CMS Emergency Preparedness Rule: Part 2, Meet the Twig!

CMS Emergency Preparedness Rule: Part 2, Meet the Twig!

This is the second part of our article looking at the proposed emergency preparedness rule published by the Centers for Medicaid & Medicare Services (CMS) on December 27, 2013.  Part One, which has been updated, lays the foundation for what follows.

Welcome back from Part One!  You now have a good handle on how a Carrot is analogous to a federal preparedness grant, a Big Stick to a federal mandate enacted by Congress, and a Stick to administrative rules issued by a federal agency.  Today, we will introduce the Twig and explain how its impotency has justified CMS' use of the Stick.

bParati Carrots, Sticks, and Twigs Image

This past December, at the National Health Care Coalition Conference in New Orleans, Dr. David Marcozzi, Director of the National Healthcare Preparedness Program (NHPP), stated, "we are not going to grant ourselves to preparedness."  Uhhh... yeah!  And we have the scars to prove it, Exhibit 1 being Super Storm Sandy.

Despite a decade of Hospital Preparedness Program (HPP) Carrots, far too many hospitals and other health care facilities stumbled with preparedness 101 basics, causing unnecessary human suffering.  Unnecessary, because the suffering was caused, not by the storm, but by preparedness omissions in hospitals and health care facilities.  Most of which earn a substantial portion of their revenue from Medicare and Medicaid.  Hmmm...

Preparedness: The Feds Business?

There is no question that the states do not want the Feds in their business, local governments do not want the states or the Feds in theirs, and hospitals and health care providers absolutely do not want government near their business.

But, when disaster strikes, all expect the feds to immediately respond, provide money, equipment, supplies, and rule waivers.  And all become extremely "disappointed with the federal response."  And the suffering public wants the President to "do whatever it takes to ensure such a tragedy never happens again."  From Governors to mothers, the mantra plays out 24/7 on CNN--where is FEMA and why is Washington not doing more?  How could we not be eligible for federal disaster aid?  How could the hospital's fuel supply for the generators be in the basement?

Federal intervention after a disaster is not a constitutional mandate--it is a humanitarian mandate, and a media-driven political mandate.  So, if Congress and the White House know that: (1) Disasters are inevitable, (2) Human suffering will occur, (3) Federal support for response and recovery will be anticipated and expected, (4) Response and recovery are far more expensive than preparedness and mitigation, and (5) There will be political consequences for inaction, then funding disaster preparedness and mitigation is a no brainer.  Yeah...a no brainer in Washington.  Sweet!

So, even if they did nothing to prepare, when people suffer and the 24-hour news cycle kicks off:  Mayors will blame County Managers and Governors, County Mangers will blame Mayors and Governors, and Governors will blame County Managers, Mayors, and Washington.  And Washington blames...uhhh...hmmm...So Congress enacts and the President signs, an emergency appropriation bill into law to fund the federal response and recovery efforts.

 So, maybe it is the Feds business after all?

Fighting the Stick With the Twig

When it comes to hospitals, history shows that until Washington made preparedness an issue of federal concern in 2002, the states had zero interest in doing so and that hospitals had somewhat less interest than that.  The remainder of the health care sector, which was left off the Carrot Express, has been and continues to be in a preparedness black-hole.  So how was it that the Feds reached into the predominately private and not-for-profit health care system and plucked hospitals as the torch bearer?

Some see CMS' proposed Stick and argue that the federal government needs to get out of the way and stop trying to tell hospitals and other health care providers how to prepare for disasters.  Well, they tried the hands off approach with hospitals, and now, the whole health care system is paying the price.  You see, when hospital preparedness became an issue of federal concern in 2002, Congress did not pull out a Big Stick, nor, for that matter, did federal agencies swing the Stick.

The Feds did not force the hospitals to do anything.  Maybe some in Washington wanted to, but as discussed in Part One, there are some constitutional limitations with the Big Stick.  And when it comes to using Sticks, the advocates from special interests groups have well-funded Political Action Committees (PAC) and legal teams that have a clear obligation to their members to eliminate or reduce the effect of any new Stick.  Not that they have a say.  Do they?

So, the Feds deferred to the wishes of hospital representatives who promised self-regulation through accreditation as the route to better hospital preparedness.  They would police themselves by adding a new emergency preparedness Stick to their hospital accreditation standards.

Their argument went like this:

Industry Advocate:  "There is no need for a new federal Stick, because the industry has its own Stick that it will swing with all its might at its dues-paying members during their accreditation review."

Fed:  "Really, all your might?"

Industry Advocate:  "Absolutely, and since another federal Stick is already in place that requires Medicare and Medicaid participating hospitals to be accredited, all is good--right."

Fed:  "RRRight!"

Industry Advocate:  "Great!  You know, it would be really pleasant if you could send us some Carrots to pay our members for the inconvenience of the new rules."

Fed:  "Huh!  What about the other segments of health care, like long-term care centers and home health providers?"

Industry Advocate:  "Who?"

Fed:  "And what if your members do not like the new emergency preparedness standards and go rogue with some new, competing accreditation body that does not have such stringent standards?"

Industry Advocate:  "Huh!  Sorry, I have to take this call; it is Senator Good Idea Fairy, Chair of the Budget Committee." 

Fed:  "Understood."

Hmmm...sounds a lot like a Stick, but maybe not quite as big.  Let's call self-regulation a Twig.  A Twig looks like a Stick, but it is a lot smaller.  It causes some inconvenience, some annoyance, but not too much since the perpetrator wielding it is often on the payroll and will swing it softly.  Maybe the running joke was, speak softly and carry a big Twig.

Any jokes lost their punch in August of 2005 when Hurricane Katrina exposed the Twig for what it was--a paper solution to a human problem; an association drafted a template needed to get through the accreditation review unscathed.

Read Part 3 Here

About Karl Schmitt

Karl Schmitt Photo Karl is the passionate Founder of He is on a mission to align the disaster preparedness programs of healthcare institutions with those of emergency management, public health, and others in the public, private, and not-for-profit sectors who care for the physical, mental, and spiritual health of people each day. Learn more about him here. He can be reached at

Karl Schmitt, MPA

Karl Schmitt, MPA

Karl is the Passionate Founder & CEO of bParati. He is on a mission to build a national network of effective, sustainable healthcare coalitions. More...

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