises is the general financing problems that plague the health care sector. The U.S. health care sector represents $2.2 trillion of the economy--half of which is spent on Medicare and Medicaid and other public programs and the other half on private sector spending. This amounts to one-sixth of the entire U.S. economy. Unlike virtually every other sector of the economy, the normal operation of market forces, which routinely control costs, is largely absent. Especially absent is consumer choice. Out of every $100 spent on health care coverage, for example, only $3.50 is spent directly by individuals and families.
The biggest challenge facing health care, then, is rising cost. Currently, health care consumes more than 16 percent of GDP, and the federal government's portion amounts to 8.6 percent of GDP. That federal share is expected to grow to 20 percent of GDP by 2050. In real terms, health care sector spending is growing 2.5 percent faster than the economy. The number of those eligible for Medicare will be doubling from 40 million people to 80 million over the next 30 years, beginning with the first wave of the baby boom generation in 2011. And as a demographic sector, those over 65 account for a disproportionate percentage of health care expense. The aging of the population, the retirement of the baby boomers, expansion of the entitlement programs (e.g., the new Medicare Prescription Drug Program and rising Medicaid enrollment), and lower fertility rates have led the U.S. to a point where our healthy and growing economy cannot as easily absorb the cost of this rapid demand for medical services as it did in the past 30 years. There is a broad consensus among health policy analysts that Americans are facing an unsustainable growth in the cost of health care, particularly in Medicare and Medicaid.
Cost pressures are one of the inhibitors to development of robust emergency response approaches, but also one of the main drivers for health care reform. Strategic solutions to constrain health care spending, or, even more importantly, to enable individuals and families to secure value for money, may enable more efficient approaches to homeland security and medical emergency response requirements.
b. National versus Local Risk Assessment
Pushing down planning responsibility for first response to the local level creates a disincentive to invest. At the national level, there is clearly substantial risk that a major disaster of some sort will occur in the next few years. For a locality, the risk of a disaster in that particular community is much less. It is very difficult to justify taking money away from pressing local needs to address an event that is highly unlikely to occur. So while it makes sense to insist that local communities form specific local plans, a regional or national approach to stockpiling and positioning resources to support first response seems a wiser and more economical approach. Rapid deployment plans would be needed. Some of the strategic technology solutions to improve health care will also facilitate more centralization of expertise and real-time dissemination to remote locations. Telemedicine is an example of this capability.
c. Identification and Funding of Federal Public Health Priorities
It is easy to forget our health care delivery system's interdependency with public health initiatives. Certain activities are vital to the national interest and should be funded at the federal level. An example is surveillance of animals and humans for emerging diseases. There should be a single federal agency charged with identifying critical public health priorities and educating legislators and the public on the dangers and objectives. By funding these at the national level, resources are assured for activities that are in the national interest and practitioners and other health care entities can be adequately compensated for their efforts and contributions to achieving public health objectives.
d. Pay and Incentives for Health Care Practitioners
Current pay and incentives for doctors, in both the public and the private sectors, are oriented toward performing procedures and prescribing drugs, rather than preventing illness, managing medical conditions effectively, or achieving satisfactory health outcomes. Financing influences delivery.
For emergency medicine, in particular, public and private officials should look toward changing current compensation. Compensation and measurement systems must be adapted to encourage greater efficiency and effectiveness in the delivery of care. In pursuing health care reform, policymakers should give special consideration to emergency response objectives and means of compensating practitioners for their roles in planning, training, and carrying out these essential activities. The medical profession too must be directly engaged. Without a disaster health specialty or dedicated advanced trauma centers, it is more difficult to generate and disseminate this vital expertise across the health care sector.
e. Information and Communication Gaps
Information and communication systems are still fragmented across the health care sector. Resolving the fragmentation will require leadership to ensure coordination and significant investment in both information systems and communications network infrastructure. The development and widespread usage of an electronic medical record, with proper regard for patient privacy and liberty, should be a key element of health care reform initiatives to reduce administrative costs and errors. As more medical records and data flow across networks and are stored on information systems or portable media, the requirements for ensuring data recovery, privacy, and security are paramount. Ensuring the availability of these systems in crisis scenarios will need full consideration in the development and execution of emergency plans.
While progress is being made in medical emergency planning at the local, state, regional, and federal levels, many inhibitors remain to be addressed. Strategic solutions are needed to ensure a robust and resilient health care sector for the decades to come. Large, complex problems do not lend themselves to quick fixes. Addressing health system issues often requires long-term commitment, sustained effort, and strong leadership to achieve success. Many of the strategic solutions will depend on generating public and political support for these initiatives. One way to build support and test the viability of strategic solutions is through pilot or demonstration projects.
Incremental and tactical solutions provide quick fixes to strengthen readiness. Immediate steps can be taken in both the health care and homeland security sectors to resolve minor issues under discussion while providing the foundation for the longer-term strategic solutions.
As tactical and strategic solutions to improve health systems are agreed on and implemented, we must ensure that they address requirements for emergency response.
a. Strategic Solutions
While there are many actions that may be taken quickly, it is important to focus on the overall goals and select those activities required to move key strategies forward.
Below are six strategic solutions for the health care sector followed by three strategic solutions for the homeland security sector. Even though the health care solutions fall short of full reform, taken together, these strategic solutions should improve the nation's position of readiness for a major disaster. Tactical solutions supporting each strategic goal are identified by a T and their number in the listing of tactical solutions that follows this section.
In addition, an interim strategic solution is offered to deal with the potential catastrophic event that occurs before any of the strategic, or many of the tactical solutions, can be fully implemented. We need to envisage the potentially dire circumstances of our current unprepared status.
Health Care Sector
Homeland Security Sector
b. Tactical Solutions
Immediate steps can be taken in both the health care and homeland security sectors to resolve minor issues under discussion while providing the foundation for longer-term strategic solutions. Many of the tactical solutions address broader issues causing stress on the health care sector. Steps to alleviate these conditions may also strengthen disaster and emergency response capacity.
Health Care Sector
About the McCormick Tribune Foundation
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About Martin, Blanck & Associates
Martin, Blanck & Associates is a leading health care consulting firm that brings a team of partners with unparalleled leadership experience--as health executives, policy makers, physicians and other providers--who have served throughout the federal government and the private sector. We help our private sector and government clients move forward in a challenging environment, by identifying solutions and helping to implement them.
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