TMA Interim Testimony by Lisa Ehrlich, MD
Senate Health and Human Services Committee
Hearing to Review State Response to Hurricane Harvey
Nov. 8, 2017
Good morning/afternoon Chairman Schwertner and committee members. I am Lisa Ehrlich, MD, a family physician from Houston, and I served as the medical director for the NRG Stadium shelter following Hurricane Harvey. I am testifying today on behalf of the Texas Medical Association and its more than 50,000 physician and medical student members. 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 Texas’ official emergency responders and the thousands of volunteers who immediately came to the aid of hurricane survivors and their communities.
As the saying goes, hindsight is 20/20. Looking back, it is always easier to see what we should do differently in a crisis. Through careful and critical evaluation, we ensure Texas’ response to future disasters will be that much better.
With that in mind, let me share some observations and recommendations of frontline physicians who cared for evacuees, as well as my own, on opportunities to fine-tune Texas’ disaster preparedness.
- State financial assistance will be essential to helping medically underserved communities rebuild their health care infrastructure.
Most of today’s speakers represent members from urban communities. But smaller communities arguably were affected more seriously because of a reduced availability of resources, although their stories are less well-known. Of the 58 counties in Gov. Greg Abbott’s disaster declaration eligible for Federal Emergency Management Agency (FEMA) assistance, approximately half are designated as rural. Prior to the storm, all were designated in whole or in part as medically underserved, meaning they already lacked a sufficient number of physicians and other health care professionals. After the storm, this scenario is likely to worsen permanently.
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. Many intend to reopen eventually, but doing so will depend not only on their own financial wherewithal, but also on whether and how the local health care ecosystem rebounds.
- Rural, for-profit hospitals are ineligible for federal disaster aid, hampering their 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, and psychologists, among many others — also have not been able to return to full-time practice 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. TMA has received reports that in some areas there is no FEMA-supported housing within 150 miles.
- 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, use the rebuilding process as an opportunity to also modernize local systems so they can rebound more easily after a future disaster, and encourage investing in electronic health records and telemedicine.
Furthermore, we respectfully urge Texas to implore Congress swiftly and vigorously for federal funding to (1) provide temporary health insurance coverage to low-income, uninsured Texans, many of whom 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 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 initiating daily hurricane-related communications to disseminate answers quickly. With regard to 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 entire 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 steady 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, the Texas Health and Human Services Commission’s (HHSC’s) communications were focused almost entirely on the Medicaid and CHIP health plans, which were invited to participate in regular 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 disjointed information, creating considerable confusion. Because there inevitably will be another natural disaster in the future, we urge HHSC to establish conference calls with representatives of all impacted stakeholders, an approach used successfully 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. Likewise, Texas should consider establishing mobile units that can be readied for activation and dispatch as soon as disaster declarations are made or urgent need is identified. Additionally, MRCs should be housed with government institutions, not private organizations, so they can be activated more quickly when a crisis requires it, as most government entities remain functional during disasters. This availability requirement should apply to both rural and urban MRCs. Lastly, credentialing of health care professionals must be streamlined so volunteers can preregister easily with MRC for more expedient activation, as is done with the Texas National Guard.
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 came 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.
As expected, 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, volunteers, 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, volunteers, and evacuees. Currently, adults wishing to share their vaccine status with the registry face a significant burden to 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 more easily allow the storage of adult vaccine records with their consent, and any expungement of preexisting child records should cease permanently until consent is revoked.
- 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 emergency shelter sites because the liability coverage of schools and teaching hospitals applies to these residents and students only if they are 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. Because protections offered by the Good Samaritan law are insufficient in a disaster, Texas should incorporate a special provision under this 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, with the understanding that the school/facility still may need protection if the student/resident is permitted to be there.
- Lack of early evacuation of patients with special health care needs jeopardized their health and safety and resulted in inefficient and costly EMS services.
Over the past decade, Texas Medicaid has made great strides in promoting in-home long-term care services and supports for adults and pediatric patients with special health care needs. In previous generations, many of these patients would have been cared for in a nursing home or other long-term care facility. This evolution in long-term care is broadly supported by patients, physicians, and providers. But Texas’ disaster-preparedness system has not kept pace with the changes to ensure patients receiving in-home care are properly cared for prior to, during, and following a disaster. Power outages put the safety and health of technology-dependent patients, such as those using ventilators, in peril. But disaster plans did not consider preventive emergency evacuation of these patients to specially equipped shelters before the storm’s arrival. Moreover, following the storm, patients whose ventilator back-up power packs were near failure were not defined as emergent, delaying arrival of the emergency medical service (EMS). Flooding also prevented patients reliant on wheelchairs or walkers from moving to higher ground. As water poured into these people’s houses, first responders and teams of volunteers raced to evacuate them, but this haphazard approach endangered patients and first responders alike. Florida took a different approach. When Hurricane Irma threatened Florida, that state issued emergency mandatory evacuation orders for special needs patients residing in communities expected to flood or lose power. Texas should evaluate implementing a similar approach.
Thank you, Chairman Schwertner and members of the committee, for allowing me to share this information with you. I’m happy to answer questions today or whenever they may arise.
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