[Senate Hearing 111-946]
[From the U.S. Government Printing Office]
S. Hrg. 111-946
A REVIEW OF DISASTER MEDICAL
PREPAREDNESS: IMPROVING COORDINATION AND
COLLABORATION IN THE DELIVERY OF MEDICAL ASSISTANCE DURING DISASTERS
=======================================================================
HEARING
before the
AD HOC SUBCOMMITTEE ON STATE, LOCAL,
AND PRIVATE SECTOR PREPAREDNESS
AND INTEGRATION
of the
COMMITTEE ON
HOMELAND SECURITY AND
GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
JULY 22, 2010
__________
Available via the World Wide Web: http://www.fdsys.gov
Printed for the use of the Committee on Homeland Security
and Governmental Affairs
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COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
JOSEPH I. LIEBERMAN, Connecticut, Chairman
CARL LEVIN, Michigan SUSAN M. COLLINS, Maine
DANIEL K. AKAKA, Hawaii TOM COBURN, Oklahoma
THOMAS R. CARPER, Delaware SCOTT P. BROWN, Massachusetts
MARK L. PRYOR, Arkansas JOHN McCAIN, Arizona
MARY L. LANDRIEU, Louisiana GEORGE V. VOINOVICH, Ohio
CLAIRE McCASKILL, Missouri JOHN ENSIGN, Nevada
JON TESTER, Montana LINDSEY GRAHAM, South Carolina
ROLAND W. BURRIS, Illinois
EDWARD E. KAUFMAN, Delaware
Michael L. Alexander, Staff Director
Brandon L. Milhorn, Minority Staff Director and Chief Counsel
Trina Driessnack Tyrer, Chief Clerk
Joyce Ward, Publications Clerk and GPO Detailee
AD HOC SUBCOMMITTEE ON STATE, LOCAL, AND PRIVATE SECTOR PREPAREDNESS
AND INTEGRATION
MARK L. PRYOR, Arkansas
DANIEL K. AKAKA, Hawaii JOHN ENSIGN, Nevada
MARY L. LANDRIEU, Louisiana GEORGE V. VOINOVICH, Ohio
JON TESTER, Montana LINDSEY GRAHAM, South Carolina
Donny William, Staff Director
Ryan Tully, Minority Staff Director
Kelsey Stroud, Chief Clerk
C O N T E N T S
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Opening statement:
Page
Senator Pryor................................................ 1
WITNESSES
Thursday, July 22, 2010
Robert J. Fenton Jr., Deputy Assistant Administrator for
Response, Federal Emergency Management Agency, U.S. Department
of Homeland Security........................................... 3
Kevin Yeskey, M.D., Deputy Assistant Secretary and Director of
Preparedness and Emergency Operations, Office of the Assistant
Secretary for Preparedness and Response, U.S. Department of
Health and Human Services...................................... 5
Paul Cunningham, Senior Vice President, Arkansas Hospital
Association.................................................... 14
Alphabetical List of Witnesses
Cunningham, Paul:
Testimony.................................................... 14
Prepared statement........................................... 39
Fenton, Robert J. Jr.:
Testimony.................................................... 3
Prepared statement........................................... 21
Yeskey, Kevin, M.D.:
Testimony.................................................... 5
Prepared statement........................................... 27
APPENDIX
Statement submitted by CriticalCareRoundtable.org................ 50
A REVIEW OF DISASTER MEDICAL
PREPAREDNESS: IMPROVING COORDINATION AND COLLABORATION IN THE DELIVERY
OF MEDICAL ASSISTANCE DURING DISASTERS
----------
THURSDAY, JULY 22, 2010
U.S. Senate,
Ad Hoc Subcommittee on State, Local, and
Private Sector Preparedness and Integration,
of the Committee on Homeland Security
and Governmental Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:05 a.m., in
room 342, Dirksen Senate Office Building, Hon. Mark L. Pryor,
Chairman of the Subcommittee, presiding.
Present: Senator Pryor.
OPENING STATEMENT OF SENATOR PRYOR
Senator Pryor. I will go ahead and call the meeting to
order. I want to welcome everyone and thank you for being here
today, especially our panelists.
I know that we have some Senators who could not attend
today, but we are going to keep the record open for questions
for a few days after the hearing. I will do a quick opening
statement and then we will let you guys do your opening
statements. I think we are limiting those to 5 minutes, so if
you could keep those at 5 minutes each, that would be great.
And then I will have some questions and I may get some
questions from various Senate offices but otherwise, we will
leave the record open and get you guys to follow up.
We have two panels and I just want to welcome everyone here
and thank you all for coming. Today, we are talking about the
National Disaster Medical System, (NDMS), and I appreciate you
all's expertise and you all's work in this program and to help
this Subcommittee to provide some oversight here.
Weakness in our public health and medical response
capabilities have been highlighted in catastrophic events over
the last decades, such as the September 11 terrorist attacks,
Hurricane Katrina, and the H1N1 outbreak. To that end, Congress
has enacted legislation to improve Federal medical preparedness
and response efforts, such as the Pandemic and All Hazards
Preparedness Act.
I really believe that strong planning is the foundation for
effective action, and I think last year we saw how our
investments had mitigated the effects of the H1N1 outbreak.
However, State and local entities continue to worry about the
next severe health threat or event that could overwhelm the
medical system, and they have a series of concerns. We will
talk about some of those today.
To begin addressing these uncertainties, today we will
examine the National Disaster Medical System as a case study of
Federal medical response efforts. NDMS, operated by the
Department of Health and Human Services (HHS), partners with
other Federal agencies and the private sector to provide
medical services in response to emergencies and disasters. More
frequently, NDMS sends teams of volunteer medical providers to
areas affected by a disaster, and that is great. I think we
need to be doing that.
And on three occasions, NDMS has activated volunteer
hospitals to ensure patients affected by a disaster are able to
receive medical care services in an unaffected area. As
hospitals were activated for the first time, we discovered gaps
in our planning and faced newly identified challenges with the
NDMS. I think this Subcommittee is very interested in closing
those gaps and making sure that as we go forward, we don't see
these problems on a continuing basis.
Today, we will hear from Federal officials regarding
medical preparedness and response efforts as it pertains to
NDMS. That is our first panel. On our second panel, we will
hear from the Arkansas Hospital Association and they will share
the experiences of volunteer Arkansas hospitals that were
activated in response to Hurricane Katrina and Hurricane Gustav
and their suggestions on ways to improve NDMS.
It is my hope that this hearing will provide a better
understanding of our utilization of the NDMS and how we can
learn from these experiences to improve medical response needs
of those affected by disasters. I believe what we will learn
today will not only strengthen the current program, but will
serve as a model of disaster medical response efforts for other
Federal, State, and local stakeholders.
With all that said, let me go ahead and introduce our first
panel, and our first witness is Robert Fenton. He is the Deputy
Assistant Administrator for Response for the Federal Emergency
Management Agency (FEMA). Mr. Fenton is responsible for
coordinating and integrating Federal interagency all-hazards
disaster planning and response operations. He also manages
Emergency Response Teams and oversees Disaster Emergency
Communications (DEC) programs.
Our next witness is Dr. Kevin Yeskey. He is Deputy
Assistant Secretary and Director of Preparedness and Emergency
Operations of the Office of the Assistant Secretary for
Preparedness and Response (ASPR), at the Department of Health
and Human Services. Dr. Yeskey is responsible for managing the
National Disaster Medical System and addressing medical
response efforts to disasters and emergencies. Dr. Yeskey has a
long history in working on a variety of disaster response
positions within the government.
So, like I said, if you can do your opening statements in 5
minutes, that would be great, and then I will have some
questions.
Mr. Fenton, would you like to go first?
TESTIMONY OF ROBERT J. FENTON, JR.,\1\ DEPUTY ASSISTANT
ADMINISTRATOR FOR RESPONSE, FEDERAL EMERGENCY MANAGEMENT
AGENCY, U.S. DEPARTMENT OF HOMELAND SECURITY
Mr. Fenton. Good morning, Chairman Pryor. I am Robert
Fenton, Jr., the Federal Emergency Management Agency's Deputy
Assistant Administrator for Response. I am responsible for
ensuring the delivery of coordinated disaster response
operations, integrated Federal interagency all-hazards disaster
planning and response operations, and managing the Disaster
Emergency Communications programs.
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\1\ The prepared statement of Mr. Fenton appears in the appendix on
page 21.
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As you know, States, not the Federal Government, have the
fundamental authority for evacuations. The State or local
governments may order mandatory evacuation or recommend a
voluntary evacuation when a State or local government
determines that evacuation is necessary. It may also request
assistance from the Federal Government. Emergency mass
evacuation is the movement of general population from a
dangerous area due to the threat of occurrence of a natural or
terrorist attack, including the movement of patients in health
care facilities and individuals in the community who have
medical needs. HHS is a key partner to FEMA in carrying out
disaster medical evacuation activities.
FEMA's support to and involvement in medical evacuation
activities falls into four key areas, the first being
preparedness. FEMA is helping prepare State and local
governments to provide updated guidance for incorporating the
evacuation planning into emergency operations plans, as well as
providing technical assistance to facilitate evacuation
planning. Many of FEMA's grant programs are used to support
evacuation-related activities. For example, the Regional
Catastrophic Preparedness Grant (RCPG) program promotes
planning for both evacuation and reception of evacuees and
emphasizes the need to work with potential host-State
communities to develop agreements prior to the occurrence of
incidents.
The second area is planning. In partnerships with State and
local governments, FEMA is developing Federal-level
Catastrophic Disaster Response Plans that include evacuation
and medical evacuation elements. This planning takes into
account the need for a significantly higher level of response
assets, the possibility of little or no advance notice or
warning, and the need to rapidly respond with massive support.
The third area is coordination of Federal support. During
response and recovery operations, the interagency community
through the National Response Framework's Emergency Support
Functions convene at the national level to support regions and
States by leveraging authorities, supporting resource
allocations and decisions, addressing policy issues, and
supporting operational planning efforts. Many Federal
departments and agencies provide their own resources and
expertise that are critical to life-saving operations.
Supporting the local response and recovery process. The
Stafford Act authorizes FEMA to direct other Federal
departments and agencies to utilize their own resources in
support of State and local assistance efforts. State and local
governments may request resources from FEMA to address unmet
needs. Through mission assignments, FEMA can task appropriate
departments or agencies to provide support to the requesting
governmental entity. In anticipation of or in response to a
Presidential declaration or a major disaster or emergency, FEMA
can issue mission assignments to support medical response and
evacuation activities.
Under Emergency Support Function (ESF) #8, NDMS can be
mission-assigned to deploy to support the medical response
activities of the State and local governments overwhelmed in
disaster situations. FEMA, Health and Human Services (HHS), the
Department of Defense (DOD), and the U.S. Coast Guard together
have developed prescripted mission assignments that are
specifically available to request medical support and other
associated capabilities. ESF #8 alone has more than 20
prescripted mission assignments available to cover a variety of
health and medical issues. FEMA also administers a contract
that can provide ambulance and paratransit services that can
support patient and medical evacuations.
The fourth area is our recovery programs. FEMA also
provides assistance to State and local governments as well as
the individuals and families through two recovery programs.
Under the Public Assistance Program, when the Emergency Medical
Service Delivery System within a designated disaster area is
severely compromised or destroyed by a disaster event, FEMA may
reimburse State and local governments and certain private
nonprofits for the cost of extraordinary medical care and
medical evacuation expenses. Assistance for emergency medical
care and medical evacuations for disaster survivors from
eligible public and private nonprofit hospitals and custodial
care facilities may also be made available.
Under Individual Assistance, FEMA may provide eligible
disaster survivors with a full range of programs designed to
help meet individual needs, including but not limited to
individual and household grants for housing and other needs
assistance, crisis counseling, disaster unemployment
assistance, and SBA low-interest loans.
Certainly in the future, major disasters or emergencies
will seriously threaten and damage local medical facilities
which will necessitate patient evacuation and transport to
either a temporary facility or an existing facility with spare
capacity. With the appropriate coordination of Federal agencies
working together with States, local Tribes, and voluntary
agencies, we can meet the great challenges presented to the
public when medical mass evacuations are required.
Thank you for the invitation to appear before you today to
explain FEMA's roles and responsibilities in medical evacuation
during disasters and I look forward to any questions that you
may have today. Thank you.
Senator Pryor. Thank you. Dr. Yeskey.
TESTIMONY OF KEVIN YESKEY,\1\ M.D., DEPUTY ASSISTANT SECRETARY
AND DIRECTOR OF PREPAREDNESS AND EMERGENCY OPERATIONS, OFFICE
OF THE ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Dr. Yeskey. Good morning, Chairman Pryor. Thank you for the
opportunity to discuss the National Disaster Medical System and
the key role it plays in our Nation's response to disasters.
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\1\ The prepared statement of Dr. Yeskey appears in the appendix on
page 27.
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NDMS remains one of the Nation's most significant Federal
medical response resources. Conceived in 1981 as an evolution
of the Civilian-Military Contingency Hospital System, NDMS is
an interagency cooperative effort among HHS, the Department of
Defense, Veterans Administration (VA), and the Department of
Homeland Security (DHS) that has over 7,800 employees, 95
response teams, and approximately 1,700 participating
hospitals.
HHS can activate the NDMS to provide aid to victims of a
public health emergency or to be present at locations at risk
of a public health emergency. In recent years, NDMS has been
called upon to respond to hurricanes, earthquakes, floods, ice
storms, and a variety of national special security events,
including the 2009 Presidential inauguration. In 2010 alone,
NDMS has deployed over 1,700 personnel.
NDMS has three components that I will briefly discuss:
Field medical care, patient movement, and definitive care.
Field medical care is provided by Disaster Medical
Assistance Teams (DMATs). In response to the Haiti earthquake,
NDMS deployed over 1,200 personnel that began deploying within
24 hours of the request for assistance.
The second component of NDMS, patient movement, requires
extensive collaboration with our partners. DOD has the lead for
providing air assets for movement out of the affected area.
FEMA provides ambulance transport for short-distance patient
evacuation.
The final component of NDMS is definitive care, the
provision of inpatient hospital services in participating
hospitals. Hospitals participate on a voluntary basis and agree
to provide available beds when requested by NDMS. Patient
distribution is coordinated with the States and localities.
NDMS as an organization continues to evolve and improve as
it learns from previous responses. Some of those lessons
learned include the need to enable more rapid deployments,
improve the provision of definitive care, reduce costs, and
more effectively coordinate activities regarding the evacuation
of victims, their tracking, and their return. We employed these
and other lessons learned in our recent Haiti response,
including the deployment of HHS Service Access Teams to serve
as case managers for patients evacuated to NDMS hospitals.
HHS greatly appreciates the contributions made by Little
Rock, Arkansas, hospitals to the victims of Hurricane Gustav.
The Arkansas Hospital Association has challenged us to do
better. This collaboration is helping us achieve a higher
standard of response. ASPR leadership met with the Arkansas
Hospital Association three times, most recently in May 2010.
ASPR staff have ongoing communications with the Arkansas
Hospital Association and the Arkansas Department of Health.
In our corrective action process, several issues were
identified and changes have been implemented that should all
but eliminate those problems from recurring. We are working
with the Department of Veterans Affairs to determine if it
would be suitable to place an HHS-staffed Federal Medical
Station at the Little Rock VA Hospital, which would serve as a
temporary medical facility for those patients who are ready for
discharge but unable to return to home.
HHS has also worked with Louisiana to establish a 250-bed
Federal Medical Station in Northern Louisiana to serve as a
temporary receiving facility for patients discharged from
Arkansas hospitals if patients are unable to return to their
home of record or starting location.
We will deploy our Service Access Teams early to assist in
the case management of NDMS-evacuated patients. As mentioned
previously, we are awarding a standing contract that will make
non-emergent medical transport available to return evacuated
patients to their homes or other receiving facilities.
Our improvements made to NDMS and the newly implemented
efforts dedicated to improving patient return are based on a
thorough process of evaluations and system modifications. We
are confident that these changes will prevent recurrence of
delays experienced by Arkansas hospitals in 2008. NDMS has been
a national resource for over 25 years and we are committed to
the continuous improvement that will enable NDMS to remain
flexible and responsive to current and new public health
threats.
Thank you for the opportunity to testify this morning, and
I am happy to answer any questions you may have.
Senator Pryor. Thank you both, and Mr. Fenton, let me start
with you. Really, this is for both of you, but I will start
with you, Mr. Fenton.
I know that in this circumstance, you get two Federal
agencies. You have FEMA and HHS, and HHS is the lead agency for
medical care, but FEMA is the overall coordinating agency for
all emergency response. And so I guess my first question is a
general one, and that is when it comes to the kind of roles and
missions here, is FEMA clear on its appropriate role and how it
interfaces with HHS and vice-versa? Do you guys have a good
working relationship, or have you noticed that there are some
overlaps or gaps that needs to change and that needs to be
honed a little bit? Mr. Fenton.
Mr. Fenton. Yes, sir. I do believe we have a very cohesive
and a very good working relationship and team up on a number of
issues as it relates to medical areas. I think, first, starting
from a doctrine perspective, the National Response Framework
outlines roles and responsibilities. The National Incident
Management System is the architecture for how we come together
and how it organizes us into a management system. When we
respond, we not only both understand this system and its roles
and responsibilities as outlined in there, but we also partner
together in many planning activities throughout the year, from
the national level down to the regional level. So in each one
of FEMA's regional offices, there are Health and Human Services
personnel that are down there working collaboratively at that
level.
And then in addition, FEMA also brings together the
interagency body which Health and Human Services is a part of
through the Emergency Support Function Leadership Group that
meets monthly to discuss specific issues or planning issues,
like a lessons learned refined processes and procedures or
those kinds of things at the national level. Also, at each
region, they have a Regional Interagency Steering Committee
(RISC) that is doing the same thing to align State and local
and Federal Government at that level.
And then, in addition, there are a number of exercises that
we do together throughout the year to look at the plans for
developing, continue to assess them, evaluate them, and make
sure that we are able to adequately respond. And I think that
just the number of mission assignments that I have talked to
you about, we have outlined--as we continue to work through and
see lessons learned, we either amend them or develop mission
assignments that give HHS clear guidance on what we expect from
them during disasters and how those relationships work. So I
think it is a good relationship and we continue to work at it
and resolve issues.
Senator Pryor. Good. I may have some follow-ups there in a
minute----
Mr. Fenton. Yes, sir.
Senator Pryor [continuing]. But that is good. I would like
to hear from Dr. Yeskey.
Dr. Yeskey. Yes. I would reiterate what Mr. Fenton said
about our very good collaborative and cooperative interactions
that we have. We support the DHS and FEMA in the National
Response Framework as the lead for Emergency Support Function
#8 Public Health and Medical Services.
We have Regional Emergency Coordinators in each of the 10
HHS regions, which overlap with FEMA regions, and they are
interactive with the FEMA regional offices and participate in
planning exercises. As HHS develops its response playbooks, we
bring in partners from the interagency to include FEMA and DHS
to participate in the development of those playbooks.
In responses, we have HHS liaison officers and the Joint
Field Office that FEMA runs. We put liaison officers in the
Operations Centers, the National Incident Command Center and
the Regional Coordination Centers that FEMA manages. And then
FEMA participates on all our ESF #8 calls that we have as we
respond. So we think there are very good communications and it
is not unusual for us to pick up the phone and call one another
if there are glitches, and so we have that relationship, as
well.
Senator Pryor. Good. Well, that is encouraging.
Let me ask about a little more about roles or missions, and
I am not sure where the line is, but one of the challenges I
think we will hear about from the second panel today, from our
Arkansas witness, is that some things seem to go very well,
good planning and preparation but maybe there were a few areas
that didn't go so well and one of those would be discharging
the patient or returning the patient back to their home area.
Whose responsibility is that? Is that HHS's responsibility?
Dr. Yeskey. HHS maintains the responsibility to return
patients back to their home of record, and that is usually
accomplished through a mission assignment from FEMA.
Senator Pryor. OK. So there again, that is collaborative,
as well, in terms of how that works. And also, when it comes to
the hospitals and other medical professionals getting
compensated for their services, is that more under HHS or under
FEMA?
Dr. Yeskey. That is more under HHS.
Senator Pryor. Let me go ahead and ask about that, then.
You probably are familiar and probably know a lot more about it
than even I do, but there was maybe an outstanding balance, I
guess you might say, a few hundred thousand dollars in our
State. I understand you guys are working through this right now
with Arkansas, and we appreciate that. But again, is that more
on the HHS side or the FEMA side?
Mr. Fenton. We mutually work together on these issues and
we are taking from this, I think, in lessons learned, we are
taking issues to mitigate this in the future. But FEMA has a
Host State Evacuation Sheltering Policy (HSESP) to reimburse
local and State governments that host evacuees and FEMA
reimbursed through the State of Louisiana to the State of
Arkansas funding for certain costs that would be eligible, some
of those for providing non-congregate care sheltering for
individuals released from hospitals.
It appears that the mechanism to capture that would be from
the hospitals to Arkansas to Louisiana and then we would
reimburse it. It appears that a number of hospitals, we didn't
have their information through that system, so now that we have
been made aware of it, we have gone back and we are going to
recapture any costs that are eligible underneath that system.
In addition to that, and I think because there are two
different streamlines of patients going to the hospitals, there
is one set of patients coming through NDMS's system, through
the mission assignment that we tasked HHS underneath their
authority to evacuate patients from Louisiana, and then there
are other patients that are moving through normal means, maybe
from hospitals to hospitals. So we have one system that allows
us to reimburse local and State governments for those costs,
for those out-of-pocket costs for that. Underneath HHS, what we
have done now is we are expanding their mission assignment to
allow them to capture and support those costs so it doesn't
need the extra coordination of the receiving State to be able
to do that.
I don't know if you want to add anything to that or not.
Dr. Yeskey. Yes, just a couple of things, and again, we are
working with FEMA on all those issues. Just understand, the
NDMS reimbursement is that NDMS reimburses after private third-
party insurers and Medicare but before Medicaid. So if a person
has other insurance, then hospitals in the MOU that they sign,
they go to bill those insurers first before they come to NDMS.
Now, if a person doesn't have insurance or is Medicaid-
eligible, or a Medicaid recipient, then NDMS covers the
reimbursement ahead of those self-pays or Medicaid.
Senator Pryor. And if I understand, part of what you are
both saying is that this is an area that you are trying to
address, the Arkansas specific situation----
Dr. Yeskey. Yes, sir.
Senator Pryor [continuing]. But also, it is a lesson
learned area that you guys are working on to try to make sure
it doesn't happen like this in the future, or at least that it
is handled appropriately in the future, is that the
understanding?
Dr. Yeskey. Yes, sir, and I think what we are trying to do
is prevent the delays in returning patients, and some of the
things I outlined as far as having our case managers actively
engaged so we know when patients are ready for discharge and we
can get them discharged, looking at alternate facilities, so if
there is a mitigating circumstance where they cannot be
returned to their home of record--in 2008, it was Hurricane Ike
that was coming through Louisiana and Texas--we want to have
the ability to have other outlets so the hospitals don't have
to hold onto those patients, making sure that we have a liaison
officer in the State Emergency Operations Center (SEOC), if
requested, so they can work through those details about how
those patients are going out, making sure that those are
implemented as well as having that contract in place with a
medical transport organization to take patients back when they
are ready to go back home.
Senator Pryor. So it sounds like this is a lot more
involved than just the two of you sitting down, because you
have already referred to--like in that case, to the Louisiana
Emergency Management People, the Arkansas Department of
Emergency Management, and then the transportation company.
There are probably a lot of--well, of course, the hospital, and
there are a lot of other interested parties that are involved
in this process.
Do you feel like, for any of those hurricanes, Gustav, Ike,
Katrina, do you feel like there was adequate planning and
preparedness on this specific area, or is that part of the
lessons learned is that you found some gaps, and obviously one
of those might be the payment issue, but you found other gaps
that you guys are addressing to make sure it won't happen in
the future?
Dr. Yeskey. Yes. I think we try and learn from every
response that we do, whether it is an exercise or whether it is
an actual response, and we have a corrective action process
that we have implemented so we can try and learn from these
lessons and prevent them from recurring. Some of these are very
complex interactions, as you stated. But we think we are making
a great deal of progress and learning from this and hope to be
able to generalize what we learn from Arkansas to the rest of
the system so it doesn't happen there or elsewhere.
Mr. Fenton. I was just going to add that, I think as you
outlined, there are a number of moving parts when you start to
execute medical evacuations or evacuations of the general
public, and FEMA has a number of things to prepare for
Hurricane Gustav, as lessons learned from Hurricane Katrina,
from issuing contracts to--we have a contract for ambulances,
for paratransit, to developing plans, to funding a lot of
planning at the local and State level, to issuing policies that
we never had before that allow us to reimburse host States, to
bring States together to sign agreements on how many personnel
they can accept and exactly where you go and work on
transportation resources and bringing in the Department of
Defense to this and the U.S. Coast Guard and everyone else that
has a capability that may benefit that.
And so we took on a number of activities to prepare us for
Hurricane Gustav and make sure that we could respond, but I
think that the best laid plans never survive the first disaster
and there are a number of lessons that we learned from there
and we will continue to make progress to improve those or
address any shortfalls within those.
Senator Pryor. OK. Let me see. I was going to ask about, I
believe it was you, Dr. Yeskey, mentioned that maybe one of
lessons learned or part of the plan that you are working on now
are these Federal Medical Stations, and you are talking about
one in Northern Louisiana and maybe one in Little Rock. What
does that mean exactly? I don't know who to direct the question
to. OK, Dr. Yeskey.
Dr. Yeskey. No, that is for me.
Senator Pryor. And so how will those work, and
logistically, what is that?
Dr. Yeskey. Yes, sir. A Federal Medical Station is a 250-
bed capacity that can be modularized in 50-bed capacities, but
the maximum capacity is 250 beds. We staff those with medical
personnel and they can perform a number of different functions,
anywhere from just providing basic primary care to patients, or
in previous experiences, we have had our Federal Medical
Stations providing care to critical care patients as we were
looking for other facilities. So we usually have a staff of
about anywhere from 60 to 100 medical providers in those
facilities. We look for buildings of opportunity, so they don't
come with--it is not really a field hospital, but we look for
large spaces where we can set up our cots, put our equipment
in, and then we can house those patients and take care of them
in those facilities.
Senator Pryor. So you just need a building with adequate
space for you to modularize this and kind of build it as you
need it?
Dr. Yeskey. Yes, sir. It is space and sanitation, water,
things like that, and then wrap-around services, as we call
them.
Senator Pryor. And where do you get the personnel to do
that?
Dr. Yeskey. We draw our personnel from the National
Disaster Medical System for a large part of this. We also used
the Commissioned Corps of the Public Health Service, one of
their Rapid Deployment Force teams. They provide help. We also
use our Federal interagency partners, such as Veterans
Administration. We can task them to provide clinical personnel
for those and have in the past.
Senator Pryor. I have heard, and I don't know how accurate
it is, that it may be difficult for a lot of Federal employees
to actually serve on those response teams. Is that accurate,
that because of the Federal regulations or Federal rules? Do
you know?
Dr. Yeskey. I don't know. It requires some administrative
activity so that person doesn't--since if they are an NDMS
employee, they get paid by NDMS for their salary. If a Federal
employee who is already receiving a Federal paycheck wants to
join a team and participate on a team, they have to get
approval from their parent organization, and then if they want
to get paid from NDMS, then they would have to take an
administrative break in pay so they could do that. Otherwise,
we would expect them to participate in that Federal
organization as part of that Federal organization and our
tasking to that organization to participate in our response.
Senator Pryor. OK. I will have to think about that a little
bit to think through if that is the right way to handle that,
because it seems if the Federal Government has a lot of
expertise, has a lot of people that have expertise that might
be part of that team, I just wonder if there are maybe too many
barriers for them to serve. But let me think through that. We
may have some follow-up questions.
And you mentioned the Federal Medical Station in Northern
Louisiana, and did you say you are going to do one in Little
Rock, as well?
Dr. Yeskey. We are working with the VA on the suitability
of putting one at the VA facility there. And again, if this is
to take care of patients who are ready for discharge, it would
be a small facility and require a minimal level of care that we
would be able to staff that.
Senator Pryor. Would you do that in other locations around
the country?
Dr. Yeskey. Sure.
Senator Pryor. And I assume you just have to look at their
list of disasters and potential disasters to know strategically
where to plan on putting those, is that right?
Dr. Yeskey. Yes, sir. As part of NDMS and the Patient
Evacuation System, we have Federal Coordination Centers. There
are 72 of them nationwide, and that is where we, in our plans,
where we choose from to evacuate patients to. And then we have
VA or DOD Federal Coordinating Center staff there who work with
the local hospitals and public health and emergency management
to arrange the transport from the receiving point of
debarkation to the hospitals. So those are the cities that we
choose from to use for evacuation.
Senator Pryor. OK. Dr. Yeskey, I don't know if this should
go to you, but I will direct it to you unless Mr. Fenton wants
to jump in here. In his written testimony, I don't know exactly
what Paul Cunningham is going to say here in a few minutes, but
in his written testimony, he mentions that the instructions
provided by FEMA usually, or maybe through HHS, as well, but
the instructions provided from the government seem to be
constantly changing and oftentimes confusing. I understand how
the aftermath of a major catastrophe can be very confusing. I
get that. But to me, that seems that planning would take care
of a lot of that.
Can you all evaluate how you did in terms of communicating
to the hospitals and other medical providers during this very
challenging time? And again, I don't know if that is for you,
Dr. Yeskey, or for you, Mr. Fenton, but----
Dr. Yeskey. I can take a first crack at that. I think it is
clear that we try and communicate as much as we can and we try
and make sure that the information is clear and gets to the end
users, the people who have to implement the guidance or the
communications that go out. We try, when appropriate, to have
telephone calls with appropriate personnel, whether that is the
hospitals or a State Health Department or emergency management.
We have an ongoing presence in the region through our Regional
Emergency Coordinators (RECs) that, hopefully in the planning
process and the exercises have a presence there and can answer
questions and can provide a unified HHS response to questions
that are asked. We also have other organizations, like Centers
for Medicare and Medicaid Services (CMS) and Food and Drug
Administration (FDA) in the regions who have a presence there
who can answer some of the technical aspects about those
programs.
It is clear that we didn't do as good of a job as we would
have liked to have done and continue to try and work with the
localities to improve our communications.
Senator Pryor. Dr. Yeskey, before Mr. Fenton jumps in on
that answer, and it looks like he wants to, but let me ask a
quick follow-up to that specific thing, and that is when you
set up your relationship with these hospitals and you want them
to participate in this, I am assuming that there is some sort
of Memorandum of Understanding (MOU), or, Memorandum of
Agreement (MOA) or whatever you may call it, but I am assuming
there is some written understanding between HHS and the
hospitals, and I am assuming that comes from HHS, not from
FEMA.
Dr. Yeskey. Yes, sir.
Senator Pryor. Is that in the form of a blanket agreement,
where you have a standard form that they sign onto, in other
words, maybe--I hate to say this phrase, but a one-size-fits-
all, or do you tailor that based on the specific needs or
requirements or circumstances of that particular institution?
Dr. Yeskey. The MOA is a standard form that all
participating hospitals sign.
Senator Pryor. Does every one fit every circumstance,
though?
Dr. Yeskey. I don't know the answer to that question, per
se. I think that the form is general. It talks about
obligations of--responsibilities of HHS, responsibilities of
hospitals, etc.
Senator Pryor. OK. Mr. Fenton, did you want to jump in on
this idea of the communication, either between FEMA--actually,
I heard it was between FEMA and the hospitals was changing and
there was maybe contradictory information given at different
times to different people, different meetings. Do you have any
comments on the communication and kind of evaluate how you guys
did on that?
Mr. Fenton. I would just, I guess, offer that I think that
anytime during a major disaster, communications, whether
physical communications or just the ability of communications,
seems to be the root of most issues. It is not that there
aren't plans in place or people in place trying to take the
right actions. And in the case of Hurricane Gustav, I think you
look back and you look at Hurricane Katrina and a number of new
policies, laws that were pushed into effect following Hurricane
Katrina as part of the Post-Katrina Reform Act, and then those
new laws causing new policies was a substantial amount of new
information to get out, educate, and communicate and rebuild
plans to allow us to do some of those things now that we have
been given authority to do underneath that legislation.
So, that could be some of the changes. Some of the other
changes could be as we continue to look at areas that we never
looked at before, like the policy I referred to that allows us
to provide--host States to accept evacuation and us to
reimburse them at 100 percent of the costs. In there, there is
an agreement that the host State has to accept. They have to
agree to give 10 percent of their shelter capacity to a State
that is evacuating.
And so there are a number of things that we continue, as we
go to whether it is September 11, 2001, Hurricane Katrina,
other events, and we see areas that we either in our planning
or historically never had to deal with before, we are
continuing to build the capacity to work through and provide
assistance to those issues. And after Hurricane Katrina, it was
build a better ability to evacuate and receive people. So I can
only guess that some of that, maybe the new policies coming out
and the ability to communicate those, educate those, train the
whole Nation on what those are. I think we have done an
effective job on doing that, but obviously we need to continue
to do that and to be able to improve on that.
Senator Pryor. Dr. Yeskey, let me ask you another follow-up
question here about the NDMS and the overall response from
hospitals that you are reaching out to. Are hospitals generally
willing to do this? Are they generally agreeable to participate
in the program?
Dr. Yeskey. I think they are generally willing to
participate in the program. Hospitals have certain requirements
for accreditation that participation in NDMS helps satisfy.
They get to do exercises. They get to perform mass casualty
drills and things like that. So I think there are some
intangible benefits for the hospitals participating in that.
Senator Pryor. What are the biggest barriers, the biggest
reasons why hospitals wouldn't want to participate?
Dr. Yeskey. I think one may be unfamiliarity with all the
details that goes into participation as an NDMS hospital. Some
may have fears that it may become an involuntary agreement to
participate as an NDMS hospital, or they may be tasked to do
that. This is a voluntary system and certainly we would not
force any hospital to take patients that they wouldn't. But
those might be some of the reasons they would not want to----
Senator Pryor. Do you have any areas of the country where
you have a deficiency in hospitals, that you need more
volunteers, more hospitals?
Dr. Yeskey. I would have to go back and look at that, but I
can get that answer for the record.
Senator Pryor. Well, speaking of answers for the record, I
have some more questions for our two panelists, but what I will
probably do is just submit those for the record and I will
bring up our second panel here in a moment.
But do either of you two have something you want to say in
closing, or is there any point that I----
Mr. Fenton. I would just say, when you look at this very
complex issue, whether it is FEMA or HHS, we are just part of a
team, a team that includes State, local government, the
hospital providers, and private entities and all those, and to
make it work, it takes all those entities coming together and
the communication involved in all those. It is FEMA's
responsibility to coordinate against a broad spectrum, not just
medical evacuations, but everything from evacuations of the
general population to debris removal to life-saving to, you go
on and on of all the things that happen when a disaster comes
together.
I think we continue to work at that. We continue to develop
capabilities to local and State governments to improve the
planning, to improve the education, training, and exercising,
to continue to try to validate those and improve our
capability, and we will continue to work toward those. So thank
you for the opportunity to be here today.
Senator Pryor. Thank you. Dr. Yeskey.
Dr. Yeskey. Thanks for the opportunity to discuss NDMS.
Senator Pryor. Well, thank you all for being here. I think
we see this on this Subcommittee as just part of our general
oversight. I think that everybody's heart is in the right
place, trying to do the right thing. We just want to make sure
our system works well, and the preparedness and the planning
just works the way it should, because in a crisis, you don't
have time to think through that. I am sure in any given crisis,
no matter when or where, nothing works 100 percent of the time
exactly the way you wanted it to go, but I think--it sounds
like you guys have identified some areas that we need to focus
on and it sounds like you guys are focusing on those.
So again, we may have some follow-up questions for you, but
I do want to thank both of you for being here today and I will
go ahead and dismiss you all and we will bring up our second
panel. So thank you for being here.
As the staff here is switching out the table, I will go
ahead and introduce our second panelist today. I want to
welcome Paul Cunningham, who is from Arkansas and is a Senior
Vice President at the Arkansas Hospital Association. He is
responsible for policy analysis, Federal relations, and
reimbursement issues for the Arkansas Hospital Association. Mr.
Cunningham will speak to the experience of Arkansas volunteer
hospitals that were activated under NDMS. He brings a lifetime
of experience to this equation and this conversation and we
appreciate you being here today and appreciate the work that
your association does.
I want you to give your opening statement, but if you can
remind me how many members you have in your association. How
many member hospitals are there?
Mr. Cunningham. We have 104 member hospitals in the
association.
Senator Pryor. Go ahead with your opening statement,
please.
TESTIMONY OF PAUL CUNNINGHAM,\1\ SENIOR VICE PRESIDENT,
ARKANSAS HOSPITAL ASSOCIATION
Mr. Cunningham. Thank you, Mr. Chairman. I am Paul
Cunningham, Senior Vice President of the Arkansas Hospital
Association in Little Rock, Arkansas.
---------------------------------------------------------------------------
\1\ The prepared statement of Mr. Cunningham appears in the
appendix on page 39.
---------------------------------------------------------------------------
I am here today speaking on behalf of a dozen hospitals
located in and around the metropolitan Little Rock area which
were, until June 1 of this year, participants with the National
Disaster Medical System. They were also part of the only
activations of civilian hospitals in NDMS's 25-year history for
the combination of patient evacuation and definitive medical
care purposes following disasters that occurred on U.S. soil.
During their activation in late August of 2008, prior to the
landfall of Hurricane Gustav, our hospitals identified several
problems with the system. We have been working since then to
resolve those issues, but with limited progress.
During the activation 2 years ago, Little Rock hospitals
received and cared for 225 patients who were included in the
evacuation from Hurricane Gustav in Southern Louisiana. They
continued caring for many of the patients for nearly a month,
and in some cases more, waiting for Hurricane Gustav and then
Hurricane Ike to clear the area, allowing the returning of
patients to their home State. During the activation, it became
clear that the NDMS Memorandum of Agreement with hospitals
needs to be revised to make the program more viable for similar
events in the future, wherever they might occur in the country.
Efforts to get our concerns addressed date back to late
September 2008, and more than a year has gone by since we first
notified HHS about the need for changes in the agreement.
Delays in getting that needed attention prompted Little Rock
hospitals to withdraw their participation effective June 1 of
this year. We want to point out that there has been progress
made in the past few months working with the ASPR, Dr. Nicole
Lurie, and Dr. Kevin Yeskey, and yet we are disappointed that
there has been no specific action to address our proposed
revisions to the agreement that were submitted in June 2009.
Our hopes were that at least some of the changes could be
incorporated before the 2010 hurricane season began last month.
They were not. We believe the same concerns could later prove
to be a barrier that will hold back hospitals in other States
from participating, as well, limiting NDMS's capabilities in
the future.
A key change involves getting patients back to their home
States following an evacuation. At this time, the agreement
doesn't speak to the return of patients. Although the Air Force
is directly involved with evacuation of patients from a
disaster area to a host State, it is not an available NDMS
resource for getting those same patients back to their home
States or to the original transferring hospital. Private
contractors must be used.
Delays in getting the contractor ready to transport
patients and the inability to return them in a timely manner
created a number of problems. Those included extended hospital
stays, the need to feed and to shelter some patients who could
be discharged, and their families if they were there, and to
transport other patients back to Louisiana. All of that was
done at the hospitals' own expense.
Local patients were also affected by having to postpone or
delay elective procedures because beds or staffing in those
hospitals were not available due to the demands of the
evacuated patients.
Another problem stems from reimbursement limits imposed by
Medicare payment policies. Those alone govern hospitals'
reimbursement for care provided to Medicare patients who are
caught up in these evacuations. The agreement offers a fair
approach to helping pay for the care for uninsured patients and
Medicaid patients and even some insured patients, but Medicare
patients are left out. NDMS offers no reimbursement for them.
They are simply Medicare's responsibility.
The policy fails to understand and to adjust for the
idiosyncracies of Medicare's rules, especially those involving
patient transfers and limits on covered day. Whatever Medicare
reimburses is full payment, regardless of the extenuating
circumstances. NDMS's unique Federal-State partnership
shouldn't create such obstacles to hospitals' participation.
However, it does just that.
The Little Rock hospitals have withdrawn from NDMS
participation for now, but we believe there are broader
implications. Most immediate will be the cost of evacuations
from the Louisiana Gulf Coast to locations further away than
Little Rock in the event of another hurricane. NDMS also stands
to lose the experience in such patient movements that is
available with the Little Rock hospitals, and they were highly
praised for their work during the Hurricane Gustav event.
While losing 12 hospitals in Arkansas may seem
insignificant to a program with over 1,800 participating
volunteer hospitals nationwide, it is very possible that
hospitals in other States might also later decide to withdraw
their participation if the changes to the agreement are not
made. That could severely limit NDMS's abilities to respond to
disasters in the future.
We want to thank you for the opportunity to be here and to
speak on this today and certainly will answer any questions
that you have.
Senator Pryor. Thank you very much, and let me go ahead and
jump in. You mentioned that the Little Rock area hospitals have
withdrawn from NDMS, at least for now, until some changes are
made in the system. Of course, that concerns me about the
overall integrity of the system, if you guys feel like it is
just not a workable situation. But what sort of changes are you
all suggesting to the Memorandum of Agreement?
Mr. Cunningham. We would like something in the agreement
specifically regarding the repatriation or the return of
patients from a host State to their home State. We would like
to have those agreements in place, authorized, and signed prior
to the event actually occurring. We would also like to see
something in the plan regarding the establishment of Federal
medical shelters, where patients who can be discharged have a
place to go. In the case of Hurricane Gustav and then Ike as it
came ashore later, we had patients from Louisiana who were
ready to be discharged but who literally had no place to go.
Senator Pryor. Right. OK. And also, you mentioned Medicare
in----
Mr. Cunningham. Medicare is a very distinct problem. Under
the NDMS agreement, Medicare is responsible for paying for care
provided to Medicare patients, who again are caught up in these
patient evacuations. That presents a problem on a couple of
fronts. First is Medicare's policy regarding transfer of
patients. Now, normally, if a patient is transferred from
Hospital A to Hospital B, the transferring hospital gets a per
diem, not the full Diagnosis Related Group (DRG) amount, and
the receiving hospital does get the full DRG amount but then
can discharge the patient.
In evacuations such as this, the patient actually goes from
Hospital A to Hospital B and then theoretically back to
Hospital A. Well, in a very short transfer, that doesn't
present a real problem because the payment is made under
arrangement. The transferring hospital and the receiving
hospital agree to a payment.
In the case of Hurricanes Gustav and Ike, we found our
patients having to stay very lengthy periods. Some patients
were in the hospitals for 30 days or more. If you look at just
the DRG limit--and let me make a clarification that in
November, and this was sometime after the event itself, HHS did
agree that those patients at hospitals in both States could
bill those patients the full DRG amount. But that is not an
overall umbrella policy. That policy has to be made on each
individual event, such as if something else happened this year
or next year, HHS would also have to say that policy was in
place for that event, too. It is not an overall policy.
But the length of stay under the Medicare DRG system puts
patients at a point where if they cannot be discharged--if they
are ready to be discharged and cannot go anywhere, well, that
is now considered medically unnecessary care. Medicare does not
pay for medically unnecessary care, regardless of the
extenuating circumstances. So our hospitals were left having to
keep some patients who had no place else to go for lengthy
periods of time without any Medicare reimbursement.
Senator Pryor. Yes. I was going to follow up on that. So I
am sure--I don't know how many patients came up during those
hurricanes----
Mr. Cunningham. Well, there were 225 total----
Senator Pryor. Two-hundred-and-twenty-five.
Mr. Cunningham. I can't tell you how many were uninsured or
Medicare or whatever, but 225.
Senator Pryor. I am sure there are different circumstances
on every single one----
Mr. Cunningham. Exactly.
Senator Pryor [continuing]. But am I correct in my
understanding that some of them stayed in the hospital in the
Little Rock area not because they needed the medical services
anymore, because they just didn't have anywhere to go?
Mr. Cunningham. That is correct.
Senator Pryor. And that does present all kinds of problems.
Mr. Cunningham. Absolutely.
Senator Pryor. I mean, obviously, that is the least
efficient place you want to have someone.
Mr. Cunningham. In addition just to the payment problems
themselves, it created problems for local patients who had to
postpone or delay elective procedures or admissions because
staffing was needed to take care of the patients who were here
from Louisiana.
Senator Pryor. Out of the 225, do you know how many would
fit into that category that they really had no more need for
medical services, but because they just didn't have anyplace
else----
Mr. Cunningham. Senator, I don't have that information. We
could probably get it for you, but I don't have it right now.
Senator Pryor. And it sounds like you are still in
discussions with FEMA and HHS----
Mr. Cunningham. That is correct.
Senator Pryor [continuing]. To try to get this resolved.
Mr. Cunningham. We are working with Dr. Yeskey. We have
been trying to resolve some of these issues. But as of June 1,
and this was not an easy decision for our hospitals, we feel
like there were still enough concerns out there that merited
their withdrawal from the system until a more definite plan of
action, more written plan of action could be presented to us.
Senator Pryor. I am not trying to put words in your mouth,
but I am curious about your impression of this. Is that because
the two agencies are being inflexible, or is it because you are
dealing with two or more Federal agencies and it just takes a
long time for them to make a decision?
Mr. Cunningham. I think your second assessment would be
correct. I think it is just a complicated situation that could
probably be improved with some additional work, some closer
ties, and it sounds to me from the previous presentation like
both agencies are working on that.
Senator Pryor. And have they told you that they are willing
to make some changes to the MOA?
Mr. Cunningham. They have indicated a willingness, but we
have yet to see something in writing to the point that our
hospitals feel comfortable enough that they would not be in the
same situation, let us say, if a hurricane were to hit this
year as they were when Hurricanes Gustav and Ike hit in 2008.
Senator Pryor. And I don't know the working definition for
everyone on what is medical care versus other----
Mr. Cunningham. Exactly.
Senator Pryor [continuing]. Type of services that you
provide, but give us a sense of things that you did for these
patients that wouldn't be necessarily considered medical care.
And I can think of a lot, but I am curious about what some of
those might be.
Mr. Cunningham. Well, there were occasions, and we did work
closely with the Arkansas Department of Health on this. If
there were patients in the hospitals who were ready to be
discharged and who did not have a way to get back to Louisiana,
for instance, our hospitals worked in conjunction with the
Health Department to try to find places, such as local hotels
where they could put these people up for several days. They
found themselves in a need to both feed patients and families
if families had come with them, that sort of thing.
There were two hospitals that we are aware of who actually
took it on themselves to take patients who were ready for
discharge and transport them on their own back to Louisiana.
Those are all non-medical costs and certainly are not the
responsibility of the NDMS, but it would be good if, again, a
closer tie between NDMS and FEMA, if there could be some
agreement where we felt confident that in those cases where
hospitals do have to provide non-medical care, that there was
an avenue for reimbursement.
Senator Pryor. It seems to me that you don't really get
compensated for that non-medical care unless FEMA has----
Mr. Cunningham. Unless FEMA has a way to do it, we do not.
That is correct.
Senator Pryor. But it seems to me that they ought to
consider that compensation, because most of those patients
wouldn't have that except for these circumstances, right?
Mr. Cunningham. That is true, and there were extenuating
circumstances here. We had a situation where we had Hurricane
Gustav come on shore, and then about 2 weeks later Hurricane
Ike came on shore.
Senator Pryor. Right.
Mr. Cunningham. And you might think that this is a very
unlikely scenario, but we would like to point out that in 2005,
you had Hurricanes Katrina and Rita that came on shore very
closely together, too. So it can happen and it has happened
twice in the last 5 years.
Senator Pryor. Let me ask you about something I think was
in your written testimony--you maybe said it a few moments
ago--but about the communication between FEMA and your local
hospitals. My understanding is that there was some confusion,
maybe contradictory information----
Mr. Cunningham. Well, it was very confusing. I know that we
at the Hospital Association, along with most of our
participating hospitals, were on daily calls with FEMA and NDMS
about what exactly do we need to do? What is the process? When
is the transport contractor going to be in place? How soon can
they transport patients back? How long will that take, things
like this. And there were many occasions where you literally
got different information every day.
Senator Pryor. And do you know why you were getting that? I
mean, is that because maybe FEMA and/or HHS hadn't coordinated
or they just hadn't thought through all the details?
Mr. Cunningham. Probably that. I guess for Arkansas, at
least, the first case of this magnitude. I don't know what may
have happened after Hurricanes Katrina and Rita. We did get a
few patients in Arkansas. I think a lot of those went to other
States. But regardless, the process of getting patients into
the State into hospitals went very smoothly. The process of
getting them out did not, and it may be that this is just
something that we need to put more effort in, more planning,
more practice, things like that.
Senator Pryor. Again, not trying to put words in your
mouth, but it sounds like what you are saying is that NDMS is
something that we should continue, that it is important in a
time of crisis----
Mr. Cunningham. Absolutely.
Senator Pryor [continuing]. But it also needs to work well,
and hopefully, lessons learned here would be some of the
experience that the hospitals in the Little Rock area had that
we just need to make sure these don't happen again, and
hopefully you can get compensated for some of the things you
did now. Is that fair to say?
Mr. Cunningham. Yes. I think, absolutely, you are correct.
NDMS is a valuable resource. We need it to respond to emergency
disaster events wherever they occur in the country. I think it
is also set up and it is needed to take in civilian and troop
casualties that might occur from conventional wars in other
places or to respond in the event that somebody would actually
use a weapon of mass destruction in the country, not to mention
things like H1N1. So it is very valuable. We want it to work.
We want to be a player in it. We just feel like some changes
are needed before we feel comfortable in making that step.
Senator Pryor. Yes, and I am not critical of your decision
to get out of it, at least temporarily, because given your
experience, it is understandable. But it does concern me that
it is sending a signal to other hospitals around the country--
--
Mr. Cunningham. Exactly.
Senator Pryor [continuing]. To be careful before they sign
onto something like this, because it is not as smooth as you
might think on the front end.
Mr. Cunningham. And I think if Arkansas hospitals continue
to be out and are out if something else occurs, then that puts
the evacuation to another city even further away from the Gulf
Coast, the Louisiana Coast, in particular, than Little Rock.
For instance, Oklahoma City would be the next city, is my
understanding. That is about an additional hour's flight to
shuttle patients back and forth. If they were to leave, it
could be El Paso, Texas, could be another city. But yes, there
are some Federal costs involved here, too.
Senator Pryor. Right. Well, thank you for your statement.
Thanks for answering the questions. Thanks for coming up here
for this. Did you have anything you wanted to say in closing?
Mr. Cunningham. I wanted to say that we certainly
appreciate the opportunity to come and to review these concerns
with you.
Senator Pryor. Well, thank you for being here and thank you
for your efforts. First, thanks for participating in the
program and taking care of people. That is important.
Hopefully, you will be the sort of catalyst for getting things
worked out in the future to improve the program over time.
What we are going to do is we are going to leave the record
open for 15 days, so it is very possible that other Senators
and other offices will submit questions, if you would work with
staff to try to get those answers back to us.
I again want to thank you and thank all our panelists for
being here and participating in this.
With that, we will adjourn the hearing. Thank you for doing
what you do.
Mr. Cunningham. Thank you.
[Whereupon, at 11:06 a.m., the Subcommittee was adjourned.]
A P P E N D I X
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