Lessons Learned: TMA Recommends Improvements to Hurricane Response

TMA Testimony by Isabel Menendez, MD

House Committees on Human Services and Public Health
Joint Hearing on State’s Response to Hurricane Harvey

Nov. 1, 2017

Good morning/afternoon Chairman Price, Chairman Raymond, and committee members. I am Isabel Menendez, MD, an internal medicine physician from Portland, Texas, testifying today on behalf of the Texas Medical Association. Thank you for the opportunity to provide a physician’s perspective regarding Texas’ response to Hurricane Harvey, one of the most consequential disasters in Texas’ history. While the storm arrived with great sound and fury, its humanitarian devastation was countermanded by an army of state officials and first responders, including physicians, health professionals, and volunteers who swiftly aided stranded, wounded, and traumatized Texans, helping to mitigate the storm’s loss of life. Without question, TMA commends not only Texas’ official emergency response but also that of the thousands of volunteers who came to the aid of hurricane survivors and their communities.

Now that Texas is well past the emergency disaster response and is in the process of recovery and rebuilding, it is critical that state and local governments as well as health care systems assess what Texas did well and what it did not. As the saying goes, hindsight is 20/20. Looking back, it is always easier to see what we would do differently in a crisis. But in so doing, we also ensure Texas’ response to future disasters will be that much better.

With that in mind, let me share the observations and recommendations of frontline physicians who cared for evacuees on opportunities to fine-tune Texas’ disaster preparedness.

  • State financial assistance will be essential to helping medically underserved communities rebuild their health care infrastructure.

Much will be discussed today about the impact of the storm on Houston, Beaumont, and larger metropolitan communities, and rightly so. Those communities experienced unprecedented flooding and damage and will be rebuilding for years to come. But as a practicing physician from a storm-ravaged rural town, I’d like to be a voice of smaller communities that were no less impacted but whose stories are not as well known. Of the 58 counties in Gov. Greg Abbott’s disaster declaration eligible for FEMA assistance, approximately half are designated as rural. Prior to the storm, all were designated in whole or in part as medically underserved, meaning that prior to the storm they already lacked a sufficient number of physicians and other health care professionals. After the storm, this scenario is likely to worsen.

According to TMA’s post-storm survey, some 67 percent of impacted rural physicians temporarily closed their practices following the disaster. Many incurred extensive and costly damage. While anecdotally we understand many intend to reopen, doing so will depend not only on their own financial wherewithal, but also on whether and how the local health care ecosystem rebounds.

  • In my own town, the local for-profit hospital is ineligible for federal disaster aid, hampering its ability to rebuild quickly but also hindering some subspecialty physicians with hospital-based practices from returning. 
  • Beyond physicians, essential members of the local health care team — nurses, radiology technicians, pharmacists, psychologists, among many others — also have not been able to return full time because they have no place to practice and/or their houses are uninhabitable or were destroyed so they have no place to live. With very limited local temporary housing options, moving may be necessary in lieu of commuting a long distance.  
  • Furthermore, the closure of local businesses, even if temporary, likely will result, if it hasn’t already, in more patients becoming uninsured, driving up uncompensated care and jeopardizing the financial viability of the local health care delivery system. 

To aid smaller communities devastated by the hurricane, Texas should consider passage of a Hurricane Harvey Rescue Act to provide short- and long-term financial aid to rural communities without a broad tax base. This will help communities rebuild their health infrastructure on their own, use the rebuilding process as an opportunity to also modernize local systems so they can more easily rebound after a future disaster, and allow investing in adoption of electronic health records and telemedicine.  

Furthermore, we respectfully urge Texas to swiftly and vigorously ask Congress for federal funding to (1) provide temporary health insurance coverage to low-income, uninsured Texans, many of whom will have hurricane-related health and behavioral health needs but no financial means to obtain treatment; and (2) reauthorize federal funding for the Children’s Health Insurance Program (CHIP), which expired Sept. 30, 2017. Without funding renewal, Texas will exhaust its federal CHIP allotment in January 2018, resulting in some 400,000 low-income children across Texas losing coverage by February 2018. Many of these children reside in counties ravaged by the storm and may suffer from storm-related health issues, particularly post-traumatic stress disorders, anxiety, and depression. Without CHIP coverage, children likely will go without early diagnosis and treatment of mental health disorders in addition to the preventive and primary care needed to stay healthy.

  • Decentralized and inefficient communications hindered timely distribution of information to frontline physicians and vice versa. 

Throughout the storm and its immediate aftermath, TMA received multitudes of calls from local physicians seeking guidance and clarification on numerous disaster-related issues, ranging from what types of vaccines should be provided to first responders, to whether the local water was safe to drink, to how to sign up to volunteer. The volume of calls resulted in TMA instigating daily hurricane-related communications to disseminate answers quickly. As regards public health, Texas Department of State Health Services (DSHS) staff were invaluable in addressing common physician inquiries, and TMA relied on them heavily. But in a future disaster, it would be more useful and practical for the agency to establish regular call-in communications with the health care community — physicians, hospitals, and long-term care facilities — and with local public health officials to allow for ready, two-way exchange of information about what is actually happening on the frontline — in shelters, physician offices, hospitals, and long-term care facilities — and to ensure timely transmission of updates. With the steadfast decline in physician and clinical leadership at health and human service agencies, it is critical that DSHS seek timely feedback from physicians treating disaster-impacted patients to ensure the agency learns quickly of real-time needs and concerns.  

Likewise, Texas Health and Human Services Commission (HHSC) staff responded to TMA inquiries as timely as possible. But initial agency communications were focused almost entirely on the Medicaid and CHIP health plans, which were invited to participate in daily, then weekly, conference calls allowing them to seek guidance and pose questions related to coverage and eligibility issues following the disaster. While the health plans were quick to share what they learned on the calls with TMA as well as their network physicians, the approach often resulted in hodge-podge, unofficial information, creating lots of confusion.  In the future, we urge HHSC to establish conference calls with representatives of all impacted stakeholders, an approach used during previous widespread natural disasters.   

Furthermore, it took HHSC weeks to respond officially to mundane, turnkey Medicaid questions, such as whether out-of-network benefits would be provided for Medicaid and CHIP patients displaced far from home, or whether physicians and providers in disaster-declared counties would be provided additional time to submit claims. In the future, once the governor officially declares a disaster, HHSC should immediately publicize answers to predictable, routine questions, thus saving valuable time educating physicians and patients about what to expect regarding coverage, eligibility, and payment.   

  • Inadequate information about the Texas Medical Reserve Corps impeded timely deployment of physician volunteers to rural areas. 

As the scope of the disaster quickly became apparent, TMA members and out-of-state physicians did what they do best — jump to action, at times overwhelming the association with calls asking how to volunteer their services. TMA referred physicians to the Texas Medical Reserve Corps (MRC), where physicians and other health professionals can register to volunteer during a disaster. According to DSHS, “MRC units are community-based and function to locally organize and utilize volunteers who want to donate their time and expertise to prepare for and respond to emergencies and promote healthy living throughout the year. MRC volunteers supplement existing emergency and public health resources.” 

Over the last few weeks, we have learned that while urban areas have active MRC units, MRC is not well known in other parts of the state, resulting in slower deployment of volunteers in hard-hit small and rural towns. Texas should consider dedicating state resources to inform smaller communities about MRC and to encourage physicians and other health care professionals to register for it to expedite local disaster health care services.  

In communities affected by Hurricane Harvey, thousands of people responded over many days to transport patients, often providing lifesaving care to people stranded during and after the disaster. While volunteers were from the community and other parts of Texas and other states, most were first responders — people trained to respond to the needs of those whose lives are at risk. State statute provides a broad definition of a first responder to include both public, professionally trained employees and volunteers. State statute should be amended to clearly define physicians as first responders.

  • Lack of information on the immunization status of first responders and adult evacuees resulted in unnecessary and redundant vaccinations.

During and immediately following the storm, first responders, including physicians, came into contact with thousands of patients, increasing the risk of transmission of infectious diseases, ranging from the flu to tetanus to hepatitis A, causing the demand for vaccinations among first responders to spike. Likewise, patients residing in shelters also sought vaccines in high numbers. All told, Texas distributed 70,000 doses of vaccines in the wake of the hurricane. Unfortunately, vaccinating people during an emergency is not ideal, since most people, even physicians, cannot recall easily if their vaccines are already up to date, leading to redundant — and costly — repeat vaccinations. This also depletes reserves and can cause shortages in other areas. Thus, following a disaster, it is especially important that Texas work with local public officials, hospitals, and emergency responders to ensure they are informed about the appropriate vaccination requirements for first responders and patients as recommended by local public health officials or the Centers for Disease Control and Prevention.  

Furthermore, Texas’ redesigned immunization registry — ImmTrac2 — should be used to verify the vaccination status of first responders and evacuees. Currently, adults wishing to share their vaccine status with the registry cannot do so, meaning in a disaster first responders cannot easily assess who really requires vaccination and who does not. State statute should be amended to permit the storage of adult vaccine records with their consent, and any expungement of preexisting child records should cease permanently until a person removes consent.  

  • Vague and inadequate professional liability protections for physician volunteers hindered the ability to deploy residents and out-of-state physician volunteers.

During the response to Hurricane Harvey, more than 200 out-of-state physicians came to Texas under temporary licenses, and even more Texas physicians volunteered their services to treat victims of the historic storm. However, most of these physicians were unaware that their good deeds put them at risk, since current federal and state volunteer immunity laws do not provide protection for most of these physicians. Some of the problems with existing laws meant to address these situations include (1) requirements that the care be provided at the request of certain agencies, (2) requirements that the recovery activity requires resources beyond the capabilities of a local jurisdiction, (3) requirements that volunteers act within the scope of their responsibilities at a nonprofit organization or governmental entity, (4) lack of explicit coverage under state sovereign immunity, and (5) requirements to obtain signed statements from each patient notifying him or her that the physician will not be paid and that patients will be limited in damage recovery. 

Another volunteer concern is the barrier for resident physicians and medical students to volunteer at shelter sites. The liability coverage of schools and teaching hospitals would apply to these residents and students only if they were at their facility or campus. Their liability coverage currently does not extend to an off-site location such as an emergency shelter. One potential option is to permit entities such as medical schools and facilities to temporarily extend the definition of their location to include disaster shelters in officially declared emergencies. This potentially would address that gap in coverage. Another option is to provide a special provision under the Good Samaritan law for these types of facility-based providers (which likely would benefit nurses and other health professionals as well) if they are providing care in an “uncovered” situation, but the school/facility still may need protection if the student/resident is permitted to be there.  

Disaster Preparedness & Response Resource Center: Hurricane Harvey 

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April 25, 2018