Rebuilding the Tower of Babel – A CEO’s Perspective on Health Information Exchanges

The United States is facing the largest shortage of healthcare practitioners in our country’s history which is compounded by an ever increasing geriatric population. In 2005 there existed one geriatrician for every 5,000 US residents over 65 and only nine of the 145 medical schools trained geriatricians. By 2020 the industry is estimated to be short 200,000 physicians and over a million nurses. Never, in the history of US healthcare, has so much been demanded with so few personnel. Because of this shortage combined with the geriatric population increase, the medical community has to find a way to provide timely, accurate information to those who need it in a uniform fashion. Imagine if flight controllers spoke the native language of their country instead of the current international flight language, English. This example captures the urgency and critical nature of our need for standardized communication in healthcare. A healthy information exchange can help improve safety, reduce length of hospital stays, cut down on medication errors, reduce redundancies in lab testing or procedures and make the health system faster, leaner and more productive. The aging US population along with those impacted by chronic disease like diabetes, cardiovascular disease and asthma will need to see more specialists who will have to find a way to communicate with primary care providers effectively and efficiently.

This efficiency can only be attained by standardizing the manner in which the communication takes place. Healthbridge, a Cincinnati based HIE and one of the largest community based networks, was able to reduce their potential disease outbreaks from 5 to 8 days down to 48 hours with a regional health information exchange. Regarding standardization, one author noted, “Interoperability without standards is like language without grammar. In both cases communication can be achieved but the process is cumbersome and often ineffective.”

United States retailers transitioned over twenty years ago in order to automate inventory, sales, accounting controls which all improve efficiency and effectiveness. While uncomfortable to think of patients as inventory, perhaps this has been part of the reason for the lack of transition in the primary care setting to automation of patient records and data. Imagine a Mom & Pop hardware store on any square in mid America packed with inventory on shelves, ordering duplicate widgets based on lack of information regarding current inventory. Visualize any Home Depot or Lowes and you get a glimpse of how automation has changed the retail sector in terms of scalability and efficiency. Perhaps the “art of medicine” is a barrier to more productive, efficient and smarter medicine. Standards in information exchange have existed since 1989, but recent interfaces have evolved more rapidly thanks to increases in standardization of regional and state health information exchanges.

History of Health Information Exchanges

Major urban centers in Canada and Australia were the first to successfully implement HIE’s. The success of these early networks was linked to an integration with primary care EHR systems already in place. Health Level 7 (HL7) represents the first health language standardization system in the United States, beginning with a meeting at the University of Pennsylvania in 1987. HL7 has been successful in replacing antiquated interactions like faxing, mail and direct provider communication, which often represent duplication and inefficiency. Process interoperability increases human understanding across networks health systems to integrate and communicate. Standardization will ultimately impact how effective that communication functions in the same way that grammar standards foster better communication. The United States National Health Information Network (NHIN) sets the standards that foster this delivery of communication between health networks. HL7 is now on it’s third version which was published in 2004. The goals of HL7 are to increase interoperability, develop coherent standards, educate the industry on standardization and collaborate with other sanctioning bodies like ANSI and ISO who are also concerned with process improvement.

In the United States one of the earliest HIE’s started in Portland Maine. HealthInfoNet is a public-private partnership and is believed to be the largest statewide HIE. The goals of the network are to improve patient safety, enhance the quality of clinical care, increase efficiency, reduce service duplication, identify public threats more quickly and expand patient record access. The four founding groups the Maine Health Access Foundation, Maine CDC, The Maine Quality Forum and Maine Health Information Center (Onpoint Health Data) began their efforts in 2004.

In Tennessee Regional Health Information Organizations (RHIO’s) initiated in Memphis and the Tri Cities region. Carespark, a 501(3)c, in the Tri Cities region was considered a direct project where clinicians interact directly with each other using Carespark’s HL7 compliant system as an intermediary to translate the data bi-directionally. Veterans Affairs (VA) clinics also played a crucial role in the early stages of building this network. In the delta the midsouth eHealth Alliance is a RHIO connecting Memphis hospitals like Baptist Memorial (5 sites), Methodist Systems, Lebonheur Healthcare, Memphis Children’s Clinic, St. Francis Health System, St Jude, The Regional Medical Center and UT Medical. These regional networks allow practitioners to share medical records, lab values medicines and other reports in a more efficient manner.

Seventeen US communities have been designated as Beacon Communities across the United States based on their development of HIE’s. These communities’ health focus varies based on the patient population and prevalence of chronic disease states i.e. cvd, diabetes, asthma. The communities focus on specific and measurable improvements in quality, safety and efficiency due to health information exchange improvements. The closest geographical Beacon community to Tennessee, in Byhalia, Mississippi, just south of Memphis, was granted a $100,000 grant by the department of Health and Human Services in September 2011.

A healthcare model for Nashville to emulate is located in Indianapolis, IN based on geographic proximity, city size and population demographics. Four Beacon awards have been granted to communities in and around Indianapolis, Health and Hospital Corporation of Marion County, Indiana Health Centers Inc, Raphael Health Center and Shalom Health Care Center Inc. In addition, Indiana Health Information Technology Inc has received over 23 million dollars in grants through the State HIE Cooperative Agreement and 2011 HIE Challenge Grant Supplement programs through the federal government. These awards were based on the following criteria:1) Achieving health goals through health information exchange 2) Improving long term and post acute care transitions 3) Consumer mediated information exchange 4) Enabling enhanced query for patient care 5) Fostering distributed population-level analytics.

Regulatory Aspects of Health Information Exchanges and Healthcare Reform

The department of Health and Human Services (HHS) is the regulatory agency that oversees health concerns for all Americans. The HHS is divided into ten regions and Tennessee is part of Region IV headquartered out of Atlanta. The Regional Director, Anton J. Gunn is the first African American elected to serve as regional director and brings a wealth of experience to his role based on his public service specifically regarding underserved healthcare patients and health information exchanges. This experience will serve him well as he encounters societal and demographic challenges for underserved and chronically ill patients throughout the southeast area.

The National Health Information Network (NHIN) is a division of HHS that guides the standards of exchange and governs regulatory aspects of health reform. The NHIN collaboration includes departments like the Center for Disease Control (CDC), social security administration, Beacon communities and state HIE’s (ONC).11 The Office of National Coordinator for Health Information Exchange (ONC) has awarded $16 million in additional grants to encourage innovation at the state level. Innovation at the state level will ultimately lead to better patient care through reductions in replicated tests, bridges to care programs for chronic patients leading to continuity and finally timely public health alerts through agencies like the CDC based on this information.12 The Health Information Technology for Economic and Clinical Health (HITECH) Act is funded by dollars from the American Reinvestment and Recovery Act of 2009. HITECH’s goals are to invest dollars in community, regional and state health information exchanges to build effective networks which are connected nationally. Beacon communities and the Statewide Health Information Exchange Cooperative Agreement were initiated through HITECH and ARRA. To date 56 states have received grant awards through these programs totaling 548 million dollars.

History of Health Information Partnership TN (HIPTN)

In Tennessee the Health Information Exchange has been slower to progress than places like Maine and Indiana based in part on the diversity of our state. The delta has a vastly different patient population and health network than that of middle Tennessee, which differs from eastern Tennessee’s Appalachian region. In August of 2009 the first steps were taken to build a statewide HIE consisting of a non-profit named HIP TN. A board was established at this time with an operations council formed in December. HIP TN’s first initiatives involved connecting the work through Carespark in northeast Tennessee’s s tri-cities region to the Midsouth ehealth Alliance in Memphis. State officials estimated a cost of over 200 million dollars from 2010-2015. The venture involves stakeholders from medical, technical, legal and business backgrounds. The governor in 2010, Phil Bredesen, provided 15 million to match federal funds in addition to issuing an Executive Order establishing the office of eHealth initiatives with oversight by the Office of Administration and Finance and sixteen board members. By March 2010 four workgroups were established to focus on areas like technology, clinical, privacy and security and sustainability.

By May of 2010 data sharing agreements were in place and a production pilot for the statewide HIE was initiated in June 2011 along with a Request for Proposal (RFP) which was sent out to over forty vendors. In July 2010 a fifth workgroup,the consumer advisory group, was added and in September 2010 Tennessee was notified that they were one of the first states to have their plans approved after a release of Program Information Notice (PIN). Over fifty stakeholders came together to evaluate the vendor demonstrations and a contract was signed with the chosen vendor Axolotl on September 30th, 2010. At that time a production goal of July 15th, 2011 was agreed upon and in January 2011 Keith Cox was hired as HIP TN’s CEO. Keith brings twenty six years of tenure in healthcare IT to the collaborative. His previous endeavors include Microsoft, Bellsouth and several entrepreneurial efforts. HIP TN’s mission is to improve access to health information through a statewide collaborative process and provide the infrastructure for security in that exchange. The vision for HIP TN is to be recognized as a state and national leader who support measurable improvements in clinical quality and efficiency to patients, providers and payors with secure HIE. Robert S. Gordon, the board chair for HIPTN states the vision well, “We share the view that while technology is a critical tool, the primary focus is not technology itself, but improving health”. HIP TN is a non profit, 501(c)3, that is solely reliant on state government funding. It is a combination of centralized and decentralized architecture. The key vendors are Axolotl, which acts as the umbrella network, ICA for Memphis and Nashville, with CGI as the vendor in northeast Tennessee.15 Future HIP TN goals include a gateway to the National Health Institute planned for late 2011 and a clinician index in early 2012. Carespark, one of the original regional health exchange networks voted to cease operations on July 11, 2011 based on lack of financial support for it’s new infrastructure. The data sharing agreements included 38 health organizations, nine communities and 250 volunteers.16 Carespark’s closure clarifies the need to build a network that is not solely reliant on public grants to fund it’s efforts, which we will discuss in the final section of this paper.

Current Status of Healthcare Information Exchange and HIPTN

Ten grants were awarded in 2011 by the HIE challenge grant supplement. These included initiatives in eight states and serve as communities we can look to for guidance as HIP TN evolves. As previously mentioned one of the most awarded communities lies less than five hours away in Indianapolis, IN. Based on the similarities in our health communities, patient populations and demographics, Indianapolis would provide an excellent mentor for Nashville and the hospital systems who serve patients in TN. The Indiana Health Information Exchange has been recognized nationally for it’s Docs for Docs program and the manner in which collaboration has taken place since it’s conception in 2004. Kathleen Sebelius, Secretary of HHS commented, “The Central Indiana Beacon Community has a level of collaboration and the ability to organize quality efforts in an effective manner from its history of building long standing relationships. We are thrilled to be working with a community that is far ahead in the use of health information to bring positive change to patient care.” Beacon communities that could act as guides for our community include the Health and Hospital Corporation of Marion County and the Indiana Health Centers based on their recent awards of $100,000 each by HHS.

A local model of excellence in practice EMR conversion is Old Harding Pediatric Associates (OHPA) which has two clinics and fourteen physicians who handle a patient population of 23,000 and over 72,000 patient encounters per year. OHPA’s conversion to electronic records in early 2000 occurred as a result of the pursuit of excellence in patient care and the desire to use technology in a way that benefitted their patient population. OHPA established a cross functional work team to improve their practices in the areas of facilities, personnel, communication, technology and external influences. Noteworthy was chosen as the EMR vendor based on user friendliness and the similarity to a standard patient chart with tabs for files. The software was customized to the pediatric environment complete with patient growth charts. Windows was used as the operating system based on provider familiarity. Within four days OHPA had 100% compliance and use of their EMR system.

The Future of HIP TN and HIE in Tennessee

Tennessee has received close to twelve million dollars in grant money from The State Health Information Exchange Cooperative Agreement Program.20 Regional Health Information Organizations (RHIO) need to be full scalable to allow hospitals to grow their systems without compromising integrity as they grow.21and the systems located in Nashville will play an integral role in this nationwide scaling with companies like HCA, CHS, Iasis, Lifepoint and Vanguard. The HIE will act as a data repository for all patients information that can be accessed from anywhere and contains a full history of the patients medical record, lab tests, physician network and medicine list. To entice providers to enroll in the statewide HIE tangible value to their practice has to be shown with better safer care. In a 2011 HIMSS editor’s report Richard Lang states that instead of a top down approach “A more practical idea may be for states to support local community HIE development first. Once established, these local networks can feed regional HIE’s and then connect to a central HIE/data repository backbone. States should use a portion of the stimulus funds to support local HIE development.”22 Mr. Lang also believes the primary care physician has to be the foundation for the entire system since they are the main point of contact for the patient.

One piece of the puzzle often overlooked is the patient investment in a functional EHR. In order to bring together all the pieces of the HIE puzzle patients will need to play a more active role in their healthcare. Many patients do not know what medicines they take every day or whether they have a living will. Several versions of patient EHR’s like Memitech’s 911medical id card exist, but very few patients know or carry them.23 One way to combat this lack of awareness is to use the hospital as a catch-all and discharge each patient with a fully loaded USB card via case managers. This strategy also might lead to better compliance with post in patient therapies to reduce readmissions.

The implementation of connecting qualified organizations began earlier this year. To fully support organizations to move toward qualification the Office of National Coordinator for HIE (ONC) has designated regional education centers (TN rec) who assist providers with educational initiatives in areas like HIT, ICD9 to ICD10 training and EMR transition. Qsource, a non-profit health consulting firm, has been chosen to oversee TNrec. To ensure sustainability it is critical that Tennessee build a network of private funding so that what happened with Carespark won’t happen to HIP TN. The eHealth Initiatives 2011Survey Report states that of the 196 HIE initiatives, 115 act independently of federal funding and of those independent HIE’s, break even through operational revenue. Some of these exchanges were in existence well before the American Recovery and Reinvestment Act in 2009. Startup funding from grants is only meant to get the car going so to speak, the sustainable fuel, as observed in the case of Carespark, has to come from value that can be monetized. KLAS research reports that 54% of public HIE’s were concerned about future sustainability while only 35% of private HIE’s shared this concern.

Hospital Implications of HIP TN (A Call to Action)

From a Financial perspective, taking our hospital into the future with EMR and an integrated statewide network has profound implications. In the short term the cost to find a vendor, establish EMR in and outpatient will be an expensive proposition. The transition will not be easy or finite and will involve constant evolution as HIP TN integrates with other state HIE’s. To get a realistic idea of the benefits and costs associated with health information integration. we can look to HealthInfoNet in Portland, ME, a statewide HIE that expects to save 37 million dollars in avoided services and 15 million in productivity reduction. Specific areas of savings include paper or fax costs $5 versus $0.25 electronically, virtual health record savings of $50 per referral, $26 saved per ED visit and $17.41 per patient/year due to redundant lab tests which amounts to $52 million for a population of 3 million patients. In Grand Junction Colorado Quality Health Network lowered their per capita Medicare spending to 24% below the national average, gaining recognition by President Obama in 2009. The Santa Cruz Health Information Exchange (SCHIE) with 600 doctors and two hospitals achieved sustainability in the first year of operation and uses a subscription fee for all the organizations who interact with them. In terms of government dollars available, meaningful use incentives exist to encourage hospitals to meet twenty of twenty five objectives in the first phase (2011-2012) and adopting and implement an approved EHR vendor. ARRA specified three ways for EHR to be utilized to obtain Medicare reimbursement. These include e-prescribing, health information exchange and submission of clinical quality measures. The objectives for phase two in 2013 will expand on this baseline. Implementation of EHR and Hospital HIE costs are usually charged by bed or by the number of physicians. Fees can range from $1500 for a smaller hospital up to $12,000 per month for a larger hospital.

The National Disaster Medical System, Can it Respond to a Major Southern California Earthquake?

Since the events of September 11, 2001 and the further highlighting of the state of our National vulnerability as demonstrated by the issues raised in the response to Hurricane Katrina in 2004, The Federal Government has focused enormous resources in developing a National Response Framework, Establishing National Preparedness Goals and implementing a National Incident Management System. However, in the midst of all of these changes and improvements, the Nation Disaster Medical System has been tossed like a ping pong ball from the Department of Health and Human Services (HHS) to FEMA, and then Subordinated to the Department of Homeland Security when FEMA was integrated into that new organization, and then tossed back to the Department of Health and Human Services as of January 1, 2007. During this time, publicly released documents continue to claim the NDMS has the capacity to respond to National Disasters. This article will look into the foundations of the NDMS, its current standing, and its capacity to respond to the California Earthquake scenario developed by FEMA, in conjunction with the State of California, in 1980.


After viewing the destruction wrought by the eruption of Mt. St. Helens in Washington State in May 1980, President Carter became concerned about the impacts a catastrophic earthquake in California, and the state of readiness to cope with the impacts of such an event. He directed that the National Security Council conduct a review of the state of preparedness of the Nation to meet such an event. FEMA determined that “the Nation is essentially unprepared for the catastrophic earthquake (with a probability greater than 50 percent) that must be expected in California in the next three decades” (Federal Emergency Management Agency, 1980). Casualties projected for this type of event ranged between three thousand and twenty three thousand dead, and between twelve and ninety-one thousand requiring hospitalization (based upon 1980 census data). The ranges were based upon the location of the epicenter and the time of day that the incident struck. The California Office of Statewide Health Planning and Development (OSHPD) recently found that nearly half of hospital floor space that needs retrofitting to meet current codes and comply with a 2013 state seismic safety deadline is in buildings that are considered vulnerable to collapse during a major earthquake (California Health Care Foundation, 2007). Current FEMA Scenario planning estimates that nearly two thirds of the Hospital Beds in Los Angeles, Orange, Riverside, and San Bernardino County will be non-functional (Science Daily, 2008). Based upon this estimate, a service population of approximately ten million, and that the United States presently maintains 3.6 Hospital Bed per 1000 people (Nationmaster, n.d.); this equates to a loss of approximately 24,000 patient beds, which for the most part are occupied with chronic and or acute patients, as well as the infrastructure to support them. These facilities would simultaneously be experiencing a surge of new patients presenting as a result of the injuries sustained from the Earthquake event. Even assuming occupancy rates of only 60% (low for the industry) approximately 14,400 patients would be displaced and require discharge, inter-facility transfer or evacuation outside the impacted area, without regard to the casualties that were generated by the event.

In 1981, President Ronald Reagan established the Emergency Mobilization Preparedness Board to develop a national medical response system (Kramer & Bahme, 1992). The board consisted of representatives from the Federal Emergency Management Agency (FEMA), the Department of Defense (DOD), the Veterans Administration, and the Public Health Service of the Department of Health and Human Services. This Board developed the National Disaster Medical System (NDMS); which was established by Presidential Directive in 1983. Originally conceived as a partnership to respond to the scenario of large numbers returning military personnel who were injured in an overseas conflict to an overwhelmed Continental United States (CONUS) military medical system; the NDMS was never activated to fulfill this original mission (Franco, E., Waldhorn, Inglesby, & O’Toole, 2007).

The mission of the NDMS evolved to create a system whereby civilian hospital beds, in non affected areas, could be used in the event of a disaster within the U.S. and Disaster Medical Assistance Teams (DMATs) who could respond to the impacted areas of a disaster (National Association of DMATS, n.d.). Prior to the NDMS, the assets available to fulfill these type missions were the one thousand-nine hundred and thirty Civil Defense Emergency Hospitals that had been pre-positioned throughout the country by 1964. The Civil Defense Emergency Hospitals, later renamed Packaged Disaster Hospitals, were 200 bed mobile hospitals based on mobile military hospitals that used the same federally procured military equipment. These hospitals were equipped with supplies for 30 days of operations. According to the 1964 DOD Office of Civil Defense Annual Statistical Report; “the Civil Defense Emergency Hospital (CDEH) is an austere but completely functional 200-bed general hospital designed to be set up within an existing structure such as a school, church, or community center. They required 15,000 square feet of floor space which permitted the separation of wards, operating rooms and other functional sections. The staffing requirement was for 316 personnel, including 10 physicians, 4 administrators and assistants, 34 professional nurses, 18 practical nurses, 6 anesthetists, 2 pharmacists, 128 medical aides and 124 other personnel, including dentists, laboratory technicians, X-Ray technicians, maintenance engineers, clerks, helpers, messengers, and housekeepers to be drawn from local resources” (Civil Defense Museum, n.d.). A little more than one half (25%) of the Civil Defense Emergency Hospitals pre-positioned in 1964 could conceivably have provided a total of 100,000 patient beds, with a staffing requirement of about 150,000 personnel. This number of beds exceeds the worst case scenario of developed by FEMA in 1980.

The NDMS System:

Presently the National Disaster Medical System has fifty-five Disaster Medical Assistance Teams. A Type I DMAT team is able to muster a 35 person roster in 4 hours, has 105 or more deployable personnel assigned including 12 physicians, has a Full Federal DMAT Cache of Equipment and Supplies, and is able to triage and treat 250 mixed category patients per day for three days. The DMAT is not and does not operate a field type hospital, but with augmentation from the national strategic stockpile and with additional personnel being recruited (local survivors with the needed skill sets), they can provide the Triage and Emergency room functions of a field type hospital with the patient holding capacity being provided by a co-located Federal Medical Station. The Federal Medical Station requires a team of 100 personnel and can sustain 250 stable primary care patients who require bedding services (U.S. Department of Health & Human Services, n.d.). Therefore, the maximal number of patient beds that the NDMS system can generate, providing that there was at least one Federal Medical Station (FMS) per DMAT team, and that all DMAT teams were at Type I readiness would be 13,750 patent beds, with a staffing requirement of 11,275 personnel. This number of beds does not even address the 14,400 patients would be displaced and require discharge, inter-facility transfer or evacuation outside the impacted area, without regard to the casualties that were generated by the event.

The rationale behind the apparent lack of concern for the additional 90,000 plus patient beds required for the worst case scenario presented is the over 110,000 pre-committed patient beds from the 1,800 participating National Disaster Medical System fixed facility hospitals. Community, teaching and trauma Hospitals across the nation have joined with the National Disaster Medical System, through Memorandums of Understanding, to make available their empty patient beds in times of disaster. Like the military combat medial delivery system, patients are to be evacuated out of the impacted (combat) area to the safe and secure Zone of the Interior (ZI).

The Challenges:

The challenge for this scenario is that the aero-medical and ground evacuation assets required to perform a mission of this magnitude are scarce. Mission planning factors for the aero-medical evacuation of a maximum of 6,000 patients a day from Iraq during Operation Just Cause accounted for 97% of the aero-medical evacuations assets available to the United States Military. Further, the actual mission accomplishment of 12,632 patents being evacuated on 671 Aero-medial flights averaged less than 20 patents per airframe (Green, n.d.). Thus, at this density, to evacuate even 50,000 patients would require 2500 airframes. Even assuming 250 flights per day, it would require ten days time to evacuate 50,000 patients. Other forms of transportation can also be used, such as railroad and bus assets; but these assets are not pre-configured, and the patients would require beds until such coordination was completed. It is reasonable to expect that a significant number of patients would not be able to be evacuated until at least ten days after the incident and therefore disaster level patient care beds should be planned for as they will be required to maintain the patients until evacuation assets became available.

To further confound the premise of evacuating the majority of patients requiring hospitalization to the Zone of the Interior is the harsh reality that patients must be first stabilized before they can be safely evacuated. Using techniques such as delayed closure, external fixation and the like, definitive care of some orthopedic and surgical patients can be delayed, without a significant increase in morbidity and with the attendant savings of the logistics overhead of providing the required supplies to perform these procedures in the austere medical environment expected within the impacted area. However, stabilization of internal injuries (crush) and other medical conditions must be attained before an aero-medical staging facility, or other evacuation management site will clear a patient for further evacuation. The general rule for military medical evacuation to the zone of the interior has been that the patient was expected to remain stable with onboard care supplies for at least 24 hours. In the case of an overwhelmed medical system within the impacted area, an evacuation policy that facilitated short haul evacuations for further stabilization to the closest medical facilities outside the impacted area could be envisioned; however, these facilities would likewise need to be transfer and evacuate their patients further into the zone of the interior. Additionally, to avoid becoming overwhelmed themselves, and lose their ability to receive new patients from the impacted area for lack of patient beds, they too would need to be augmented by resources from the National Disaster Medical System.

The Reality:

This returns our discussion to the present DMAT teams within the National Disaster Medical System. Unfortunately not all DMAT teams are at the TYPE I level of readiness. In fact, according to David G.C. McCann MD, Former Chief Medical Officer of FL-1 DMAT since 2003, a 2008 Senior Policy Fellow in Homeland Security at George Washington University’s Homeland Security Policy Institute, and Current Chair of the American Board of Disaster Medicine (ABODM), the “NDMS is being marginalized as DHHS (Department of Health and Human Service) prepares to upgrade the Commissioned Corps of the USPHS (United States Public Health Service) to serve as the “first-line” in disaster response” (McCann, 2008). To support this assertion Dr. McCann reflects that the number of voluntary members of the DMAT teams has dropped from over 7000 to about 5,000; that the contract that provided the training to DMAT members that was required for teams to be certified as being Type I expired October 31, 2005 and has not been renewed or replaced (University of Maryland, Baltimore County, 2005); that despite a budget increase of 6.3% for FY08 over FY07, teams have had their budgets significantly reduced and their administrative officer is forced to maintain the team’s credentials and records on little over 20% of the budget he had last year. Further, he asserts that there had been a complete freeze on hiring new NDMS personnel lasting over 2 years; consequently, “Maybe 10% of the 55 teams are at Type 1”. According to the RI-1 DMAT team Deputy Commander, Tom Lawrence, their team is one of the 31% of all NDMS team assets that have reached Type I readiness, and that they are also “very short on nurses” (Rhode Island Hospital, 2008).

Bill Hall, Spokesperson for the Department of Health and Human Services disputes Dr. McCann’s claims; he says the department remains “fully committed” to NDMS. “We are not closing down or eliminating teams. In fact, for fiscal 2009, HHS is proposing a $7 million increase for NDMS”. The commanders of six Florida-based DMATs posted a letter online on the National Association of DMATS website (Kruschke, et al., 2008) saying they had “confirmed through multiple independent sources” within the department that HHS officials are “engaged in a systematic plan to deemphasize” NDMS and to replace DMATs with new PHS Commissioned Corps Health and Medical Response (HAMR) teams; but Hall insisted that the HAMR teams will play a “complementary role” to DMATs. “Nobody is being replaced”. (Garza, 2008)

Regardless of the validity of the claims made by either the Commanders of the Florida DMATS or the Spokesperson of the Department of Health and Human Services, it becomes readily evident that the current status of the DEMAT teams within the National Disaster Medical System is sub optimal. In a presentation on their website targeting elected officials, the National Association of DMATS express their concern over the HAMR teams, Budget Issues, the loss of Warehouse Space, Inability to use Team owned equipment, Training, and Delays in Application Processing. They close their remarks with the statement “NDMS team members feel we are less prepared now to respond to a disaster than before Hurricane Katrina. This is a direct response to action taken by ASPR to dismantle NDMS. As the primary disaster medicine response agency we feel our elected leadership must look into the problems facing NDMS and the citizens of the United States who are the potential victims of the next disaster, natural or man-made” (National Association of DMATS, n.d.) .

In September 2008, The National Biodefense Science Board (NBSB) provided feedback to the U.S. Department of Health and Human Services on the review of the National Disaster Medical System (NDMS) and national medical surge capacity as required by the Pandemic and All-Hazards Preparedness Act (PAHPA) and as specified by Paragraph 28 of Homeland Security Presidential Directive (HSPD)-21. (National Biodefense Science Board, 2008). The report, marked confidential was available on the open web. It made thirteen recommendations which have been condensed and listed below:

1. Strategic Vision: NDMS…does not represent an overall system to provide for the medical needs of patients at a time of national need.

2. DEVELOPMENT OF AN NDMS / ESF-8 ADVISORY GROUP: The establishment of ongoing civilian advisory groups for the National Disaster Medical System.

3. MONITORING AND DOCUMENTING NDMS IMPROVEMENT; previous studies have identified opportunities for improvement in the NDMS… there does not appear to be an organized methodology to track and monitor attempts to address these identified issues.

4. MEDICAL RESPONSE PERSONNEL: To achieve full staffing and operational status for all NDMS response teams… An improved, streamlined application process for DMAT membership is necessary. A training curriculum should be developed, adopted and implemented.

5. NDMS FIELD PERSONNEL CAPABILITY AND GAP ANALYSIS: Consideration should be given to improving the NDMS personnel capability especially in terms of volunteers’ conflicting obligations and time to respond, for multiple specified national scenarios.

6. DEFINITION OF THE NDMS PATIENT: The definition of what constitutes an “NDMS patient” should be reviewed and expanded for the purposes of reimbursement.

7. REFINEMENT OF PATIENT MOVEMENT CONCEPT OF OPERATIONS: The ability to implement an effective, smooth mass evacuation of patients from an impacted area remains an unresolved issue.

8. NDMS ELECTRONIC MEDICAL RECORD (EMR): Although the advantages of the EMR are many… Its use must not compromise the efficiency of the healthcare providers in the field.

9. IMPROVED COMMUNICATION WITH STATE/LOCAL REPRESENTATIVES: Serious consideration should be given to returning the DMAT program to its original intent of first building local and state capability, and then exporting these volunteer resources through the NDMS for federal assistance to other parts of the country impacted by a disaster.

10. DEVELOPMENT OF IMPROVED NDMS STANDING CAPACITY: Serious consideration should be given to establishing improved alliances between NDMS and the public/private healthcare sector to provide assistance in field care, patient transport and definitive patient care.

11. FEDERAL REGULATIONS: Criteria should be developed in advance to specify when health-related federal regulations (e.g. HIPPA) should be considered for temporary suspension.

12. OVERALL NDMS FUNDING: It is clear that the funding level for NDMS is inadequate to support even the current level of the NDMS operation.

13. The Department of Health and Human Services is requested to respond to these recommendations in writing during their summer 2009 Public meeting.

Conclusion: The materials presented herein clearly show a National Disaster Medical System that is not ready to respond to an earthquake of major magnitude in California. The NDMS system can currently be safely called broken, and the challenge of the next administration is to address these issues in a timely manner before the system needs to be called upon to respond to the medical needs of our citizens during a major or catastrophic event.

Navigating Through Tough American Economic and National Health Care, Health Insurance Reform Issues

For Practicing Agency Brokers, Trusted Insurance Advisers, And Financial Planning Consultants….

From time to time, there is a need for guidance in Financial Services Practice; now is definitely one of those times. There are two distinct issues working in tandem which determine modifications in the future conduct of our business: The Economy and the Reforms. Here are ideas on how to navigate our way through the maze. This can most certainly be done. With care, thoughtful performance, and innovation, Financial Services Professionals can serve the general public and make the experience satisfying and profitable. Let’s begin with some commentary on the general economic circumstances first. Following that, we’ll take up the Reform issues, how to move through them, and how the way we advise members of the general public on savings, insurance, investment, and retirement concerns.

1.To begin the economic discussion, we need to address the full and true extent of just what we as a nation and we as practitioners are up against. As of this writing, in the winter of 2009, unemployment, including the employed, self-employed, and business owners, has passed 10%, about 15 to 16 million people. Add another 6 to 7 percent to that, which includes the part-timers, disabled, retired, and those of working age who have stopped looking. We are looking at about 22 million Americans not drawing active paychecks. The closing of businesses, branch locations, shops, stores, retail, wholesale, and service sectors, adds to the severity of the overall problems. It is conceded that there are many who are drawing from savings, taking early pensions/Social Security income, receiving extended unemployment compensation, and retirees on full pensions. That said, the loss of productivity is simply staggering. All this decreases the taxes available from which cities, counties, states, and the federal government must fund budgets. Naturally, all this leads to ever worsening annual deficits and unfunded liabilities. Finally, federal government for the past 30+ years has pursued deficit-spending policies which add to all of this. A look at USDEBTCLOCK.ORG tells the whole story in real time. Take a look and notice a few things.

The national debt stands at some $12+ trillion, while the federal budget shows in the neighborhood of $3+ trillion. Take a closer look and it can be seen that $1.7 trillion is taxes, while the difference is annual debt – sale of treasuries, printing of currency. The unfunded liabilities of Medicare/Medicaid, Prescriptions, Social Security top $106 trillion! To get an idea of what these liabilities mean, consider that this funding is what must be contractually paid out in entitlements over the lifetime of those presently enrolled in these programs, say, from now and over the next 20 to 30 years. And that will become progressively larger as the Baby Boomers begin checking into the systems. This is merely the highlighted treatment of the issues and doesn’t take in figures on the levels below the federal programs and subsidies: state, and related deep concerns over inflation, tax increases, brain drain, not to mention the TARP, STIMULUS, industry handouts/loans, and funds to individuals and non-governmental organizations under Acts in force, such as new mortgages and existing mortgage relief.

We read, see, and hear the word “unsustainable” a lot. Another phrase is ” the debasing of our currency.” Still another is “breaking the buck.” Are these figures actually important to us? Well, yes. One example will suffice: the interest alone on just the national debt is about $340 billion/year, or about 12% of the national budget. And that is going to get much higher. Relate that to a family making, say, $75,000/year. With this level of household debt, that family will pay some $9,000/yr. merely to pay interest, not even to reduce its debt obligations! Just recently on CNBC, a professor of finance designated the U.S. Dollar as fiat currency, which it is. Watch just about any television station and note all the advertisements about gold. Yet, many Americans just roll on as if everything is going to be just fine. Let’s hope for that miracle. The American People have been through some very difficult times over the past 250+ years and have managed to rebound. That could happen again. This time, however, things are quite different and difficult.

Does all this mean that Americans should just roll over, play dead, and let the federal government take care of everything? As a nation, will we file for default and a kind of national bankruptcy? This may be a legitimate senario; and it could be solved through establishment of a new currency sometime in the future, after everything gets paid off in near worthless U.S. currency. But, nations and the people in them, get hurt—badly. Russia, Panama, Argentina, Germany, Cuba (and there are more examples out there), all went through this, and the people there know just how bad this is: a national nightmare from which one cannot awaken. Special note on Argentina: The collapse of that country’s currency, the Peso, not long ago, lead to black markets, swap meets, trading for needed goods with hard assets, such as gold, bartering and trading in kind, not to mention increases in violence and crime. When new prices and wages readjust to some new currency, the resultant pricing of goods and services is extremely unfavorable to individuals and businesses. One can hope and pray that this does not happen or at least is some years away. Some experts suggest anything from 2 to 20 years—-read: nobody knows for sure! That said, this leads to strategies that we in the financial services industry can and should probably look into and maybe adopt. If all this sounds like gloom and doom and just too ridiculous, let me assure readers that this writer has done his research, can back it all up, and is most assuredly not making it all up as he goes along! Independent corraboration and documentation on all of this is readily available on the internet, libraries, university papers/archives, and other public records.

2. Here are some practical suggestions for Financial Services Professionals. While nobody can predict the future, this portion of the narrative is best described within two arbitrary time frames: A. 2010 to 2014-2015. B. Beyond that to, say, 2020-2025. This time division is established for specific reasons. At the time of this writing, the U.S. Government is poised to pass and place into effect a national healthcare/health insurance reform act. It doesn’t much matter whether or not one is in favor of this particular piece of legislation or some others, reform is necessary and will come very soon regardless of what the final act turns out to be.

Care rationing is a matter of fact, already in place for some years, and will get more pronounced for everyone. There really is no other sustainable way to do any kind of reform in attempts to control steeply increasing costs of insuring seniors and those below age 65 yr. who can either not afford to be insured, can’t qualify, or act as though they don’t want to protect themselves(checking into their local hospital ER so we can all pay for that; and hospitals, in order to remain in business are already tightening up on the emergency provisions of the law). The projected costs of the one that looks like it will become the law of the land, warts and all, is estimated at between $1 and $2 trillion over the next 10 years. It will no doubt end up by 2019 considerably more. If it doesn’t, it will stand alone among all the U.S. entitlement programs in the history of the Republic to come in at or below the CBO cost estimates. Look for increasing income taxes, fewer paychecks to tax, very slow employment recovery, very fragile equities markets, more federal currency creation, more inflation, weakening U.S.Dollar.That’s the context in which we find ourselves and determines what we do as financial services advisors and implementers. Good luck. That said, let’s discuss Part A – the next 3 years.

Part A. During the next three years, things will proceed at more or less normal conduct of business in an atmosphere of continuing inflation and increasing taxes. As practitioners, we can expect to market the same or similar coverages as we do now. Adverse Selection(taking into account pre-existing conditions) will still be there to control premiums on life, individual, family, group healthcare, disability coverage, long term care insurance, retirement plans(more on this later), to mention the prominent ones. We still will be doing our due-care, due-diligence, financial planning, fact finding, observing compliance, and doing what is best for the client. There are going to be less people and businesses with which to work, and they will have less money with which to do things. Remember, the client always comes first. Words to live by.

Certainly, we owe it to those who favor us with their business to let them know what is coming as soon as we know what is in store for them and for ourselves. For the most part, we will try to continue as before – for about the next several years. After that, things begin to get very different. Let us progress to Part B, Beyond that.

Part B. After 2014-2015, health insurers drop Adverse Selection and pre-existing conditions no longer play a part in the health underwriting process, at least for much of the individual, family, small group medical insurance, and Medicare Supplementary coverages. We’ll all most likely be undergoing training, certification testing, and more state/federal regulation. There’s an upside to all of this. As long as the health insurance industry remains in play, we should be able to make as much or even more money. Nobody knows what the effect of some U.S. Health Insurance Company, Co-op, or Exchange might have on the viability of the health insurers. The CBO states that some very small percentage of the public will enroll in the Public Option plans. That remains to be seen. Many people will be subject to non-enrollment penalties and fees.

What we do know about public plans and elimination of pre-existing conditions is the example we have in Texas. This public option is called the Texas Health Insurance Risk Pool, under the jurisdiction of the State of Texas. In Pool plans, there are no pre-existing conditions to stop one from procuring a pretty good major medical insurance coverage; in fact, one actually has to have significant medical condition or conditions to be eligible. Approximately 29,000 Texans are presently enrolled, out of the millions who have commercial coverage of individual, family, or group coverage. Even with State and Federal subsidy grants each year, the premiums on these plans run 2.5 to 4 times what a similar commercial plan might cost and the coverage is not as good. In a word, it is really expensive. It may be that, since the great majority of Americans probably generally qualify by providing medical evidence of insurability anyway, the impact of accepting all applicants by the commercial insurance companies may not send the overall individual/group premiums skyrocketing(an outcome with which this author does not agree). Those who can’t afford health insurance may get federal subsidies. The fact is that nobody really has a clue. We won’t discuss the MA and OR state-run health care/insurance plans. Not working out very well. Adverse Selection Elimination is a main culprit, leading into healthcare rationing and increasing premiums.

For insurance professionals, the marketing opportunities may just turn out to be positive. Bringing into the insuring public millions of previously uninsured and underinsured younger people may be a good thing. Supplementing health insurance for seniors will be there. We need to work hard at staying in the game and not getting squeezed out by federal competition. All people out there will certainly still need competent financial services professionals, maybe even more than at present. There are those in professional positions of economics, demographics, medicine, actuarial science, and other disciplines who think that any public option may not drive out the insurers, especially knowing that private enterprise, ingenuity, innovation, increased efficiency, would allow the private sector even to drive out the public option. Look at how the Post Office, Medicare, Medicaid, VA hospitals, Social Security, and other entitlements have worked out. Remember that $106 trillion(and climbing) of unfunded liabilities and where that has put the nation and the American People. As these liabilities keep coming due, they increase the federal budget! Doesn’t sound like some great efficiency to this writer.

Finally, there is this prediction regarding earned and renewal compensation. Don’t look for some sudden drop off just because of Reform. This author has found from experience that most people are quite cautious and suspicious of new programs and will tend to retain what they have for just as long as they can, until they gain confidence in such programs, or are forced into them. Even then, many, if not most, will still retain current health insurance coverage in some form to pick up what Reform does not. That was this writer’s great surprise with Harris County here in Texas, when in 1970, the County government replaced an outdated and woefully inadequate set of fringe benefits with full comprehensive coverage. Most all the supplemental coverages that were marketed to large numbers of employees from 1965 to 1970 remained on the books for many years. That is likely to happen in our national future. So take heart.

Earlier, the topic of currency debasement, creation of trillions of dollars by the Fed out of thin air, and inflation(about 2.5% annually, by the way) was touched upon, especially as related to obtaining goods, services, and accumulation/distribution of retirement funding. This leads into the arena of retirement capital, funds formation, equities markets, cash value life insurance, annuities, precious metals, commodities, bank deposits, money markets, treasury instruments, and the like. This also includes non-tax qualified and tax-qualified retirement vehicles, such as IRAs and 401(k)s, as examples. One suggestion is the recommendation that some portion of a client’s capital or retirement portfolio of funds be placed in hard assets. Gold and silver come to mind. We would defer to a precious metals specialist for that. Hedging and potential gains are two objectives that come to mind.

Everything is open to new ideas based upon the changing circumstances. Your practice is obviously going to change; caution and creativity are the guides. Whether we operate in single needs, multiple needs, or comprehensive planning modes and implementations, all of our recommendations are going to be different as compared to past years. It is a bit like attempting to walk in quicksand. And this applies to all product implementation, not just the health insurance arena. So be careful out there.

The way we operate in ethical conduct of business will change. The suggestion is put forth that in the future, starting in 2010 and beyond, we in financial services when advising businesses and individuals, will need to either form alliances with other financial professionals who are licensed in areas where we are not, or refer people to other trusted advisors in order to fully inform the people we serve of the risks and rewards to allow them to make proper, informed decisions that work for them and provide them the opportunity to form strategies and thus to protect themselves. We are definitely in for quite a ride; so fasten your seatbelts. A tip from one who is an investor, not a sales agent: dollars are currency;gold is money. Get to know the difference. Know all the new rules, regulations, and compliance requirements. Study. Engage with other professionals. There is a big job ahead for all of us, starting now.

This is by no means an exhaustive analysis of what’s ahead, but it is a beginning. Still, taken to heart, it gives us inspiration to continue to provide the most excellent advice and coverage implementation to our clients and would-be clients. We who are true professionals are in the unique position to guide, advise, offer direction, clarify, and eliminate confusion. No government bureaucrat can come close to what we do. Imagine that!

Florida Senate Candidate Vows to Repeal Florida Health Insurance Reforms

Amid widespread health care reform in Florida and a heated national health care debate, both Republicans and Democrats worry about potential changes to the Florida health care system. Florida Democrats, who are in favor of health care reform efforts, worry that an up-and-coming GOP Senate candidate may pose a serious threat to the quality of the Florida health care system.

Republican Marco Rubio has, until now, not appeared to pose a serious threat to health care reform in Florida. However, as the Republican candidate continues to build support for his nomination to the GOP Senate seat, Democrats are growing increasingly concerned about what Rubio might do if elected to office. Most importantly, Democrats worry that Rubio will repeal Florida health reforms if he is elected.

That’s no wonder; Rubio has said himself that he plans to repeal Florida health insurance reforms if he wins the Senate seat. That repeal, he said, could mean decreasing health costs for Florida residents and improving health care accessibility for all. The Democrats, however, don’t see it the same way, and are calling Rubio “nothing more than a typical politician who is in the hands of the health industry,” said Eric Jotkoff, Florida Democratic Party spokesman.

According to Jotkoff and a press release issued by the Florida Democratic party, if Rubio does indeed have an alliance with Florida insurance companies, as the Democrats suspect, Florida residents will have to pay more for their healthcare than ever before. Moreover, such an alliance would increase the federal budget, reduce health care access, and create financial difficulties for many Florida residents participating in the Medicare program.

“By pledging today to repeal health insurance reforms Marco Rubio not only promised to add to the federal budget deficit and deny Florida’s families access to health care, but Rubio’s repeal would also force senior citizens to continue paying for the skyrocketing costs of prescription drugs out of their pockets by re-opening the Medicare Part D donut hole,” said the Florida Democratic Party in a press release issued earlier this month. Rubio’s repeal also means that he wants allow insurance companies to deny coverage when you get sick because of a pre-existing condition.”

As health care costs continue to increase, including the costs of health insurance plans, one of the best things that Florida residents can do to help protect their health and their wallets is to enroll in a health insurance plan now to lock in the monthly premium rates before they increase.

There are many different types of health plans and health providers. In order to find the right health plan for their specific needs, lifestyles, and budgets, Florida residents should consult with a qualified health insurance plan broker who can help compare health insurance plan offerings and rates to find the best one for each individual applicant. For example, Florida residents may be able to receive health insurance plans through their employers in addition to health insurance plans that they qualify for on their own. Even if a Florida resident is able to get a health insurance plan through an employer, he or she may be able to get a better rate on a plan he or she gets independently of the employer.

One of the most popular health options is a Health Savings Account plan, which allows participants to save money into a high-interest yielding savings account that they can earmark to pay for health insurance expenses. With a Health Savings Account, participants will also receive a tax deduction for the funds they deposit into their Health Savings Account and use on qualifying medical expenses. Also, Health Savings Account options come with high deductible health plans that have low monthly premiums, significantly reducing participants’ monthly health care expenses.

Whenever enrolling in a new health ins. or changing health ins., it is important for individuals to speak with an experienced health insurance advisor to ensure that they have all the information they need to make a wise financial an healthcare decision for their specific needs, budgets, and lifestyles.