Healthcare reform – an important but complex and frequently controversial subject – has been on the back burner of national politics in the last few years, but may well develop into an important domestic campaign issue in the 2008 presidential and congressional elections. Because changes in the healthcare system will undoubtedly affect the ability of healthcare facilities and personnel to respond to a disaster, how, and how much, healthcare is reformed will matter significantly.
Unlike many other issues, though, healthcare is a major concern, and responsibility, of not only officials and decision makers at all levels of government – local, state, and federal – but also of private-sector managers and decision makers. In addition to the hands-on work done by state, local, and federal healthcare agencies and medical responders, all levels of government play major roles both in setting and in enforcing healthcare policies. However, in the private sector healthcare is first and foremost a business. Partly because of this division both of interests and of responsibilities, the development of healthcare reforms that improve response capacity but do not at the same time impede the competitive nature of the business of healthcare will have to be exceptionally well crafted to be as effective as they should and must be.
Following are a few suggestions not about the specifics of any healthcare changes that might be advocated this year and next, but about the guidelines and principles that should be considered in the development and/or implementation of those changes:
#1: Improvements in Efficiency Will Be More Important Than Additional Funding
Private-sector healthcare “systems” – hospitals and clinics, primarily, along with medical practitioners – are businesses that depend on Medicare and other medical-reimbursement plans to meet their operating expenses. The U.S. private-sector healthcare system, considered as a whole, is not built specifically to cope with disaster-response situations, though – and, should it break, those operational expenses will not be paid. During and in the aftermath of a sustained disaster – such as an avian-flu outbreak or a weather-related disaster such as Hurricane Katrina – healthcare workers and the suppliers of equipment and medicines also may not be paid. In short, the business side of the private-sector healthcare system must be able to sustain itself financially – or be sustained, at least in part, by the government – in times of crisis if the medical facilities that constitute the largest part of that system are to remain open.
At present, unfortunately, most if not all healthcare businesses are paid through a rather Byzantine system of “billing codes” that are submitted in various forms to healthcare insurers (which collectively constitute yet another major U.S. business). There are literally thousands of these codes – more formally called “International Statistical Classification of Disease and Related Health Problems” (abbreviated ICD-9) – as well as a broad spectrum of qualifying criteria and rules of usage. To understand and use this complex morass of billing, auditing, and regulating processes – which from the outside seems distressingly similar to the equally complicated U.S. tax code in a number of ways – requires a virtual army of accountants, auditors, and other personnel to translate the medical care provided into the various reimbursement codes.
The most common experience of the public with the business side of healthcare, probably, is contesting “allowed” vs. “disallowed” procedures and medications from a healthcare insurer. There are so many healthcare insurers, in fact – each with its own rules for reimbursement, it seems – that dealing with Medicare and/or private-sector insurance plans is an onerous task for everyone involved. Moreover, the duplication of effort, combined with the complexities of billing, adds considerably to the “tooth to tail” nature of medical systems even under best-case normal operations. Providing more, and more affordable, healthcare insurance for all Americans may therefore be a laudable goal from a humanitarian perspective, but it does not address this fundamental structural weakness in the nation’s current medical system (again, considered as a whole).
#2: Free Medical Disaster-Response Planning from “Normal Day” Rules and Regulations.
Emergency care in the United States is governed by a number of laws that not only require the evaluation of every patient who declares an emergency condition, but also prevent the transfer of care to other facilities without such an evaluation. These laws, as well as most if not all medical-malpractice liability plans, remain in effect no matter how overwhelmed a medical facility may be during a time of disaster.
However, to remain solvent, the acute medical care system in the United States must be about 97 percent full on a so-called “normal day.” Should any type of disaster occur, therefore, many if not all local (or regional) medical facilities would be forced to delay, degrade, and/or deny care either to current patients or to the disaster victims, or perhaps both. The end result is that medical-care decisions must be made very quickly in such situations, and sometimes on the basis of incomplete and/or perhaps even erroneous information.
Making such decisions even more precarious, of course – financially as well as from a medical point of view – is that a host of regulatory and liability professionals will review these crisis decisions retrospectively, with much more information available to them, and perhaps a political agenda as well. The recent prosecution of healthcare professionals in New Orleans for alleged mistakes made during the Hurricane-Katrina crisis is an example of the type of inequities that might arise.
To optimally manage the medical consequences of a disaster, therefore, planners and decision-makers must be provided flexible authority in altering triage, transfer, and treatment rules and not be constricted by “normal day” regulations that do not work in a crisis.
#3: Build Extra Medical Capacity into Healthcare Reform
One of the more common complaints related to emergency care in the United States is about the long waiting times so often involved before receiving that care. But long waiting times are unavoidable whenever there are more patients in need of care than there are resources (i.e., medical personnel and facilities) available to meet the demand. Every day, though, emergency departments throughout the United States routinely operate above their scaled capacity to meet the need. However, should a disaster cause a much larger influx of patients, the diversion of staff from other areas of the hospital and/or the calling in of volunteers would expand medical capacity for at least a short period of time, but would not be a long-term solution. For one thing, all of those who volunteer eventually will have to abandon their volunteer duties to return to their regular duties. Fortunately, in this case, the building of extra capacity into an emergency-care system would not only be the key to coping with unforeseen and unforeseeable disasters, but also would help to improve and perhaps even expand normal-day staffing capabilities.
Building extra capacity into a healthcare system cannot be achieved, though, in a normal competitive marketplace, if only because unused healthcare capacity – particularly in the private sector – translates directly into a loss of revenue. In fact, even disaster drills – which are extremely important in themselves – take medical staff away from their duties on a normal day. If a facility’s profits are used to pay for disaster-preparedness classes, hazmat suits, and so forth, that same facility cannot add more nurses or space to its existing care areas. Perhaps the only way to create and sustain an excess capacity, therefore, would be for some component of the healthcare facility and personnel to be funded and regulated through the investment of public funds.
This would be a viable alternative, politically as well as from a financial point of view. Investing public funds to build extra capacity into the healthcare system may save many lives in future times of disaster, and in that context should be recognized as being somewhat analogous to investments in fire departments, police departments, and other “just in case” agencies of government.
To summarize: As the candidates for next year’s elections discuss their various healthcare proposals, plans, and options, the nation’s disaster-response community should be asking its own questions about the effects that those plans and options might have on the ability of healthcare facilities to improve and expand their current capacity to the extent needed to cope successfully with future crises.
Dr. Allswede is the Director of the Strategic Medical Intelligence Project on forensic epidemiology. He is the creator of the RaPiD-T Program and of the Pittsburgh Matrix Program for hospital training and preparedness. He has served on a number of expert national and international groups on preparedness.