Editor’s note: This post expands on the theme of the December issue of Health Affairs, The Future of Emergency Medicine: Challenges And Opportunities.
Disasters always make the big headlines. In large part, this is because they can take away lives in an instant. They also make for big news because in some way, shape or form, we identify with those who suffer, if only to think – “at least it wasn’t me”.
In 2013, there were plenty of tragedies that caught our attention. The massive F5 tornado that destroyed Moore, OK. The cowardly bombings of the Boston Marathon followed two days later by the West, TX fertilizer plant explosion that destroyed half of the town, and the super typhoon that struck the Philippines, leaving a swath of death and destruction in its path.
The risks are ever present. And when something big and bad occurs, we are sure to hear about it. But there is a headline that you haven’t seen plastered atop the front pages of newspapers, or on the scroll that occupies the bottom of your television screens. Decreasing emergency preparedness funding is every bit a looming disaster as those noted above and very well may impact the manner and degree to which we are able to respond to such events.
In its December issue, Health Affairs focuses on the delivery of emergency care in the United States. The journal presents a kaleidoscope of viewpoints that address emergency care service delivery. A number of pieces highlight the importance of our emergency care system as both a safety net and the foundation upon which emergency preparedness and response is built. The creation of these capabilities has taken time and money. The US Department of Health and Human Services (HHS) awarded a total of $916 million in emergency preparedness grants for states and territories for fiscal year 2013, a decrease of $55 million from the previous year. This is money that goes to support both the Public Health Emergency Preparedness (PHEP) grant, focused on public health capacity building, and the Hospital Preparedness Program (HPP), focused on hospital preparedness.
Going Backwards On Preparedness Funding
Let’s specifically consider hospital funding for preparedness, which prior to the September 11 attacks and the subsequent anthrax letters in the fall of 2001, was essentially non-existent. This was truly an unfunded mandate, with few meaningful capabilities in evidence in the immediate aftermath of those twin attacks. Attention was focused on the need to support such efforts, and these cooperative grant programs were funded by Congress beginning in 2002.
Now, fast forward to 2013, and we see that funding for HPP has dropped significantly. From $515 million per year at the beginning of the program in 2003, current funding levels are $331 million. Upcoming budget proposals for HPP reduce the funding to this program even further — it is expected to decrease to $255 million in upcoming years. The forecast that this funding stream could erode completely in upcoming budget cycles may be coming true.
To those who think this couldn’t happen, look no further than the Metropolitan Medical Response System (MMRS). This program was funded by Congress in the late 1990s in consideration of the need to prepare communities for response to events such as the 1995 sarin gas attacks on the Tokyo subway system. This program funded over 120 cities across the United States; it focused on both a regional approach to preparedness and the integration of emergency response system components, including not just the hospitals but also public health and emergency medical services agencies.
Two key elements of the MMRS approach — regionalization, and integration of multiple stakeholders in the emergency response system — both have received strong emphasis in recent years in the HPP grants. However, a program that preceded the current PHEP and HPP grant programs, and has widely been credited with initiating the development of emergency response plans in communities large and small, was put on the chopping block with the 2011 Homeland Security budget and has not been funded since.
The Consequences Of Funding Reversals
Why are we allowing this to occur? Does it make sense to start and fund programs, only to let them wither and collapse? Shouldn’t sustainability of these efforts be prioritized? After all, creating meaningful preparedness and response capabilities is about as hard as it gets. Add to this the uncertainties that come with passage and implementation of the new health care laws. What does the changing face of health care delivery under the Affordable Care Act mean for health care emergency preparedness? The answers are not encouraging.
Decreases in funding mean loss of capacity building where it counts the most: getting the health care community involved and invested in preparedness. Sticking with the discussion of hospital preparedness, the effects of decreased funding are fairly clear. Hospital and medical staff are a busy group of folks. Getting them to think, plan, and train for emergency preparedness takes time, and time means opportunity cost and money. The Veterans Health Administration detailed a list of 72 capabilities that hospitals need for a comprehensive emergency management program. Some of these capabilities are complex and difficult to master. Staff roles and responsibilities in performing patient decontamination, and operation of communications and information management systems, are but two examples.
Even more time consuming is getting staff to sit together to discuss the ethical and operational challenges of making resource allocation decisions in the setting of scarcity. Such planning efforts, in which considerations must be made to consider the transition of health care service delivery from conventional care to crisis care, require thoughtful and prolonged discussion and, when possible, consensus. Staff who may be asked to shift from individual patient care outcomes, which is the way medicine is practiced every day, to population based decisionmaking, in which the needs of the community are put ahead of the needs of the individual, require the time to grapple with the effects and consequences that such plans will surely bring.
Budget cuts for preparedness also have created a domino effect. In addition to the steady decline in the amount of funding provided to the HPP, there has been a loss of discretionary funding that health care organizations are able to provide to help support hospital and community preparedness. While the single greatest losses have been registered in the public health community, where thousands of positions have been eliminated — including those affecting coordination and joint planning between hospitals and their respective health departments — hospitals, too, have suffered under these current budgetary constraints. Programs like those supporting health care emergency management are often prime targets for elimination, albeit mistakenly so, because “they haven’t been needed”.
An all-hazards approach and a quick review of key events over the past decade should dissuade those who think these programs are “nice to have” but not fundamental to the success of a health care organization. Now should be the time to further the support of such efforts, not whittle them down. Do cost-saving measures that undermine a health care organization’s commitment to community preparedness really make sense in the context of developing accountable care organizations? What is more accountable than knowing that a hospital is ready, willing, and more than able to meet the challenges of disaster events, large and small, that are yet to come?
What CMS And Other Stakeholders Could Do
With the erosion in funding for health care sector emergency preparedness, there is real risk of losing ground and undermining the sustainability of the past decades’ many achievements. Further investments must be made now, while the programs are still strong, including those that will support and encourage training and education for doctors, nurses and other health professionals. There is an important role for the Centers for Medicare and Medicaid Services (CMS) to help provide financial support for preparedness. CMS already helps to fund graduate medical education. Getting medical and nursing school curricula to mandate health care system preparedness training would be a worthwhile augmentation of such support.
As we begin 2014, there is at long last some movement on the part of CMS. After much deliberation, CMS has released a proposed rule that would establish emergency preparedness conditions of participation for hospitals, and related healthcare organizations. Participation in the Medicare and Medicaid programs would require attention to emergency preparedness. The proposed rule would require participating providers and suppliers to meet four standards which include developing and maintaining: (1) an emergency plan based on a risk assessment and using an all-hazards approach focusing on capacities and capabilities; (2) policies and procedures based on the plan and risk assessment; (3) a communication plan to coordinate patient care within the facility, across health care providers and with state and local public health departments and emergency systems; and (4) training and testing programs, including initial and annual trainings, conducting drills and exercises or participating in an actual incident that tests the plan.
After all, our emergency response programs are only going to be as good as the people who are expected to make them work. We cannot simply rely upon the equipment, supplies and pharmaceuticals that are laying in wait to make the difference. Without trained and experienced staff, these materials will not be put to effective use. In cutting funding, are we missing the opportunity to get more health care practitioners involved in the fight?
While the proposed CMS rules focusing on emergency preparedness is an important step forward, coming as it does after well over a decade of intensive focus on this issue, there is more that could be done. CMS could help to incentivize hospital participation in regional health care coalitions, the substrate that currently defines hospital preparedness planning and response. Pay hospitals for participation in such efforts, and for engaging in the 4 standards noted previously. Why not put needed funding to the collective support of community preparedness? Moreover, calling for plans, policies, resources and training misses an important point: CMS ought to fund an emergency preparedness coordinator at each participating hospital, a qualified expert in healthcare emergency management who can help coordinate these complex efforts. Pay for this position the same way graduate medical education spots are paid for.
And to that end, why are we not also insisting on contributions to the sustainment of preparedness from private payers, including the health insurance industry? What is holding back the major payers from supporting such sustainability efforts? Why are we not insisting on contributions from the private sector entities that benefit from a robust health care system, such as the suppliers of IT solutions (including the electronic medical records that are being placed in hospitals throughout the country) and the pharmaceutical companies and medical suppliers?
The remarkable successes in responding to the destruction of Mercy Hospital in Joplin, MO, and to the victims of the bombings during the Boston Marathon occurred in no small part to the tremendous successes of the HPP. These include the investments made in supporting the development of hospital coalitions, the growth and maturation of emergency response systems, and the encouragement of joint training exercises and drills that have pulled the response community together. But while talk may be cheap, time is not. To bring responders and their organizations and agencies together on a regular basis to plan, prepare, train and exercise for these sorts of “predictable surprises” costs money. Loss of funding for these activities, coupled with the absence of creative strategies that encourage more private-public partnership and investment in preparedness, spell trouble. Add to this the mounting financial stresses facing the health care community, and municipal response agencies, and you can quickly get a sense of where, after all our gains, we may be headed.
Building the capacity and capability required for a prepared community takes an investment in time and money. We have done a decent job of this over the past decade. But now is not the time to pull back funding. The sustainment and continuity of these efforts must remain a political priority, regardless of which side of the aisle the support comes from. Disasters, in fact, do not discriminate between blue states or red state victims. Both are fair game.
But in the worst case scenario, the waning financial support for these efforts will translate into lives lost, significant economic damages and further erosion of confidence in government and the political leadership that is supposed to place the people’s interests above all else. Let’s not continue this trend of flirting with disaster. Let’s invite the opportunities to fund preparedness to the levels that are required to ensure we are meeting our national health security goals.