Maurice A. Ramirez, DO, CNS, CMRO

The Unprepared Beware

Last year a High Alert, LLC white paper had raised the specter of NRP/NIMS compliance being linked to CMS (Medicare, Medicaid and Tricare) billing, the discussion had been strictly theoretical. Several federally funded training programs have now brought to the table a new and ominous implication of the NIMS Integration Center Implementation Plan for Hospitals and Healthcare. Additionally, hospitals have reported being informed that disaster preparedness will be linked to CMS reimbursement (Medicare, Medicaid and Tricare payments).

Almost immediately, a National Incident Management System (NIMS) update alert from the NIMS Implementation Center, included obscure reference to a frequently asked question (FAQ) document on the FEMA website.  This document, posted on April 20, 2007, like many documents before it was deeply buried within the FEMA website, accessible only to those who knew where to find it. 

The last two questions on this FAQ document dealt with a raging debate regarding the repercussions of failing to be NIMS compliant before the looming September 30, 2007 deadline. 

The first answered the question of whether the Joint Commission required NIMS compliance for accreditation.  The answers stated “Not at this time.”

The second question similarly was a response to inquiries regarding whether CMS required NIMS compliance for Medicare and Medicaid benefits and reimbursements.  Again the answer was “Not at this time.”

Times have changed.

On October 18, 2007, President George W. Bush signed Homeland Security Presidential Directive 21 (HSPD-21) into law establishing the new specialty of Disaster Healthcare and fulfilling many of the predictions of the original High Alert, LLC white paper. HSPD-21 is available for download here:

Download HSPD-21.pdf

High Alert, LLC published a new white paper on the implications of HDPS-21, Sarbanes-Oxley (SAR-OX) and Federal False Claims (FFC) legislation for healthcare law and disaster healthcare. The new High Alert, LLC white paper is available for download here:

Download preparedness_and_the_force_of_lawrevised_20oct07.pdf

Each of the critical infrastructure industries identified in the National Response Plan (NRP) and the National Incident Management System (NIMS) have similar HSPD’s. The correlations made regarding healthcare law can easily be extrapolated to each of these critical infrastructure industries as well.

Although the federal government has not acted on these possibilities, they are very aware of the potential. FEMA even issued a series of statements directed to hospitals indicating that FEMA has no plan to pursue SAR-OX or FFC’s action under HSPD-21. The problem is that it is the Department of Justice (DOJ), not FEMA who pursues such claims and FEMA does not speak for DOJ.

This white paper has been vetted through contacts in D.C. and while not confirmed as an active plan, no part has been refuted except in the afore mentioned FEMA statements. However, the observations in this white paper is bolstered by the recent alignment of Joint Commission guidelines with NIMS guidelines. These Joint Commission changes occurred after the publication of the white paper, but were predicted despite the insistence of FEMA that such Joint Commission changes would not occur. It is now anticipated that Emergency and Disaster Preparedness will become a Core Performance Benchmark for Joint Commission in 2009. Given that Joint Commission is now provides de facto the Medicare and Medicaid compliance inspection, these 2009 changes will complete the alignments described in the white paper.

The Unprepared Beware!

Basic and Advanced Skills for Disaster Healthcare

My company recently reviewed the existing core competency documents for disaster healthcare in light of the October 18, 2007 Homeland Security Presidential Directive (HSPD-21) which in part calls for:

“...the recognition of the unique principles in disaster-related public health and medicine merit the establishment of their own formal discipline.  Such a discipline will provide a foundation for doctrine, education, training, and research and will integrate preparedness into the public health and medical communities.”

Stakeholders in the development of the discipline described in HSPD-21 have proposed either publicly or privately a body of knowledge and skills core to such a discipline. This essential body of knowledge is codified as Core Competencies. To date the American Association of Physician Specialists (AAPS), the American Medical Association (AMA) and the American Osteopathic Association (AOA) have prepared core competency documents.

In the past, divergent core competency documents within a medical discipline such as emergency medicine or family practice have resulted in decades of division and discord within the profession and specialty. Ultimately, wherever such divergence has existed medical science and evidence based medical practice have resulted in convergence of the core competency documents and near universal agreement on the skills and knowledge that define and are essential to a distinct medical discipline.

Unfortunately, the United States and its citizens cannot afford to wait decades for the medical politicians and special interests to conclude that there is already agreement on the knowledge base and skills core to the discipline and specialty of disaster medicine. HSPD-21 places further impetus on resolving the issue of core competencies so that the disaster medicine discipline called for in HSPD-21 may advance with all alacrity.

The core competency documents from AAPS, AMA and AOA are each developed in differing taxonomy systems. This difference in taxonomy systems combined with differences in batching of skills and knowledge within documents complicated the extraction of commonly agreed upon core points of knowledge and key skills.

The complete review and core competency crosswalk is available for download here:

Download disaster_healthcare_core_competencies_review_crosswalk_25oct07.pdf

We propose a single summary core competency document presented as a “crosswalk reference” with the associated AAPS, AMA and AOA core competency documents. Given that the AOA currently has no core competencies to contribute, the crosswalk would require update when the AOA document becomes available.

It is our that this composite summary and associated “crosswalk reference” along with all three core competency documents form AAPS, AMA and AOA be recognized by the United States Department of Homeland Security (DHS); Department of Health and Human Services (HHS); Department of Defense (DOD); Institutes of Medicine; National Institute of Health (NIH); Centers for Disease Control (CDC) and Department of Education (DoE). This will establish the needed basis for the foundation of a distinct discipline in disaster healthcare as called for by HSPD-21 while bypassing the inherent delay in recognizing that all three systems enumerate the same core knowledge and skills.