| Home > Events > 2nd National Symposium > James Bentley Challenges for Hospitals
James D. Bentley, PhD What we want to talk about here in at least this particular session is what happens when despite the best detection, the best prevention, the best information, people get sick in a bioterrorism attack and wind up going to the hospital. The hospital because it's 24 hours a day, 365 days a year, and it's where you and I and our friends and neighbors assume we're going to get care.
The question before us is: what are the challenges facing hospitals as they confront the environment you've heard described so well this morning and afternoon?
I'd like to share three things with you in the 15 minutes that we have available. First, let's talk about -- and the first slide -- three things or the first of three things that are really bothering the hospital community in terms of knowns today.
The first one is the financial crisis that our hospitals face in terms of what they may think of as the perfect storm. Like the book or movie you may have read or seen which brings together three weather patterns together, we currently have an unprecedented change in the three major payment systems that support hospitals. The Balanced Budget Act passed in 1997 has extracted significantly more money from the Medicare payment stream than Congress intended, and whether or not they're going to fix that in the remaining days of this legislative year is anyone's guess.
Secondly, most states have moved from a Medicaid payment system for the low income citizens to a system of using managed care plans, and in doing that on a per person basis they said we will spend no more before moving to managed care than we do afterwards, even though the administrative costs of managed care add 15 to 20 percent to the cost of the program so that that 15 to 20 percent had to come out of the cost of caring. And thirdly, private payers concerned about their cost and competitiveness have been extremely diligent in holding back on their payments. For the hospital that now says, "I want to spend on behalf of my community significant sums of money preparing for bioterrorism or a similar event," that is a red flag to the payer community of saying, "We overpaid you. There's room to negotiate downward because no one pays for planning and preparation." We are in the midst of a major and significant work force shortage throughout the hospital community. Every ten to 15 years for the past 40 years, someone from the American Hospital Association or the American Nurses Association could have stood up here and described how we had a shortage of nurses, particularly at a time when the economy was doing well. That case exists today, but it's not longer the core problem. We have a shortage that's not just nurses. It's pharmacists, it's technologists, it's technicians, it's housekeepers, it's food service workers. It's throughout the entire establishment, and that shortage is the real constraint on capacity and surge. The shortage is not only short term, to be eliminated perhaps if the economy softens, but it is long term because we face a demographic shift in which the Baby Boom generation had more people going into health careers proportionately than the smaller, subsequent generations coming along. And third, as we work with young people, we find that involvement in health care careers has moved from a favorable occupation 30 years ago to an unfavored occupation or set of occupations today, and so we're not recruiting well. So financial problems, work force problems, and if we have too much of one thing, it's regulatory burden on the institutions. This list is a partial list of the regulations currently out there requiring attention by the executives in the nation's hospitals. Every one of those lines lists something that a federal agency believes is appropriate to require the health care system to do. The difficulty for the health care system is that the sum of those regulatory initiatives exceed both in cost and management capacity the ability of the institution to adapt change and manage. And so we have as the hospital moves forward and looks a bioterrorism a situation in which funds are tight, staffing is short, and regulatory burden for other areas is high. When the CEO and his team or her team sits down and then says, "Let's look at bioterrorism. Let's look at a biological event," what are the unknowns? Here's a partial list. - What's the substance or agent?
- When and where might it strike?
- On what scale will it spread in our community?
- What personal protective gear will OSHA require?
- What will EPA require in the way of disposal of contaminants?
- What will be the impact on the still coming stream of current patients? After all, if you are a mother about to give birth to a child, you may not find going to a hospital that has a large number of infected patients a very tolerable idea.
- And what do we know about the science and procedures for addressing this?
In most cases when the hospital executive sits down with folks like in this room and asks those questions, we generate more questions and very few answers on which they can begin to plan.
In the face of that, the Office of Emergency Preparedness, Dr. Knouss' agency, gave us a small grant about a year ago to bring together people from the federal government, some in this room, people from hospitals throughout the country ranging from CEOs to people responsible for equipment and materiel in the institutions, begin to look at what would we find in a mass casualty situation. A couple of general conclusions. One, mass casualties by definition will overwhelm the capacity of hospitals and the health care system in this country. We have for 20 years in the interest of cost containment striven to reduce capacity and flexibility. A mass casualty incident with great numbers of new patients will take us beyond the capabilities to address in any normal sense. In that environment the hospital needs to react in three levels. First, it has to react to that overwhelming capacity as an organization in its own right, its own disaster plan, its own accommodations and changes. Secondly, the hospital has to react as a part of the community's health care system, the physicians, the public health agencies, the laboratories, the school health nurses, the visiting health nurses, the nursing homes. And third, and perhaps most difficult, because we have not had a lot of experience in this country, the hospital must react as a part of a community-wide effort that extends far beyond the health care system as one begins to look at police and fire in terms of public safety roles, schools in terms of perhaps feeding and housing roles in a bioterrorism incident. And so we have the hospital trying to work at three separate levels. Now, when we got the group together, and we have about 60 recommendations from them, you can get the entire report if you care to download it. It's only about 70 pages on our Web site, which is www.aha, for American Hospital Association, .org, and you go to member services and click under it and there is the report. The recommendations for hospital preparedness centered in four areas: the need to prepare for a community wide response, staffing, communications including the need for a single voice for the community, and public policy. I'd like to emphasize staffing and public policy in the last few minutes because I think there are a couple of examples there of the kinds of concerns that don't often make it to the top of the list of a meeting of this nature.
You can see in the light gray some of the things we often talk about. I'd like to ask you to focus on the bottom item, the one in blue. As we've in the past two years brought together hospitals and talked about mass casualty or mass disaster incidents and asked them what was the real, most important and most unexpected bottleneck. It is care for family members of the hospital staff. Seventy to 85 percent of the hospital work force is female. Most of those people are heads of household or are responsible for the care of family members in that household. Lots of disasters, an airplane crash, a truck blows up, a bus goes off a highway, are very short incidents. They're here. They're gone in 24 hours, minus a couple of people who stay in the institution. Hurricanes, floods, bioterrorism incidents by contrast are going to be long duration events requiring that staff stay, remain, and return, and their ability to do that consistently depends upon the ability of their family to be protected and cared for. Hospitals have tried two patterns that haven't worked. One pattern has been to say you may bring your family to the institution. Then you'll know they're safe. That's probably not a welcome strategy in a bioterrorism incident. Similarly, saying to the staff as some hospitals have, "Go home. Take care of your family and return," may not be a successful strategy to the staff member who goes home, turns on television, and sees whatever the media focus is in terms of uncertainty, risk, and the next scary story. We cannot tell our hospitals and their staffs that there is a national decision that the staff members and their families will somehow have priority in terms of immunizations or antibiotics, and it's very -- let's say it the other way -- it's very likely that at least some hospital staff will question whether they want to put themselves in harm's way if prior to an incident we're not able to staff staff whether our society has valued them and protected them. So I would ask you in addition to all of the sophisticated topics, all the electronics, all the detection equipment, the social organization of the community, the ability to sustain the hospital staff at work in our members' judgment becomes one of the critical factors as to whether the hospital can survive or not. There are areas of public policy that look to be quite detached from bioterrorism or biomedical warfare, if you will. One of them here is the Emergency Medical Treatment and Labor Act. That's probably something as you've worked on bioterrorism you've not thought of, but this is what it requires. One, the hospital must screen and stabilize every patient who presents him or herself even if the emergency department is closed. Two, it has a bias of caring for the individual over the community, and it doesn't allow the community to separate hospitals, if you will, in an infectious incident into hospitals that are clean and hospitals that are exposed and tell the clean hospitals not to admit, not to care for an exposed patient, and vice versa. Both categories simply have to see, stabilize and screen any patient who makes it on the property. And, third, there is no concept of an exception circumstance such that a mayor, governor, or other official could waive the general rules of the Emergency Medical Treatment and Labor Act in the public health interest of the community. Now, the act was passed for very good purposes. It was designed to prevent a hospital or physicians in a hospital from refusing to see a patient who did not have insurance and simply sending that patient on to another hospital. A very legitimate purpose. But in the context of a bioterrorism incident and the ability to differentiate hospitals and make community wide or community level decisions, EMTALA gets in the way just as we see in other places there are limitations on what the hospitals can do. So the bottom line here that I would raise to you is three things. Number one, hospitals already face severe challenges, and they're really not looking for more unfunded mandates. Number two, there are issues like care of families or federal statutes like EMTALA that get in the way. Number three, as the hospital's CEO and leadership team sit down with the trustees and try to balance today's requirements for care and needs with tomorrow's possibilities, I would like to ask you to rethink one phrase that we've heard in this room throughout the day, and that is weapons of mass destruction. There is no more harmful term to interesting the hospital community in preparedness than weapons of mass destruction. It holds out no hope. It's a very politically charged term. It is a very negative term. And if as you address the issues of mass casualties by bioterrorism or by any other cause you can find a term that offers people the prospect of hope, the prospect of participation, and makes it reasonable for a board of trustees to say we will put money into tomorrow because it's in the interest of our community rather than put money in tomorrow to deal with weapons of mass destructions. The words being used are important, and as we work with hospitals and communities around the country, the words currently being used, particularly weapons of mass destruction, are reducing preparedness and reducing interest. Thank you very much.
(Applause.) |
