Health Care Coalitions 2002-2006:  HHS Strategy?

Health Care Coalitions 2002-2006: HHS Strategy?

In 2003, the U.S. Department of Health and Human Services (HHS) commissioned a study that demonstrated the necessity of healthcare coalitions to medical and public health preparedness and emergency response.  In 2004, based on the study, they published the strategy forward – yet failed to implement it.  The 2004 commissioned publication titled, Medical Surge Capacity and Capability:  A Management System for Integrating Medical and Health Resources During Large-Scale Emergencies dedicated the second chapter to, Management of the Healthcare Coalition. So why did most states act as if healthcare coalitions were a foreign concept when required in 2012?

Public Health Security and Bioterrorism Preparedness and Response Act of 2002:  Congress' Response To A Human Problem

In the wake of the 9/11 terrorist attacks and the anthrax incident weeks later, America was on edge.  And when America is on edge and the 24-hour news cycle is fixated on the federal government, ready to pounce on every move made or not made, Congress and the White House have a problem.  And in this case, the problem was both a political problem and a human problem that cried out for action.  And human problems on the scale of 9/11 require more than "investigation" and a report.  They require more than a few dog and pony shows to pass the time until the media finds a new story. 9/11 and the anthrax attacks required federal action – action that could not be carried out without each and every state on board.

As we lay out in our series published this spring – CMS Emergency Preparedness Rule: A Shift From The Carrot To The Stick For Healthcare Providers? – when it comes to changing policy and priorities within the states, Congress has limited authority.  There are 50 states with Constitutionally guaranteed rights that make implementing National solutions tedious – and expensive.

In the days and months that followed 9/11, questions being asked by citizens, elected leaders, and the media alike were "worst case scenario," and to use a term familiar to computer junkies, "what if statements."  What if there had been nuclear material aboard the planes that hit the World Trade Center and the Pentagon?  What if there had been thousands of anthrax letters sent to all parts of the Nation?  What if there were another attack on American soil?  What if hundreds of thousands were or are injured or sickened?  What if hospitals ran out of supplies, medications, ventilators, and beds?

For the first time, healthcare was on the federal agenda being dissected in ways that were not familiar.  The terms being thrown around were not front of mind most in the disaster preparedness and emergency management community.  "Medical-surge," "mass-casualty," "bioterrorism," "decontamination," and "medical countermeasures" were new buzzwords in the chambers of Congress.  And Congress had to act.

There were many problems that required federal attention, and most could not be implemented and managed from Washington.  So, Congress used the only tools available to it – legislation that would mandate new federal programs with associated funding opportunities for the states.  Such programs and funding enabled Congress to implement National policy that would increase medical surge capability within the states and private healthcare institutions.

On June 12, 2002, President Bush signed the Public Health Security and Bioterrorism Preparedness and Response Act, hereinafter referred to as the Bioterrorism Act. It was followed shortly thereafter by the Homeland Security Act. But, it was Bioterrorism Act that established the Public Health Emergency Preparedness Program (PHEP) at the Centers for Disease Control and Prevention (CDC) and the National Bioterrorism Hospital Preparedness Program (NBHPP) in the Health Resources and Services Administration (HRSA) at HHS.  The Bioterrorism Act was important for HHS, as it put Public Health and Medical Services, Emergency Support Function (ESF) #8, on the radar as it had never been.

The Disconnect:  Strategy vs. Implementation

In 2002, the Assistant Secretary for Preparedness and Response (ASPR) did not yet exist within HHS.  So, when the Bioterrorism Act, was enacted, HHS placed the NBHPP in the Health Resources and Services Administration (HRSA). 

In 2003, the aforementioned commissioned study was completed by the CNA Corporation and the George Washington University, Institute for Crisis, Disaster and Risk Management (ICDRM). The study clearly demonstrated the necessity of healthcare coalitions for effective medical and public health preparedness and emergency response.  In 2004, based on the study, HHS published their healthcare preparedness strategy going forward that outlined six tiers for healthcare system preparedness and response.

The 2004 publication was the first edition of the, Medical Surge Capacity and Capability: A Management System for Integrating Medical and Health Resources During Large-Scale Emergencies, also known as the MSCC Handbook. Chapter 1 was Management of Individual Healthcare Assets (Tier 1), and Chapter 2 was Management of the Healthcare Coalition (Tier 2). It is important to note that the six tiers and both Chapters remain substantially the same in the most recent version, MSCC Handbook, Second Edition, published in September of 2007 by the newly formed ASPR. 

The Handbook defines Tier 1 as, "...the primary site for point-of-service (i.e., hands-on) medical evaluation and treatment.  It includes hospitals, integrated healthcare systems, clinics, community health centers, alternative care facilities, private practitioner offices, nursing homes and other skilled nursing facilities, hospice, rehabilitation facilities, psychiatric and mental health facilities, and Emergency Medical Services (EMS)."

Let's call Tier 1 Facilities Preparedness.  Yes, facilities, not facility. And facilities was not defined as more than one hospital, a strategy that was consistent with the many types of facilities found to be necessary in the 2003 study.  Many at the state level will find it interesting that the critically important component necessary for managing medical surge, Emergency Medical Services (EMS), was also included. There was a clear perception by most that NBHPP funds could not be used for EMS.

In describing Tier 2, the Handbook stated, "[t]he healthcare coalition (Tier 2) is composed of healthcare organizations (HCOs) and other assets described in Tier 1 that form a single functional entity to maximize MSCC in a defined geographic area.  It coordinates the mitigation, preparedness, response, and recovery actions of medical and healthcare providers, facilitates mutual aid support, and serves as a unified platform for medical input to jurisdictional authorities (Tier 3)."

Let's lean on the 2012 ASPR publication, Healthcare Preparedness Capabilities: National Guidance For Healthcare System Preparedness and call this Healthcare System Preparedness, which happens to be Capability 1.  You see, as early as 2004, HHS appeared to "get it."  The policy wonks understood that to manage medical surge capacity and capability during a catastrophic disaster, public health incident, or terrorist attack, that it would take the entire healthcare system to collaborate in preparedness and coordinate in response. One could even say that they understood it would require the "whole community."

So, what happened in translation, why did most states act as if healthcare coalitions were a foreign concept when required in the 2012 cooperative agreement, and what happened between HHS' endorsement of healthcare coalitions in the 2004 MSCC Handbook and the miserable day that Katrina waltzed into New Orleans and shook the healthcare industry to its core?

Why was there such a hyper-focus on a  single type of facility? Why was the program titled the National Bioterrorism Hospital Preparedness Program when the strategy was clearly broader?

Musical Chairs

We are the USA!  We are a Democratic society, or as many argue, a Representative Republic.

We are fortunate:  to have the opportunity to elect our federal, state, and local leaders to terms of office; that we have the power to vote for change on a regular cycle; that elected leaders can appoint like minded contemporaries to high level policy positions (within reason. i.e. Supreme Court Case, Rutan v. Republican Party of Illinois); that we have a Civil Service system and labor laws that ensure continuity within the ranks of government; that we live in a nation that has the means to fund so many important programs; that we have so many skilled at massaging, and disrupting, the bureaucratic system – and we're also cursed by it all.

You see, because of regular shifting philosophies and priorities or just the potential for them with each approaching election; because of the trickle of change in senior leadership within agencies that follow each election; because of the "no new policy" dead zone that that are mandatory the year before and following each election; because of the one constant in government, secure Civil Servants that often resist change at every turn and grab for power whenever a void opens; because of never ending structural reorganizations, and because of the shear size of the machine that is government, it is not nimble.

It takes a long time to turn a big ship. And because the Captain and crew are fired and replaced regularly, almost always in the middle of a turn, the resulting course is a zig-zag. Some might say – a ship to nowhere.

Government is what it is for a reason.  It is built to move slow and spits out change agents that move too fast.  The academics use the term "incrementalism" to describe government's approach to policy changes. Why incrementalism? Incremental changes are much easier to reverse course on when a media circus ensues, there is push back from the public, or a powerful special interest group riles up Congress.

But, incrementalism is in direct opposition to rapid, drastic change that is sometimes necessary.  So, when major upheaval occurs, as was the case with the September 11, 2001 attacks and the anthrax incidents that followed, and major policy shifts occur quickly, the government bureaucracy implodes.

It is the propensity for rapid enactment of new legislation by Congress and the State Legislatures that follows crisis, and it is the competitive nature of the White House and Governors to get ahead of lawmakers with Policy Directives and Executive Orders that choke Executive Branch agencies designed for slow, incremental change.

So, was HHS choking on the shear volume of work to be done in the years that followed 9/11, were laws, rules, polices, and systems already on the books in direct conflict with the new legislation, or were they waiting on legal opinions from counsel? Had the newly appointed agency executives of the Bush administration not yet figured out how to close the blinds in their offices?

The answer is likely yes on all fronts.  Well, maybe not the thing about the blinds, but you get the point.  Regardless, if one works for a state or local agency or a grant-receiving hospital today, it likely unimportant what caused the disconnect from 2003-2007.  States and sub grantees got money to build out new programs, hire new staff, and buy stuff. All was good. For those with healthcare institutions other than hospitals, such as long-term care centers, home health agencies, and community health centers, or with an EMS provider, there is likely a little anger knowing that HHS' Tier 1 strategy to prepare a myriad of healthcare facilities, and their Tier 2 strategy to build healthcare coalitions, was somehow lost in translation.

Maybe the translation problem is on HHS' back.  Maybe when the policy wonks finished the strategic framework for the NBHPP, the grant dudes said "whatever," and went their own way, maybe there was political pressure on the Bush administration from industry lobbyist to get the hospitals preparedness programs built out first, maybe the legal interpretation of the Bioterrorism Act by HHS' legal counsel tied the agency's hands, crushing implementation of the strategy, maybe the guidance to the states was just too vague?

Maybe it is on the states. Maybe they were scrambling to implement a new program while simultaneously hiring staff and building out new offices, maybe they just interpreted the federal guidance as they wanted and went their own way, maybe Governors and agency leaders saw a money pot they could raid to fill budget holes?

Maybe its on the states sub grantees. Maybe the states got it right, but the sub grantees went their own way knowing that state preparedness offices were overwhelmed and could not follow up, maybe they were just scrambling to implement their new programs and spend their grants down before the deadline, or maybe the guidance from the states was just too vague?

Maybe it was a little part of each that incrementally added up to upend the strategy,

Regardless of where fault lies for the disconnect, the Tier 1 and Tier 2 strategies that HHS identified did not translate to broad, multi-discipline health and medical capability at the local level. And that contributed to greater human suffering and loss of life than was necessary when Katrina waltzed into New Orleans in 2005.

And, of course, when the Nation was again caught unprepared to respond the resulting human problem became a political problem – and Congress had to act. 

Coming In Part 2 | Healthcare Coalitions: 2007-2011: ASPR Had Strategy In 2007?

On August 29, 2005, Hurricane Katrina hit New Orleans.  It was the costliest natural disaster in the history of the United States, as well as one of the five deadliest hurricanes. It was Katrina that illuminated problems with the NBHPP and other programs that compelled Congress to enact the Post Katrina Emergency Management Reform Act (PKEMRA) and the Pandemic and All Hazards Preparedness Act (PAHPA).

PAHPA was necessitated by the immense suffering and loss of life in predominantly private, self regulated hospitals and other healthcare facilities, as well as the complete breakdown of the human services system in Louisiana.  PAHPA amended the Public Health Service Act (PSA) to, among other things, establish the Assistant Secretary for Preparedness and Response (ASPR) in HHS.

President Bush signed PAHPA into law on December 19, 2006, and ASPR hit the ground running in early 2007.  They had a blank slate, a healthy budget, and a legislative mandate from Congress to correct what went wrong in New Orleans.  From the beginning, ASPR appeared to "get it." One of their very first publications was the MSCC Handbook, Second Edition, which reemphasized the need for the development of healthcare coalitions and the preparedness for numerous type of healthcare facilities.

Yes ASPR had a good strategy. And they provided the states with funding opportunities to develop healthcare coalitions as early as 2007. So, what happened? How did their strategy not translate to programmatic implementation in the vast majority of states? 

Stay tuned!


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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In all we do, we seek to reduce human suffering and loss of life caused by disasters.

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Yes, we believe healthcare coalitions are the path forward.

Karl Schmitt, Passionate Founder & CEO, bParati

Karl SchmittPassionate Founder & CEO

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