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Beleaguered hospitals can’t muster readiness
Beset by financial maladies and constricting regulations that have converged like a "perfect storm," the nation’s hospitals are seriously unprepared to deal with the threat of bioterrorism, an American Hospital Association official warned recently.
James D. Bentley, PhD, senior vice president of strategic policy planning at the American Hospital Association (AHA) in Washington, DC, reported findings from a research study funded by the Office of Emergency Preparedness.
Bentley spoke Nov. 28, 2000, at a national symposium on medical and public health response to bioterrorism. The principal organizer of the meeting was the Center for Civilian Biodefense at Johns Hopkins University in Baltimore.
No more challenges needed
"A couple of general conclusions [were] mass casualties by definition will overwhelm the capacity of hospitals and the health care system in this country," he said. "We have for 20 years, in the interest of cost containment, striven to reduce capacity and flexibility. . . . Hospitals already face severe challenges, and they’re really not looking for more unfunded mandates."
Like the "perfect" combination of destructive weather systems depicted in a popular book and movie, hospitals are reeling from unprecedented change in the three major payment systems, Bentley said.
The Balanced Budget Act passed in 1997 has extracted significant funds from the Medicare payment stream, he noted. In addition, many states have moved from a Medicaid payment system for low-income patients to a system of using managed care plans that cost hospitals 15% to 20% more, he said. All the while, private payers concerned about their costs and competitiveness have been extremely diligent in "holding back" payments to hospitals.
What’s the result? Hospitals that try to set aside funds for bioterrorism preparations can expect this reaction from payers: "We overpaid you. There’s room to negotiate downward because no one pays for planning and preparation," Bentley said.
Throw in the staffing shortages reported at many facilities, and you have a national hospital system with little capacity to respond to a surge of incoming patients, he added. "And if we have too much of one thing, it’s regulatory burden on the institutions. So as the hospital moves forward and looks at bioterrorism, [we have] a situation in which funds are tight, staffing is short, and regulatory burden is high."
Clinicians need assurance of backup
Beyond the chronic labor shortage issues, there are real concerns — as many epidemiologists have observed — that hospitals could maintain medical staff in the face of a spreading, infectious agent. "Seventy to 85% of the hospital work force is female," Bentley said. "Most of those people are heads of household or are responsible for the care of family members in that household."
Like a hurricane or flood, bioterrorism incidents may be long-duration events requiring that staff remain and return, he said. "Their ability to do that consistently depends upon the ability of their family to be protected and cared for," he said. In past emergencies, hospitals have told workers to bring their families to the institution so staff will know their loved ones are safe.
"That’s probably not a welcome strategy in a bioterrorism incident," he said. "Similarly, saying to the staff as some hospitals have, Go home. Take care of your family and return,’ may not be a successful strategy. The staff member who goes home, turns on the television, and sees whatever the media focus is in terms of uncertainty, risk, and the next scary story."
Though there have been many discussions of preparedness in recent years, Bentley said hospitals and health care workers have not been sufficiently reassured that full support will be thrown behind them.
"We cannot yet 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," he said.
"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 [state] whether our society has valued them and protected them," Bentley added.