GAO reports progress, pitfalls in state medical surge planning

Jul 14, 2008 (CIDRAP News) – The Government Accountability Office (GAO) released a status report yesterday on progress states have made toward preparing for a flood of people needing medical care in the wake of an event such as a terrorist attack or an influenza pandemic.

The 59-page report, requested by various US Senate and House members, looked at four main components of medical "surge" readiness: increasing hospital capacity, pinpointing alternative care sites, enlisting medical volunteers, and planning for altered standards of care. The GAO also examined how federal departments have helped states make medical surge preparations, as well as what states have done for themselves. Lastly, investigators asked states what concerns they have about their medical surge planning.

From 2002 to 2007 the federal government awarded states about $2.2 billion in medical preparedness funds through the Department of Health and Human Services (HHS) Hospital Preparedness Program, the GAO said in the report. Federal agencies have also issued several preparedness guidance documents for states, such as a game plan for reopening shuttered hospitals.

Nongovernmental groups have also played an important role in issuing medical surge capacity guidance. In May, an expert task force issued a series of reports that took stock of current capabilities and recommended a framework for distributing care to as many patients as possible.

Plotting surge-capacity progress
GAO auditors found that of 20 states that were surveyed, many have made progress on three of the key components of medical surge planning: increasing hospital capacity, determining alternative care sites, and recruiting volunteer staff. However, only seven of them had adopted or were developing altered standards of medical care in response to a mass-casualty event.

All the states that were surveyed had developed bed-reporting systems, and 18 have systems in place to report the number of available hospital beds within the state. For comparison, in 2005 only one of the states had developed a Web-based tracking system.

Nearly all states that had military or Department of Veterans Affairs (VA) hospitals had started talks about coordinating care to boost hospital capacity. In one state, military hospital officials served on state emergency preparedness committees and participated in related training and exercises. Eight of 10 states in the survey group that have military hospitals reported that the military facility would take civilian patients in the event of an emergency if they have enough resources.

However, the contribution of VA hospitals varied widely across the 19 states in the survey that have them. Four states reported that their VA hospitals would not take nonveteran patients in a medical surge setting.

Eighteen of 20 states said they were selecting either fixed or mobile alternative care sites. States told GAO auditors that most counties are still identifying fixed alternative care sites, though some had already developed memorandums of understanding with facilities such as churches, schools, military bases, and shopping malls. Two states said they had fleshed out plans for mobile care facilities.

Fifteen states have started registering volunteers in electronic medical volunteer databases, and 12 of those have begun verifying participants' qualifications.

Though only 7 of the 20 states had adopted or drafted altered standards of care, 11 said they had started discussions with stakeholders such as medical professionals and attorneys.

States worry about staffing, payments
States told the GAO they faced several challenges in building surge capacity. While most states surveyed said they could boost the number of hospital beds in an emergency, some said they worried about how to staff the effort. Some state officials reported difficulty in selecting alternative care sites, particularly in small rural communities. Other states said that some facilities that could be used as care sites have already been earmarked as emergency shelters.

Officials from several states aired concerns about how the Centers for Medicare and Medicaid Services would reimburse providers for care delivered at the alterative sites. Some said knowing the payment status ahead of time would make the planning and exercise exercises easier and more realistic. They also said they were unclear on how federal laws relating to patient privacy and emergency care would apply in a mass casualty event, particularly at care sites away from medical facilities.

In terms of registering medical volunteers, states projected that some helpers might be reluctant to sign up because of worries that, as part of a required national database, they might be deployed to another state. Some states also said volunteer enlistment should be better coordinated to avoid overlap between programs.

When addressing altered standards of care, some states requested more federal guidance, such as a summit of experts that could discuss complex issues related to allocating scarce resources.

State officials cited several funding roadblocks in their medical surge planning. They suggested longer funding cycles for federal hospital preparedness grants to afford more time to prepare. They also cited concerns about decreasing federal funds for hospital preparedness, particularly in light of what they say are increased requirements. GAO auditors reported that hospital preparedness funds decreased about 18% from fiscal year 2004 to 2007.

Agencies' responses to recommendations
The GAO recommended that HHS serve as a clearinghouse for states to share information about altered standards of care.

HHS did not respond to that recommendation, but it did concur with the GAO's findings. In a letter that accompanied the reports, Vincent Ventimiglia Jr, assistant secretary for legislation at HHS, wrote, "Overall, the report is a fair representation of progress that has been made to improve medical capacity since 2001."

He suggested that because "all disasters are local," the GAO's findings would be more useful if local perspectives were included, along with the feedback from states.

The Department of Homeland Security (DHS) agreed with the GAO's findings, but suggested that HHS may need to consider producing guidance to "direct states' discussion" on allocating scarce resources. However, the GAO disagreed with the suggestion. "We believe a clearinghouse role is more appropriate for HHS than a directive role because the delivery of medical care is a state, local, and private function," the authors wrote.

In response to the report, a VA official said the VA's varied role from state to state in emergency situations is rooted in its medical centers' diverse ability to provide emergency treatment—not all centers provide the services or have the necessary emergency supplies.

See also:

GAO report on state medical surge preparations

May 13 CIDRAP News story "Critical care panel tackles disaster preparation, surge capacity, rationing"

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